Measuring Long-Term Services and Supports Rebalancing

MaryBeth Musumeci
Published: Feb 02, 2015

Over the last several decades, states have been working to rebalance their long-term services and supports (LTSS) systems by devoting a greater proportion of Medicaid spending to home and community-based services (HCBS) instead of institutional care.¹ Rebalancing efforts are driven by beneficiary preferences for HCBS, the fact that HCBS are typically less expensive than comparable institutional care, and states’ community integration obligations under the Americans with Disabilities Act and the Olmstead decision.² While most states continue to rely on § 1915(c) waivers to expand beneficiary access to Medicaid HCBS, a significant number of states (13 in FY 2014 and 16 in FY 2015) report that incentives built into their managed LTSS programs are expected to increase beneficiary access to HCBS.³ As a result, measuring LTSS rebalancing is an important means of determining the extent to which Medicaid managed LTSS programs are achieving their intended goals. This fact sheet provides a brief overview of quality measures related to LTSS rebalancing; it is not an exhaustive review of quality measures in this area. Table 1 summarizes some of the existing measures, with specific examples provided in Tables 2, 3, and 4. A companion issue brief summarizes key themes from a roundtable discussion of issues related to the assessment of rebalancing in capitated Medicaid managed LTSS programs.⁴

Some existing quality measures focus on the extent of community integration experienced by people with LTSS needs. These measures generally survey individual beneficiaries by asking them to report on factors such as their level of satisfaction with where they currently live, their ability to choose where they live, the degree of control they have over their daily activities, the amount of community involvement they have in their work and leisure activities, and whether they are receiving adequate services to support their needs (Table 2). One of the more long-standing sets of these measures, dating to 1997, is the National Core Indicators (NCI).⁵ The NCI presently are used in 39 states in programs that serve people with developmental disabilities; one NCI domain focuses on individual outcomes, including community inclusion. More recently, the NCI-Aging and Disabilities has been developed to survey seniors and people with physical disabilities about similar issues. The NCI-Aging and Disabilities survey was piloted in three states in 2014, and the year one survey will take place in 2015.⁶

Some Medicaid managed LTSS programs include measures related to LTSS rebalancing. For example, several of the capitated financial alignment demonstrations for dual eligible beneficiaries⁷ require states to report on the number or percentage of beneficiaries living in institutional or community-based settings, those transitioning between institutional and community-based settings, and those experiencing decreases in personal care hour authorizations (Table 3). Some of these measures are specified in the memoranda of understanding between the Centers for Medicare and Medicaid Services (CMS) and the states that authorize the demonstrations, while others are still to be determined in the three-way contracts between CMS, the state, and the health plans. As illustrated in Table 3, these measures vary among the states. In most of these demonstrations, one or two of these measures is included in the subset of measures used to determine whether health plans can earn back their quality withhold funds. Although LTSS rebalancing is not among CMS’s § 1915(c) HCBS waiver quality measures,⁸ CMS’s 2013 guidance requires states to have a “comprehensive quality strategy” in Medicaid managed LTSS waivers. ⁹ Reporting requirements related to LTSS rebalancing are included in a few states’ managed LTSS demonstrations (Table 4). In addition, the evaluation of Kansas’ § 1115 managed LTSS demonstration must assess whether the demonstration reduces the percentage of beneficiaries in institutions by providing additional HCBS and the impact of including LTSS in the capitated benefit, with a subfocus on HCBS. CMS also has awarded Testing Experience and Functional Assessment Tools grants to states to use health information technology to develop HCBS quality measures.¹⁰

Measuring LTSS rebalancing remains a gap in assessing HCBS quality, with work to develop these measures continuing. In August 2014, the National Quality Forum (NQF) Measure Applications Partnership “emphasiz[ed] that new and improved measures are needed to evaluate community integration/inclusion and participation” for dual eligible beneficiaries and identified this area as among the “high priority measure gaps.”¹¹ NQF is accepting nominations in late 2014 for a multi-stakeholder committee to create a conceptual framework, conduct an environmental scan, identify gaps, and recommend measure development efforts as part of its two-year Quality Measurement for HCBS project.¹²

Table 1: Examples of Quality Measures Related to LTSS Rebalancing and Community Integration
Type of Measure	Type of Information Collected
Beneficiary surveys	Beneficiary’s level of satisfaction with current living arrangement Beneficiary’s ability to choose where she lives Beneficiary’s degree of control over her daily activities Beneficiary’s amount of community involvement in work and leisure activities Whether beneficiary is receiving adequate services to support her needs
Numeric reporting requirements	Number or percentage of beneficiaries living in institutional or community-based settings Number or percentage of beneficiaries transitioning between institutional and community-based settings Number or percentage of beneficiaries experiencing decreases in personal care hour authorizations

Looking Ahead

As additional states express interest in implementing managed LTSS programs, the design, use, and interpretation of quality measures related to LTSS rebalancing will be an important aspect of evaluating these programs. Although some measures in this area exist, LTSS measures generally are not as well developed as those for care provided in clinical settings, and work is continuing in this area. Along with measuring the extent to which beneficiaries are served in community-based settings as opposed to institutions, it also is important to assess whether the services provided in community-based settings are adequate to support beneficiary needs. Along with evaluating whether and how community integration is achieved, additional areas in which quality measures important to people who use LTSS could be further developed include those related to beneficiary satisfaction, quality of life, and disability accessibility. Quality measures play an important role in ensuring that information is available to adequately assess whether HCBS programs, including managed LTSS, are achieving their intended goals.

Table 2: Selected Quality Measures Related to Community Integration
Source	Year	Measures
National Core Indicators (for people with developmental disabilities)	In use since 1997; currently used in 39 states	Proportion of people who report that they would like to live somewhere else Proportion of people who make choices about their everyday lives, including community job, day activity, home Proportion of people who report having been provided options about where to live, work, and go during the day (e.g., number of homes visited) Proportion of people who regularly participate in everyday integrated activities in their communities Proportion of people who have a job in the community
National Core Indicators – Aging and Disabilities	Piloted in 3 states in 2014; year 1 survey in 2015	Do services meet needs (no, some services/some needs, yes); what additional services are needed? Would person prefer to live somewhere else (no, yes); what prevents person from living somewhere else? Would person have to live somewhere else without current services (no, maybe/not sure, yes, don’t know) Where would person like to move (own home/apt., assisted living, NF) Has person participated in some social activity in last 30 days inside or outside home? If not, why? Does person get to do things outside of home when wants to? If not, why? Does person feel as independent as they can be? (no, in-between, yes)
Agency for Healthcare Research and Quality Environmental Measure Scan	2007	Participants reporting unmet need for community involvement Satisfaction with community activities Proportion of people who participate in everyday integrated activities in their communities People live in communities Proportion of people who participate in integrative community activities
University of California, San Francisco Center for Personal Assistance Services Selected Inventory of Quality-of-Life Measures for LTSS Participant Experience Surveys	2012	Satisfaction with living arrangement (e.g., do you like where you’re living now?)· Choice in living arrangement (e.g., did you choose to live in the community instead of living in an institution?) Control over transportation and leaving the house (e.g., can you plan a trip or decide when to go out?) Control over leisure activities (e.g., who decides how you spend your free time?) Control over other daily activities (e.g., who decides your daily schedule?) Satisfaction with amount of social contact (e.g., I would like more companionship or contact with other people: strongly agree, agree, neither agree nor disagree, disagree, strongly disagree) Satisfaction with extent of social network (e.g., in general, how would you rate your satisfaction with your social activities and relationships? Excellent, very good, good, fair, poor) Satisfaction with use of time (e.g., overall are you satisfied or dissatisfied with the way you are spending your life these days?) Satisfaction with level of activity (e.g., how satisfied are your with your level of activity? Very dissatisfied, dissatisfied, neither satisfied nor dissatisfied, satisfied, very satisfied) Roles, fulfillment, meaning (e.g., I do paid or unpaid work or activities that give me a role in life: strongly agree, agree, neither agree nor disagree, disagree, strongly disagree) Satisfaction with extent of participation (e.g., are you as socially active as you’d like to be – like participating in community activities?) Quality or nature of participation (e.g., is there anything you want to do outside your home that you don’t do now?) Membership in community (e.g., I feel that I am a part of my community. Would you say that statement is true, mostly true, mostly false, or false?)
SOURCES: National Core Indicators, available at http://www.nationalcoreindicators.org/; National Core Indicators – Aging and Disabilities State Initiative (Sept. 2014), http://www.nasuad.org/initiatives/national-core-indicators-aging-and-disabilities; Agency for Healthcare Research and Quality, Medicaid Home and Community-Based Services Measure Scan (July 2007), available at http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/hcbsreport/index.htmll; H. Stephen Kaye, Center for Personal Assistance Services, University of California San Francisco, Selected Inventory of Quality-of-Life Measures for Long-Term Services and Supports Participant Experience Surveys (Dec. 2012), available at http://dredf.org/Personal-experience-domains-and-items.pdf.

Table 3: Selected Quality Measures Related to Rebalancing in States’ Capitated Financial Alignment Demonstrations for Dual Eligible Beneficiaries
State	Measures
CA	IHSS utilization NF utilization Unmet LTSS needs (ADLs, IADLS, IHSS functional level)
IL	Number of beneficiaries moving from institutional to waiver services*, community to waiver services, community to institutional care, and waiver to institutional care (excluding institutional stays ≤90 days)
MA	Percent of beneficiaries with LTSS needs who have LTSS coordinator* Documented discussion of beneficiary rights and choice of providers
MI	Percent of enrollees with LTSS needs who have an LTSS Supports Coordinator Number of enrollees who lived outside NF during current measurement year as proportion of enrollees who lived outside NF during previous year
NY	Number of NF certifiable beneficiaries who lived outside NF during the measurement year as proportion of NF certifiable participants who lived outside NF during previous year* Number of beneficiaries who did not reside in NF >100 continuous days in a year as a proportion of total number of beneficiaries in plan Number of participants who were discharged to community setting from NF and who did not return to NF during current year as proportion of number of beneficiaries who resided in NF during previous year (>100 continuous days) Percent of beneficiaries who reside in NF, wish to return to community and were referred to preadmission screening team or Money Follows the Person
OH	Number of beneficiaries who did not reside in NF as proportion of total number of beneficiaries in health plan (>100 continuous day stay)* Number of beneficiaries who lived outside NF during current year as proportion of beneficiaries who lived outside NF during previous year (>100 continuous day stay)* Number of beneficiaries who were discharged to community setting from NF and did not return to NF during current year as proportion of number of beneficiaries who resided in NF during previous year Number of beneficiaries who were in NF during current year, previous year or combination of both years who were discharged to community setting for at least 9 months during current year as proportion of number of enrollees who resided in NF during current year, previous year or combination of both years (100+ days)
SC	Percent of enrollees newly approved or eligible for HCBS with waiver care plan jointly approved by waiver case manager, state, and health plan and included in overall care plan within 30 days of waiver enrollment; and percent of enrollees already receiving HCBS with waiver care plan included in overall care plan within 30 days of health plan enrollment* Health plan has work plan and systems in place to ensure smooth transitions among hospitals, NF and community* Percent of enrollees eligible for HCBS with a waiver care plan within specified timeframes; and percent of enrollee waiver care plans that contain documented discussion of care goals within specified timeframes* Percent of enrollees who transition to and from hospitals, NF and community; proportion of those who transition among settings who return to an institutional or community setting; and percent of care transitions recorded and transmitted to plan care coordinator* Number of enrollees transitioning from institutional care to waiver services, community to waiver services, community to institutional care, and waiver services to institutional care (excluding institutional stays of less than 90 days) Number and percent of all enrollees referred to LTSS, NF and HCBS Percent of enrollees who require HCBS as indicated by care assessment and care plan and receive services within 90 days of enrollment Percent of enrollees receiving HCBS who experience decrease in authorization of attendant care or companion service hours, compared across demonstration years experience decrease or increase in authorization of personal care or respite care hours, compared across demonstration years experience decrease in HCBS authorization Number of enrollees who use assisted living, other congregate housing, and independent living options
TX	Two LTSS measures to be determined* NF/HCBS measure to be determined
VA	Health plan has established work plan and systems in place for ensuring smooth transitions to and from hospital, NF and community· Percent of beneficiaries who transition to and from hospital, NF, and community Percent of waiver beneficiaries who: experience decrease in authorization of personal care hours experience increase in authorization of personal care hours Number of beneficiaries moving from institutional care to waiver services, community to waiver services, community to institutional care, and waiver services to institutional care (> 90 day stay) Number and percent of all new enrollees who have LOC indicating need for institutional or waiver services Number and percent of waiver beneficiaries who: have service plans adequate and appropriate to their needs and personal goals as indicated in assessment received services of the type specified in service plan received services in the scope specified in service plan received services in the amount specified in service plan received services for the duration specified in service plan received services in the frequency specified in service plan records contain appropriately completed and signed form that specifies that choice was offered between institutional and waiver services; and that choice was offered among waiver services records document that choice of waiver providers was provided to beneficiary
WA	Number of members moving from institutional to waiver services; community to waiver services; community to institutional services, and waiver to institutional services* HCBS services are delivered in accordance with individualized care plan, including type, scope, amount, duration and frequency* Enrollee report of personal care hours noted in eligibility tool and what was authorized Enrollee report of DME requests documented in eligibility tool and those that were authorized/provided
NOTES: * indicates quality withhold measure. CA, OH, MI, SC, TX, and VA’s MOUs also indicate that CMS will work closely with state to monitor other measures related to community integration.SOURCE: KCMU analysis of states’ financial alignment demonstration memoranda of understanding with CMS, available at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/ApprovedDemonstrationsSignedMOUs.html.

Endnotes

See generally Kaiser Commission on Medicaid and the Uninsured, Medicaid Beneficiaries Who Need Home and Community-Based Services: Supporting Independent Living and Community Integration (March 2014), available at https://www.kff.org/medicaid/report/medicaid-beneficiaries-who-need-home-and-community-based-services-supporting-independent-living-and-community-integration/; Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and Community-Based Services Programs: 2010 Data Update (March 2014), available at https://www.kff.org/medicaid/report/medicaid-home-and-community-based-service-programs/.

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See generally Kaiser Commission on Medicaid and the Uninsured, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid: 15 Years After the Supreme Court’s Olmstead Decision (June 2014), available at https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/.

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Kaiser Family Foundation, Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015 at 29 (Oct. 2014), available at https://www.kff.org/medicaid/report/medicaid-in-an-era-of-health-delivery-system-reform-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2014-and-2015/.

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Kaiser Commission on Medicaid and the Uninsured, Assessing Rebalancing in Capitated Medicaid Managed Long-Term Services and Supports Programs (Jan. 2015), available at https://www.kff.org/medicaid/issue-brief/rebalancing-in-capitated-medicaid-managed-long-term-services-and-supports-programs-key-issues-from-a-roundtable-discussion-on-measuring-performance/.

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National Core Indicators, available at http://www.nationalcoreindicators.org/.

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National Core Indicators – Aging and Disabilities, http://www.nasuad.org/initiatives/national-core-indicators-aging-and-disabilities.

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See generally Kaiser Commission on Medicaid and the Uninsured, Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS (July 2014), available at https://www.kff.org/medicaid/issue-brief/financial-alignment-demonstrations-for-dual-eligible-beneficiaries-compared/.

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CMS, Modifications to Quality Measures and Reporting in § 1915(c) Home and Community-Based Waivers (March 2014), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/3-CMCS-quality-memo-narrative.pdf. Measure areas include level of care determinations; service plan adequacy; provider qualifications; abuse, neglect, and exploitation; financial accountability; and state oversight.

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CMS, Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports Programs at 6, 15 (May 2013), available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf.

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CMS, Testing Experience and Functional Assessment Tools, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Grant-Programs/TEFT-Program-.html.

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National Quality Forum, 2014 Input on Quality Measures for Dual Eligible Beneficiaries (Aug. 2014), available at http://www.qualityforum.org/Publications/2014/08/2014_Input_on_Quality_Measures_for_Dual_Eligible_Beneficiaries.aspx.

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National Quality Forum, Quality Measurement for Home and Community-Based Services, available at http://www.qualityforum.org/ProjectDescription.aspx?projectID=77692.

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Measuring Long-Term Services and Supports Rebalancing

Looking Ahead

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