NEW YORK STATE DEPARTMENT OF HEALTH
Office of Quality and Patient Safety
Plan – Technical Report
For
Independence Care System
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 ......................................................................................................................... 8 Section Six: Performance Improvement Projects ...................................................................................... 13 Section Seven: Summary/Overall Strengths and Opportunities ................................................................. 17 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 Independence Care System (ICS) is a regional, partially capitated Managed Long‐Term Care (MLTC) plan. The following report presents plan‐specific information for their partially capitated product line:  Plan ID: 01865329  Managed Long‐Term Care Start Date: April 2000  Product Line(s): Partially Capitated  MLTC Age Requirement: 18 and older  Contact Information: 257 Park Ave South 2nd Floor New York, NY 10010 (877) 427‐2525 (212) 584‐2500 Participating Counties and Programs New York, Kings, Queens, Bronx Partial Cap 3 Section Three: Enrollment Figure 1 depicts membership for Independence Care System’s partially capitated 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 partially capitated plan grew over this period, increasing by 41.7% from 2012 to 2013 and by 5.6% from 2013 to 2014. Figure 1a trends enrollment. Figure 1: Membership: Partially Capitated 2012‐2014 2012 Partially Capitated 3,560 Number of Members 84.6% % Change From Previous Year Figure 1a: Enrollment Trends 2012‐2014 2013 2014 5,046 41.7% 5,328 5.6% Number of Members
Independence Care System Enrollment 2012‐2014
6,000
5,000
4,000
5,328
5,046
3,560
3,000
2,000
Part Cap
1,000
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 Independence Care System’s partially capitated product line was 26.0% (150 respondents out of 578 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 Independence Care System’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.
5 Figure 2: Satisfaction Survey Results ICS Compared with all Partially Capitated Plans, and all Plans Statewide Description Plan requested list of Rx/OTC meds ** Plan explained the Consumer Directed Personal Assistance option ++ Plan rated as good or excellent Quality of Care Rated as Good or Excellent Dentist Eye Care‐Optometry Foot Care Home Health Aide Care Manager Regular Visiting Nurse Medical Supplies Transportation Services Timeliness‐ Always or Usually On Time Home Health Aide, Personal Care Aide Care Manager Regular Visiting Nurse Transportation TO the Doctor Transportation FROM the Doctor Access to Routine Care (<1 Month) Dentist Eye Care/Optometry Foot Care/Podiatry Access to Urgent Care (Same Day) Dentist Eye Care/Optometry Foot Care/Podiatry Advance Directives 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 ◊ ICS 2012‐2013 (N=156)a nb Overall Part Cap 2012‐2013 (N=1,662)a ICS 2014‐2015 (N=150)a % nb % nb % nb 132
76%
1,439
87%
2,197
88%
‐
‐
‐
‐
‐
152
82%
1,625
84%
107
122
101
138
136
126
128
128
79%
81%
82%
81%
83%
79%
81%
75%
1,009
1,279
1,087
1,358
1,389
1,420
1,185
1,242
138
136
122
112
107
83%
78%
68%
69%
71%
96
115
88
Overall Part Cap 2014‐2015 (N=3,306)a Statewide 2014‐2015 (N=4,592)a % nb % nb % 132
92%
2,677
94%
3,702
94% ‐
96
81%
1,831
77%
2,495
75% 2,458
84%
132
85%
2,688
87%
3,739
87% 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%
88
109
98
131
126
117
118
112
73%
87%
83%
86%
78%
81%
81%
73%
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%
130
121
113
94
92
94%
88%
84%
82%
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% 47%
39%
40%
832
1,093
932
47%
43%
45%
1,234
1,647
1,390
46%
43%
45%
75
99
84
79%
84%
81%
1,323
1,767
1,608
75%
80%
82%
1,873
2,486
2,220
73% 79% 80% 73
88
74
25%
15%
19%
612
788
692
28%
25%
27%
920
1,195
1,039
26%
22%
26%
58
74
69
28%
37%
33%
1,062
1,497
1,368
31%
34%
35%
1,526
2,165
1,912
29% 33% 34% 135
64%
1,346
64%
2,087
68%
128
71%
2,660
64%
3,757
67% 132
55%
1,387
55%
2,145
61%
124
57%
2,645
53%
3,722
58% 47
81%
533
74%
956
77%
45
80%
913
75%
1,506
79% 6 Statewide 2012‐2013 (N=2,522)a Symbol a
b
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 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 and urgent care, as well as for timeliness of services. In contrast, there was a slight decline in the quality of care of dentists, care managers, and transportation services.
7 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: Falls Diagnosis/Prognosis/Surgeries Neuro/Emotional Behavioral Status Living arrangements ADL/IADLs Supportive assistance 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 Independence Care System’s (ICS’s) July 2013 SAAM results for their partially capitated line, and Figure 3b contains Independence Care System’s January‐June and July‐December 2014 UAS results.
1
NYS Department of Health, 2014 Managed Long Term Care Report. http://health.ny.gov 8 Figure 3a: ICS Partially Capitated and Statewide SAAM 2013 July 2013 Statewide Plan SAAM SAAM N=106,975 N=4,737 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 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 9 78%
93%
76%
90%
74%
88%
66%
79%
77%
91%
75%
88%
99%
99%
35%
26%
68%
79%
55%
40%
60%
33%
55%
37%
63%
75%
50%
44%
69%
54%
63%
73%
SAAM July 2013 A higher percentage of ICS members exhibited no cognitive impairment, confusion, feelings of anxiety, pain, or falls requiring medical intervention compared to members statewide. In contrast, a lower percentage of ICS members were able to perform the majority of ADLs represented above in Figure 3a. Additionally, a lower percentage of ICS members experienced no feelings of depression, and had received an influenza vaccine. It should be noted that SAAM questions pertaining to mood and behavior are prone to a high level of subjectivity on the part of the assessor and may also be scored based upon behavior/attitude exhibited solely at the time of the assessment visit. 10 Figure 3b: ICS Partially Capitated and Statewide UAS Data 2014 Jan‐June 2014 UAS Items Plan UAS N=4,703 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 – % experiencing no severe daily pain Falls Resulting in Medical Intervention – % of members experiencing no falls requiring medical intervention 11 Statewide UAS N=125,702 July‐Dec 2014 Plan UAS N=4,792 Statewide UAS N=132,429 40%
56% 41%
53%
15%
20% 14%
16%
22%
33% 20%
31%
10%
19% 9%
16%
53%
64% 52%
58%
80%
88% 80%
86%
37%
36% 35%
36%
71%
83% 69%
83%
53%
38% 49%
33%
76%
76% 74%
75%
69%
71% 67%
68%
32%
26% 31%
21%
92%
88% 92%
91%
Jan‐June 2014 UAS Items Plan UAS N=4,703 Statewide UAS N=125,702 July‐Dec 2014 Plan UAS N=4,792 Statewide UAS N=132,429 Prevention Dental Exam – 52%
49% 50%
50%
% who had dental exam in last year Eye Exam – 65%
71% 66%
73%
% who had eye exam in last year Hearing Exam – 27%
33% 28%
34%
% who had hearing exam in last 2 years Influenza Vaccine – 65%
75% 66%
76%
% who had influenza vaccine in last year UAS January‐June 2014 Compared with members statewide, ICS members demonstrated a lower level of ability in performing the six ADLs represented in Figure 3b. Additionally, a lower percentage of ICS members had an eye exam, a hearing exam and an influenza vaccine compared with members statewide. In contrast, a higher percentage of ICS members demonstrated intact cognitive functioning, no severe daily pain and no falls requiring medical intervention. UAS July‐December 2014 Similar to the January‐June reporting period, a lower percentage of ICS members had an eye exam, hearing exam and influenza vaccine, and could perform the six ADLs. Also similar to the health conditions outcomes in the first half of the year, there were higher rates among ICS members for the health conditions indicators, as well as for cognitive functioning. 12 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 Independence Care System’s PIP for 2013: Independence Care System (ICS) implemented a streamlined direct access initiative where select members were offered the opportunity to self‐schedule transportation to their medically necessary appointments directly with the transportation provider. Transportation is the second largest service provided to ICS members, and telephone calls to the ICS call center to book transportation have historically made up 80% of the call volume. Each transportation reservation involves multiple phone calls:  Member calls ICS to book their trip.  ICS calls medical provider to verify member’s appointment and then calls the transportation company to book the trip.  All three entities (ICS, transportation provider and member) are then involved in confirmation phone calls. Therefore, the ICS intervention was designed to streamline the process by giving select members (stratified as those with a demonstrated ability to manage and direct their own care) direct access to this service. Member satisfaction with access to transportation service would then be measured by a satisfaction survey: Numerator: Number of members in the study group with positive four star satisfaction survey results. Denominator: The total number of study group respondents who participated in the Direct Access Transportation Initiative and were assessed for satisfaction. These members were compared with: Numerator: The number of members in the control group with positive four star satisfaction survey results. Denominator: The total number of control responders who were assessed for satisfaction A letter of introduction was sent to 148 study group members with instructions and rules of participation for the Direct Access to Transportation Initiative. Of the 148 study group members, there were 115, or 78%, that agreed to participate in the Direct Access to Transportation Initiative. The study group satisfaction response rate was effectively improved by the following interventions:  Contacting study group members after business hours  Mailing copies of the survey to study group members requesting they contact ICS Member Services with their study responses Results are summarized on the following page: 13 76%
80%
67%
70%
60%
50%
Control Group
40%
Study Group
30%
22%
19%
20%
10%
6%
2%
4% 3%
0%
One Star
Two Stars
Three Stars
Four Stars
Overall the study group members were more satisfied with their ability to access transportation compared to the control group as demonstrated by the comparisons of 3 and 4 star ratings provided by the control group and the study group. It should be noted that the transportation provider that remained in the study for all of 2013 provided livery car service and, if the results are filtered for only the livery provider, the satisfaction results for the study group are 85% with 4 stars and 15% with a 3 star rating. When asked what specifically could be improved to increase satisfaction with access to transportation: The study group responses were as follows: 3 = issues with reservations made 2 = booking staff rude or not helpful 1 = long hold times 80 of the 86 responded N/A The control group responses were as follows: 14 = unable to get through 10 = long hold times 1 = issues with reservations made 1 = waiting for a Spanish speaking staff 1= transportation drivers talk on the phone 117 of the 144 responded N/A Conclusions: Self‐scheduling transportation improved member satisfaction with access to transportation. There was a significant unexpected ICS administrative burden in monitoring utilization thresholds as the transportation providers were unable to do so. For successful implementation of the project, the participating transportation providers must have the ability to track and act on authorization trip limits per member per month. 14 The following represents a summary of Independence Care System’s PIP for 2014: The New York State hospital readmission rate is 13% and the New York City hospital readmission rate is 15%. The ICS hospital readmission rate has historically been 5% and this lower rate is likely related to both under‐reporting, since hospitalization is not included in MLTC capitation, and the plan’s average member age, which has historically been younger. ICS enrolled an older population in 2013 and anticipated the hospital readmission rate would rise. An analysis of Q4 2013 admissions by age indicates that 61% of the hospital admissions were members with an age of 65 or greater and 73% of the hospital admissions in Q4 2013 were for ICS members of age 60 or greater. The impact of age in relation to hospital admissions is clearly demonstrated. The primary goals for this project were to determine and address the cause for unplanned inpatient hospitalizations and to prevent a re‐hospitalization from occurring within 30 days for the same diagnosis or a related diagnosis. The project indicator is as follows:  Numerator: The number of individual members re‐admitted inpatient in 2014 within 30 days for the same diagnosis or related diagnosis  Denominator: The total number of ICS members admitted to the hospital in 2014. An ICS Hospitalization Policy was created and education was provided to the IDT with case study examples to ensure timely and appropriate coordination of care before, during and after hospitalization. The ICS Interdisciplinary Care Teams (IDT) have a member centered focus to ensure that a member’s wishes regarding his or her care are followed during the hospital stay. Facility Discharge Assessments were completed when the hospital discharge planner confirmed the member’s discharge date. TOC RN Assessments were made post hospital discharge to assess the member, review their discharge plan, and reinforce the member’s or caregiver’s self‐management skills within a week of discharge. The TOC RN Assessment includes the following interventions to be performed during the visit:  Education on and reconciliation of medications;  Education regarding disease/condition;  Education regarding red flags (symptoms); and  Education regarding follow up treatment plan. Results are summarized on the following page:
15 Table 1: Post Intervention (Final) Results 2014 Jan # of 230 Hospitalizations Unique 213 Members* # of 17 Readmissions # Individuals 10 Readmitted Total ICS 5,110 Census Feb Q1 Mar Apr May Q2 Jun Jul Aug Q3 Sep Oct Nov Q4 Dec 207 278 265 264 224 253 253 226 246 252 251 196 250 240 240 204 230 228 210 223 238 232 17 29 33 48 28 16 23 20 17 15 22 14 19 17 32 20 16 21 19 17 15 17 5,113 5,120 5,101 5,112 5,138 5,159 5,209 5,267 5,337 5,391 5,420 5% 5% 4% 5% 5% 5% 6.32% 9.09% % Census with 5% 4% 5% 5% 5% 4% hospitalization % Readmissions in 30 Days with 7.39% 8.21% 10.43% 12.45% 18.18% 12.50%
same diagnosis * Unique/Individual members with admissions for the month 8.40% 7.60% 6.30% 9.40%
The overall ICS admission rate for 2014 was 4.8%, and consistently between 4% and 5% on the monthly hospital reports. The admission rate was calculated by the number of admissions divided by the ICS census. The average ICS 2014 readmission rate for 2014 was 9.67% with a monthly low of 6.30% and a monthly high of 18.18%. ICS did not have a baseline re‐admission rate prior to the 2014 Readmissions study. The NYS readmission rate is 13% and the New York City readmission rate is 15% for the Medicare population. Conclusions: ICS was able to maintain hospital readmission rates below NYS and NYC readmission benchmarks. In quarters one, two and three, there was a greater number of readmissions for members 65 years or older; however, in quarter four, there were significantly more readmissions for members less than 65 years of age. The higher‐than‐average 2014 readmission rate in Q2 was attributed to several specific individuals readmitted more than once within 30 days for uncommon diagnoses/comorbidities; for example, an ICS member with sickle cell anemia who was pregnant. The age breakdown of Q2 ICS members with multiple admissions was 33% under 65 years and 67% who were 65 or older.
16 Section Seven: Summary/Overall Strengths and Opportunities Strengths Advance Directives The results of the 2014‐2015 satisfaction survey demonstrate that ICS members report that the plan discusses appointing someone to make health care decisions at a higher rate than both members of partially capitated plans and members statewide (71% vs. 64% and 67%, respectively). Cognition Compared with members statewide, a higher percentage of those enrolled in ICS reported a higher level of cognitive functioning; 49% of ICS members demonstrated intact cognitive functioning, compared with 33% of members statewide in the second UAS reporting period (53% vs. 38%, respectively, in the first reporting period). Pain UAS data from both reporting periods in 2014 indicate that a higher percentage of ICS members experience no severe daily pain, when compared with members statewide (31% vs. 21%, respectively). These results may be indicative of effective pain management protocols. PIP In 2013, ICS designed and implemented a successful performance improvement project that benefited their membership. The Plan sought to improve satisfaction among their membership with access to transportation, by giving members the option to self‐schedule their trips directly with the transportation vendor. This initiative resulted in a marked improvement in satisfaction. Opportunities Activities of Daily Living (ADLs) A lower percentage of members were able to perform the six ADLs when compared with members statewide. With regard to the most recent UAS reporting period in 2014 (July‐December), the largest difference was in ambulation/locomotion (41% vs. 53% for ICS members and members statewide, respectively), whereas the smallest difference was in bathing (14% vs. 16%, respectively). ICS may consider evaluating whether additional physical / occupational therapy interventions may be appropriate for certain members, as enhancements to their care which may result in improved ADL outcomes. Preventive Screenings ICS members had lower rates for most of the prevention measures, with the exception of dental exams. Rates for eye exam, hearing exam and the influenza vaccine were all below the statewide averages. Possibly performance improvement projects focusing on these screenings may be considered. 17