NCQA Distinction: Helping Coordinate LTSS

More than 3 million people in the United States rely on Medicaid for Long-Term Services and Support (LTSS) in nursing homes, home care, and community-based settings.

LTSS supports people with functional limitations and chronic illnesses who need help to do routine daily tasks, such as bathing, dressing, preparing meals, and taking medications.

NCQA’s LTSS Distinction for Health Plan program is designed to help healthcare organizations and payers improve their operations and initiatives that target quality care delivery. A standard framework used is one that delivers effective, person-centric care that meets people’s needs and aligns with the state’s unique requirements.

Show coordination

NCQA’s LTSS Distinction for Health Plans help payers who offer managed health services and coordinated social services, by providing a framework for delivering operational efficiencies, integrated care, planning and contracting support.

The Health Plan LTSS Distinction focuses on:

  • person-centered care planning;
  • effective care transitions;
  • coordinating caregiver, individual, LTSS provider, and clinical services;
  • providing an incident management system; and,
  • quality and assistance for LTSS providers.

The LTSS Distinction for Health Plans is based on an organization’s ability to demonstrate the effective coordination of services between caregivers, individuals, LTSS providers and clinicians. Measuring LTSS quality examines the different ways care should work for these individuals.

 With LTSS, it’s important to track non-medical benefits, such as repairs to accommodate the person remaining at home (including construction of wheel chair ramps, installing tub railings, etc.). The health plan should know their state’s LTSS requirements and whether their information system supports tracking, whether changes need to be made to collect the data, whether data needs retrofitting, and whether the systems are performing/reporting accurately.

Through assessments, IQVIA’s Healthcare Center of Excellence (COE) can assist the health plan in determining what’s working and what’s not accurate. The COE can determine whether the health plan is misinterpreting the state requirements or if in fact, a minor tweak in workflow or policy may meet the requirement.

Risk stratification

The state government sets the initial level and utilization requirements, and the health plan does its own leveling from time-to-time. For example, a member who suffered a stroke may have recovered the following year, so the risk level needs modification. We recommend weaving the risk stratification into the health plan’s current assessment.

There are several Risk Stratification methods used, including:

Hierarchical Condition Categories (HCCs): Part of CMS’ Medicare Advantage Program, HCCs have 70 categories selected from ICD codes that include expected health expenditures.

Adjusted Clinical Groups (ACG): Developed by Johns Hopkins University, ACGs use inpatient and outpatient diagnoses to classify patients into one of 93 categories. These are used to predict hospital utilization.

Elder Risk Assessment (ERA): For adults over 60, ERA uses age, gender, marital status, number of hospital days over two years, and selects comorbid medical illness to assign an index score.

Chronic Comorbidity Count (CCC): Based on publicly available information from the Agency for Healthcare Research and Quality (AHRQ)’s Clinical Classification Software, which is the total of selected comorbid conditions grouped into six categories.

Minnesota Tiering (MN): Based on Major Extended Diagnostic Groups (MEDCs), MN Tiering groups patients into one of five tiers: Tier 0 (Low: 0 Conditions), Tier 1 (Basic: 1 to 3), Tier 2 (Intermediate: 4 to 6), Tier 3 (Extended: 7 to 9), and Tier 4 (Complex: 10+ Conditions).

Charlson Comorbidity Measure: This measure predicts the risk of one-year mortality for patients with a range of comorbidities.

One thing the models share is they are based on comorbidity. Understanding comorbidity is important to population health management because comorbidities can increase the risk and cost of delivering care.

An initial assessment to determine LTSS Distinction includes completing between 8-15 forms. We review the forms from various systems, evaluate the health plan, and determine whether they are ready for the NCQA audit. Audit ready means the health plan satisfies the state’s requirements. IQVIA’s Healthcare Center of Excellence can identify care management processes, stratification, etc., that because of our years of experience, we are prepared to ask.

If the health plan performed a review of its case management in the past, and has associated medical management processes, then they’re much closer to NCQA accreditation than they may have thought. Often, we find that the health plan doesn’t have to start from the beginning.

One example of where a health plan may need to start its initial work, is if it’s now offering Medicare products/services, expanding into a new market, or were acquired by another plan and had not previously offered a Medicare plan.

Tracking measurements

We often discover health plans where teams are documenting care in an Excel spreadsheet, meaning the information being entered is not reportable. It’s really an informal vs. formal system, whereby we need to get them to document things in their information systems, so things are recorded and tracked.

One health plan we worked with recently had 17 separate Excel spreadsheets for recording Utilization Management reviews, however, this documentation never made it into their information systems, and therefore was not being tracked and used for HEDIS measures.

Because of the amount of work needed throughout the day, the health plan created a process whereby team members would document things in the system, but also track things on a separate spreadsheet. With over 700 activities at the start of their day, they quickly reverted away from the formal system to an informal one.

When we begin working with a client, we often ask if we can review their formal and informal systems to get an understanding of how they document. Maintaining two separate documents, means extra work, and increases the chance of HIPAA and other regulatory compliance issues.

NCQA’s LTSS Distinction for Health Plan program finds and documents what the plan is doing. The LTSS program aligns the health plan’s assessment and care management planning. It also aligns their policies, procedures, and desk level procedures, which are guided by the higher-level policies and procedures.

To learn more about the IQVIA’s Healthcare Technology Population Health practice and what we can do to help organization with NCQA Accreditation needs, please reach out to Chris McShanag, vice president, population health.