JULY 2023 FACT SHEET Managed Long-Term Services and Supports: Quality Improvement Initiatives T Current Quality Strategies he delivery of high-quality health care in Medi-Cal is an ongoing priority for the state and other stakeholders, and several state and and Gaps federal government initiatives aim to increase and improve quality metrics and transparency in Medi- DHCS Comprehensive Quality Cal. These initiatives are operating in the context Strategy of broad reforms to the delivery of Medi-Cal ser- While not specific to LTSS, the DHCS Comprehensive vices through the CalAIM (California Advancing Quality Strategy (CQS) summarizes DHCS's quality and Innovating Medi-Cal) initiative. priorities and approach to improving the quality of care and outcomes for all Medi-Cal enrollees.2 The CalAIM will transition more responsibility for cov- 2022 CQS report includes a review of CalAIM and its erage and coordination of long-term services and various quality initiatives and notes the intention to supports (LTSS)-which provide day-to-day assistance develop an addendum (expected to be released in to older adults and people with disabilities-to Medi- 2023) addressing quality issues and policy changes Cal Managed Care Plans (MCPs) statewide by 2027. that will impact enrollees receiving LTSS. The report More detail on this model (known as Managed Long- also highlights DHCS's intention to improve LTSS data Term Services and Supports, or MLTSS) is available in transparency, focusing on quality and equity metrics the California Health Care Foundation (CHCF) report to be identified through a multidepartment initiative Medi-Cal Managed Care and Long-Term Supports: and vetted in collaboration with LTSS stakeholders. Opportunities and Considerations Under CalAIM.1 DHCS also describes its intention to align approaches to assessing quality and equity across different Medi- Medi-Cal LTSS are delivered across multiple systems, Cal subpopulations, including those receiving LTSS, and until recently, limited data were made publicly avail- to ensure a consistent approach across the state and able on the quality of these services. The transition to among all Medi-Cal enrollees. a statewide MLTSS model provides an opportunity for lawmakers, state regulators, and other stakeholders to As outlined in the CHCF report Using Data for Good: implement statewide LTSS quality initiatives, improve Toward More Equitable and Community-Based information sharing across systems, and create more Services in Medi-Cal,3 there are opportunities to data transparency. This fact sheet will examine several increase quality oversight, improve data collection initiatives that could help support oversight and trans- and reporting, and increase the transparency of the parency of Medi-Cal LTSS quality with the intention to data specific to home and community-based ser- drive improvements in care coordination and delivery. vices (HCBS) and LTSS. For example, public data on demographics, utilization, quality, access, and equity could be collected and stratified by age, gender, race/ ethnicity, and language spoken. This would let LTSS the delivery of Medi-Cal LTSS. A key component of programs be evaluated and improved through an iter- the PHM program is the PHM Service (explored fur- ative process. ther on page 3), which will provide data sharing and infrastructure to support increased coordination under the statewide MLTSS model.5 As part of the PHM pro- Five Quality Initiatives gram, MCPs are required to: Relevant to LTSS $ Show that a PHM strategy is in place either by One of the stated goals of CalAIM is to "improve qual- obtaining full National Committee for Quality ity outcomes, reduce health disparities, and transform Assurance (NCQA) Health Plan Accreditation, or the delivery system through value‑based initiatives, by showing DHCS that the MCP otherwise meets modernization, and payment reform."4 To work toward these standards effective January 1, 2023. this goal, the California Health and Human Services Agency (CalHHS) is taking a multipronged approach $ Obtain NCQA Health Plan Accreditation and that includes several key components relevant to LTSS: NCQA Health Equity Accreditation by January 1, 2026. 1. Population Health Management Program $ Continue to implement standardized LTSS refer- 2. Dual Eligible Special Needs Plans Quality ral questions to identify members who may need Reporting Requirements LTSS and align with NCQA time frames for care management assessments (initial assessment 3. National Committee for Quality Assurance LTSS within 30 days of identifying a potential LTSS Distinction Survey need, and completing the assessment within 60 4. Long-Term Services and Supports Dashboard days). 5. Master Plan for Aging's Data Dashboard for $ Submit an updated annual Population Needs Aging Assessment (PNA) summarizing the needs of the enrollee, focusing on cultural, linguistic, and The summary below highlights how these five initia- health education needs, and health disparities. tives, which are either underway or in developmental stages, could collectively improve service delivery $ Maintain LTSS care plans in alignment with fed- through better care coordination and provide data eral regulations.6 to assess the impact, delivery, and quality of LTSS in Medi-Cal. Together, these activities can inform poli- DHCS has released an updated PHM Policy Guide cies to support high-quality care statewide through (PDF) which includes an additional section on how it MLTSS. will track the MCP implementation of the PHM pro- gram, including quality metrics and key performance indicators.7 It also released a concept paper (PDF) for 1. Population Health Management stakeholder comment with an updated PNA approach Program to promote increased alignment and engagement A foundational initiative of CalAIM, the Population with community stakeholders and local health depart- Health Management (PHM) program has several com- ments to more accurately identify Medi-Cal enrollee ponents intended to proactively help all Medi-Cal health and social needs.8 enrollees stay well by addressing unmet health needs and health-related social needs, which will also impact Managed Long-Term Services and Supports: Quality Improvement Initiatives 2 Transitional Care Services Initiative to use the PHM Service to create a standardized risk MCPs also must comply with the Transitional Care assessment process that will help identify specific Services (TCS) initiative under PHM, which will be populations, including members that need or have fully implemented by January 1, 2024. TCS holds already accessed LTSS, and require that MCPs use this MCPs responsible for making sure enrollees being information to conduct proactive outreach and case discharged from a hospital or facility, and those trans- management. ferring from one setting to another in the community, are successfully connected to all needed services and The standardized processes and data collection under supports, and that a lead care manager is assigned to the PHM Service should also provide DHCS with more provide and coordinate all TCS.9 While the TCS initia- tools to conduct statewide oversight and tracking of tive is not specific to LTSS, many Medi-Cal enrollees LTSS delivery and coordination. This information could transitioning between settings would need LTSS, and help identify trends in service use and outcomes and the initiative further builds on requirements to ensure lead to the development and refinement of policies the MCP is the single responsible entity for provid- that can support the successful and sustained imple- ing or coordinating these services, or both, under the mentation of a statewide MLTSS model. statewide MLTSS model. Population Health Management Service 2. Dual Eligible Special Needs Plans The PHM Service is a statewide technology solu- Quality Reporting Requirements tion intended to support the overall PHM strategy Dual Eligible Special Needs Plans (D-SNPs) are a type and requirements. As outlined in the PHM Strategy of Medicare Advantage plan that enrolls people eli- and Roadmap and the PHM Policy Guide, "the PHM gible for and enrolled in both Medicare and Medicaid Service will provide a wide range of Medi-Cal stake- ("dually eligible enrollees"). For a D-SNP to oper- holders with data access and availability for Medi-Cal ate in a state it must have a State Medicaid Agency members' health history, needs, and risks including Contract, which outlines additional state-specific historical administrative, medical, behavioral, dental, requirements for coordinating benefits and includes and social service data, and other program informa- care coordination service requirements and LTSS pro- tion from current disparate sources."10 DHCS will pilot cess measures.11 D-SNPs are responsible for covering the PHM Service with multiple partners to prepare for all Medicare-covered services, and Medicaid wraps a scheduled statewide launch by December 31, 2023. around to pay Medicare premiums and cost sharing More guidance on how MCPs are expected to use it (at varying levels based on the enrollee's income and is forthcoming. eligibility) as well as some services not covered under Medicare, such as many LTSS. In 2021, more than When fully implemented, the PHM Service should one in five California Medicare enrollees were dually provide MCPs and DHCS with access to more data eligible for Medi-Cal and Medicare, and about 69% that can support the coordination of LTSS benefits of Medi-Cal HCBS were provided to dually eligible across the continuum of care. MCPs and LTSS provid- enrollees.12 ers more easily accessing and sharing member data on LTSS through the PHM Service would provide a Under CalAIM, DHCS is moving toward statewide more comprehensive picture of Medi-Cal LTSS needs availability of Exclusively Aligned Enrollment (EAE) and gaps in care across the delivery system. This D-SNPs, also referred to by DHCS as "Medicare Medi- increased access to member data should help address Cal Plans." Under this model, dually eligible people some of the challenges faced by Medi-Cal enrollees, can enroll in an EAE D-SNP operated by the same caregivers, providers, and MCPs. Also, DHCS intends Caliifornia Health Care Foundation 3 parent company that runs an MCP. The EAE D-SNP 3. NCQA Long-Term Services and choice will signal to DHCS default enrollment into the Supports Distinction Survey matching MCP, to promote more coordinated and The National Committee for Quality Assurance integrated care. DHCS also has in place a matching (NCQA) is a national organization that creates standard plan policy for any D-SNP in certain counties where measurement and accreditation tools for health plans, this same enrollment logic is applied.13 medical homes, and providers.15 As part of CalAIM, DHCS will require all contracted MCPs and their sub- In 2023, California's EAE D-SNPs launched in seven contractors to achieve NCQA accreditation by 2026. counties, and in 2024 will expand to four more coun- Once an MCP has achieved its NCQA plan accredi- ties. All MCPs statewide will be required to operate tation, DHCS will establish a timeline by which the an EAE D-SNP by 2026. The EAE D-SNP model is MCPs must meet the requirements of the NCQA LTSS among several CalAIM reforms intended to provide Distinction Survey (currently proposed to be required a more robust Medi-Cal managed care delivery sys- by 2027 after all MCPs are operating EAE D-SNPs).16 tem for dually eligible enrollees statewide as part The NCQA LTSS Distinction Survey includes a frame- of the movement toward statewide MLTSS. Other work for the MCPs to show in a standardized format to reforms include mandatory Medi-Cal managed care DHCS that requirements for the delivery and quality of enrollment statewide, coverage of skilled nursing Medi-Cal LTSS are being met. The survey includes sev- facility care under the MCPs, and implementation eral key areas of focus including an assessment of the of MCP-provided Enhanced Care Management and MCPs' person-centered care planning approaches, Community Supports for populations needing LTSS.14 care transitions, coordination of services, critical inci- To support this part of CalAIM, specifically as it relates dent management systems, and qualifications and to LTSS quality, tracking, and oversight for dually eli- assistance for LTSS providers.17 gible enrollees, DHCS has implemented a broad set of state-specific reporting for EAE D-SNPs. 4. Long-Term Services and Supports The combination of data on LTSS-specific measures Dashboard and NCQA's LTSS distinction requirements (explored The primary goal of the LTSS Dashboard, an initiative below) should provide DHCS with significant informa- of California's Home and Community-Based Services tion on the delivery and quality of LTSS by its MCPs Spending Plan, is to track demographic, use, quality, and contracted D-SNPs. These data should provide and cost data related to LTSS.18 The data are provided robust information that can be used by policymakers through the CalHHS Open Data Portal to provide and stakeholders to evaluate coordination and access "increased transparency to make it possible for regu- to LTSS for dually eligible enrollees and provide lators, policymakers, and the public to be informed insights on best practices and challenges in coordinat- while the state continues to expand, enhance, and ing across the Medi-Cal LTSS delivery system. These improve the quality of LTSS in all home, community, insights will have implications for all those access- and congregate settings."19 Launched in December ing LTSS through MCPs under the statewide MLTSS 2022, the LTSS Dashboard includes 40 enrollment and model, including Medi-Cal-only enrollees. use measures reported from 2017 to 2021 across 10 demographic and plan-related dimensions including age, race/ethnicity, sex, delivery system, county, and primary language spoken. Although the availability of the data at a more granular level has improved, the data can be stratified by only one variable at a time. Managed Long-Term Services and Supports: Quality Improvement Initiatives 4 To adequately evaluate data for specific subpopula- specifically intended to provide data on MCP quality tions, it would be helpful if future iterations of the LTSS measures, the Data Dashboard for Aging includes sev- Dashboard allowed for further stratification of these eral indicators that should provide useful information variables. on the LTSS and caregiving landscape in California and for Medi-Cal. The Master Plan for Aging Data As the LTSS Dashboard continues its phased-in imple- Dashboard includes data on: mentation, more programs will be added in 2023, as outlined in Figure 1. Also, DHCS intends to add $ Availability of services and supports quality and cost information and to provide enhanced $ Gaps in services and supports data visualization capabilities to the LTSS Dashboard. More information on the initial high-level findings and $ Enrollment in safety-net programs such as Medi- trends is available in DHCS's LTSS Dashboard fact Cal, Medicare, and Program of All-Inclusive Care sheet from December 2022.20 The data and summary for the Elderly (PACE) trend information expected to be available should $ Routine and personal care needs provide insights about the Medi-Cal LTSS landscape, providing policymakers and other stakeholders infor- $ Consequences of unmet care needs mation to support evaluation of targeted policies $ Primary care shortages to improve the delivery system under the statewide MLTSS model. $ Long-term care needs and skilled nursing facility availability 5. Master Plan for Aging's Data The Data Dashboard for Aging is intended to help Dashboard for Aging California policy leaders put the goals of the Master The Data Dashboard for Aging, an initiative of Plan for Aging into action. Key parts related to LTSS California's Master Plan for Aging, provides indica- include data about adults (not limited to older adults) tors to measure progress toward advancing the "five who live in a community setting and self-identify as bold goals" outlined in the Master Plan.21 While not having difficulties with concentrating, remembering, Figure 1. Development of the Long-Term Services and Supports Dashboard Currently Included Programs Programs to be Added in 2023 $ AIDS Medi-Cal Waiver Program $ California Community Transitions $ Assisted Living Waiver $ Home Health $ Cal MediConnect $ Intermediate Care Facilities for the Developmentally $ Community-Based Adult Services Disabled $ Home and Community-Based Alternatives Waiver $ Managed Long-Term Services and Supports $ Home and Community-Based Services $ Self-Determination Program $ Home and Community-Based Services for the Developmentally Disabled $ In-Home Supportive Services $ Multipurpose Senior Services Program $ Program of All-Inclusive Care for the Elderly $ Skilled Nursing Facilities Source: "California Long-Term Services and Supports Dashboard," California Dept. of Health Care Services, accessed May 12, 2023. Caliifornia Health Care Foundation 5 or making decisions; dressing or bathing; or doing Conclusion errands, to indicate a potential need for LTSS. In addi- Medi-Cal LTSS is a complicated system with histori- tion, the Data Dashboard for Aging includes a progress cally limited transparency about access to, use of, and dashboard designed to provide an at-a-glance view of quality of services. CalAIM includes several key initia- where progress is being made on specific goals and tives related to improving LTSS quality transparency strategies. While this does not provide the granular to make long-term improvements that can sustain detail needed to evaluate specific Medi-Cal popu- the transition to statewide MLTSS. These initiatives lations receiving or in need of LTSS, it does provide provide a great opportunity for stakeholders and poli- context for the landscape of aging in California and cymakers to make meaningful improvements in their the expectation that the state is facing a significant ability to assess gaps and to improve access and deliv- influx of older adults that will need supports across ery of high-quality care. the system to age safely in the community. Many of these people will need and be eligible for Medi-Cal While there are many initiatives related to quality LTSS, so it is important for policymakers to understand monitoring and improvement, there is an opportunity the potential impacts of this growing population and to use these different sources of data and information how to use data effectively to anticipate and plan for to gain a more comprehensive understanding of the increased capacity, access, education, and outreach. LTSS delivery system and to inform the development and implementation of MLTSS under CalAIM. Managed Long-Term Services and Supports: Quality Improvement Initiatives 6 About the Author Endnotes Athena Chapman, MPP, is president and Elizabeth 1. thena Chapman and Elizabeth Evenson, Medi-Cal Managed A Care and Long-Term Services and Supports: Opportunities and Evenson is associate vice president at Chapman Considerations Under CalAIM, California Health Care Foundation Consulting, which provides strategic planning, (CHCF), March 2023. meeting facilitation, organizational support, market 2. "DHCS Comprehensive Quality Strategy," California Dept. of research, and regulatory and statutory analysis to Health Care Services (DHCS), accessed April 16, 2023. organizations in the health care field. 3. Amber Christ and Tiffany Huyenh-Cho, Using Data for Good: Toward More Equitable and Community-Based Services in Medi- Cal, CHCF, December 2021. About the Foundation 4. "CalAIM," DHCS. The California Health Care Foundation (CHCF) is an 5. "CalAIM Population Health Management Initiative," DHCS. independent, nonprofit philanthropy that works to 6. Draft Population Health Management (PHM) Strategy and improve the health care system so that all Californians Roadmap 2022 (PDF), DHCS, April 20, 2022. have the care they need. We focus especially on mak- 7. CalAIM: Population Health Management (PHM) Policy Guide ing sure the system works for Californians with low (PDF), DHCS, updated June 2023. incomes and for communities who have traditionally 8. Concept Paper: Strengthening Medi-Cal Community faced the greatest barriers to care. We partner with Collaboration Through a Reimagined Population Needs Assessment (PDF), DHCS, May 2023. leaders across the health care safety net to ensure they have the data and resources to make care more just 9. CalAIM: Population Health Management (PHM) Frequently Asked Questions (PDF), DHCS, last updated December 2022. and to drive improvement in a complex system. CHCF 10. PHM Policy Guide, DHCS. informs policymakers and industry leaders, invests in ideas and innovations, and connects with change- 11. Boilerplate 2023 State Medicaid Agency Contract Exclusively Aligned Enrollment Dual Eligible Special Needs Plans (PDF), makers to create a more responsive, patient-centered DHCS. health care system. 12. "Medi-Cal Long-Term Services and Support Annual Data," California Health and Human Services Agency, last updated December 14, 2022. 13. "Medi-Cal Matching Plan Policy for Dual Eligible Beneficiaries," DHCS, last modified April 26, 2023. 14. "Dual Eligible Special Needs Plans in California," DHCS, last modified December 28, 2022. 15. "About NCQA," National Committee for Quality Assurance (NCQA). 16. "Long-Term Services and Supports Distinction for Health Plans," NCQA. 17. "Long-Term Services and Supports," NCQA. 18. "Home and Community-Based Services Spending Plan," DHCS, last modified April 18, 2023; and "California Long-Term Services and Supports Dashboard," DHCS, last modified March 10, 2023. 19. "Long-Term Services and Supports Measures and Dashboard Data," California Health and Human Services Agency, last updated December 14, 2022. 20. California Long Term Services and Supports Dashboard: Initial Release Fact Sheet (PDF), DHCS, December 12, 2022. 21. "MPA Dashboard," California Dept. of Aging; and "Data Dashboard for Aging," Let's Get Healthy California. Caliifornia Health Care Foundation 7