NEW YORK STATE DEPARTMENT OF HEALTH
Office of Quality and Patient Safety
Plan – Technical Report
For
GuildNet
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 ...................................................................................................................... 12 Section Six: Performance Improvement Projects ....................................................................................... 21 Section Seven: Summary/Overall Strengths and Opportunities ................................................................. 25 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 GuildNet is a regional Managed Long Term Care (MLTC) plan, servicing both partially capitated and Medicaid Advantage Plus (MAP) products. The MAP product is serviced under the name GuildNet Gold. GuildNet is a subsidiary of the Lighthouse Guild in New York City. The following report presents plan‐
specific information for both MLTC product lines.  Partially Capitated Plan ID: 01827572  MAP Plan ID: 02942923  Managed Long‐term Care Start Date: 2000 (Partially Capitated) and 2008 (MAP)  Product Line(s): Partially Capitated and MAP  MLTC Age Requirement: 18 and older  Contact Information: 15 West 65th Street
4th Floor New York, NY 10023 (800) 284‐4422 Participating Counties and Programs
Nassau Partial Cap MAP Suffolk Partial Cap MAP New York Partial Cap MAP Westchester Partial Cap 3 Section Three: Enrollment Figure 1 depicts membership for GuildNet’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 grew over this period, increasing by 46.6% from 2012 to 2013 and by 0.8% from 2013 to 2014. For the MAP line, membership grew by 52.0% from 2012 to 2013 and by 28.0% from 2013 to 2014. Figure 1a trends the enrollment for both the partially capitated and MAP product lines. Figure 1: Membership: Partially Capitated and MAP 2012‐2014 2012
Partially Capitated
9,822 2013 2014
14,397 14,513 34.9% 46.6% 0.8% Number of Members 373 567 726 % Change From Previous Year 3.9% 52.0% 28.0% Number of Members % Change From Previous Year MAP
Figure 1a: Enrollment Trends 2012‐2014 Number of Members
GuildNet Enrollment 2012‐2014
14,397
15,000
12,000
14,513
9,822
9,000
Part Cap
6,000
3,000
373
726
567
MAP
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 GuildNet’s partially capitated product line was 23.2% (132 respondents out of 568 members in the sample). GuildNet’s MAP product line had a response rate of 29.6% (134 respondents out of 452 members in the sample). 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 GuildNet’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 GuildNet’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 GuildNet GuildNet Compared with all Partially 2012‐2013 Capitated Plans, and all Plans (N=125)a Statewide Description nb % Plan requested list of Rx/OTC meds ** 111
80%
Plan explained the Consumer Directed ‐
‐
Personal Assistance option ++ Plan rated as good or excellent 124
85%
Quality of Care Rated as Good or Excellent Dentist 80
73%
Eye Care‐Optometry 98
89%
Foot Care 83
83%
Home Health Aide 106
91%
Care Manager 104
90%
Regular Visiting Nurse 104
89%
Medical Supplies 84
94%
Transportation Services 91
77%
Timeliness‐ Always or Usually On Time Home Health Aide, Personal Care Aide 99
77%
Care Manager 90
71%
Regular Visiting Nurse 101
60%
Transportation TO the Doctor 89
62%
Transportation FROM the Doctor 91
60%
Access to Routine Care (<1 Month) Dentist 64
56%
Eye Care/Optometry 81
47%
Foot Care/Podiatry 68
57%
Access to Urgent Care (Same Day) Dentist 50
32%
Eye Care/Optometry 61
18%
Foot Care/Podiatry 52
23%
Advance Directives Plan has discussed appointing someone 104
64%
to make decisions Overall Part Cap
2012‐2013 (N=1,662)a Statewide 2012‐2013 (N=2,522)a GuildNet 2014‐2015 (N=132)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 117
% 97%
nb 2,677
% 94%
nb 3,702
% 94% ‐
‐
‐
‐
71
79%
1,831
77%
2,495
75% 1,625
84%
2,458
84%
114
95%▲
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%
76
91
77
104
102
104
93
85
76%
86%
90%
92%
86%
89%
85%
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%
101
91
97
73
76
96%
90%
86%
85%
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%
57
79
72
72%
76%
85%
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%
47
67
62
28%
36%
26%
1,062
1,497
1,368
31%
34%
35%
1,526
2,165
1,912
29% 33% 34% 1,346
64%
2,087
68%
109
62%
2,660
64%
3,757
67% 6 Member has legal document appointing someone to make decisions Health plan has a copy of this document ◊ 105
57%
1,387
55%
2,145
61%
107
56%
2,645
53%
3,722
58% 40
83%
533
74%
956
77%
31
71%
913
75%
1,506
79% 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 Represents a significantly higher rate versus the Partially Capitated/statewide rate (p < .001)
Item based on a skip pattern ▲ ◊ 7 GuildNet Partially Capitated Satisfaction Survey Results Summary 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 the ratings for timeliness for transportation to and from the doctor, and for the regular visiting nurse. In contrast, there was a decline in the percentage of members with a copy of their completed advance directive on file with the plan. In the most recent satisfaction survey administered to GuildNet membership, there was a statistically significant difference between the percentage of GuildNet members who rated their health plan as good or excellent when compared with members enrolled in other partially capitated plans and members statewide (95% vs. 87% and 87%, respectively). 8 Figure 2b: Satisfaction Survey Results GuildNet Overall MAP Statewide GuildNet Compared with all MAP Plans, 2012‐2013 2012‐2013 2012‐2013 a a and all Plans Statewide (N=91)
(N=414)
(N=2,522)a Description nb % nb % nb % Plan requested list of Rx/OTC meds ** 79 96%▲
377
93%
2,197
88%
Plan explained the Consumer Directed ‐
‐
‐
‐
‐
‐
Personal Assistance option ++ Plan Rated as Good or Excellent 88
85%
403
85%
2,458
84%
Quality of Care: Rated as Good or Excellent Regular Doctor (PCP) 84
94%
375
88%
2,247
89%
Dentist 60
63%
230
62%
1,530
70%
Eye Care‐Optometry 72
83%
317
78%
1,951
81%
Foot Care 65
85%
275
77%
1,640
80%
Home Health Aide 78
85%
361
85%
2,056
87%
Care Manager 83
87%
353
84%
2,108
84%
Regular Visiting Nurse 75
83%
352
79%
2,132
84%
Medical Supplies 64
84%
304
82%
1,844
86%
Transportation Services 72
74%
287
69%
1,916
78%
Timeliness: Always or Usually On Time Home Health Aide, Personal Care Aide 68
85%
320
78%
1,897
78%
Care Manager 69
77%
310
67%
1,876
69%
Regular Visiting Nurse 73
64%
336
64%
2,027
69%
Transportation TO the Doctor 63
70%
249
66%
1,766
69%
Transportation FROM the Doctor 66
68%
252
63%
1,742
67%
Access to Routine Care: Always or Usually Able to Get an Appointment When Needed Regular Doctor (PCP) 79
49%
358
58%
2,104
59%
Dentist 44
39%
173
46%
1,234
46%
Eye Care/Optometry 68
32%
272
40%
1,647
43%
Foot Care/Podiatry 58
35%
235
40%
1,390
45%
Access to Urgent Care: Same Day Regular Doctor (PCP) 65
35%
307
38%
1,755
45%
Dentist 33
30%
135
29%
920
26%
Eye Care/Optometry 55
27%
207
21%
1,195
22%
Foot Care/Podiatry 42
29%
184
25%
1,039
26%
9 GuildNet 2014‐2015 (N=134)a nb % Overall MAP 2014‐2015 (N=712)a nb % 112
96%
593
95%
Statewide 2014‐2015 (N=4,592)a nb % 3,702
94% 79
75%
397
74%
2,495
75% 109
92%
598
90%
3,739
87% 109
71
92
73
105
105
108
90
88
92%
79%
87%
85%
89%
88%
85%
87%
76%
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% 105
95
99
79
79
97%
86%
82%
86%
79%
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% 100
54
71
62
89%
69%
82%
76%
533
297
419
357
86%
67%
79%
76%
3,328
1,873
2,486
2,220
88% 73% 79% 80% 85
45
67
44
47%
27%
31%
34%
460
243
390
309
49%
32%
33%
32%
2,885
1,526
2,165
1,912
50% 29% 33% 34% Figure 2b: Satisfaction Survey Results GuildNet 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 ◊ GuildNet 2012‐2013 (N=91)a Overall MAP 2012‐2013 (N=414)a Statewide 2012‐2013 (N=2,522)a GuildNet 2014‐2015 (N=134)a 81%
352
70%
2,087
68%
120
77%
600
75%
3,757
67% 75
73%
363
62%
2,145
61%
111
69%
583
61%
3,722
58% 32
60%
154
65%
956
77%
53
72%
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 Symbol a
b
Statewide 2014‐2015 (N=4,592)a 77
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 10 GuildNet MAP Satisfaction Survey Results Summary 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 across all providers. In contrast, there was a slight decline in the percent of members who indicated their plan had discussed appointing a healthcare proxy with them, as well as a lower percentage of members indicating that they had a fully executed advance directive. A higher percentage, however, indicated their health plan had a copy of their advance directive on file. In the most recent satisfaction survey administered to GuildNet’s membership, plan ratings for the quality and timeliness of services categories were similar to other MAP plans and all plans statewide. 11 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 GuildNet’s July 2013 SAAM results for their partially capitated line, and Figure 3b contains GuildNet’s January‐June and July‐December 2014 UAS results. Figure 4a contains GuildNet’s July 2013 SAAM results for their MAP line, and Figure 4b contains GuildNet’s January‐June and July‐December 2014 UAS results.
1
NYS Department of Health, 2014 Managed Long Term Care Report. http://health.ny.gov 12 Figure 3a: GuildNet Partially Capitated and Statewide SAAM Data 2013 July 2013 Plan Statewide SAAM SAAM N=13,966 N=97,746 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 13 91%
92%
90%
89%
87%
87%
77%
79%
89%
91%
86%
88%
99%
99%
32%
26%
79%
79%
40%
40%
40%
34%
19%
40%
71%
75%
July 2013 Plan Statewide SAAM SAAM N=13,966 N=97,746 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 41%
45%
49%
56%
48%
76%
SAAM July 2013 A slightly higher percentage of GuildNet members had no confusion. A lower percentage of GuildNet members received the influenza vaccine, and reported no feelings of anxiety, as well as no pain, compared with members statewide. 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. 14 Figure 3b: GuildNet Partially Capitated and Statewide UAS Data 2014 Jan‐June 2014 UAS Items Plan UAS N=14,223 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 – 15 Statewide UAS N=125,702 July‐Dec 2014 Statewide
Plan UAS UAS N=132,42
N=14,204 9 42%
57% 41%
54%
17%
20% 16%
16%
29%
33% 30%
30%
16%
19% 14%
16%
55%
64% 54%
58%
85%
88% 85%
86%
34%
36% 34%
36%
80%
83% 80%
83%
34%
40% 29%
34%
67%
77% 62%
76%
66%
72% 60%
69%
28%
26% 27%
21%
Jan‐June 2014 UAS Items Plan UAS N=14,223 % 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=14,204 9 81%
89% 84%
92%
45%
50% 47%
50%
68%
72% 70%
73%
32%
33% 33%
33%
69%
75% 70%
76%
UAS January‐June 2014 Compared with members statewide, a lower percentage of GuildNet members could perform the 6 ADLs represented in Figure 3b. Additionally, GuildNet demonstrated lower percentages of members with intact cognitive functioning, members with no feelings of anxiety or depression, members experiencing no falls requiring medical intervention and all of the prevention measures (dental exam, eye exam, hearing exam and influenza vaccine). In contrast, a higher percentage of GuildNet members reported experiencing no daily pain. UAS July‐December 2014 A lower percentage of GuildNet members were able to ambulate, had no feelings of anxiety or depression, no falls requiring medical intervention and had an influenza vaccine, compared with members statewide. In contrast, a slightly higher percentage of GuildNet members experienced no severe daily pain. 16 Figure 4a: GuildNet MAP and Statewide SAAM Data 2013 July 2013 Plan Statewide SAAM SAAM N=497 N=111,215 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 17 93%
92%
93%
89%
88%
87%
84%
79%
92%
91%
89%
88%
100%
99%
33%
27%
87%
79%
47%
40%
47%
34%
15%
38%
83%
74%
July 2013 Plan Statewide SAAM SAAM N=497 N=111,215 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 51%
44%
45%
55%
45%
73%
SAAM July 2013 A greater percentage of GuildNet members demonstrated urinary and bowel continence, as well as intact cognitive functioning, no confusion and no feelings of depression. In contrast, a lower percentage of members reported no feelings of anxiety, and a lower percentage of members received the influenza vaccine. 18 Figure 4b: GuildNet MAP and Statewide UAS Data 2013‐2014 Jan‐June 2014 UAS Items Plan UAS N=667 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 – 19 Statewide UAS N=125,702 July‐Dec 2014 Statewide
Plan UAS UAS N=132,42
N=703 9 44%
56% 41%
53%
18%
20% 17%
16%
25%
33% 25%
30%
16%
19% 15%
16%
60%
63% 57%
57%
85%
87% 85%
86%
39%
36% 38%
36%
82%
83% 81%
83%
42%
39% 38%
34%
75%
76% 70%
75%
73%
71% 67%
68%
31%
26% 32%
22%
Jan‐June 2014 UAS Items Plan UAS N=667 % 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=703 9 86%
88% 86%
91%
43%
49% 43%
50%
66%
71% 68%
73%
30%
33% 31%
33%
77%
75% 76%
76%
UAS January‐June 2014 Compared with members statewide, a lower percentage of GuildNet members could perform the ADLs listed in Figure 4b above and received preventive services (dental exam, eye exam and hearing exam). UAS July‐December 2014 A lower percentage of GuildNet members could ambulate independently, had no falls requiring medical intervention and had a dental and/or eye exam, compared with members statewide. In contrast, a slightly higher percentage of GuildNet members demonstrated intact cognitive functioning and experienced no severe daily pain. 20 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 GuildNet’s PIP for 2013: GuildNet determined that Cardiovascular Disease, including Congestive Heart Failure, Acute Myocardial Infarction, Ischemic Heart Disease and Cardiac Dysrhythmias, occurs frequently in their chronically ill members and results in preventable hospitalizations/hospital readmissions. Due to the chronic conditions and co‐morbidities of GuildNet members, they are at a high risk for cardiovascular disease and cardiac‐related complications. Based on a review of their SAAM data, including demographic information and hospitalization data, a multi‐year study on member education and self‐management related to cardiovascular disease was proposed. For members with cardiovascular disease, the following objectives were proposed:  Reduce preventable/unplanned hospital admissions by 10%  Reduce unplanned readmissions by 10%  Increase primary care physician visits within 14 days of hospital discharge by 10%  Increase rate of Medication Reconciliation Post‐discharge by 10%  Increase Annual Wellness Visits with the primary care physician by 10% Interventions for Year 2 of the study continued with wellness initiative topics and member education scripts and built on the foundation of interventions from Year 1. Case Managers (CM) administered the quarterly wellness initiatives telephonically as part of their ongoing case management processes and member interactions. Scripts ensured that all members received the same information. All members received a supplementary newsletter via mail with an article reinforcing the wellness information provided by the CM and was published in GN’s four top languages: English, Spanish, Russian and Chinese. The following four wellness initiatives were completed during Study Year 2:  October 2012 – December 2012: “Know your ABCs – Preventing Heart Attacks and Strokes”  January – March 2013: “Good Communication = Good Care”  April – June 2013: “Greet Spring with Healthy Eating”  July – September 2013: “Staying Active and Exercising Can Help You Feel Better” Results are summarized on the following page: 21 Results for the final measurement were disappointing, with no significant improvement shown from baseline to re‐measurement for any of the project indicators. Hospitalizations increased 2.5%, from 56.9% at baseline to 58.4% at re‐measure, and the readmission rate increased by 3.7% from a baseline rate of 17.0% to a re‐measurement rate of 17.6%. Similar results were noted for annual wellness visits which decreased by 1.4% from 93.5% to 92.2%, and for the two post‐hospitalization measures: PCP Visit </= 14 Days Post Hospitalization, baseline rate 64.2%, re‐measure rate, 60% (‐6.5%) and Medication Reconciliation </= 30 Days Post Discharge, baseline rate 81.1% and re‐measure rate 76.9% (‐5.2%). Annual Wellness PCP Visits and Medication Reconciliation decreased by 6.5% and 5.2%, respectively (Z‐
test calculations revealed that the changes were not statistically significant.) Conclusions: While the results of the study did not meet GuildNet’s performance goals, they believe the findings were positive based on a comparison against their own internal benchmarks for the overall GN membership as well as when comparing their rates to external benchmarks. Additional data on the GN membership presents the following member profile: mean age is 75.9 and 61% of members are 75 years of age and older. By comparison, the study population mean age is 78.3 years and 67% are 75 and older. The number one reason for hospital admissions (GN) in the second half of 2012 was Myocardial Infarction at 18% compared to the NYS mean of 3%; and over 36% of the GN membership that met the study’s continuously enrolled criteria for the 2‐year period, had a least one of the selected CVD diagnoses. These factors highlight that GN’s membership is at high‐risk for cardiac‐related complications, hospitalizations and readmissions. 22 When they compare their hospitalization and readmission rates to external benchmarks, they believe they are having a positive impact on their member’s health outcomes. For example, a recent study sponsored by the Robert Wood Johnson Foundation, The Revolving Door: A Report on U.S. Hospital Readmissions (February 2013) places readmission rates for Acute Myocardial Infarction (MI) at 18.1% and Congestive Heart Failure (CHF) at 21.1% (2010) and Hospital Compare, accessed via Medicare.gov, reports that the national admission rate for MI is 18.3% and CHF is 23%. The readmission rates for GN’s members with CVD, including MI and CHF, were 17 % and 17.6% for Year 1 and Year 2 of the study. While not a direct correlation, GN believes that their data are trending positively when compared to the national data for these conditions. The following represents a summary of GuildNet’s PIP for 2014: The CDC emphasizes the importance of regular health exams to help find problems before they start and also to help find problems early, when chances for treatment and cure are better. The importance of preventive care and screenings is well documented by professional organizations and agencies. For GuildNet members who qualify for long‐term nursing home level of care, this is especially important. To promote ongoing wellness, the GuildNet case management staff educates members and their caregivers on wellness topics throughout the year. Three of the capitated services authorized by GuildNet include Audiology, Vision and Dental, which are to be targeted to improve utilization by members in the years 2014 and 2015. Therefore, this is an interim report for the current status and plans for interventions in 2015. Interventions included the following: 2014  Winter Wellness Initiative: During the winter of 2014, the topic of the quarterly wellness initiative encouraged members to have health screenings for vision, dental and audiology. This was conveyed to members and/or their caregivers during a monthly case manager contact.  GuildNet’s quarterly member newsletter focused on the importance of health screening for these 3 types of services.  A screensaver for staff computers was developed and implemented to serve as a reminder to Case Managers of the IPRO Study goals and importance of member health screenings for vision, hearing and dental services.  GuildNet Reassessment nurse(s) encourage health screenings during assessment visits beginning December 2014. A list of providers of these services that make home visits was also provided to staff. 2015  Continue Reassessment nurses’ encouragement of health screenings for dental, vision and hearing.  Propose home care agency nurses encouraging members to obtain these health screenings during authorized and supervision visits and include results in their visit reports.  Request that a medical transportation company provide member with reminders on these health screenings – during calls and/or by handing reminder cards.  Recommend that the Case Manager call post UAS assessment and inquire what barriers exist in accessing health screenings and address these in order to facilitate appointments.  GuildNet’s Quality Department complete a follow up audit of a sample of records to determine what barriers to health screenings can be identified and addressed. 23 


Collaborate with Adult Day Health Care (ADHC) providers to encourage GuildNet members to obtain health screenings for vision, dental and hearing. Request ADHC staff coordinate these screenings when possible and report to GuildNet. GuildNet’s own ADHC may facilitate vision screenings. Collaborate with facility staff for members who reside in a nursing home to encourage health screenings and obtain status updates. Collaborate with GuildNet’s Diabetes Treatment Center to address GuildNet members and screening for oral and vision screenings as part of Diabetic management. Interim results are summarized on the following page: As of 2014 year‐end, results below show modest improvement for members with health exams for dental, audiology and hearing. Baseline First Half Results
Second Half Results # Yes
5993
45.28%
6667 46.97%
Dental Exams 45.83% # No
7242
7527 # Yes
9029
68.22%
9988 70.37%
Eye Exams 66.80% # No
4206
4206 # Yes
4191
31.67%
4655 32.80%
Hearing Exams 30.38% # No
9044
9539 Conclusions: In 2015, GuildNet will utilize other sources to reach out to members and their caregivers to supplement health education in progress by the case management department. These include GuildNet’s reassessment nurses and providers. Although GuildNet did not achieve its goal of 10 % improvement in utilization of the vision, dental and hearing benefit there was incremental change noted over the time period. Some other findings arose when stratifying by gender and age. As shown by the results, male members were more likely than female to avail themselves of these services. Additionally, for the hearing screen, all months showed that males and members over the age of 65 were more likely than those younger than 65 to have had screening exams. Inversely, members under the age of 65 were more likely to have dental exams than members over 65. Interventions will continue to be re‐evaluated throughout 2015 and UAS data results analyzed for effectiveness. 24 Section Seven: Summary/Overall Strengths and Opportunities Strengths Partially Capitated Overall Plan Rating GuildNet members rated their health plan more favorably than members enrolled in other plans throughout the state in the most recent satisfaction survey (2014‐2015). Of the GuildNet members who responded to this question on the satisfaction survey, 95% rated the plan as good or excellent, which is significantly higher than similar plans and all other plans statewide. This is compared to the 87% of other partially capitated plan members and the 87% of statewide members who rated their plan as good or excellent. Quality of Care With the exception of transportation services, the 2014‐2015 satisfaction survey results indicate that a higher percent of GuildNet members rated the quality of their health care providers and services as good or excellent, compared with other partially capitated plan members, and all other plan members statewide (for transportation services, GuildNet, other partially capitated plans and other plans statewide had the same percentage (77%) of members rating this service as good or excellent). Health Conditions UAS data from the second reporting period in 2014 indicate that a higher percentage of GuildNet members (27%) experience no severe pain daily, when compared with other members statewide (21%). The same trend was observed in the first reporting period, however to a lesser extent (28% of GuildNet members experienced no severe pain, compared with 26% of members statewide). MAP Quality of Care Satisfaction survey results indicate that a higher percentage of GuildNet Gold members rated the quality of their dentist and care manager as good or excellent compared to other MAP plans and all plans statewide. Seventy‐nine percent (79%) of GuildNet members rated their dentist as good or excellent, compared with 72% of other MAP members and 73% of members statewide. Eighty‐eight percent (88%) of GuildNet members rated the quality of their care manager as good or excellent, compared with 81% of other MAP members, and 83% of all members statewide. Timeliness The 2014‐2015 satisfaction survey results indicate that GuildNet members perceived their home health care workers (home health aide, care manager and regular visiting nurse) and transportation services to be timelier, compared with the other MAP plan members and members statewide. The higher quality ratings associated with these services could be related to their perceived timeliness. Advance Directives GuildNet appears to be addressing the need and importance of advance directives, as evidenced by the higher percentage of respondents with an advance directive in place, as well as who indicated the Plan had discussed appointing someone to make health care decisions. 25 Opportunities Partially Capitated Access to Urgent Care Twenty‐six percent (26%) of respondents in the 2014‐2015 satisfaction survey indicated they were able to access their podiatrist for same day urgent care. This is compared to 35% of other partially capitated members and 34% of all other plan members statewide who are able to see a podiatrist for same day urgent care. A focused member survey should be considered, to determine if access issues exist with these providers. Ambulation/Locomotion A lower percentage of GuildNet members could ambulate independently, with setup help/device, or with supervision compared to the percentage statewide in both UAS assessments in 2014. It is recommended that GuildNet conduct a focused study on physical therapy visits with their members, to determine if more physical therapy sessions are needed. Anxiety and Depression A lower percentage of GuildNet members reported no feelings of anxiety or depression compared to other partially capitated plans and all plans statewide. Questions pertaining to mood and behavior are prone to 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. It is therefore recommended that GuildNet conduct an inter‐rater reliability project for clinical assessments, to aid in determining whether these members do in fact have higher levels of impairment than on a statewide basis, or if there are scoring issues. Two assessors could independently conduct the same assessments on a sample of members, to test the validity of responses. Health Conditions The percentage of GuildNet members experiencing no falls requiring medical intervention was lower than members statewide (84% vs. 92% respectively). GuildNet should consider conducting a performance Improvement project to identify fall risks for their members, in an effort to reduce falls requiring medical intervention. MAP Prevention A lower percentage of GuildNet Gold members had a dental, eye, and/or hearing exam in both UAS reporting periods in 2014, when compared with members statewide. It is recommended that GuildNet attempt to validate these data through comparison to medical records care management correspondence, and to claims data if feasible. In this manner, the plan may be able to identify if under‐reporting issues exist or if there are barriers to obtaining these services and/or data. 26