NEW YORK STATE DEPARTMENT OF HEALTH
Office of Quality and Patient Safety
PLAN – Technical REPORT
FOR
VNSNY CHOICE
Reporting Years 2013 and 2014
February 2017
Table of Contents Section One: About This Report ................................................................................................................... 1 Section Two: Plan Profile ............................................................................................................................. 3 Section Three: Enrollment ........................................................................................................................... 4 Section Four: Member Satisfaction .............................................................................................................. 5 Section Five: SAAM and UAS ...................................................................................................................... 10 Section Six: Performance Improvement Projects ...................................................................................... 19 Section Seven: Overall Strengths and Opportunities .................................................................................. 24 Section One: About This Report New York State (NYS) is dedicated to providing and maintaining the highest quality of care for enrollees in managed long term care (MLTC) plans. MLTC enrollees are generally chronically ill, often elderly enrollees and are among the most vulnerable New Yorkers. The New York State Department of Health’s (NYSDOH) Office of Quality and Patient Safety (OQPS) employs an ongoing strategy to improve the quality of care provided to plan enrollees, to ensure the accountability of these plans and to maintain the continuity of care to the public. The MLTC Plan‐Technical Reports are individualized reports on the MLTC plans certified to provide Medicaid coverage in NYS. The reports are organized into the following domains: Plan Profile, Enrollment, Member Satisfaction, SAAM and UAS Clinical Assessment Data, and Performance Improvement Projects (PIPs). When available and appropriate, the plans’ data in these domains are compared to statewide benchmarks. The final section of the report provides an assessment of the MLTC plan’s strengths and opportunities for improvement in the areas of service quality, accessibility, and timeliness. For areas in which the plan has opportunities for improvement, recommendations for improving the quality of the MLTC plan’s services are provided. During the review period of this report (2013‐14), there were three (3) MLTC plan types: a) Partially Capitated b) Program of All‐inclusive Care for the Elderly (PACE) c) Medicaid Advantage Plus (MAP) A description of each of the plan types follows: Partially Capitated ‐ A Medicaid capitation payment is provided to the plan to cover the costs of long term care and selected ancillary services. The member’s ambulatory care and inpatient services are paid by Medicare if they are dually eligible for both Medicare and Medicaid, or by Medicaid if they are not Medicare eligible. For the most part, those who are only eligible for Medicaid receive non‐ MLTC services through Medicaid fee for service, as members in partially capitated MLTC plans are ineligible to join a traditional Medicaid managed care plan. The minimum age requirement is 18 years. PACE‐ A PACE plan provides a comprehensive system of health care services for members 55 and older, who are otherwise eligible for nursing home admission. Both Medicaid and Medicare pay for PACE services on a capitated basis. Members are required to use PACE physicians. An interdisciplinary team develops a care plan and provides ongoing care management. The PACE plan is responsible for directly providing or arranging all primary, inpatient hospital and long term care services required by a PACE member. The PACE is approved by the Centers for Medicare and Medicaid Services (CMS). Medicaid Advantage Plus (MAP)‐ MAP plans must be certified by the NYSDOH as MLTC plans and by CMS as a Medicare Advantage plan. As with the PACE model, the plan receives a capitation payment from both Medicaid and Medicare. The Medicaid benefit package includes the long term care services and the Medicare benefit package includes the ambulatory care and inpatient services. 1 An MLTC plan can service more than one of the above products and, where applicable, the report will present data for each product. In an effort to provide the most consistent presentation of this varied information, the report is prepared based upon data for the most current calendar year available. Where trending is desirable, data for prior calendar years may also be included. This report includes data for reporting years 2013 and 2014.
2 Section Two: Plan Profile Visiting Nurse Services of New York (VNSNY Choice) is a regional, not‐for‐profit prepaid health services plan (PHSP) with Managed Long‐Term Care (MLTC) product lines. VNSNY Choice services partially capitated and Medicaid Advantage Plus (MAP) products. The following report presents plan‐specific information for both MLTC product lines.  Partially Capitated Plan ID: 01750467  MAP Plan ID: 02914056  Managed Long‐Term Care Start Date: 1998  Product Line(s): Partially Capitated and MAP  MLTC Age Requirement: 65 and older (Part Cap) 18 and older (MAP)  Contact Information: 1250 Broadway 11th Floor New York, NY 10001 (888) 867‐6555 (212) 609‐5600 Participating Counties and Programs
Albany Part Cap Montgomery
Part Cap
Schenectady Part Cap
Columbia Part Cap Nassau
Part Cap
Schoharie Part Cap
Delaware Part Cap New York
Part Cap
Suffolk Part Cap
Dutchess Part Cap Onondaga
Part Cap
Sullivan Part Cap
Erie Part Cap Orange
Part Cap
Ulster
Part Cap
Fulton Part Cap Otsego
Part Cap
Warren Part Cap
Greene Part Cap Putnam
Part Cap
Washington Part Cap
Herkimer Part Cap Rensselaer
Part Cap
Westchester Part Cap
Madison Part Cap Rockland
Part Cap
Monroe Part Cap Saratoga
Part Cap
3 MAP
Section Three: Enrollment Figure 1 depicts membership for VNSNY Choice’s partially capitated and MAP product lines for calendar years 2012 to 2014, as well as the percent change from the previous year (the data reported are from December of each of these years). Membership in the partially capitated plan increased by 8.7% from 2012 to 2013 and decreased by 4.8% from 2013 to 2014. For the MAP line, membership grew by 189.8% from 2012 to 2013 and decreased by 16.9% from 2013 to 2014. Figure 1a trends the enrollment for the partially capitated and MAP product lines. Figure 1: Membership: Partially Capitated and MAP 2012‐2014 2012
Partially Capitated
Number of Members 2013
2014
17,772
16,924 8.7%
‐4.8% 88
255
212
2.3%
189.8%
‐16.9% 16,351
% Change From Previous Year 65.3%
MAP
Number of Members % Change From Previous Year Figure 1a: Enrollment Trends 2012‐2014 VNSNY CHOICE Enrollment 2012‐2014
Number of Members
18,000
16,351
17,772
16,924
15,000
12,000
9,000
Part Cap
6,000
3,000
MAP
88
255
212
0
2012
2013
2014
Year
4 Section Four: Member Satisfaction IPRO, in conjunction with the NYSDOH, conducted a member satisfaction survey mailed between December 2014 and May 2015. The NYSDOH provided the member sample frame for the survey, which included the primary language for the majority of members. From this file, a sample of 600 members from each plan was selected, or the entire membership if the plan’s enrollment was less than 600. Of the 18,909 surveys that were mailed, 1,109 were returned as undeliverable due to either mailing address issues or the member being deceased. This yielded an adjusted population of 17,800. A total of 4,592 surveys were completed, yielding an overall response rate of 25.8%. The response rate for VNSNY CHOICE’s partially capitated product line was 23.6% (135 respondents out of 573 members in the sample). The response rate for VNSNY CHOICE’s MAP product line was 31.0% (61 respondents out of 197). IPRO had previously conducted a similar satisfaction survey that was mailed between December 2012 and May 2013. Figure 2a represents the results of these two satisfaction surveys for VNSNY CHOICE’s partially capitated product line, compared with all other partially capitated plans throughout the state, as well as all MLTC plans statewide, in the areas of plan rating, quality ratings for key services, timeliness of critical services, access to critical services, and advance directives. Figure 2b represents survey results for VNSNY CHOICE’s MAP product line, compared with all other MAP plans throughout the state, as well as all MLTC plans statewide, in these same areas.
5 Figure 2a: Satisfaction Survey Results VNSNY VNSNY Compared with all Partially 2012‐2013 Capitated Plans, and all Plans (N=124)a Statewide Description nb % Plan requested list of Rx/OTC meds ** 109
93%
Plan explained the Consumer Directed ‐
‐
Personal Assistance option ++ Plan rated as good or excellent 123
91%
Quality of Care Rated as Good or Excellent Dentist 56
61%
Eye Care‐Optometry 94
77%
Foot Care 86
76%
Home Health Aide 110
91%
Care Manager 106
88%
Regular Visiting Nurse 111
87%
Medical Supplies 100
85%
Transportation Services 96
77%
Timeliness‐ Always or Usually On Time Home Health Aide, Personal Care Aide 101
75%
Care Manager 96
73%
Regular Visiting Nurse 113
74%
Transportation TO the Doctor 97
62%
Transportation FROM the Doctor 90
63%
Access to Routine Care (<1 Month) Dentist 50
40%
Eye Care/Optometry 80
40%
Foot Care/Podiatry 74
42%
Access to Urgent Care (Same Day) Dentist 37
35%
Eye Care/Optometry 66
23%
Foot Care/Podiatry 56
27%
Advance Directives Overall Part Cap
2012‐2013 (N=1,662)a Statewide 2012‐2013 (N=2,522)a VNSNY 2014‐2015 (N=135)a Overall Part Cap
2014‐2015 (N=3,306)a Statewide 2014‐2015 (N=4,592)a nb 1,439
% 87%
nb 2,197
% 88%
nb 107
% 93%
nb 2,677
% 94%
nb 3,702
% 94% ‐
‐
‐
‐
71
76%
1,831
77%
2,495
75% 1,625
84%
2,458
84%
110
88%
2,688
87%
3,739
87% 1,009
1,279
1,087
1,358
1,389
1,420
1,185
1,242
71%
82%
82%
88%
84%
84%
85%
77%
1,530
1,951
1,640
2,056
2,108
2,132
1,844
1,916
70%
81%
80%
87%
84%
84%
86%
78%
61
88
86
103
103
106
85
77
66%
82%
80%
93%
83%
83%
81%
77%
1,669
2,167
1,903
2,437
2,479
2,412
2,066
2,000
73%
81%
83%
87%
83%
83%
82%
77%
2,382
3,079
2,637
3,351
3,445
3,355
2,937
2,853
73% 82% 83% 87% 83% 83% 82% 77% 1,258
1,225
1,351
1,147
1,124
79%
70%
70%
68%
67%
1,897
1,876
2,027
1,766
1,742
78%
69%
69%
69%
67%
100
94
105
71
66
96%
79%
78%
80%
79%
2,471
2,270
2,297
1,763
1,753
92%
83%
81%
81%
78%
3,385
3,144
3,177
2,515
2,505
93% 83% 81% 81% 78% 832
1,093
932
47%
43%
45%
1,234
1,647
1,390
46%
43%
45%
45
74
75
60%
77%
76%
1,323
1,767
1,608
75%
80%
82%
1,873
2,486
2,220
73% 79% 80% 612
788
692
28%
25%
27%
920
1,195
1,039
26%
22%
26%
40
66
65
25%
26%
29%
1,062
1,497
1,368
31%
34%
35%
1,526
2,165
1,912
29% 33% 34% 6 Plan has discussed appointing someone to make decisions Member has legal document appointing someone to make decisions Health plan has a copy of this document ◊ 101
78%
1,346
64%
2,087
68%
116
76%
2,660
64%
3,757
67% 97
64%
1,387
55%
2,145
61%
110
61%
2,645
53%
3,722
58% 42
67%
533
74%
956
77%
42
74%
913
75%
1,506
79% LEGEND Description N reflects the total number of members who completed the survey n reflects the total number of members who responded to each survey item ** Represents question that has been added to the 2013‐2014 technical report ++ ◊ Represents new question in 2014‐2015 survey Item based on a skip pattern Symbol a
b
VNSNY members rated their plan similarly to other partially capitated plans and plans statewide in both the 2012/2013 and 2014/2015 satisfaction surveys. Although not significant, there are some notable improvements. There was an improvement in satisfaction in timeliness for home health/personal care aides from 2012/2013 to 2014/2015 for VNSNY members (75% vs. 96%, respectively). Additionally, there was a substantial improvement in the percentage of VNSNY members who indicated they had access to a dentist, optometrist, and podiatrist for routine care. In the most recent satisfaction survey administered to VNSNY’s membership, a lower percentage of VNSNY members reported having access to routine care for a dentist compared with other partially capitated members and members statewide (60% vs. 75% and 73%, respectively). Conversely, a higher percentage of VNSNY members reported that the Plan had discussed appointing someone to make healthcare decisions for them. A higher percentage of VNSNY members also reported having legally appointed a healthcare proxy as compared to members in other partially capitated plans and in all plans statewide. 7 Figure 2b: Satisfaction Survey Results VNSNY VNSNY Compared with all MAP Plans, 2012‐2013 (N=23)a and all Plans Statewide Description nb % Plan requested list of Rx/OTC meds ** 22
96%c
Plan explained the Consumer Directed ‐
‐
Personal Assistance option ++ Plan Rated as Good or Excellent 23
83%c
Quality of Care Rated as Good or Excellent Regular Doctor (PCP) 23
83%c
Dentist 16
56% c
Eye Care‐Optometry 19
74% c
Foot Care 18
78% c Home Health Aide 22
82%c
Care Manager 20
85%c
Regular Visiting Nurse 23
74%c
Medical Supplies 18
89% c
Transportation Services 21
67%c
Timeliness‐ Always or Usually On Time Home Health Aide, Personal Care Aide 20
90%c
Care Manager 21
86%c
Regular Visiting Nurse 16
81%c
Transportation TO the Doctor 18
83% c
Transportation FROM the Doctor 18
72% c
Access to Routine Care (<1 Month) Regular Doctor (PCP) 23
70%c
Dentist 15
40% c
Eye Care/Optometry 14
14% c
Foot Care/Podiatry 17
59% c
Access to Urgent Care (Same Day) Regular Doctor (PCP) 20
50%c
Dentist 10
40% c
Eye Care/Optometry 14
14% c
Foot Care/Podiatry 13
0% c
Overall MAP 2012‐2013 (N=414)a nb % 377
93%
Statewide 2012‐2013 (N=2,522)a nb % 2,197
88%
VNSNY 2014‐2015 (N=61)a nb % 50
98%
Overall MAP 2014‐2015 (N=712)a nb % 593
95%
Statewide 2014‐2015 (N=4,592)a nb % 3,702
94% ‐
‐
‐
‐
30
97%▲
397
74%
2,495
75% 403
85%
2,458
84%
52
94%
598
90%
3,739
87% 375
230
317
275
361
353
352
304
287
88%
62%
78%
77%
85%
84%
79%
82%
69%
2,247
1,530
1,951
1,640
2,056
2,108
2,132
1,844
1,916
89%
70%
81%
80%
87%
84%
84%
86%
78%
53
38
51
38
48
51
49
44
42
93%
71%
92%
84%
94%
92%
92%
84%
79%
583
376
521
412
541
552
542
471
432
90%
72%
86%
80%
86%
81%
81%
81%
72%
3,572
2,382
3,079
2,637
3,351
3,445
3,355
2,937
2,853
91% 73% 82% 83% 87% 83% 83% 82% 77% 320
310
336
249
252
78%
67%
64%
66%
63%
1,897
1,876
2,027
1,766
1,742
78%
69%
69%
69%
67%
50 100%▲
48 94%▲
51 92%▲
36
89%
37
87%
540
494
512
382
382
95%
81%
78%
75%
73%
3,385
3,144
3,177
2,515
2,505
93% 83% 81% 81% 78% 358
173
272
235
58%
46%
40%
40%
2,104
1,234
1,647
1,390
59%
46%
43%
45%
46
24
40
37
91%
67%c
85%
81%
533
297
419
357
86%
67%
79%
76%
3,328
1,873
2,486
2,220
88% 73% 79% 80% 307
135
207
184
38%
29%
21%
25%
1,755
920
1,195
1,039
45%
26%
22%
26%
40
21
37
31
48%
10%c
43%
39%
460
243
390
309
49%
32%
33%
32%
2,885
1,526
2,165
1,912
50% 29% 33% 34% 8 Figure 2b: Satisfaction Survey Results VNSNY Compared with all MAP Plans, and all Plans Statewide Advance Directives Plan has discussed appointing someone to make decisions Member has legal document appointing someone to make decisions Health plan has copy of this document ◊ VNSNY 2012‐2013 (N=23)a Overall MAP 2012‐2013 (N=414)a Statewide 2012‐2013 (N=2,522)a VNSNY 2014‐2015 (N=61)a 78% c 352
70%
2,087
68%
52
79%
600
75%
3,757
67% 20
70%c
363
62%
2,145
61%
46
72%
583
61%
3,722
58% 10
70% c 154
65%
956
77%
25
76%c
245
71%
1,506
79% ** Represents question that has been added to the 2013‐2014 technical report ++ ▲ ◊ Represents new question in 2014‐2015 survey Represents a significantly higher rate versus the MAP/statewide rate (p < .001) Item based on a skip pattern Significance testing could not be performed due to small sample size (n<30) Symbol a
b
c Statewide 2014‐2015 (N=4,592)a 18
LEGEND Description N reflects the total number of members who completed the survey n reflects the total number of members who responded to each survey item Overall MAP 2014‐2015 (N=712)a There was an improvement in satisfaction across the majority of categories of care from 2012/2013 to 2014/2015. This difference was especially notable in access to routine care (< 1 month) and access to the majority of urgent care (same day) services. There was a decline in the percentage of members who indicated they had same day access to a dentist. In the most recent satisfaction survey administered to VNSNY membership, there was a statistically significant difference between the percentage of VNSNY members who reported the Plan explained the Consumer Direct Personal Assistance Option, compared to other MAP members and members statewide (97% vs. 74% and 75%, respectively). Similarly, a higher percentage of VNSNY members indicated they had a legal document appointing a healthcare proxy, when compared with other MAP members and members statewide (72% vs. 61% and 58%, respectively). Additionally, a higher percentage of VNSNY members rated the timeliness of services and care more favorably when compared with the MAP and statewide percentages. Conversely, a significantly lower percentage of VNSNY members reported that they had access to same day dental care compared to the MAP and statewide averages (10% vs. 32% and 29%, respectively). 9 Section Five: SAAM and UAS The Semi Annual Assessment of Members (SAAM) was the assessment tool utilized by the MLTC plans to conduct clinical assessments of members, at start of enrollment and at six month intervals thereafter, through 2013. There are fifteen (15) care categories, or domains, in SAAM, as follows: Diagnosis/Prognosis/Surgeries Falls Living arrangements Neuro/Emotional Behavioral Status Supportive assistance ADL/IADLs Medications Sensory status Equipment Management Integumentary status Emergent Care Respiratory status Hospitalizations
Elimination status Nursing Home Admissions SAAM data were submitted to the NYSDOH twice annually, in January and July, through July 2013. The January submission consisted of assessments conducted between July and December of the prior year; the July submission consisted of assessments conducted between January and June of the same year. Twice annually, following submissions, the NYSDOH issued plan‐ specific reports containing plan mean results and comparison to statewide averages. In 2007, the SAAM was expanded beyond its role as a clinical assessment tool, to determine MLTC plan eligibility. An eligibility scoring index was created; the scoring index consisted of 13 items/questions, as follows: Ability to dress lower body Urinary Incontinence Bathing Bowel incontinence frequency Toileting Cognitive functioning Transferring Confusion Ambulation/Locomotion Anxiety Feeding/Eating Depression Ability to dress upper body Each item had a point value; a combined total score of 5 or greater constituted MLTC eligibility. Effective October 2013, the SAAM tool was replaced by the Uniform Assessment System for NY (UAS‐
NY). The UAS‐NY is a web based clinical assessment tool based on a uniform data set, which standardizes and automates needs assessments for home and community based programs in New York1. Data are immediately available to users during and upon completion of the assessment. Figure 3a contains VNSNY CHOICE’s July 2013 SAAM results for their partially capitated line, and Figure 3b contains VNSNY CHOICE’s January‐June and July‐December 2014 UAS results. Figure 4a contains VNSNY CHOICE’s July 2013 SAAM results for their MAP, and Figure 4b contains VNSNY CHOICE’s January‐June and July‐December 2014 UAS results. 1
NYS Department of Health, 2014 Managed Long Term Care Report. http://health.ny.gov 10 Figure 3a: VNSNY CHOICE Partially Capitated and Statewide SAAM Data 2013 July 2013 Plan Statewide SAAM SAAM N=23,231 N=88,481 SAAM Items Activities of Daily Living (ADL) Ambulation/Locomotion – % of members who could perform task independently, with setup help/device, or with supervision Bathing – % of members who could perform task independently, with setup help/device, or with supervision Upper Body Dressing – % of members able to perform task independently, with setup help, or with supervision Lower Body Dressing – % of members able to perform task independently, with setup help, or with supervision Toileting – % of members able to perform task independently, with setup help, or with supervision Transferring‐ % of members able to transfer independently, with use of an assistive device, or with supervision/minimal assistance Feeding/Eating – % of members able to eat/drink independently, with setup help, or with supervision Continence Urinary Continence – % who are continent, have control with catheter/ostomy, or were infrequently incontinent Bowel Continence – % who are continent, have control with ostomy, or were infrequently incontinent Cognition Cognitive Impairment – % members with no cognitive impairment When Confused – % with no confusion Mood and Behavior Anxiety – % with no feelings of anxiety Depressed – % with no feelings of depression 11 92%
92%
87%
89%
85%
88%
75%
80%
90%
91%
86%
88%
99%
99%
25%
27%
79%
79%
55%
36%
46%
31%
61%
31%
85%
71%
July 2013 Plan Statewide SAAM SAAM N=23,231 N=88,481 SAAM Items Health Conditions Frequency of Pain – % experiencing no pain, or pain less than daily Falls Resulting in Medical Intervention – % of members experiencing no falls requiring medical intervention Prevention Influenza Vaccine – % who had influenza vaccine in last year 61%
40%
49%
56%
82%
70%
VNSNY CHOICE Partially Capitated SAAM July 2013 A higher percentage of VNSNY members had no cognitive impairment, no feelings of anxiety or depression, and no pain, when compared with members statewide. Additionally, a higher percentage of members indicated they had received the flu vaccine in the last year (82% compared with 70% of members statewide). In contrast, a lower percentage of VNSNY members experienced no falls requiring medical attention when compared with members statewide (49% vs. 56%, respectively). 12 Figure 3b: VNSNY CHOICE Partially Capitated and Statewide UAS Data 2014 Jan‐June 2014 UAS Items Plan UAS N=16,228 Activities of Daily Living (ADL) Ambulation/Locomotion – % of members who could perform task independently, with setup help/device, or with supervision Bathing – % of members who could perform task independently, with setup help/device, or with supervision Upper Body Dressing – % of members able to perform task independently, with setup help, or with supervision Lower Body Dressing – % of members able to perform task independently, with setup help, or with supervision Toileting – % of members able to perform task independently, with setup help, or with supervision Feeding/Eating – % of members able to eat/drink independently, with setup help, or with supervision Continence Urinary Continence – % who are continent, have control with catheter/ostomy, or were infrequently incontinent Bowel Continence – % who are continent, have control with ostomy, or were infrequently incontinent Cognition Cognitive functioning – % with intact functioning Mood and Behavior Anxiety – % with no feelings of anxiety Depressed – % with no feelings of depression Health Conditions Frequency of Pain – 13 Statewide UAS N=125,702 July‐Dec 2014 Statewide
Plan UAS UAS N=132,42
N=14,149 9 53%
56% 48%
53%
17%
20% 10%
17%
29%
34% 25%
31%
15%
19% 10%
16%
64%
63% 57%
57%
88%
87% 86%
85%
31%
36% 29%
36%
77%
83% 77%
84%
54%
37% 40%
33%
73%
76% 82%
74%
70%
72% 74%
68%
35%
25% 23%
22%
Jan‐June 2014 UAS Items Plan UAS N=16,228 % experiencing no severe daily pain Falls Resulting in Medical Intervention – % of members experiencing no falls requiring medical intervention Prevention Dental Exam – % who had dental exam in last year Eye Exam – % who had eye exam in last year Hearing Exam – % who had hearing exam in last 2 years Influenza Vaccine – % who had influenza vaccine in last year Statewide UAS N=125,702 July‐Dec 2014 Statewide
Plan UAS UAS N=132,42
N=14,149 9 73%
90% 89%
91%
43%
50% 43%
51%
78%
70% 78%
72%
24%
34% 26%
34%
79%
74% 81%
75%
VNSNY CHOICE Partially Capitated UAS January‐June 2014 Compared with members statewide, a lower percentage of members indicated they had no falls resulting in medical intervention, had received a hearing exam in the last two years, and a dental exam within the last year. In contrast, a higher percentage of members indicated experiencing no severe daily pain, had intact cognitive functioning and had an eye exam in the last year. VNSNY CHOICE Partially Capitated UAS July‐December 2014 In the most recent UAS assessment, a higher percentage of VNSNY members indicated they experienced no anxiety when compared with members statewide (82% vs. 74%, respectively). In contrast, a lower percentage of members indicated they had urinary or bowel continence. 14 Figure 4a: VNSNY CHOICE MAP and Statewide SAAM Data 2013 July 2013 Plan Statewide SAAM SAAM N=294 N=111,418 SAAM Items Activities of Daily Living (ADL) Ambulation/Locomotion – % of members who could perform task independently, with setup help/device, or with supervision Bathing – % of members who could perform task independently, with setup help/device, or with supervision Upper Body Dressing – % of members able to perform task independently, with setup help, or with supervision Lower Body Dressing – % of members able to perform task independently, with setup help, or with supervision Toileting – % of members able to perform task independently, with setup help, or with supervision Transferring‐ % of members able to transfer independently, with use of an assistive device, or with supervision/minimal assistance Feeding/Eating – % of members able to eat/drink independently, with setup help, or with supervision Continence Urinary Continence – % who are continent, have control with catheter/ostomy, or were infrequently incontinent Bowel Continence – % who are continent, have control with ostomy, or were infrequently incontinent Cognition Cognitive Impairment – % members with no cognitive impairment When Confused – % with no confusion Mood and Behavior Anxiety – % with no feelings of anxiety Depressed – % with no feelings of depression 15 90%
92%
86%
89%
82%
87%
71%
79%
87%
91%
86%
88%
97%
99%
21%
27%
79%
79%
48%
40%
35%
34%
59%
37%
86%
74%
July 2013 Plan Statewide SAAM SAAM N=294 N=111,418 SAAM Items Health Conditions Frequency of Pain – % experiencing no pain, or pain less than daily Falls Resulting in Medical Intervention – % of members experiencing no falls requiring medical intervention Prevention Influenza Vaccine – % who had influenza vaccine in last year 64%
44%
27%
55%
78%
73%
VNSNY CHOICE MAP SAAM July 2013 There were a higher percentage of VNSNY CHOICE members with no feelings of anxiety or depression, and a higher percentage experiencing no pain, when compared with members statewide in the July 2013 SAAM assessment. In contrast, a lower percentage of VNSNY CHOICE members had no falls resulting in medical intervention when compared with members statewide (27% vs. 55%, respectively). 16 Figure 4b: VNSNY CHOICE MAP and Statewide UAS Data 2014 Jan‐June 2014 UAS Items Plan UAS N=216 Activities of Daily Living (ADL) Ambulation/Locomotion – % of members who could perform task independently, with setup help/device, or with supervision Bathing – % of members who could perform task independently, with setup help/device, or with supervision Upper Body Dressing – % of members able to perform task independently, with setup help, or with supervision Lower Body Dressing – % of members able to perform task independently, with setup help, or with supervision Toileting – % of members able to perform task independently, with setup help, or with supervision Feeding/Eating – % of members able to eat/drink independently, with setup help, or with supervision Continence Urinary Continence – % who are continent, have control with catheter/ostomy, or were infrequently incontinent Bowel Continence – % who are continent, have control with ostomy, or were infrequently incontinent Cognition Cognitive functioning – % with intact functioning Mood and Behavior Anxiety – % with no feelings of anxiety Depressed – % with no feelings of depression Health Conditions Frequency of Pain – 17 Statewide UAS N=125,702 July‐Dec 2014 Statewide
Plan UAS UAS N=132,42
N=167 9 53%
56% 43%
53%
19%
19% 12%
16%
29%
33% 22%
30%
16%
19% 8%
16%
66%
63% 55%
57%
86%
87% 85%
86%
32%
36% 32%
36%
80%
83% 78%
83%
58%
39% 43%
34%
78%
76% 82%
75%
77%
71% 73%
68%
30%
26% 20%
22%
Jan‐June 2014 UAS Items Plan UAS N=216 % experiencing no severe daily pain Falls Resulting in Medical Intervention – % of members experiencing no falls requiring medical intervention Prevention Dental Exam – % who had dental exam in last year Eye Exam – % who had eye exam in last year Hearing Exam – % who had hearing exam in last 2 years Influenza Vaccine – % who had influenza vaccine in last year Statewide UAS N=125,702 July‐Dec 2014 Statewide
Plan UAS UAS N=132,42
N=167 9 82%
88% 94%
91%
43%
49% 40%
50%
88%
71% 87%
73%
29%
33% 32%
33%
82%
75% 79%
76%
VNSNY CHOICE MAP UAS January‐June 2014 Compared with members statewide, a higher percentage of VNSNY members demonstrated intact cognitive functioning and had an eye exam and influenza vaccine in the last year. VNSNY CHOICE MAP UAS July‐December 2014 Similar to the UAS outcomes in the first half of the year, a higher percentage of VNSNY members had intact cognitive functioning and an eye exam in the last year. In contrast, a lower percentage of members had a dental exam, could ambulate, or dress their lower bodies, when compared with members statewide.
18 Section Six: Performance Improvement Projects MLTC plans conduct performance improvement projects (PIPs) on an annual basis. Proposed project topics are presented to IPRO and to the NYSDOH prior to the PIP period, for approval. Periodic conference calls are conducted during the PIP period to monitor progress. The following represents a summary of VNSNY CHOICE’s PIP for 2013: The objectives of VNSNY CHOICE’s project were to increase the numbers of members receiving Vitamin D supplementation and increase the number of members performing a home exercise program (HEP) or receiving physical therapy (PT) in order to support the prevention and reduction of falls among members aged 65 and older. The project indicators are as follows: 1) Vitamin D Supplementation – Defined as the number of members receiving Vitamin D supplementation per all members aged 65 or older, minus exclusions. Baseline – 31.80% Target – 39.75% 1a) Vitamin D Supplementation for Members with High Risk for Falls – Defined as the number of members receiving Vitamin D supplementation per members at high risk for falls (having 2 or more mechanically related falls). Baseline – 31.40% Target – 39.25% 2) Home Exercise Program / Physical Therapy – Defined as the members performing exercise or receiving PT per sample of members 65 and older, minus exclusions. Baseline – 9.70% Target – 20% 2a) Home Exercise Program / Physical Therapy for Members at High Risk for Falls – Defined as the number of members receiving PT intervention per members at high risk for falls (having 2 or more mechanically related falls. Baseline – 100% Target – 100% The Plan adopted a multi‐prong outreach approach aimed at maximizing education and action, while reducing barriers to care and implementation:  Members and caregiver education, including brochures in multiple languages;  Provider education on USPSTF Guidelines and phone calls to reinforce member needs; and,  Ongoing staff education and reminders on project objectives. Results are summarized as follows: Indicator Baseline Target July October December Average
1) Vitamin D Supplementation 31.8% 39.8% 28.3% 31.9% 31.4% 30.5% 1a) Vitamin D Supplementation for 31.4% 39.3% 30.2% 51.1% 23.0% 34.7% Members with High Risk for Falls 2) Home Exercise Program / Physical 9.7% 20.0% 25.6% 33.8% 32.6% 30.6%* Therapy (PT) 2a) Home Exercise Program / Physical Therapy for Members at High Risk 100% 100% 90.5% 95.5% 100% 95.3% for Falls * Statistically significant increase noted for Indicator 2. Promotion of Vitamin D Supplementation and exercise therapy was promoted and maintained in an effort to prevent and reduce falls. 19 
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For Indicator 1 – Vitamin D supplementation, there was a rate increase from July to October and steadily remained above average by the end of December. For Indicator 1a – Vitamin D supplementation for members with higher risk for falls, the rate increased over 20 percentage points from July to October, from 30.2% to 51.1%, which was above the target of 39.25%. The rate fell, however, in December to 23.0%. For Indicator 2 – Home Exercise Program / Physical Therapy, this rate increased from July to October, and then decreased very slightly in December. For Indicator 2a – Home Exercise Program / Physical Therapy Intervention for members at higher risk for falls, this rate steadily increased from July to the end of December and met the target of 100%. Conclusions: VNSNY CHOICE is committed to improving the quality of life of the members to help reduce/prevent falls, especially through the manageable measures like promotion of exercise and Vitamin D supplementation. Overall, the project was successful in increasing member use of exercise/therapy and supplementation with Vitamin D. Members, caregivers and providers were educated on the importance of the use of Vitamin D supplementation and the use of exercise and/or PT as a means to reduce/prevent falls. On a system level, the Plan will be reviewing fall incidence and interventions across the continuum of care. They will do this to further understand how they can continue to improve and help members decrease their rates of falls and injuries sustained in falls. 20 The following represents a summary of VNSNY CHOICE’s PIP for 2014: The objective of the Plan’s project was to improve the rate of Advance Directives discussed with members, during initial and subsequent reassessments. The improvement goals were set as follows:  Advance Directive discussion for members less than 180 days enrollment – increase the rate by 10 percentage points.  Advance Directive discussion for members greater than 180 days enrollment – increase the rate by 20 percentage points. Additionally, the Plan began a review of quantifying how many Advance Directives were on member file; no goal was set for this review. Interventions are described as follows:  Provider Education o Each time a member is enrolled in the Plan, care assessments and plans of care are shared with their PCP. Language was added to the PCP letter to include a reminder on the importance of Advance Directive discussions and need for PCP to share any information with the Plan to assist in member care coordination. o Newsletter articles and web postings also reinforced the importance of Advance Directive discussions with providers.  Care Management Staff o An educational module was created and shared with staff regarding the different types of Advance Directives and the workflow for the program. This mandatory educational module was presented to all staff and available for review online at anytime. o The module was also included in the orientation for all new staff over time.  Members and Appointed Caregivers o Interventions for the new members (enrolled within 180 days) included a discussion and educational brochure on Advance Directives. o For members enrolled greater than 180 days, the care managers discussed Advance Directives on every reassessment at a minimum, every 6 months. Results are summarized on the following page:
21 
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The numerator for each indicator was all members who discussed the specific indicator with their care manager. The denominator for each indicator was all active members, within the first 180 days of enrollment. *The average is calculated based on 3 quarters of data, not 4 as originally planned. Using a hypothesis test, improvement from baseline to final average rates showed statistically significant improvement for indicators 1.2, 1.3 and 1.4. 
The numerator for each indicator was all members who discussed the specific indicator with their care manager. The denominator for each indicator was all active members, with more than 180 days of enrollment. *The average is calculated based on 3 quarters of data, not 4 as originally planned. 22 
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Indicator 2.5 demonstrated significant change in the rate change from baseline demonstrating more members did not want to discuss or provide Advance Directives with their care team. For metrics 2.1‐2.4, the decrease noted was not significant. The Plan reviewed member files and noted there was 15% of an Advance Directives discussion documents (e.g. signed health care proxy) on file that was easily extracted for the population. Conclusions: VNSNY CHOICE supports the improvement of health and well‐being of its members and encourages opportunities for discussion on the importance of Advance Directives. The project was successful in raising the importance of the discussion of Advance Directives with members, although established goals were not met. Operational improvements in data collection, reporting of discussions and collection of Advance Directives documents are ongoing so that there is clear, actionable information continually documented and reported to impact member decision making for their health care planning needs. On a system level, the Plan will continue to review and change data collection processes for capturing evidence of discussions on Advance Directives with members. This will include a change in care management systems use to enhance data collection on discussion and the actual documents detailing planning preferences for members if one is available. The Plan will continue to:  Monitor data processes, collection and Plan performance;  Ensure follow up with members at least once per six month cycle to provide re‐education and gain access to Advance Directive documentation for Plan file;  Evaluate the effectiveness of educational and process interventions; and,  Make changes as needed to support and maintain the important discussion and concepts of planning with members. There is a continued need to address Advance Directives with members as members planning and needs may change over time. 23 Section Seven: Overall Strengths and Opportunities Strengths Partially Capitated Mood and Behavior A higher percentage of VNSNY members reported no feelings of anxiety or depression compared with members statewide in the most recent 2014 UAS reporting period (July‐December). In addition, a higher percentage of VNSNY members demonstrated intact cognitive functioning. Advance Directives A higher percentage of VNSNY members who responded to the satisfaction survey in 2012/2013 and in 2014/2015 indicated that the Plan had discussed appointing someone to make healthcare decisions for them, and that they had an advance directive in place, compared with other partially capitated members and all other members statewide MAP Consumer Directed Personal Assistance Compared to other MAP plans and all other plans statewide, VNSNY had a significantly higher percentage of members who reported that the Plan explained the Consumer Directed Personal Assistance option in the 2014/2015 survey. The rate for VNSNY was 97%, while rates for the other MAP plans and statewide were 74% and 75%, respectively. Advance Directives A higher percentage of VNSNY members who responded to the satisfaction survey in 2012/2013 and in 2014/2015 indicated that the Plan had discussed appointing someone to make healthcare decisions for them, and that they had an advance directive in place, compared with other MAP members and all other members statewide. Cognition The percent of VNSNY members with intact cognitive functioning was 58%, compared with 39% of members statewide in the first UAS reporting period in 2014, and 43% compared to 34% in the second reporting period. Preventive Screenings A higher percentage of VNSNY members had an eye exam in the last year, compared with members statewide. The rate for eye exams for VNSNY members was 87%, compared to 73% statewide. Opportunities Partially Capitated Preventive Screenings A lower percentage of VNSNY members had a dental exam (in the last year) and a hearing exam (in the last 2 years), compared with members statewide in both 2014 UAS reporting periods. 24 Based upon these results, VNS Choice may choose to consider conducting a PIP focusing on these screenings. MAP Activities of Daily Living The percentage of VNSNY members able to perform the six activities of daily living was lower than members statewide for each of these activities in the July‐December 2014 UAS assessment period. It is recommended that VNSNY investigate the cause(s) of these limitations, and identify whether or not members are receiving adequate physical therapy and/or home health aide services. On an individual basis, possibly care management interventions may need to be introduced or existing interventions may require some modification. Advance Directives (Partially Capitated and MAP) Advance directive discussion and procurement rates, though reported positively from the satisfaction survey results, appear quite low for members enrolled less than 180 days, based upon PIP results. It is recommended that VNS continue this project for an additional year, to further improve rates. 25