IPRO, in conjunction with the New York State Department of Health (NYSDOH), structured a validation study to determine Managed Long Term Care (MLTC) compliance with two Centers for Medicare and Medicaid Services (CMS)-based terms and conditions related to the expansion of the MLTC program. These terms and conditions apply to:

1. MLTC eligibility: Each MLTC plan must complete an initial clinical assessment in the individual´s home for all individuals referred to or requesting enrollment, within 30 days of that referral or initial contact. The initial clinical assessment is the basis for eligibility for MLTC program. This validation study determines the percentage of initial assessment completed within 30 days.
2. Enrollees´ transition of care period: Specifically, the transition into MLTC from Fee-For-Service (FFS). An enrollee receiving community based long term services and supports, and mandatorily enrolled into MLTC, must continue to receive the same level of services received in the FFS service plan for at least 60 days after enrollment into an MLTC plan, or until a care assessment has been completed by the MLTC plan, whichever is later. This validation study determines the percentage of members transitioning from FFS to MLTC that received at least the same level of services during the 60 days after enrollment or until a documented assessment is completed.

The study population for the validation consisted of a random sample of mandatorily enrolled recipients between September and November 2012, some of whom chose their plans and others who were auto- assigned, in MLTC plans servicing New York (Manhattan) county.

Seven (7) indicators were established for this study. The first indicator refers to the initial clinical assessment, indicators 2, 3, and 4 refer to the transition of care period, and indicators 5, 6 and 7 refer to the post transition of care period. The table below defines the specifications for each of the seven study indicators.

Indicator		Numerator	Denominator
1	Initial Clinical Assessment	Newly enrolled members with a clinical assessment conducted within 30 days of the initial referral	Newly enrolled MLTC sample
2	Transition of Care Period (No Change)	Newly enrolled members with the same level of personal care hours as prior to MLTC enrollment	Newly enrolled MLTC sample
3	Transition of Care Period (Increase)	Newly enrolled members with an increased level of personal care hours as prior to MLTC enrollment	Newly enrolled MLTC sample
4	Transition of Care Period (Decrease)	Newly enrolled members with a decreased level of personal care hours as prior to MLTC enrollment	Newly enrolled MLTC sample
5	Post Transition of Care Period (Decrease)	Newly enrolled members with a decreased level of personal care hours post transition of care (at least 60 days after enrollment)	Newly enrolled MLTC sample
6	Post Transition of Care Period (Increase)	Newly enrolled members with an increased level of personal care hours post transition of care (at least 60 days after enrollment)	Newly enrolled MLTC sample
7	Post Transition of Care Period (Appeals)	Newly enrolled members appealing the decreased level of care decision	Newly enrolled members with a decreased level of personal care hours post transition of care (at least 60 days after enrollment)

The NYSDOH provided IPRO with a file consisting of a random sample of 40 mandatorily enrolled members per plan. Twenty chose their plan (choosers) and 20 were auto assigned (auto assignees). If there were fewer than 20 per group per plan, the sample consisted of all enrollees.

The sample consisted of members with start of enrollment dates as of 9/1, 10/1, or 11/1/2012 in Manhattan County, as 9/1/12 marked the beginning of mandatory enrollment in the MLTC program. IPRO sent sample lists identifying the members to each health plan. In order to obtain the necessary information to adequately assess the study indicators, IPRO requested the following documentation for each member in the sample:

1. The member´s first clinical assessment conducted by the plan subsequent to either the MLTC referral date or enrollment date
2. All subsequent clinical assessments conducted by the plan
3. The latest service/care plan prior to MLTC enrollment (the 60 day continuity of care plan)
4. The current service/care plan in place
5. All paraprofessional care plans subsequent to MLTC enrollment
6. Any appeals filed by members addressing quality of care concerns
7. Any documented communication with the members regarding enrollment, care plans, or services to be provided

Based upon the selection criteria specified above, 522 cases were identified for review. However, the plans were unable to provide documentation for 79 records, for one of the following reasons:

1. Member dis-enrolled almost immediately after enrollment, or well within 30 days, and received no services
2. Member enrolled and moved out of the service area almost immediately, receiving no services
3. Death of member soon after enrollment
4. Never enrolled in the plan

As a result, the study sample consisted of 443 member records for which there was sufficient information for the review. Documentation review by IPRO clinical staff commenced in May 2013 and was completed in September 2013.

Project results are summarized below. The results for the transition of care audit appear in Table 1, and are presented in three columns: combined results, auto-assigned members, and choosers. Indicator 1 was the only indicator where significant differences were observed between auto-assigned and choosers.

Indicator 1: Initial Clinical Assessment

Of the 443 member records reviewed, 360 (81.3%) reflected a SAAM assessment conducted within 30 days of the initial referral date or start of enrollment date. Of the 83 assessments found to be untimely, 43 were late due to either inability to contact the members, or members´ refusal to be assessed within the 30-day period. Forty assessments were found to be untimely with no reasons documented. IPRO observed no significant differences in the reasons for late assessments between the auto assigned and chooser groups. The percentage of timely assessments for choosers was somewhat higher than for auto-assigned members (86.9% versus 74.0%) and the difference was found to be statistically significant.

During IPRO´s initial outreach to the plans regarding this study, several plans made reference to assessment timeliness issues due to the impact of Hurricane Sandy. However, reviewers found no reference to Hurricane Sandy in any of the records reviewed, across all of the plans.

It should be noted that of the 443 records reviewed, 16 were excluded from Indicators 2-4 due to at least one of the following reasons:

1. Members dis-enrolled shortly after 30 days, in some instances re-enrolling with another plan
2. Members died while hospitalized, shortly after 30-day period
3. Members refused all services and subsequently dis-enrolled

Indicator 2: Transition of Care Period (No Change)

Of the 427 member records reviewed, 288 (67.4%) indicated the same level of personal care hours during the 60-day transition period as prior to enrollment. Slight differences in the indicator rates for auto-assigned members and choosers were detected (71.6% and 64.3%, respectively).

Indicator 3: Transition of Care Period (Increase)

Of the 427 member records reviewed, 104 (24.4%) indicated an increased level of personal care hours during the 60-day transition period as prior to enrollment. Indicator rates for auto-assigned and choosers were relatively similar (21.9% and 26.2%, respectively).

For the most part, the reasons for the increases in personal care were well documented in the records and were clearly attributed to changes in medical condition, or, due to changes in caregiver/family schedules which necessitated an increase in personal care hours.

It should be noted that two plans (39 records total) had the most documented number of increases in personal care hours and reflected almost 38% of the increase in the sample. In nearly all instances, as noted above, the reasons for the increases were warranted given changes in members´ condition, hospitalization, or family caregiver limitations warranting increases in personal care hour coverage.

Indicator 4: Transition of Care Period (Decrease)

Of the 427 member records reviewed, 35 (8.2%) indicated a decreased level of personal care hours during the 60-day transitional period. Slight differences in the indicator rates for auto-assigned members and choosers were detected (6.6% and 9.4%, respectively).

In most instances, the reduction in personal care hours per plan was minimal (one or at most two hours per week). However, documentation containing the reasons for the reduction in hours was often not found in the record.

Two plans had a total of eleven (11) records with personal care hour decreases.

Indicator 5: Post Transition of Care Period (Decrease)

Of the 402 records reviewed, 13 (3.2%) indicated a decrease in personal care hours during the post transition period. The rates for auto-assigned and choosers were similar (3.6% and 3.0%, respectively).

Similar to other findings, post transition reductions were generally small (either reduced 1 or 2 hours per week), often without supporting documentation.

Indicator 6: Post Transition of Care Period (Increase)

Of the 402 records reviewed, 25 (6.2%) indicated an increase in personal care hours during the post transition period. The rates for auto-assigned and choosers were similar (6.0% and 6.4%, respectively).

For the most part, documentation for the increase in hours was found in the records. The documentation clearly supported the need for an increase in personal care hours based upon the members´ condition, which necessitated additional care, due to member falls, hospitalizations, and hospitalizations followed by nursing home stays. Change of condition assessments were in place for the majority of these members.

Indicator 7: Post Transition of Care Period (Appeals)

Thirteen records indicated a decrease in post transition personal care hours. In one instance, the member´s intention was to appeal the decision.

SAAM Scoring

IPRO reviewers tracked the scores for the SAAM assessments conducted within the first 30 days of enrollment. The mean SAAM score for auto-assigned enrollees was 15.7; for choosers the mean score was 17.7.

Overall, the personal care audit results were favorable. Nearly 81% of the sample reviewed reflected SAAM assessments conducted within 30 days of enrollment or referral. Approximately one half of the untimely assessments were attributed to inability to contact the member, or members´ refusal to cooperate. The percentage of timely assessments for choosers was somewhat higher than for auto- assigned members (86.9% versus 74.0%).

Approximately 92% of the sample reviewed reflected at least the same level of personal care hours during the 60-day transition period as prior to enrollment. Increases to personal care hours were well documented and appeared justifiable based upon changes in member condition or caregiver support systems.

Only 8.2% of the sample reflected a reduction in personal care hours during the transition period. The majority of these reductions involved small number of hours weekly. However, documentation supporting these decreases was often not in the record. An even smaller percentage of the reviewed sample (3.2%) reflected personal care hour decreases during the post transition period. Again, documentation supporting these changes was often not found. It is IPRO´s intent to follow up with the plans for explanations for these reductions.

With the exception of Indicator 1, no significant differences were observed between auto-assigned and chooser enrollees in any of the personal care hour indicator analyses.

		Combined Results	Auto-Assigned Members	Choosers
SAAM Scores:	Average:	16.7	15.7	17.7
Indicator 1: Initial Clinical Assessment - Newly enrolled members with a clinical assessment conducted within 30 days of the initial referral	Numerator:	360	142	218
	Denominator:	443	192	251
	Rate:	81.3%	74.0%*	86.9%*
Indicator 2: Transition of Care Period - Newly enrolled members with the same level of personal care hours as prior to MLTC enrollment	Numerator:	288	131	157
	Denominator:	427	183	244
	Rate:	67.4%	71.6%	64.3%
Indicator 3: Transition of Care Period - Newly enrolled members with an increased level of personal care hours as prior to MLTC enrollment	Numerator:	104	40	64
	Denominator:	427	183	244
	Rate:	24.4%	21.9%	26.2%
Indicator 4: Transition of Care Period - Newly enrolled members with a decreased level of personal care hours as prior to MLTC enrollment	Numerator:	35	12	23
	Denominator:	427	183	244
	Rate:	8.2%	6.6%	9.4%
Indicator 5: Post Transition of Care Period - Newly enrolled members with an decreased level of personal care hours post transition of care (at least 60 days after enrollment)	Numerator:	13	6	7
	Denominator:	402	167	235
	Rate:	3.2%	3.6%	3.0%
Indicator 6: Post Transition of Care Period - Newly enrolled members with an increased level of personal care hours post transition of care (at least 60 days after enrollment)	Numerator:	25	10	15
	Denominator:	402	167	235
	Rate:	6.2%	6.0%	6.4%
Indicator 7: Post Transition of Care Period - Newly enrolled members appealing the decreased level of care decision	Numerator:	1	0	1
	Denominator:	13	6	7
	Rate:	7.7%	0%	14.3%

*Determined to be a statistically significant difference at p<.001