Arizona Health Care Cost Containment System

Arizona Long Term Care System (ALTCS)
Initiation of Home and Community Based Services
For Elderly and Physically Disabled Members

June 2012

“Our first care is your health care”

Thomas J. Betlach
Director, AHCCCS

Prepared by the Division of Health Care Management

ABSTRACT

Home and community-based services (HCBS) provide assistance with activities of daily living
(ADLs) for older adults and those with disabilities so they can remain in their homes. Without
such services, many recipients would otherwise reside in an institutional facility such as a
nursing home. The Arizona Health Care Cost Containment System (AHCCCS) HCBS Program
was introduced to provide members the ability to maintain control over decisions within their
daily lives; in addition, it has proven to be a cost effective alternative to institutional care.
AHCCCS, Arizona’s version of Medicaid, requires services for HCBS members to be initiated
within 30 days of enrollment into the Arizona Long Term Care System (ALTCS).
The data in this report assesses the percentage of newly placed Elderly and Physically Disabled
(E/PD) HCBS members who received specific services within 30 days of enrollment, both
overall and by contracted health plan (Contractors). The methodology used includes a random
sample from each Contractor within the measurement period October 1, 2010 through September
30, 2011.The findings indicate each Contractor met the Minimum Performance Standard for the
reported measurement year.

Arizona Long Term Care System (ALTCS) Initiation of Home and Community Based
Services for Elderly and Physically Disabled Members, CYE 2011

INTRODUCTION
All Americans regardless of age, gender, race or ethnicity want the same opportunities as the
next; the ability to have success and achievements as well as own their independence. Each
wants to be in control of their own lives so they may go to work, church, school and even
explore their own communities with family and friends if they so choose. In the past, elderly and
disabled populations have not always been able to do so. In fact any abilities a person may have
had seemed to become irrelevant when one was identified as having a disability or reached a
certain age. Through strong advocacy, these ideas shifted into a different understanding; these
populations can receive a wide variety of much needed services and remain in their own homes
and communities, thus allowing them to maintain their dignity and sovereignty.
More than 10 million Americans require long term care services and supports to assist them with
activities of daily living. Activities of daily living include: toileting, dressing, grooming, bathing,
eating and walking. Long term care consists of a variety of medical and social services to help
meet the health and personal needs of individuals with chronic illness or disability. Most prefer
to receive these services in their home in order to maintain their dignity, privacy and
independence while being closer to their families rather than residing in an institutional facility,
such as a nursing home.
Medicaid has become the largest payer of these services in the nation, financing 43 percent of all
long term care services.1 Nationally, Medicaid long term care recipients make up 6 percent of the
Medicaid population but account for nearly half of its spending.1 In addition, nearly half of
Medicaid long-term care spending goes toward institutional care while 29 percent is spent on
community-based care.1 A study in 2006 indicated HCBS waivers produced a national average
public expenditure savings of $43,947 per member. 2
The need for long term care services in the United States is on the rise, with the older population
projected to grow significantly between 2010 and 2030 as a result of the “baby boom” generation
reaching 65 years of age and the life expectancy of people with disabilities increasing due to
medical advances and enhanced living conditions.3 Nationally, 58 percent of this population is
65 years or older while the remaining 42 percent is under 65.4
AHCCCS HCBS PROGRAM
The Arizona Health Care Cost Containment System (AHCCCS) has provided home and
community based services (HCBS) through a waiver from the Centers for Medicare and
Medicaid Services (CMS) since 1989. Through its Arizona Long Term Care System (ALTCS),
AHCCCS provides comprehensive coverage for HCBS members residing in their own homes or
approved alternative residential settings, such as assisted living facilities or group homes.
Covered services include care such as home health nursing, attendant or personal care, and home
delivered meals. Members may designate a family member or friend to provide attendant care;
after completion of training, these caregivers can be paid by AHCCCS.

As of September 2011, there were 25,045 ALTCS Elderly and Physically Disabled (E/PD)
members served by AHCCCS; 33 percent were ages 0-64 years and 67 percent were 65 years of
age or older. Of those, 71.83 percent resided in home and community-based settings. By
providing a variety of alternative settings along with a wide array of HCBS options, ALTCS
members are able to delay institutionalization for a longer period of time and some are even able
to transfer from an institution to their home or other community-based settings.
Once eligibility for ALTCS is determined based on financial and medical criteria, members
enroll with a contracted health plan (Contractors). Each member is assigned a case manager who
coordinates care with the member’s primary care physician (PCP) and other providers, addresses
any problems with service delivery, and modifies the member’s care plan based on changes in
health status. Case managers visit new members and assess needs to determine the most
appropriate services and placement. AHCCCS requires that Contractors initiate home and
community-based services within timelines to meet members’ medical needs, but no later than
30 calendar days from the member’s date of enrollment. To ensure that member needs continue
to be met in the most appropriate setting, case managers reassess members’ physical and
functional status at regular intervals and AHCCCS monitors the ongoing provision through
regular reviews of Contractor operations.
AHCCCS annually measures the percentage of newly placed E/PD HCBS members who receive
specific services within 30 days of enrollment. This measurement is conducted to determine
individual Contractor compliance with contract performance standards as well as to analyze
overall rates of initiation of services for HCBS members. It should be noted that this
measurement does not include all covered home and community-based services. For example,
emergency-alert and home-modification services are not included because they are typically
provided in conjunction with nursing, personal care or other supportive services. This
measurement focuses on the health-related services that allow ALTCS members to remain in
their homes as long as possible.
Purpose:
The AHCCCS medical policy requires that services for HCBS members are initiated within 30
days of enrollment, based on a personal visit and thorough assessment of service needs by a
Contractor case manager. This measurement assesses the percentage of newly placed HCBS
ALTCS members who received specific HCBS services within 30 days of enrollment, overall
and by Contractor.
Minimum Performance Standards and Goals:
AHCCCS established a Minimum Performance Standard (MPS) that Contractors must achieve.
At minimum, 92 percent of members included in this population must have received service
within 30 days of their enrollment. AHCCCS also established a long-range goal of 98 percent for
this measure.

Methodology:
The measurement period for the current study is October 1, 2010 through September 30, 2011. A
representative random sample was selected for each Contractor. The sample frame consists of
E/PD members who:
 were enrolled for 30 days or more with an ALTCS Contractor during the measurement
period,
 were newly placed in an HCBS setting, other than an assisted living facility, and
 were not ventilator-dependent, as Contractors are required to initiate services to those
members within 14 days of enrollment.
Excluded from this study were members who died, were hospitalized, were receiving hospice
services, or refused services when these situations were documented as occurring within 30 days
of enrollment.
Data was first collected from AHCCCS encounter data (records of claims paid by Contractors).
If initiation of services within 30 days of enrollment were not found in AHCCCS encounter data,
Contractors were asked to provide information from medical or case management records or
their claims data. Contractor-submitted data was validated against supplemental documentation,
such as copies of the pertinent sections of case management records, medical/service records
from providers, or verification of claims paid by Contractors for qualifying services.
RESULTS AND ANALYSIS
The study sample included 275 HCBS members enrolled with three different ALTCS
Contractors, of those, 18 people were excluded for one of six different reasons as indicated on
Table 1.
Table 1: Study Exclusions
Reasons for Exclusions
Assisted
0
living/nursing facility
Admitted to Hospital

1

Received Hospice
service

3

Refused services

3

Awaiting designated
caregiver to be trained

11

Died

0

Total:

18

Among the remaining 257 members, 97.3 percent received services within 30 days of
enrollment, a non-statistically significant decrease from the previous rate of 97.7 percent (p=

.748). Two of the three Contractors met the MPS and one achieved the AHCCCS goal.
Contractor-specific performance is shown in Table 2 on the following page.

Table 2: Initiation of Home and Community Based Services, By Contractor
Measurement Period: Oct. 1, 2010 through Sept. 30, 2011
Minimum Performance Standard: 92%

Contractor

Percent who
Received Service
Within 30 Days

Relative Percent
Change

Statistical
Significance

Bridgeway Health Solutions

94.9%

0.1%

p=.973

-3.1%

p=.572

1.0%

p=.528

-0.4%

p=.748

94.8%
Evercare Select

95.1%
98.2%

Mercy Care Plan

100.0%
99.0%

TOTAL

97.3%
97.7%

Notes:
 A change in a rate from the previous measurement is considered statistically significant when p< .05.
 Shaded rows show results of previous measurement, Oct. 1, 2009, through Sept. 30, 2010.

There was no significant difference in performance rates between rural and urban counties or by
members’ race or ethnicity. Rates by Contractor ranged from 94.9 percent to 100 percent.
Contractors that had not met the Minimum Performance Standard (MPS) would have been
required to implement corrective action plans to bring their rates up to the minimum standard.
During the most recent Request for Proposal (RFP) cycle, four health plans were not awarded
continuing contracts. As of October 1, 2011, Cochise County Long Term Care, Pima Health
Systems, Pinal/Gila Long Term Care, and Yavapai County Long Term Care were no long er
AHCCCS Contractors. SCAN Health Plan was awarded a capped contract as of October 1,
2011; however, they discontinued as an AHCCCS Contractor as of April 30, 2012. All members
belonging to discontinued health plans were seamlessly transitioned to continuing Contractors.
Only the continuing health plans were highlighted in this report.

DATA QUALITY AND RELIABILITY
AHCCCS conducts validation studies to evaluate the completeness of its encounter data. To
validate additional information collected by Contractors, AHCCCS requires documentation of
services provided or reasons why a member did not receive services. Documentation provided by
Contractors included: copies of the pertinent sections of case management records,
medical/service records from providers, or verification of claims paid by Contractors for
qualifying services. This document was reviewed by AHCCCS staff with expertise in ALTCS
case management.
DISCUSSION
Given the variety and complexity of members’ needs and personal situations when they enroll in
the ALTCS program, Contractor case managers face distinct challenges in ensuring that
enrollees have prompt access to home and community based services that fit with their individual
choices and needs. Despite these challenges, the overwhelming majority of new ALTCS
members placed in HCBS settings receive services within 30 days of enrollment.
Since much of the data for this measure is collected from case management records when claims
or encounters for services are not available, Contractors must ensure that case managers
thoroughly and consistently document when home and community-based services are initiated
for new members or when members or authorized representatives refuse services. Over the past
few years, AHCCCS has worked with Contractors to improve documentation.
QUALITY IMPROVEMENT INITIATIVES
ALTCS Contractors have developed numerous initiatives over the years to enhance the quality of
life of HCBS members, several of which facilitate timely access to care. These include:
 Monitoring service provision to HCBS members within one to two weeks of enrollment.
Contractor reports are run at regular intervals and provided to case managers.
 The use of automated case management systems, which can be used to track timelines of
service initiation and generate reminders for case managers to follow up.
 The development of multi-disciplinary teams that coordinate case management, medical
management and quality management staff to more closely monitor needs of members in
the HCBS program and to facilitate the development of new ways to facilitate timely
access to care.
CONCLUSIONS
AHCCCS raised the minimum performance level three years ago (2008) in order to encourage
continued improvement. As a result, Contractors implemented interventions that have continued
to lead to overall improvement and continued progress toward the long-range goal for ensuring
timely initiation of services for members in home and community based settings. The three
continuing ALTCS Contractors will continue to monitor the initiation of home and community
based services to ensure members receive appropriate and timely services.

REFERENCES
1

The Henry Kaiser Family Foundation. October 2011. Medicaid’s Long-Term Care users: Spending Patterns Across
Institutional and community-based Settings. Kaiser Commission on Medicaid and the Uninsured. Doi:
http://www.kff.org/medicaid/upload/7576-02.pdf

2

M. Kitchener et al., Institutional and Community-Based Long-Term Care: A Comparative Estimate of
Public Costs, Journal of Health and Social Policy 22, no. 2 (2006): 31–50

3

U.S. Department of Health and Human Services. 2011. A Profile of Older Americans: 2011, Administration on
Aging

4

The Henry J. Kaiser Family Foundation. March 2011. Medicaid and Long-Term Care Services and Supports.
Kaiser Commission on Medicaid Facts, Figure 1. doi: http://www.kff.org/medicaid/upload/2186-08.pdf

For questions or comments about this report, please contact:
Jakenna L. Lebsock, MPA; Quality Improvement Manager
Clinical Quality Management Unit
Division of Health Care Management, MD 6700
701 E. Jefferson St.
Phoenix, AZ 85034
Jakenna.Lebsock@azahcccs.gov

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
Performance Measure Methodology: 2012

Project Title:

Initiation of Home and Community Based Services (HCBS)

Background:

Health care services and supports should be provided to members in the Arizona
Long Term Care System (ALTCS) who are residing in home and communitybased settings as quickly as possible after enrollment. These services and supports
include, but are not limited to: adult day health care, attendant care, behavioral
health services, habilitation services, home-delivered meals, home health aide
services, home health nursing, homemaker assistance, home infusion therapy and
respiratory therapy.
Arizona Health Care Cost Containment System (AHCCCS) medical policy
requires that service be provided within the first 30 days after enrollment to new
ALTCS members who are placed in the Home and Community Based Services
(HCBS) program.

Purpose:

The purpose of this study is to evaluate ALTCS Contractor compliance with
AHCCCS medical policy in initiating services to newly enrolled elderly and
physically disabled (E/PD) members in the HCBS program.

Measurement
Period:

October 1, 2010, through September 30, 2011

Study Questions:

1. What is the number and percentage (overall, by urban and rural counties, and
by individual Contractor) of sample members to whom a service was
provided within 30 calendar days of enrollment?
2. For those members who did not receive services within 30 calendar days of
enrollment, what were the reasons?

Population:

E/PD members in home and community based settings

Sample Frame:






Sample Frame
Exclusions:





The sample frame consists of E/PD members who met the following
criteria:
Enrolled in ALTCS with the same Contractor for 30 or more days during
the measurement period.
Enrolled on the last day of the measurement period.
Placed in an HCBS setting (H placement code) or temporary setting (Z
placement code) during the measurement period.
Members with Prior Period Coverage (PPC). PPC is a retroactive coverage
period for which Contractors are financially responsible for paying for
covered services.
Members placed in settings other than H or Z any time during the first 30
days of enrollment.
Members placed in Assisted Living Facilities (ALFs) any time during the
first 30 days of enrollment, as they are receiving services on the first day
of placement in such facilities. Members residing in ALFs will be
identified by the following Residence Codes contained in the AHCCCS
Prepaid Medical Management Information System (PMMIS) Recipient





Subsystem (CA 161): 5, 6, 8, 9, B, E, F, G, K, L, P and R.
Members with encounters for hospital, nursing facility or hospice services,
as identified by bill types 11X, 21X, 81X or 82X.
Members who are not in hospice and die in the first 30 days are in the
death category
Members who are in hospice in the first 30 days of enrollment (all or part
of that time) and who also die during that time (or any time after) are
included in the hospice category of exclusions in the table.

Sample Selection:

A statistical software package will be used to select a random representative
sample by Contractor from the sample frame. The sample size will be determined
using a confidence level of 95 percent and a 5-percent confidence interval, plus
oversampling to account for exclusions and missing records.

Data Sources:

AHCCCS recipient enrollment data will be used to identify members who meet the
sample frame criteria. AHCCCS encounter data, and member medical records
and/or case management files, and Contractor claims data will be used to identify
services received by members in the sample frame.

Data Collection:

Data will be first collected from AHCCCS administrative (encounter) data. If
acceptable services are not identified as being provided within 30 days of
enrollment, AHCCCS will request that Contractors use medical records, case
management files or their own claims data to verify whether any of the services
measured in this study were provided to those members within the first 30 days of
enrollment. If services were not provided within 30 days, Contractors will be
instructed to provide the reason and any supporting documentation for each case.
Contractors will be required to collect data using the AHCCCS standardized
methodology in an electronic format provided by AHCCCS. Each Contractor will
be provided an electronic file of its sample members for whom encounters for
services within 30 days of enrollment were not found in the AHCCCS encounter
system. After collection of data, Contractors will return the data to AHCCCS in the
predetermined electronic format.

Confidentiality
Plan:

AHCCCS continues to work in collaboration with Contractors to develop,
implement and maintain compliance with Health Insurance Portability and
Accountability Act (HIPAA) requirements.
The Data Analysis & Research (DAR) Unit maintains the following security and
confidentiality protocols:
 To prevent unauthorized access, the sample member file is maintained on a
secure, password-protected computer, by the DAR project lead,
 Only select Division of Health Care Management (DHCM) employees,
who enter or analyze data, have access to study data.
 Sample files given to Contractors are tracked to ensure that all records are
returned.
 All employees and Contractors are required to sign a confidentiality
agreement.
 Member names are never identified or used in reporting.
 Upon completion, all study information is removed from the computer and
placed on a compact disk, and stored in a secure location.

Data Validation:

The sample frame will be validated to ensure that members meet criteria for
inclusion in the study.
Data files received back from Contractors will be reviewed to ensure that:
 all members included in the sample are listed in the returned data file,
 services meet numerator criteria for this performance measure,
 all requested information is provided.
Service data provided by Contractors must be accompanied with documentation of
the source data (i.e., copy of the pertinent section of the medical record or case
management file and/or a copy of a paid claim), including the date(s) of service.
Contractor-supplied data will be validated by staff of the AHCCCS ALTCS unit

Indicators:

1. The number and percentage (overall, by urban and rural counties, and by
individual Contractor) of sample members who received at least one
acceptable home and community-based service within 30 days of enrollment
during the measurement periods.
2. The number and percentage of members who did not receive an acceptable
home and community-based service within 30 days of enrollment, by reason
category.

Denominator:

1. The number of members who meet the sample frame criteria

Numerators:

1.

Analysis Plan:

The number of sample members who receive an acceptable service within 30
days of enrollment in ALTCS










The numerator will be divided by the denominator to determine the
indicator rate.
Data for services received within 30 days will be analyzed by
Contractor, as a statewide aggregate, and by urban and rural
counties.
When calculating rates for initiation of services within 30 days of
enrollment (study question #1), members will be excluded from the
denominator for the following reasons if supported by appropriate
Contractor documentation.
AHCCCS will report the number of sample members excluded
from the denominator, by Contractor, in the following categories:
o Refused all applicable services, including those who refused
services while waiting for a designated caregiver to be trained
o Members who were not in hospice and died within 30 days of
enrollment comprise the death category.
o Were admitted to a hospital or nursing facility within 30 days of
enrollment.
o Received hospice services within the first 30 days of enrollment
(all or part of that time) and who also die during that time (or
any time after) are included in the hospice category.
o Were placed in an assisted living facility within 30 days of
enrollment.
Outliers will be identified using standard deviations and patterns of
abnormal distribution of data.
Differences between prior study results will be analyzed for
statistical significance and relative change.

Comparative
Analysis:

Deviations
HEDIS:



The following assumptions will be used to determine whether the
indicator criteria was met:
o Members included in the sample sent to Contractors for whom
data was not received back from the Contractor or for whom
service data was not supported by appropriate documentation
will be counted as having no service within 30 days.
o Any service documented by the Contractor that did not include
the date it was first delivered will be counted as being provided
outside the 30-day requirement.




Overall rates for urban and rural counties will be compared.
Individual Contractor rates will be compared to the Contractor’s rate for
the previous measurement and to the AHCCCS Minimum Performance
Standard and Goal.

from This indicator is based on an AHCCCS contractual requirement and is not based
on any nationally recognized methodology, such as the Healthcare Effectiveness
Data and Information Set (HEDIS).

Deviations
from AHCCCS excluded from the sample frame sent to Contractors members who were
hospitalized, or received nursing facility or hospice services during the first 30
Previous
days of enrollment using Uniform Billing (UB) bill type codes associated with
Methodology:
encounters:
 11X – Hospital (inpatient)
 21X – Nursing facility
 81X – Hospice (nonhospital based)
 82X – Hospice (hospital based)
In the current measurement, these members were excluded from Contractor
samples prior to sending samples for data collection to each Contractor. In
previous measurements, bill types were not used to exclude members from the
sample frame prior to Contractor data collection. Contractors provided
documentation of these services within 30 days of enrollment when appropriate,
and such members were excluded from each Contractor’s final sample prior to
analysis.
Quality Control:







To ensure consistency and reliability in data abstraction, AHCCCS:
Provides each Contractor with the methodology for this measure,
provides each Contractor with a data specification sheet, file layout, and
data dictionary for this measure,
provides each Contractor with detailed written instructions for data
collection,
Provides updates and ongoing technical assistance to Contractors
regarding data collection for this measure.