NEW YORK STATE DEPARTMENT OF HEALTH
Office of Quality and Patient Safety
PLAN – Technical REPORT
FOR
Total Senior Care
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 ........................................................................................................................ 9 Section Six: Performance Improvement Projects ...................................................................................... 14 Section Seven: Summary/Overall Strengths and Opportunities ................................................................. 16 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 Total Senior Care (TSC) is a regional Managed Long‐Term Care (MLTC) plan with a Program of All‐
inclusive Care for the Elderly (PACE) product line. The plan is an affiliate of Community Care of Western New York. The following report presents plan‐specific information.  Plan ID: 03056544  Managed Long‐Term Care Start Date: 2008  Product Line(s): PACE  MLTC Age Requirement: 55 and older  Contact Information: 519 North Union St. Olean, NY 14760 (716) 379‐8474 (866) 939‐8613 Participating Counties and Programs
Alleghany (Not Entire County) PACE
Cattaraugus
3
PACE
Section Three: Enrollment Figure 1 depicts membership for Total Senior Care’s product line 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 Plan remained the same from 2012 to 2013 and increased by 12.1% from 2013 to 2014. Figure 1a trends the enrollment for the PACE product line. Figure 1: Membership: Total Senior Care 2012‐2014 Number of Members % Change From Previous Year 2012
PACE 91
18.2% 2013
2014
91
0% 102
12.1%
Figure 1a: Enrollment Trends 2012‐2014 Total Senior Care Enrollment 2012‐2014
Number of Members
150
125
100
91
102
91
75
50
PACE
25
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%. Total Senior Care’s response rate was 28.2% (24 respondents out of 85 members in the sample). IPRO had previously conducted a similar satisfaction survey that was mailed between December 2012 and May 2013. Figure 2 represents the results of these two satisfaction surveys for Total Senior Care’s PACE line, compared with all other PACE 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. 5
Figure 2: Satisfaction Survey Results TSC Total Senior Care Compared with all 2012‐2013 (N=22)a PACE Plans, and all Plans Statewide Description nb % Plan requested list of Rx/OTC meds ** 21
81%
Plan explained the Consumer Directed ‐
‐
Personal Assistance option ++ Plan Rated as Good or Excellent 22
86%
Quality of Care: Rated as Good or Excellent Regular Doctor (PCP) 22
91%
Dentist 9
89% c
Eye Care‐Optometry 19
95% c
Foot Care 19
90% c
Home Health Aide 16
88% c
Care Manager 21
91%
Regular Visiting Nurse 17 100% c
Medical Supplies 20
90%
Transportation Services 22
86%
Timeliness‐ Always or Usually On Time Home Health Aide, Personal Care Aide 16
81% c
Care Manager 20
75%
Regular Visiting Nurse 16
81% c
Transportation TO the Doctor 21
76%
Transportation FROM the Doctor 21
71%
Access to Routine Care (<1 Month) Regular Doctor (PCP) 22 86%▲
Dentist 10
60% c
Eye Care/Optometry 18
61% c
Foot Care/Podiatry 18
67%
Access to Urgent Care (Same Day) Regular Doctor (PCP) 19
63% c
Dentist 9
0% c
Eye Care/Optometry 15
13% c
Foot Care/Podiatry 17
35% c
Overall PACE 2012‐2013 (N=446)a nb % 381
88%
Statewide 2012‐2013 (N=2,522)a nb % 2,197
88%
TSC 2014‐2015 (N=24)a nb % 15 100% c
Overall PACE 2014‐2015 (N=574)a nb % 432
92%
Statewide 2014‐2015 (N=4,592)a nb % 3,702
94% ‐
‐
‐
‐
8
63% c 267
58%
2,495
75% 430
86%
2,458
84%
15
100% c
453
86%
3,739
87% 405
291
355
278
337
366
360
355
387
90%
73%
80%
77%
85%
86%
87%
92%
86%
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%
15
80% c
7
86% c
14
86% c
12
75% c
13
85% c
14
86% c
11 100% c
13 100% c
14
86% c
446
337
391
322
373
414
401
400
421
90%
77%
78%
81%
84%
85%
88%
87%
87%
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% 319
341
340
370
366
77%
68%
71%
71%
68%
1,897
1,876
2,027
1,766
1,742
78%
69%
69%
69%
67%
12
92% c
12 100% c
9
89% c
13 100% c
13 100% c 374
380
368
370
370
90%
86%
86%
90%
84%
3,385
3,144
3,177
2,515
2,505
93% 83% 81% 81% 78% 343
229
282
223
70%
42%
45%
48%
2,104
1,234
1,647
1,390
59%
46%
43%
45%
10
4
9
9
90% c
75% c
89% c
78% c
383
253
300
255
86%
70%
74%
73%
3,328
1,873
2,486
2,220
88% 73% 79% 80% 324
173
200
163
49%
15%
13%
23%
1,755
920
1,195
1,039
45%
26%
22%
26%
11
5
9
9
18% c
20% c
11% c
11% c
368
221
278
235
50%
20%
27%
30%
2,885
1,526
2,165
1,912
50% 29% 33% 34% 6
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 ◊ 20
90%
389
82%
2,087
68%
22
91%▲
497
78%
3,757
67% 22
91%▲
395
83%
2,145
61%
23 100%▲
494
84%
3,722
58% 17
82% c 269
91%
956
77%
22
348
94%
1,506
79% 86%
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 Represents a significantly higher rate versus the PACE/statewide rate (p < .001) Represents a significantly lower rate versus the PACE/statewide rate (p < .001) Item based on a skip pattern Significance testing could not be performed due to small sample size Symbol a
b
c 7
Satisfaction Survey Results Summary Satisfaction survey results demonstrated that Total Senior Care’s members had both improvements and decline from 2012‐2013 to 2014‐2015 compared to members enrolled in other partially capitated plans, and in all plans statewide. There was an improvement in respondents who stated the Plan requested a list of prescription medications and an improvement in access to routine care (<1 month) for each discipline. There was an increase in satisfaction for timeliness across all disciplines and a decrease in satisfaction for access to urgent care (same day), with the exception of dental urgent care (same day), which increased. In the most recent satisfaction survey in 2014‐2015, there was a significantly higher percentage of Total Senior Care members who reported the plan discussed having a healthcare proxy with them, as well as members who had a legal document stating they had a healthcare proxy, compared to other PACE members and members statewide. 8
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 Total Senior Care’s July 2013 SAAM results for their PACE line, and Figure 3b contains Total Senior Care’s January‐June and July‐December 2014 UAS results.
1
NYS Department of Health, 2014 Managed Long Term Care Report. http://health.ny.gov 9
Figure 3a: Total Senior Care PACE and Statewide SAAM Data 2013 July 2013 Plan Statewide SAAM SAAM N=105 N=111,607 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 Health Conditions 10
91%
92%
92%
89%
88%
87%
85%
79%
83%
91%
90%
88%
100%
99%
20%
27%
69%
79%
34%
40%
20%
34%
17%
38%
55%
74%
July 2013 Plan Statewide SAAM SAAM N=105 N=111,607 SAAM Items 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 65%
44%
29%
55%
87%
73%
Total Senior Care SAAM July 2013 A higher percentage of Total Senior Care members reported experiencing no pain, or pain less than a day, and had an influenza vaccine in the last year compared with members statewide. In contrast, Total Senior Care members had a lower percentage of members with intact cognitive functioning, no feelings of anxiety and depression and no falls requiring medical intervention compared with members statewide. 11
Figure 3b: Total Senior Care PACE and Statewide UAS Data 2014 Jan‐June 2014 UAS Items Plan UAS N=91 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 – 12
Statewide UAS N=125,702 July‐Dec 2014 Statewide
Plan UAS UAS N=132,42
N=101 9 78%
56% 79%
53%
28%
19% 34%
16%
66%
33% 70%
30%
54%
19% 55%
16%
73%
63% 76%
57%
92%
87% 93%
86%
28%
36% 26%
36%
78%
83% 71%
83%
22%
39% 25%
34%
39%
76% 28%
75%
44%
71% 39%
68%
33%
26% 38%
22%
Jan‐June 2014 UAS Items Plan UAS N=91 % 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=101 9 85%
88% 80%
91%
52%
49% 45%
50%
77%
71% 68%
73%
36%
33% 34%
33%
82%
75% 86%
76%
Total Senior Care PACE UAS January‐June 2014 The percentages of Total Senior Care members that were able to perform the various ADLs represented above in Table 3a were higher compared to members statewide. In contrast, a lower percentage of members reported intact cognitive functioning and no feelings of anxiety and depression. Total Senior Care PACE UAS July‐December 2014 Similar to the UAS outcomes for ADLs in the first half of the year, there were higher percentages of Total Senior Care members who could perform these activities with a higher level of ability, when compared with members statewide. Also consistent with UAS results in the first reporting period, a lower percentage of members reported no feelings of anxiety and depression. 13
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 Total Senior Care’s PIP for 2013: Total Senior Care developed a project to improve, and internally audit the validity of the current SAAM scoring of 13 elements and the Universal Assessment System 22 elements of Nursing Facility Level of Care (NFLOC) which were used to determine eligibility for enrollment into the Plan. At each assessment, the RN determines the level of eligibility with the SAAM tool or the UAS‐NY. The objective of this project was to improve the inter‐rater reliability and determine consistency of the current SAAM and/or UAS data by a peer‐review system with an internal audit tool. The goal was to have inter‐rater reliability variance in total scoring of no greater than 5%. Project interventions include the following:  SAAM audit tool established which reviews the 13 clinical indicators to determine eligibility for Total Senior Care.  UAS audit tool established which reviews 22 clinical indicators for NFLOC to determine eligibility for Total Senior Care.  Peer assessment schedule established for 2013.  New York State Department of Health SAAM and UAS instruction review and scoring discussions for all assessment RNs to be scheduled for 2013.  SAAM tool used for clinical eligibility until 8/31/13; UAS implemented as of 9/1/13.  Home Care Coordinator, QI Director, and Center Manager trained as UAS assessors as of 9/1/13.  QI Manager trained as UAS assessor as of 12/1/13. Results are summarized as follows:  Numerator: Number of indicators assessed with concurrence  Denominator: Total number of indicators assessed Quarter 2013 1st 2nd 3rd 4th Clinical Eligibility Tool Used SAAM SAAM UAS UAS Variance in scoring 9.6% 3.07% 2.27% Inter‐Rater Reliability (IRR) 90.4% 96.93% 97.73% Conclusions: The SAAM tool was utilized for clinical eligibility for the first two quarters and the UAS for the 3rd and 4th Quarters. The peer reviewer utilized IDT assessments, participant and caregiver discussions to determine eligibility scoring. The variance in scoring was greater with the SAAM tool with peer review. Most variances were noted with anxiety level and activities of daily living performance. Higher eligibility scores were noted when Physical Therapy and Occupational Therapy assessments were utilized for scoring ambulation indicators.
14
The following represents a summary of Total Senior Care’s PIP for 2014: Total Senior Care has developed a project on Medical Orders for Life‐Sustaining Treatment (MOLST). The purpose of the project was to encourage all participants to fully participate in all decisions related to his or her end of life treatment. The absence of this form can present numerous barriers to advance directive care wishes. Many of the Plan’s members have chronic and declining health concerns and safety issues. The completion of the MOLST gives all parties involved a signed legal document that clearly states the advanced directive wishes of the member. Initially, the completion rate averaged 71% when the project began. The original goal was 80% completion rate by the end of 2014, but the Plan’s Clinical Team subsequently increased the goal to 85% due to the frail elderly population and their identified needs. Project interventions included the following:  The MOLST topic was addressed at enrollment, assessment, re‐assessment or change in condition by appropriate clinical staff. o Working with participants to make decisions regarding end of life care and whether or not to have a DNR order is a task that usually does not occur in a single visit but requires ongoing education and counseling and giving the person time to make their decisions. It takes more than one visit with a participant to fully complete the MOLST. Most participants also wish to speak with their family members and physician.  Total Senior Care’s clinical social workers utilized the National Healthcare Decisions Day (4/16/14) as another tool to increase awareness of the topic. o Tools and resources from the compassion and support website were also utilized. Results are summarized as follows: When the Plan implemented the project, the MOLST completion rate was 71%. The Clinical Team observed a gradual increase in numbers which then leveled out. The end‐of‐year results averaged at 79.3% which was is an increase of 8.3%. Total Senior Care was 5.7% below the project goal for completion; the project was done from January 2014 through Dec 2014. The entire population of enrollees was included and interventions implemented. The numerator and denominator remained consistent through the study. The monthly results are: JAN FEB MAR APR MAY JUNE
JULY AUG SEPT
OCT NOV DEC
76% 76% 75% 84% 82% 80%
80%
80%
79%
80.6% 80.4% 78.7%
Conclusions: Although the performance goal was not met, the plan feels that the PIP’s objectives were achieved to a great extent. MOLST discussion requires more than one visit with a person and/or their family. This is a limitation in increasing the Plan’s numbers. The educational component was beneficial although limitations or barriers were reticence on the part of participants that were uncomfortable discussing the possibility of dying or unwilling to recognize that this will occur in the future. The Clinical Team has decided that this is an important topic and they will continue to educate, complete and track the completion of MOLST forms into the following year.
15
Section Seven: Summary/Overall Strengths and Opportunities Strengths Overall Plan Rating Total Senior Care members rated their health plan more favorably than members enrolled in other plans throughout the state for the 2014‐2015 satisfaction survey. Of the Total Senior Care members who responded, 100% rated the plan as good or excellent. This is compared to the 86% of other PACE plan members and the 87% of members statewide. Quality of Care Satisfaction Survey results from 2014‐2015 indicate that a higher percent of Total Senior Care members rated the quality of their medical supplies as good or excellent compared to other PACE plans and plans statewide. Timeliness Satisfaction Survey responses from the 2014‐2015 survey indicate that Total Senior Care members had higher satisfaction with the timeliness transportation from the doctor, compared to other PACE plans and statewide. Total Senior Care members had a 100% satisfaction rating for the timeliness of transportation from the doctor, compared to 84% for other PACE plans and 78% for plans statewide. Advance Directives Total Senior Care is actively addressing advance directive needs, as evidenced by a significant percentage of question respondents indicating that the plan has discussed appointing a healthcare proxy and members with an advance directive in place, in the most recent 2014‐2015 survey. Rates for these questions surpass both PACE members and statewide rates. Activities of Daily Living (ADL) In both UAS reporting periods (January‐December 2014), Total Senior Care members had higher rates for performing each ADL, (locomotion, bathing, upper and lower body dressing, toileting and eating) compared to plans statewide. Opportunities Access to Urgent Care (Same Day) Eighteen percent (18%) of respondents in the satisfaction survey from 2014‐2015 indicated they were able to access their PCP for same day urgent care. This is in contrast to the 50% of other PACE members and 50% of other plan members in the state who are able to see a PCP for same day urgent care. A focused member survey should be considered, to determine if access issues exist with these providers. Mood and Behavior The percent of members with no feelings of anxiety, and no feelings of depression, were below the statewide rates in both UAS reporting periods (January‐December 2014). These UAS questions are prone to a high level of subjectivity at the time of the assessment. It should be noted that Total Senior Care conducted an inter rater reliability (IRR) study in 2013 as the PIP, and one of the findings related to variances noted with anxiety levels, so there may be reason to question the validity of this indicator’s 16
results. It may be pertinent to perform IRR again, with a focus on the behavioral health related indicators. It may also be pertinent to conduct a focused member survey addressing anxiety, depression, and other similar behavioral health indicators, to determine if these rates are reflective of their members’ behavioral health statuses, and if so, what might be contributing to their anxiety and depression. 17