A Snapshot of Uniform Assessment Practices in Managed Long Term Services and Supports California Department of Health Care Services, Home and Community Based Services Universal Assessment Workgroup February 27, 2014 Carolyn Ingram, Senior Vice President Brianna Ensslin, Program Officer www.chcs.org
Welcome and Introductions Carolyn Ingram Senior Vice President Center for Health Care Strategies Brianna Ensslin Program Officer Center for Health Care Strategies 2
Agenda I. CHCS Overview II. Our Research III. What Did We Find? IV. Best Practices and Recommendations V. Questions 3
A non profit health policy resource center dedicated to improving services for Americans receiving publicly financed care Priorities: (1) enhancing access to coverage and services; (2) improving quality/delivery system reform; (3) integrating care for people with complex needs; and (4) building Medicaid leadership and capacity. Provides: technical assistance for stakeholders of publicly financed care, including states, health plans, providers, and consumer groups; and informs federal and state policymakers regarding payment and delivery system improvement. Funding: philanthropy and the U.S. Department of Health and Human Services. 4
Select CHCS National Initiatives Enhancing Access to Coverage and Services Improving Quality/Delivery System Reform Integrating Care for People with Complex and Special Needs Building Medicaid Leadership and Capacity Technical Assistance for State Health Reform Assistance Network Charity Care Affinity Group Technical Assistance for the State Innovation Model Resource Center* Medicaid and CHIP Learning Collaboratives* Technical Assistance for CMS Integrated Care Resource Center* Integrating New Systems of Integration for Dual Eligibles (INSIDE) Medicaid Leadership Institute Annual Medicaid Boot Camp Advancing Medicaid Accountable Care Organizations: A Learning Collaborative Promoting Integrated Care for Dual Eligibles (PRIDE) *Federally funded initiatives 5
Our Research About This Project Definitions Methods Interviewees Interview Topics 6
About This Project Researched current state and health plan practices in managed long term services and supports (MLTSS) assessments to help inform California s process Thank you to The SCAN Foundation for supporting this project 7
Definitions: What is a Uniform Assessment? Definitions of uniform vary in scope and focus across all five states Uniform can mean: same tool distributed to defined population at defined intervals Uniform can mean: same data elements across tools distributed to defined population at defined intervals Uniform ideally means, a single tool used to assess the services a person needs across LTSS programs 8
RI FL ID MT WY SC TN KY OH SD KS NE IA MS ND CA NV WA AK PA ME CT WV MD NJ VT MA DE HI LA GA TX NC WI WI MN IL IN AL MI UT MO AR NH VA OK TX AZ OR NM NY CO Who Did We Interview? 9
Interviews Focused on an Array of Issues Overview Description of Assessment What is the history of the process and tool? Are the assessments uniform? Delegation and Oversight Who performs which steps? What is mandatory and what is flexible? Components of Tool Is it evidence based? State developed or purchased? 10
Additional Interview Topics Methods of Data Collection How is data reported? Is tool electronic or automated? Is rate of completion tracked? Plans to Revise How often is tool changed? Is the state satisfied with the tool and process? Do plans have flexibility to make changes? 11
What Did We Find? State Overviews Technology Timeframes Qualifications Oversight 12
Arizona Arizona Long Term Care System (ALTCS) Full risk 1989 implementation 50,000 enrollees Statewide Children, Adults < 65 with PD; Adults < 65 with ID/DD; Adults 65+ Private health plans STATE CLIMATE OVERVIEW Integrated model for high need, high cost population Will create financial alignment in 2014 across physical and behavioral health systems in Maricopa County Pursuing alternative integration model to encourage alignment between SNPs and Medicaid managed care plans Completed new procurement of Medicaid managed care plans in 2013 13
Arizona Assessment Tool Uniform Assessment Tool (UAT): assesses acuity level for nursing facility and assisted living HCBS Assessment Tool : determines service hours; was developed with plan and stakeholder input Populations and Services Covered Nursing facility residents Assisted living facility residents HCBS members Attendant Care Personal Care Homemaker Habilitation Respite Emergency Alert Systems Adult Day Care Delegation State does functional eligibility determinations MCOs administer UAT and HCBS Assessment Tool MCOs develop service plans MCO can make additions without state approval as long as no changes made to mandated tool 14
Minnesota Senior Care Plus 1of 3 programs that support people in the community Full risk 2005 implementation 12,000 enrollees; 9,000 using LTSS Statewide Adults 65+ 8 private and county based plans STATE CLIMATE OVERVIEW Implementing an administrative alignment duals demonstration Working to align administrative systems with goal to improve beneficiary experience 15
Minnesota Assessment Tool MnCHOICES : single, comprehensive and integrated assessment and support planning application for LTSS Replacing old assessments Developed with stakeholder input Contractor developed system Populations and Services Covered People with disabilities and long term care needs Developmental disability Long term care Personal care assistance Will include private duty nursing Delegation Counties, health plans, lead agencies, and tribes complete assessment and support plan development Completed by certified assessors at those agencies Nurses or social workers with HCBS experience Plans all agreed on tool, will not make own changes 16
Tennessee TennCare CHOICES Full risk 2010 implementation 31,000 enrollees Statewide Full risk contract with withholds and quality incentives Nursing facility residents; Adults < 65 with physical disabilities; and Adults 65+ 2 national and 1 local plan STATE CLIMATE OVERVIEW Pursuing integration through an alternative care model Completed reprocurement of TennCare CHOICES program in 2013 Required all bidders to have or be moving toward statewide D SNP coverage 17
Tennessee Assessment Tool Uniform Pre Admission Evaluation : assesses nursing facility and at risk levels of care Comprehensive Needs Assessment : core data elements required; based on environmental scan of tools and requirements across LTSS programs, best practice recommendations, and stakeholder input Tools developed by MCOs, based on state data elements Populations Covered CHOICES members including: Elderly, 65 + Disabled, 21 + Delegation State nurses make level of care determinations MCOs conduct comprehensive assessment and develop plan of care MCOs allowed to make changes to comprehensive needs assessment but must continue to meet state requirements 18
Texas STAR+PLUS Full risk 1998 implementation 400,000 enrollees; 71,000 using LTSS 90 of 254 counties SSI or Social Security Exclusion children <21; Adults 21+ with disability; Adults 21+ in Communitybased Alternatives HCBS waiver; Adults 65+; Full benefit Medicare Medicaid enrollees 5 health plans STATE CLIMATE OVERVIEW Moving forward with a capitated financial alignment model Will move nursing home care into an integrated care program 19
Texas Assessment Tool Form 2060 : needs assessment, task and hourly guide; developed by state Medical Necessity and Level of Care Assessment : based off of Minimum Data Set, plus state specific criteria Populations Covered State of Texas Access Reform Plus (STAR+PLUS) Community Based Alternatives program Medically Dependent Children Program Program of All Inclusive Care for the Elderly Delegation MCOs conduct functional needs assessment RN at MCO conducts Medical Necessity Level of Care MCOs are required to use Form 2060 and the MN/LOC Neither form can be amended by the MCO 20
Wisconsin Family Care 1 of 2 MLTSS programs in state, plus PACE Full risk 1999 implementation 33,000 enrollees 57 of 72 counties Adults < 65 with PD; Adults < 65 with ID/DD; Adults 65+ 9 private non profit or countybased health plans STATE CLIMATE OVERVIEW Considering inclusion of nursing facility residents in D SNPs through contract modifications Expanding Family Care into more counties 21
Wisconsin Assessment Tool Long Term Care Functional Screen : determines functional eligibility; developed by state with input from stakeholders Comprehensive Assessment : Elements prescribed by contract Formats developed by MCOs Approved by state Populations Covered Family Care Program Partnership Program PACE HCBS program for children and adults Elders and people with physical disabilities or intellectual or developmental disabilities Delegation ADRCs do initial functional screen MCOs do annual screens MCOs do not need state approval for changes; although state oversight is applied 22
Questions 23
Let s Talk Technology Arizona Minnesota Tennessee Texas Wisconsin Electronic tools used to determine Level of Care and services hours (plans can automate them) Web based/automated system leads user to next step to determine service hours Most MCOs use automated systems to determine service hours Caution: start slow! Form 2060 is not automated Medical Necessity Level of Care assessments are electronic Web based/automated system leads user to next step for functional eligibility screen 24
What are the Required Timeframes? Arizona Initial contact: within 7 business days of enrollment Initial on site visit: within 12 business days of enrollment Minnesota Assessment within 20 calendar days after initial contact Plan of care within 40 calendar days of assessment Tennessee Timeframe requirements vary for members with different acuity levels (Groups 1 3) Texas Wisconsin New member assessments conducted within 45 days Contact within 3 days Initial plan within 10 days Comprehensive assessment within 30 days 25
How are Case Managers and Care Coordinators Trained and Qualified? Requirements vary across states All health plans implement additional trainings Qualifications Degreed social worker Licensed registered nurse Certified assessor (MN) Different requirements vary with levels of need (TX) Training Many are webbased Provider specific training (i.e., AAADs, NFs) Call center/help desk for training questions (recorded calls provides data) Monthly training newsletter Continuing Education Retain professional licenses Ongoing trainings on populations served Re certification in MN every 3 years RUG training in TX every 2 years 26
Do the States Keep a Close Eye on What s Happening? Arizona: Oversight primarily occurs during audits Minnesota: Tracks data on monthly basis Tennessee: Quarterly desk audits Texas: Strong readiness reviews and periodic audits Wisconsin Requires each ADRC/MCO to have internal oversight Reliability testing every 2 years Built in cross edits Have functional screen quality unit Have function screen workgroup Each MCO has to have a screen lead expert 27
Best Practices and Recommendations Common Domains and Innovative Additions Tool Development Stakeholder Engagement Observations from Health Plans Cautionary Notes 28
What Are Some Common Domains? States include the following: Activities of Daily Living (ADLs) i.e., bathing, dressing, mobility, transfers, eating, toileting Instrumental Activities of Daily Living (IADLs) i.e., meal preparation, medication management, money management, telephone, and employment Natural Supports Cognition Health Status Mental/Behavioral Health Status 29
Domain Rock Star: Minnesota ADLs and IADLs Health General Health Risk Assessment Brain Injury Medications Eating Habits/Nutrition Many more! Psychosocial Memory and Cognition Safety/Self Preservation Sensory and Communication Employment Housing and Environment Self Direction Independent vs. Supported Service Related Rights and Choices Caregiver 30
Tool Development Strategies Arizona s HCBS Needs Assessment Tool MCOs developed a workgroup and proposed and created a tool themselves that the state then approved and formalized Tennessee s Core Data Elements Environmental scan of assessment tools and requirements across LTSS programs (managed and FFS) Looked at best practice recommendations Engaged stakeholders 31
How Are Stakeholders Engaged? Minnesota Had steering committee of stakeholders and advocates for the development of MnCHOICES Involved internal and external stakeholders, including advocates of all populations and providers A lot of concerns about how new tool would change how eligibility is determined (it won t change it!) Lesson learned: Messaging purpose of tool is crucial! 32
Observations from Health Plans Feedback from plans on the positives of having uniformity across plans Uniformity supports plans in fair hearings Detailed, descriptive, and precise questions provide assessors easiest tool to administer uniformly Negative side of uniformity: plans like flexibility to tailor to their own system 33
How are Health Risk Assessments Integrated? In Arizona, SNPs are required to do health risk assessments annually, not related to ALTCS - Health risk assessments vary a lot are not standardized! Texas eliminated an initial health risk assessment - Some plans call their clients first and administer something similar to a health risk assessment Minnesota is adding a health risk assessment, worked with the health plans to do this 34
Pros and Cons of Using Tools for Rate Setting Some states use their tools in capitated rate setting Doing so increases stake of many stakeholders Doing so ties the agreed upon tool to agreed upon rates Tools tied to rates are much more difficult to change Changing tools would likely increase costs Also increases the likelihood of reported challenges of results Tool Acuity Level Rates 35
Medicare Requirements Major Impact Minnesota New rule from CMS on Medicare side about tracking timeliness of assessments Arizona Texas Aligning state specific requirement with Medicare requirement NF also implement Minimum Data Set on Medicare side Duals get two different assessments Adopted the Minimum Data Set for their Medical Necessity/Level of Care tool, then just added state specific areas 36
Takeaways Only found one example of a true uniform assessment: Minnesota Four of the five states allow MCOs to make additions beyond prescribed criteria or tool Consideration and coordination with Medicare assessment requirements will be key Centralized databases could provide tremendous quality improvement and monitoring value, although not widely implemented yet Important to train hearing officers Good assessment tools will stand up in court Thorough assessment tools help minimize appeals 37
Resources C. Ingram, A. Lind, and B. Ensslin (2013). Uniform Assessment Practices in Medicaid Managed Long Term Services and Supports Programs. Center for Health Care Strategies. Available at: http://www.chcs.org/publications3960/publications _show.htm?doc_id=1261559#.uwudp4w7r00 Contact Us Carolyn Ingram: cingram@chcs.org Brianna Ensslin: bensslin@chcs.org 38
Visit CHCS.org to Download practical resources to improve the quality and cost effectiveness of Medicaid services Subscribe to CHCS e mail updates to learn about new programs and resources Learn about cutting edge efforts to improve care for Medicaid s highest need, highest cost beneficiaries www.chcs.org 39