Quality in Managed Long-Term Services and Supports Programs. Appendix A. Arizona Long-term CARE System

11/01/2013

  Element     Description  
MLTSS Program Arizona Long-Term Care System (ALTCS)
Lead Agency Arizona Health Care Cost Containment System (AHCCCS)
Medicaid Authority 1115 Research and Demonstration Waiver
Inception 1988-1989
Year LTSS Added At inception
Groups Enrolled Elderly, physically disabled, and DD
# Enrolled 52,251 (May 2012)
  1. State Quality Oversight Infrastructure
Infrastructure for oversight of the ALTCS program is integrated into its quality infrastructure for the larger AHCCCS Medicaid Managed Care system. The state employs nearly 75 staff to monitor MCOs and oversee their contracts and service provision. The following entities within AHCCCS are engaged in monitoring ALTCS:
  • Acute Care Operations;
  • ALTCS Operations;
  • Reinsurance;
  • Data Analysis and Research;
  • Medical Management;
  • Clinical QM;
  • OALS.
  1. State IT Infrastructure for Supporting Quality Oversight
PMMIS--The state uses an integrated information infrastructure known as the PMMIS to satisfy the processing and reporting needs of the MCOs. It is composed of 11 core subsystems, 5 reporting and quality oversight subsystems, and a security subsystem to provide extensive information, retrieval, and reporting capabilities to satisfy the data needs of the state, CMS, other state and federal agencies, counties, providers and members. The system processes MCO encounters for all members and supports the monitoring of service utilization, quality of care, and program expenditures. The state noted that the PMMIS is a mature system that has been modified over time to accommodate the growing and changing needs of the MLTSS program.

ADDS--Generates reports on performance measures, utilization data), recipient enrollment and demographic information, as well as specialized queries. There are more than 100 separate measures in ADDS that can be selected to monitor and improve quality.

  1. MCO Quality Oversight Responsibilities
The MCO is required to have several key staff position for quality oversight/reporting including:
  • Medical Director/CMO, who is a state licensed physician, who is involved in all major clinical and QM components of the MCO; oversees the QM/PI program monitoring, and evaluation activities; and, serves as chair to quality oversight committees.
  • QM Coordinator whose primary functions include ensuring individual and systemic quality of care; integrating quality throughout the organization; implementing process improvement; resolving, tracking and trending quality of care grievances; and, ensuring a credentialed provider network.
  • Performance/QI Coordinator whose responsibility is to focus organizational efforts on improving clinical quality performance measures; develop and implement PIPs; utilize data to develop intervention strategies to improve outcomes; and, report QI/performance outcome.

The MCO must ensure that the QM/QI Unit within the organizational structure is separate and distinct from any other units or departments (e.g., Medical Management or Case Management units).

  1. State Audits of MLTSS Program
The state conducts administrative OFR of each MCO to meet the federal requirements, as well as to determine the extent to which each MCO meets the state's contract requirements, policies, and additional federal and state regulations. The OFR includes the following areas that are reviewed at least every 3 years (although some areas are reviewed more frequently due to new requirements, compliance concerns and/or specific areas of interest):
  • Behavioral Health;
  • Case Management;
  • Claims System;
  • Corporate Compliance;
  • Cultural Competency;
  • Delegated Agreements;
  • Delivery System;
  • General Administration;
  • Grievance System;
  • Maternal and Child Health;
  • Medical Management;
  • QM;
  • QI;
  • Reinsurance;
  • Third Party Liability.

The state also uses the OFR to increase its knowledge of each MCO's operational and financial procedures; provide technical assistance where needed; identify areas for improvement; and, areas of noteworthy performance and accomplishment.

The state provides oversight of MCO case management through the following reports and processes:

  • Annual OFR;
  • Audit of case management administrative functions;
  • Audit of member case files/charts;
  • Member satisfaction surveys;
  • Interviews with case managers;
  • Standardized reports on programmatic requirements (e.g., timely case manager visits, CES averages);
  • Annual Case Management Plan;
  • Service Gap Reporting/Non-Provision of Services--Monthly and semi-annual reporting, documenting when services are not provided as authorized.
  1. Performance Measures and Quality-Related Reports
The state requires Performance Measures for all member populations. In addition, the state may also analyze and report results by line of business/program, GSA or county, and/or applicable demographic factors to identify opportunities for improvement. The following is a list of MCO-required performance measures:
  • Access to Behavioral Health Provider (encounter for a visit) within 7 days of being designated as "active care" for an initial visit.
  • Access to Behavioral Health Provider (encounter for a visit) within 23 days of being designated as "active care" for an initial visit.
  • ADL Maintenance/Improvement (functional status assessment): DELAYED IMPLEMENTATION, Tabled for CYE 2014.
  • Screening for Clinical Depression and Follow-Up Plan: DELAYED IMPLEMENTATION, Tabled for CYE 2014.
  • Advance Directives.
  • Use of High Risk Medications in the Elderly: DELAYED IMPLEMENTATION, Tabled for CYE 2014.
  • HCBS Member Satisfaction Survey--This survey is currently being developed. Results will not be reported out as performance measures; rather, the state will meet with contractors following receipt of survey results to discuss and plan future interventions, which may include opportunities to sustain positive feedback or Corrective Action Plans in areas of lower satisfaction.
  • Use of High Risk Medications in the Elderly: DELAYED IMPLEMENTATION, Tabled for CYE 2014.
  • Medication Reconciliation Post Discharge: DELAYED IMPLEMENTATION, Tabled for CYE 2014.
  • CAHPS Health Plan Survey v 4.0--Adult Questionnaire with Supplemental Items--A CAHPS survey is not planned for the state's elderly and/or physically disabled populations at this time; however, the state will continue to monitor national movement for LTSS satisfaction surveys and reserves the right to implement a CAHPS or CAHPS-like survey at a later date.
  • Screening for Clinical Depression and Follow-Up Plan: DELAYED IMPLEMENTATION, Tabled for CYE 2014.

LTSS-focused performance measures include:

  • Timeliness of Initial SP Development.
  • Initiation of Services (within 30 days).

The state requires MCOs to meet periodic reporting requirements to include the following contract deliverables include:

  • Case Management Plan (annually).
  • Cultural Competency Evaluation (annually).
  • Enrollee Appeal and Provider Claim Dispute Report (quarterly).
  • Enrollee Grievance Report (quarterly).
  • Medical Management Plan and Evaluation (annually).
  • Member/Provider Council Plan (annually).
  • Network Development and Management Plan (annually).
  • QM Plan and Evaluation (annually).
  • QM Reports (quarterly).
  • Service Gaps for Attendant Care, Personal Care, Homemaker and Respite Care (bi-annually).

To monitor receipt of services, the state requires the MCOs to submit a Non-Provision of Services Logs monthly and quarterly to document when services are not provided as authorized. The state defines the term "critical services" as inclusive of tasks such as bathing, toileting, and dressing, feeding, and transferring to or from bed or wheelchair, and assistance with similar daily activities. A gap in critical services is defined as the difference between the number of hours of home care worker critical service scheduled in each member's HCBS care plan and the hours of the scheduled type of critical service that are actually delivered to the member.

When a member experiences a gap in critical services, they are directed to submit the Critical Service Gap Report Form, which can be mailed to the MCO. The member is also encouraged to call the toll-free state line, the provider and/or MCO rather than mailing the Critical Service Gap Report form so that the service gap can be responded to more timely. In those instances where an unforeseeable gap in critical services occurs, it is the responsibility of the MCO to ensure that critical services are provided within 2 hours of the report of the gap.

  1. LTSS-Focused PIPs
None specified.
  1. Care Coordination
MCO case managers' responsibilities include:
  • Conducting ongoing monitoring of the services and placement of each member.
  • Visiting members in their place of residence every 180 days for members residing in NFs and every 90 days for members residing in the community.
  • Annually reviewing member handbook with the member or representative.
  • Reviewing the MCO's process for immediately reporting any unplanned gaps in service delivery.

The MCO is required to initiate a SP for each member at the first visit with the member, within 12 business days of enrollment. The MCO case manager reviews and updates the SP at each visit with the member or when there is a change in the member's condition or recommended services.

MCOs must identify and facilitate coordination of care for all members during changes or transitions between MCOs, as well as changes in service areas, subcontractors, and/or health care providers. Members with special circumstances may require additional or distinctive assistance during a period of transition. Policies or protocols have been developed to address these situations.

If a member is referred to and approved for long-term care, the MCO must coordinate the transition with the assigned long-term care facility provider to assure that applicable protocols are followed for any special circumstances of the member, and that continuity and quality of care is maintained during and after the transition.

  1. 24-Hour Back-Up
The state requires MCO's to develop a Contingency/Back-Up Plan during the initial service planning process for all members who will receive Attendant Care, Personal Care, Homemaker and/or Respite Care services (referred to as "critical services") in their own homes. In addition, the MCO's must review the plan quarterly and have it signed by the member or member's representative. The Contingency/Back-Up plan outlines the in-home service provided to the member, the member's service preference level (how quickly the member feels the service would need to be replaced if the scheduled caregiver did not show up), and actions the member, or the member's representative will take to report and resolve gaps. The SP also provides the telephone number for the state hotline and provider/MCO telephone numbers, which are available 24/7.
  1. CI Reporting and Investigation
The MCO is required to track and trend member and provider issues, which includes investigation and analysis of quality of care issues, abuse, neglect and unexpected deaths. The resolution process must include:
  • Acknowledgement letter to the originator of the concern.
  • Documentation of all steps utilized during the investigation and resolution process.
  • Follow-up with the member to assist in ensuring immediate health care needs are met.
  • Closure/resolution letter that provides sufficient detail to ensure that the member has an understanding of the resolution of their issue, any responsibilities they have in ensuring all covered, medically necessary care needs are met, and an MCO contact name/telephone number to call for assistance or to express any unresolved concerns.
  • Documentation of implemented corrective action plan(s) or action(s) taken to resolve the concern.
  • Analysis of the effectiveness of the interventions taken.
  1. Mortality Review
Mortality reviews are conducted on IDD member deaths by the MCO. The MCO for this population is the state's Division of Developmental Disabilities.
  1. EQRO Responsibilities
The state does not utilize the EQRO beyond the mandatory activities specified in CFR 438.
  1. Ombudsman/ Function
The MCO is required to have a Dispute and Appeal Manager who manages and adjudicates member and provider disputes including member grievances, appeals and requests for hearing and provider claim disputes.
  1. Experience of Care/ Satisfaction Surveys
Since its inception in the late 1980s, the state has conducted a limited number of comprehensive ALTCS member satisfaction surveys. The most recent survey was conducted in 2008 with elderly and physically disabled members. The state is currently developing a comprehensive HCBS member satisfaction survey. Beginning in calendar year 2014 the MCO contracts require that the MCOs perform an annual survey of ALTCS members including questions related to case manager performance, waiting time for appointments, transportation wait times and culturally competent treatment of members. MCOs must use personnel other than case managers to administer the survey. Targeted surveys are also conducted with a limited number of ALTCS members in conjunction with the OFR process.
  1. Membership Oversight
Venues for suggestions and feedback, such as public forums, member councils, and meetings with MCOs and providers, are regularly sponsored by the state. For the original Quality Strategy, as well as any subsequent substantive changes to the document, the state solicits input from the Director's State Medicaid Advisory Committee, which includes the Medicaid Director, representation from the American Indian community, MCO members, seniors, the disabled, and child advocacy communities, NF and HCBS advocates, the medical community (physicians), the state's Department of Health Services and the Department of Economic Security. These meetings are open are regularly attended by citizens, in addition to Council members.

MCO members also play a role in quality oversight by completing the Critical Service Gap Report Form. This mail-in form provides an opportunity for members to report a critical service gap.

  1. State Technical Assistance to MCOs
The state has frequent communications with MCOs providing an ongoing forum for feedback and technical assistance. For example, annually, contractors submit their QM/Performance Improvement Plans and Evaluations of the previous year's activities, UM Plans and Evaluations, PIP proposals and reports. The state's Clinical QM team coordinates a review of all these plans with other units within the state. After they review and analyze them along with the MCO's quarterly reports, they meet with the MCO to review any outstanding issues and use this opportunity to provide technical assistance.
  1. MCO Report Cards on LTSS
None specified.
  1. Financial Incentives, Penalties and Withholds
The state has not employed financial incentives. However, they are participating in a CHCS initiative that focuses on developing P4P programs in Medicaid. The programs under consideration focus on diabetes care, asthma, and care provided in nursing homes. Funding for the P4P programs was on hold due to state budget constraints.
  1. Other Quality Management/ Improvement Activities
The state has an immediate jeopardy process that activates MCO staff when a significant health or safety issues is identified in a placement setting. MCOs are required to go on-site upon notification to conduct health and safety evaluations and take whatever action is necessary to ensure the safety of members.

The state routinely communicates to MCOs the occurrence of adverse quality events that may have system-wide implications, so that the MCOs can address these issues in the spirit of QI.

Review of reports and other date sometimes lead the state to conduct mini-audits to understand the reasons for data variances. These activities provide the state with information that may lead to corrective action plans and/or policy changes.

ADDS = Arizona Data Decision Support System
ADL = activity of daily living
AHCCCS = Arizona Health Care Cost Containment System
ALTCS = Arizona Long-Term Care System
CAHPS = Consumer Assessment Health Care Providers and Systems

CFR = Code of Federal Regulations
CHCS = Center for Health Care Strategies
CI = critical incident
CMO = Chief Medical Officer
CMS = Centers for Medicare and Medicaid Services

EQRO = external quality review organization
GSA = geographic services area
HCBS = home and community-based services
IDD = intellectual and developmental disabilities
IT = information technology

LTSS = long-term services and supports
MCO = managed care organization
MLTSS = managed long-term services and supports
NF = nursing facility
OALS = Arizona Office of Administrative Legal Services

OFR = Operational and Financial Reviews
P4P = pay-for-performance
PIP = performance improvement project
PMMIS = Pre-Paid Medical Management Information System
QI = quality improvement

QM = quality management
SP = service plan
UM = utilization management

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