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By Monica E. Oss

Since publishing our last few pieces on the changes in the I/DD market – The Future Of IDD Is In The Home, Strategy In The I/DD Market, and The I/DD Market Evolution – we’ve had a number of OPEN MINDS Circle member requests to provide some concrete examples of performance measures, service guidelines, and value-based reimbursement (VBR) arrangements.

As it happened, the New York Office for People With Developmental Disabilities (OPWDD), in conjunction with the New York Department of Health (DOH), plans to launch care coordination organization health homes (CCO/HHs) for consumers with developmental disabilities in July 2018 (see New York Medicaid To Launch Health Homes For People With Developmental Disabilities). It is a perfect example of this shift in the market.

The Consumers & Eligible Provider Organizations

The CCO/HH program will enroll consumers with an I/DD whose condition results in a substantial handicap to their ability to function normally in society. Eligible conditions include but are not limited to mild to profound intellectual disabilities, speech and language disorders due to hearing loss, autistic disorders, epilepsy, and cerebral palsy. Individuals with I/DD who do not have a substantial handicap may enroll in the CCO/HH program if they have another chronic condition. Consumers may opt-out of the program, but must have their home- and community-based services (HCBS) case management services provided through the CCO/HH. Children with I/DD eligible to be served by the state’s children’s health home program will not be eligible to enroll in the CCO/HH program, and consumers enrolled in the state’s dual demonstration program, FIDA I/DD, will not be eligible for health home services.

Eligible providers – the CCO/HHs – must meet a few criteria. The organizations must have a 51% ownership/control by one or more organizations with a history of providing or coordinating developmental disability services. And, they must be able to provide services across the entirety of one of the state’s five I/DD regions and be able to serve at least 10,000 consumers (the state may make exceptions for organizations that are able to serve 5,000 consumers).

The Performance Measures

Care plans must track and report key performance measure to the State. The quality and process metrics for the I/DD health home population include:

Goal: Improve outcomes for persons with I/DD through care coordination (health/personal/social)
Measures Data Source Measure Description
Implementation of Council on Quality Leadership (CQL) Personal Outcome Measures (POMs)* CCO reporting Percentage of Life Plans that have minimum of two POM measures. CCO must record in Life Plan Personal Outcome Measures (POM) drawn from CQL reporting guidelines. Life Plan must reflect at least three personal goals, of which two must be POM directed.
Implementation of personal safeguards CCO reporting Percentage of Life Plans that reflect personal safeguards for all members. CCO must record personal safeguards in Life Plan
Transitioning to a more integrated setting Claims TABS Of those members who are in a 24-hour certified setting, the number/percentage of enrollees who move to a more integrated setting
Employment CCO reporting Of those members who indicate in their life plan they choose to pursue employment, the number/percentage of individuals who are employed (compared to the previous reporting period). CCO will record enrollee progress and verify support to find and maintain community integrated employment in Life Plan
Self-direction Claims Of those members who select self-direction as indicated in the life plan, the number/percentage of individuals who enroll in selfdirection) compared to the previous reporting period). CCO will identify those who choose to self-direct their supports and services with either or both employer authority and budget authority in the Life Plan.
Goal: Improve Preventive Care
Measures Data Source Measure Description
Bladder and Bowel Continence CCO reporting CAS Of those members with an identified bladder/bowel health risk, the number/percentage of those that have a care plan in place that includes recording of support or device needs bowel/incontinence tracking protocol, bowel/incontinence management protocol. CCO will report risk based on initial screening.
Falls CCO reporting Of those members with an identified risk of falls, the number/percentage of members who have a care plan that includes supervision, contact guarding, adaptive equipment, environmental modifications or other directed support. CCO will report risk based on initial screening.
Choking CCO reporting Of those members with an identified risk of choking, the number/percentage of members who have a care plan with safeguard(s) including modified consistency of foods and/or liquids, avoidance of high risk foods, requires supervision, formal training/dining plan required. CCO will report risk based on initial screening.
Goal: Improve Transitional Care
Measures Data Source Measure Description
Supporting individuals’ transition from institutional settings to community settings CCO reporting Claims CAS Of those members who move to a setting other than a 24-hour certified setting, the number/percentage of transitions identified in TABS/claims compared to number/percentage of care transition records transmitted to Health Care Professionals by the CCO. CCO must report member transitions from 24-hour certified setting to community placement/setting.

The Reimbursement Model

The state has released preliminary per member per month rates for the CCO/HH program. CCO/HHs will receive a tiered rate based on member acuity and the region where the CCO operates. The state has developed a new assessment tool known as the Coordinated Assessment System (CAS) that will be used to determine a consumer’s tier for payment purposes. Until the tool is ready for use, member acuity will be determined using the Developmental Disabilities Profile 2 Data (for more, see Developmental Disabilities Profile (DDP-2) Users’ Guide).

As with many initiatives in the U.S. health and human service system, if you’ve seen one, you’ve seen one. It’s not that this model will be replicated exactly from one payer and location to the next; but, the principles we see in this program are representative of developments we expect to see across payers and across health plans, for consumers with I/DD and for other consumers with complex needs. The challenge for executive teams is how to develop a high-value, competitive program that serves this need in their markets.

For more from the OPEN MINDS Industry Library about the I/DD market, check out these resources:

  1. The Framework For Financing Services For Consumers With I/DD
  2. I/DD Reimbursement Changes Bring New Management Challenges
  3. Managed Long-Term Services & Supports & The I/DD Market: A Market Map
  4. What Are The Medicaid Financing & Service Delivery Systems For The I/DD Population Receiving LTSS?: An OPEN MINDSMarket Intelligence Report
  5. How Many Consumers With I/DD Are Served By Medicaid HCBS Waivers & How Many Consumers Are On A Wait List?: An OPEN MINDSMarket Intelligence Report

For more, join me on September 27 for the keynote address by Nancy Thaler, Pennsylvania’s Deputy Secretary for the Office of Developmental Programs, “The Future Of Long-Term Services & Supports: A New Business Model For A Medicaid Managed Care Market,” at The 2017 OPEN MINDS Executive Leadership Retreat.

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