1. MLTSS Quality Measures
. . .a quick tour of the landscape
SNP Alliance, 13th Annual Leadership Forum
November 3, 2017
Debra J. Lipson, Senior Fellow

2. Overview Current MLTSS measure scene
Standardized MLTSS measures on the horizon
Putting MLTSS measures into use/practice
Next steps – how you can help

3. Current MLTSS Measure Landscape

4. MLTSS measures already exist
YES
BUT
State Medicaid agencies developed their own LTSS measures for MLTSS plans
CMS Financial Alignment Initiative (Dual Demo) measures
Nearly all LTSS measures are state specific
With the possible exception of “nursing facility diversion” (but not publicly reported last year due to “inconsistencies” in reporting)
No standardization across states
Most state MLTSS-specific measures have not been tested for validity and reliability and many are not clearly defined or specified
No measures specific to MLTSS plans have yet been endorsed by NQF
Gaps in some key LTSS domains

5. Which types of MLTSS Measures are needed?
Standardized national measures are medically oriented for the most part
HEDIS Medicare Advantage measures
Hospitalization for Ambulatory Care Sensitive Conditions (ACSCs) among HCBS users
Necessary but insufficient
Measure gaps remain for key LTSS domains
Rebalancing – greater use of HCBS, less use of institutional care
Comprehensive LTSS assessment and care planning
Quality of life, community integration (employment, socialization)
Integration of medical care and LTSS

6. Can we use HCBS survey-measures for MLTSS?
YES
BUT
CAHPS HCBS Experience of Care (NQF # 2967) specified for use at the state level, but could be used for MLTSS plans with adjustments
National Core Indicator-AD measures under development, designed to be apply to MLTSS
Denominator shifts from HCBS waiver participants to MLTSS members who meet minimum and continuous enrollment period requirements
NCI-AD is a proprietary survey; some states may not use it and some prefer their own surveys
Survey-based measures are important but costly and can be burdensome to members; subject to low response rates

7. Standardized MLTSS measures on the horizon

8. It’s easy to develop MLTSS measures
YES
BUT
General consensus on important measure domains and gaps:
Rebalancing: greater use of HCBS & less use of institutional care
Comprehensive LTSS assessment and person- focused care planning
Quality of life
Community integration (employment, socialization)
Integration of medical care and LTSS
Feasibility and data availability among MLTSS plans must be carefully assessed
Large differences - and capabilities – of MLTSS plan data systems
State contract and reporting requirements complicate efforts to develop standardized measures
Quality of life and community integration are subjective concepts
Data to risk adjust LTSS outcome measures often not available, or very burdensome to collect

9. Medicaid Managed Care TA Project, 2012-2013
Sponsor and Partners:
CMS, CMCS, Division of Managed Care Plans (DMCP)
Mathematica Policy Research and NCQA
Goal: Identify key MLTSS measure domains and concepts
MLTSS quality processes and outcomes, excluding person-reported outcomes measures to avoid duplicating other efforts (e.g. HCBS experience of care survey)
Result: Recommended a set of measure concepts and preliminary measure specifications to be field tested:
Assessment and Care Planning
Rebalancing/Institutional Utilization
Falls Risk Screening, Assessment and Plan of Care

10. Quality Measure Development and Testing - MLTSS, 2015-2018
Sponsors and Partners:
CMS: CCSQ, MMCO, CMCS DQ & CMCS DMCP
Mathematica Policy Research and NCQA
Goals
Conduct field testing of recommended MLTSS measures with health plans
Refine and revise measure specifications based on results
Obtain TEP review and feedback
Seek NQF endorsement, support measure implementation
Results to date
4 Assessment and Care Planning measures – next slides
3 Rebalancing/Utilization measures - near end of testing
Falls Risk Reduction measure – re-testing revised specifications

11. MLTSS Comprehensive Assessment
Percentage of MLTSS enrollees who receive an in- home (face-to-face) comprehensive assessment within 90 days of enrollment, and updated at least annually
‘Comprehensive’ defined as assessment of 28 elements in 8 domains:
Physical functioning, medical conditions, mental and behavioral health, vision/hearing/therapy needs, health risks, social support, care preferences and service use

12. MLTSS Comprehensive Assessment
Majority of enrollees had elements of 28 data elements documented
Numerator will count documentation of all 9 core elements
9 Core Elements
ADLs
Current Medications
Acute and chronic conditions
Cognitive Function
Mental Health Status
Home Safety Risk
Living Arrangement
Availability of friend/family caregiver support
Current Providers
Source: Mathematica analysis of enrollee data from 5 health plans.

13. MLTSS Comprehensive Care Plan
Percentage of MLTSS enrollees who have a comprehensive, person-centered care plan within days of enrollment, and updated at least annually
‘Comprehensive’ includes 20 types of services and supports in 6 domains:
Summary of assessed needs
Plans to meet medical, functional, cognitive, emotional and social needs
Amount, frequency and duration of LTSS services and supports
Personal goals and preferences
Provider coordination and communication
Emergency back-up

14. MLTSS Comprehensive Care Plan
About a quarter (28 percent) of enrollees had data elements documented (of 20 total)
Numerator will count documentation of 7 core elements
7 Core Elements
Medical needs
Functional needs
Cognitive needs,
List of all services received/expected to receive
Beneficiary goal
Follow-up and communication schedule
Plan for ensuring beneficiary needs are met in case of emergency
Source: Mathematica analysis of enrollee data from 5 health plans.

15. MLTSS: Shared Care Plan
Percentage of MLTSS enrollees with a care plan that was shared in whole or in part with key LTSS providers and the primary care provider (PCP) within 30 days of development
30 percent of care plans were shared with a PCP or another key LTSS provider
Of those with a shared care plan, 63% were shared within 30 days

16. MLTSS: Post-Hospital Stay Re-Assessment/Care Plan Update
Percentage of inpatient hospital discharges of MLTSS enrollees resulting in updates to the assessment and/or care plan within 30 days of discharge (excluding planned readmissions)
31% of discharges followed by re-assessment within 30 days
Only 5.2% had a re-assessment AND care plan update within 30 days
Source: Mathematica analysis of enrollee data from 5 health plans.

17. Rebalancing/Institutional Use Measures
Final stages of analyzing field test results for:
Admission to an Institution from the Community:
Number of admissions to an institution among MLTSS enrollees residing in the community per 1,000 enrollee months
3 Rates: 1. Short-stay admissions (<100 days); 2. Long-stay admissions (100+ days); 3. Total admissions
Successful Discharge after Short-Term Stay
Percentage of admissions to an institution that result in successful discharge to the community (community residence for 30 or more days) within 100 days of admission
Successful Transition after Long-Term Stay
The percentage of long-term stay (101 days or more) institutional residents who are successfully transitioned to the community (community residence for 30 or more days)
Exploring feasibility of risk-adjustment for clinical conditions

18. Re-Testing Falls Risk Reduction
PQRS (provider-level measure) restricted to people age 65 and older; plan of care limited to Vitamin D supplements and referral for balance/strength/gait training
Revised measure for MLTSS enrollees expands age range, and covers a wider set of evidence-based falls risk interventions
Three rates:
Screening
Percentage of MLTSS enrollees who were screened for future fall risk at least once within 12 months.
Assessment
Percentage of MLTSS enrollees who had a history of falls and had a risk assessment for falls completed within 12 months.
Plan of Care
Percentage of MLTSS enrollees who had a history of falls and had a plan of care with at least one evidence-based intervention documented within 12 months.

19. Putting MLTSS Measures into Practice

20. NQF endorsement is important
YES
BUT
CMS and States turn first to NQF- endorsed measures when creating performance measure sets
NQF endorsement ensures that measures meet rigorous evaluation criteria:
Importance/relevance to quality
Scientific validity and reliability
Feasibility
Usability
Alignment/harmonization with related measures
MLTSS Assessment and Care Planning measures will be submitted to NQF for potential endorsement - November 2017
NQF committees are medically- oriented and give more weight to measures with high evidence ratings (multiple studies using experimental design, control groups, etc.)
LTSS research less often meets high evidence ratings
CMS includes non-NQF endorsed measures in Medicaid Core Sets, Medicare Advantage, MMP Core Set, Nursing Home Compare, and other programs

21. MLTSS measures found valid and reliable will be used by CMS and States
YES
BUT
CMS, State Medicaid agencies, and MLTSS plans clamoring for standardized, validated LTSS measures
For MLTSS
For VBP with providers
Initially, MLTSS plans may be asked to report the measures and given time to modify data systems to reflect new expectations
States are not required to use, or report to CMS, Medicaid quality measures – even those in the Medicaid Core Sets
States and MLTSS plans may not adopt or use certain measures if they cannot be properly risk adjusted due to lack of reliable and readily available data
CMS MMCO may or may not adopt MLTSS measures for MMPs

22. Greater Alignment = Greater Use?
Across MLTSS programs -- State MLTSS programs, MMPs, FIDE-SNPs, PACE, etc.  
With heterogeneity of enrollees and variability in covered benefits covered, could one core set be applicable to all plans?
Would different measures for enrollee subgroups help with alignment?
Across federal and state payers
Some states will follow CMS’ lead
Others will continue to use their own measures
Across states
Nationally standardized measures will help to reduce variation
Some states will continue to use “home-grown” measures to address performance domains without standardized measures

23. Data Collection and Reporting Issues
Many data elements required for the new MLTSS measures are not routinely recorded or captured – health plans will need time to re-program data systems and train staff
Data elements for the measures may be stored in different places/data sets
Burden associated with abstracting data from case management records, which may not have structured fields like those in electronic medical records
Random sampling can help lower burden
Validation and auditing also needed

24. Miles to go before we sleep

25. What’s up next? CMS-Mathematica-NCQA final test data analysis
3 rebalancing/institutional use measures
Revised falls risk reduction measure
Self-direction offer & take-up measure to be tested soon
All measure development efforts subject to results that indicate low reliability, validity or feasibility
Measures may be re-specified and re-tested, e.g. Falls Risk Reduction. . . or abandoned
Concurrent LTSS & HCBS measure development and testing efforts
Need to be specified and tested for MLTSS plans too

26. How you can help Submit public comments
To Mathematica on CMS-sponsored MLTSS measures
To NCQA on adding MLTSS measures to HEDIS
To NQF on MLTSS measure endorsement decisions
Participate in MLTSS measure field tests
First in line to assess data collection/reporting feasibility
Opportunity to clarify/revise specifications
Prepares your plan to implement measures (if adopted)
Talk to CMS and State Medicaid agencies
Which measures are most important to develop and test
Appropriate uses of measures (internal QI, public reporting, P4P, etc.)

27. Posting draft technical specifications on CMS’ MLTSS website soon:
For more information
Posting draft technical specifications on CMS’ MLTSS website soon:
care/ltss/index.html
Debra Lipson, Mathematica Policy Research
Jessica Ross, Mathematica Policy Research