Community HealthChoices Overview of Evaluation Design MLTSS Sub-MAAC February 3, 2016 Howard B. Degenholtz, Ph.D. Principal Investigator Medicaid Research Center

Outline Purpose of the Evaluation Overview of the Evaluation Design

Overview The University of Pittsburgh will conduct a state-wide, 7 year evaluation of the implementation, process and outcomes of CHC Provide independent, scientifically rigorous evidence of program impact with respect to: Opportunities for community-based living Service coordination Quality and accountability Program innovation Efficiency and effectiveness Multiple Data Sources and Methods Key Informant Interviews Focus Groups Participant and Caregiver Experience Interviews Administrative Data Role of Department of Human Services Collaborated on design Provides funding and oversight through Evaluation Work Group Role of MLTSS Sub-MAAC We will provide regular updates to Sub-MAAC Provide feedback & suggest course changes Sub-MAAC representation on Work Group (Oversight)

Research Questions Goal 1: Enhance Opportunities for Community Living Increase HCBS, delay or prevent institutionalization Goal 2: Improve Service Coordination Improve coordination of medical care and HCBS, and between Medicaid and Medicare Goal 3: Enhance Quality and Accountability Impact on quality of life and well-being for participants and caregivers Impact on quality of care across spectrum of acute and LTSS Goal 4: Advance Program Innovation Models of care, care coordination, technology, housing and employment Goal 5: Increase Efficiency and Effectiveness Effect on cost and utilization of acute and LTSS

Multiple Data Sources Provide Multiple Perspectives on Program Performance Key Informant Interviews and Focus Groups (Purposive Samples) Participant and Caregiver Interviews (Representative Sample) Analysis of Administrative Data (Entire Population)

Summary of Data Sources for Each Population Age LTSS Use Key Informant Interviews Focus Groups Administrative Data Participant Interviews Caregiver Interviews 21-59 Community ✔︎ ✔   Facility 60+ None (Duals)

Key Informant Interviews Goal Monitor implementation from multiple perspectives Provide early, independent, ongoing insight (e.g., spring 2017) Methods Semi-structured, open-ended interviews Qualitative analysis Conducted on a rolling basis before, during and after implementation in each region Informants: Advocacy Groups Participants Age 21-59 HCBS User Age 60 + HCBS User Dual Eligible, no-HCBS Caregivers Age 21-59 HCBS and Facility Age 60+ HCBS and Facility Providers: Personal Care/AL Nursing Home Centers for Independent Living Home Health Personal Assistance Adult Daily Living Hospice Meals Transportation Home Modification Habilitation Respite Service Coordinator Primary Care Physician Hospital Government State Officials County Officials Area Agency on Aging Ombudsperson

Participant and Caregiver Focus Groups Goal Gather early impressions and feedback from participants and caregivers during rollout (in each Phase) Group settings elicit different responses than individual interviews Methods Professional focus group moderator will lead structured conversation Thematic analysis Conducted early in the implementation year in each phase Sample Represent major categories: Urban Rural/Adjacent Participants Caregivers

Participant and Caregiver Experience Interviews Goal Measure quality of life and satisfaction Methods Structured, closed and open-ended interviews Prior to enrollment, 1st and 2nd year of enrollment In-person with participant, phone with proxy and caregivers Sample Age 21-59 Community LTSS users Age 60+ Community LTSS users Age 60+ non-LTSS users (duals) Caregivers (unpaid) for each subgroup

Study Design – PCE Interviews In 2017 (12m), we will compare participants living in the Phase I region to people in Phase II & III During 2018 (24m), we will compare Phase I & II to Phase III In 2019 (36m), the program will be statewide, so we will measure outcomes, but there is no comparison group. Month Type of Analysis Region 12 24 36 Before and After w/ Comparison Groups Phase I  Phase II Observational Phase III

Administrative Data Analysis Goal Effect of CHC on use of HCBS, institutionalization, acute care, and cost Methods Medicaid & Medicare Claims Nursing Home Minimum Data Set (MDS) 3.0 Level of Care & Service Plan Managed Care Organization Performance Metrics Analysis Difference-in-difference models compare trend in Phase I to trend in Phase II and Phase III groups Propensity score models adjust for unobserved differences between participants in each region Data lag by 6-8 months E.g., data for Year 1, Phase I, will be available in late 2018 Analysis of two year’s of data for all 3 phases in 2022 2017 2018 2019 2020 2021 2022 Phase I Start Year 1 Year 2 Year 3 Phase II Phase III (Year 3)

Study Design – Administrative Data 2016 2017 2018 2019 2020 2015 2021 Phase I Phase II Phase III Baseline Data Comparison Groups Notes: 2015-2016 data will be used for pre-post comparisons Phase II, III data from 2017 will be used as contemporaneous comparison for Phase I Phase III data from 2018 will be used as contemporaneous comparison for Phase I, II Program Groups

Challenges Key Informant Interviews Participation and cooperation of stakeholders Participant and Caregiver Interviews Recruitment and retention of sample Are Phase II and Phase III regions good comparison groups? Administrative Data Complex data Changes to data systems Quality concerns

Summary Evaluation is designed to provide rigorous, independent analysis of the effects of CHC on multiple outcomes for multiple populations Rigorous: Study design takes advantage of phased implementation to construct comparison groups and estimate causal effects Multiple Perspectives: Wide range of providers types and advocacy groups Participants in different living arrangements, health conditions, urban/rural settings Multiple Methods: Participants and providers interviews, focus groups and administrative data provide multiple perspectives on the big picture Short and Longer-Term: Early insights are important for planning: “What’s happening?” Inform course correction for 2018, 2019 Phases Longer-term outcomes important to answer the question: “Does it work?”

Study Team Department of Health Policy and Management Howard B. Degenholtz, PhD, Principal Investigator Marian Jarlenski, PhD Damian DaCosta Lexi Drozd Ray VanCleve Meredith Hughes Health Policy Institute - Medicaid Research Center Evan Cole, PhD Phil Rocco, PhD Aiju Men Qualitative, Evaluation and Stakeholder Engagement Center Susan Zickmund, PhD Megan Hamm Office of Health Survey Research Todd Bear Health Services Research Data Center Jeremy Kahn, MD Dan Ricketts Consultants Richard Morycz, MD (Abuse and Safety Concerns) Julie Donohue, PhD (Pharmacy and Mental Health) Walid Gellad, MD (Pharmacy) Richard Schulz, PhD (Caregiving)

Contact Information Howard B. Degenholtz, PhD, Principal Investigator Department of Health Policy and Management Graduate School of Public Health Center for Bioethics and Health Law Health Policy Institute Medicaid Research Center University of Pittsburgh 130 DeSoto St., A748 Pittsburgh, PA 15261 (412) 624-6870 degen@pitt.edu

Additional Slides

Goal 1: Enhance Opportunities for Community Living Study Aims Primary Research Questions (Directional Hypotheses or Descriptive) To study the effect of CHC on the use of HCBS. HCBS use will increase among CHC participants, relative to comparable individuals in non-participating areas. To study the effect of CHC preventing or delaying institutionalization. CHC participants will have lower rates of institutionalization, relative to comparable individuals in non-participating areas. To study the effect of CHC on facilitating return to the community. CHC participants will be more likely to return to the community after a hospitalization or facility based post-acute care, relative to comparable individuals in non-participating areas. CHC participants who are long-stay residents will be more likely to return to the community, relative to comparable individuals in non-participating areas.

Goal 2: Improve Service Coordination Study Aims Primary Research Questions (Directional Hypotheses or Descriptive) To describe coordination among different types of care. To what extent does CHC facilitate improved care coordination between acute, ambulatory, behavioral and LTSS providers? To describe integration of care between Medicare and Medicaid. To what extent does CHC lead to improved care coordination for dual eligibles without LTSS needs?

Goal 3: Enhance Quality and Accountability Study Aims Primary Research Questions (Directional Hypotheses or Descriptive) To study the effect of CHC on quality of life and well-being for participants and family caregivers. CHC participants will have higher quality of life and well-being, relative to comparable individuals in non-participating areas. Informal caregivers of CHC participants will have higher quality of life and well-being, relative to comparable individuals in non-participating areas. To describe quality of care across the spectrum of acute and LTSS providers. What is the association between CHC and quality of care across the spectrum of acute and LTSS providers?

Goal 4: Advance Program Innovation Study Aims Primary Research Questions (Directional Hypotheses or Descriptive) To describe the model of care used by physical health providers. To what extent does CHC lead to incorporation of innovations such as person-centered care goals into primary care? What proportion of participants receive physical health care from a multidisciplinary team? To describe models for care coordination. Is CHC leading to new models of care coordination? (e.g., that span chronic and LTSS needs) To describe changes in LTSS providers and service provision. Is CHC leading to new types of LTSS providers or new combinations of housing and LTSS services? To describe changes in use of technology. Is CHC leading to increase use of technology among LTSS providers? (e.g., telehealth, electronic medical records, visit verification) To describe the impact of CHC on employment opportunities. Is CHC leading to new forms of employment for participants? Are there new types of community supports for employment? To describe the impact of CHC on the type of housing. Is CHC leading to new combinations of housing and services? Is CHC expanding the opportunities for participants to remain in the community?

Goal 5: Increase Efficiency and Effectiveness Study Aims Primary Research Questions (Directional Hypotheses or Descriptive) To study the effect of CHC on cost of care. Monthly and annual cost of care for CHC participants will be the same or lower than comparable individuals in non-participating areas. To study the effect of CHC on utilization patterns. Aggregate care utilization measures for CHC participants will be the same or lower than comparable individuals in non-participating areas. HCBS use will be higher, and hospitalizations lower, among CHC participants relative to comparable individuals in non-participating areas.

Study Design – PCE Interviews 2016 2017 2018 2019 2020 2021 Phase I Phase II Phase III Baseline Data Notes: Baseline interviews conducted in late 2016 Follow-up interviews in spring and fall New samples for Phase II and Phase III will be recruited in 2017 and 2018 Individuals will be interviewed for 3 years Comparison Groups Program Period