Data Collection Key to a Successful LTSS Community Care Strategy

A truth in providing long-term services and support (LTSS) to patients is that people almost always want to be served in their home or in their community. Such a home and community-based services (HCBS) strategy, compared to institutionalizing people, achieves better outcomes, saves money, and garners higher patient satisfaction.

To this point, The Centers for Medicare and Medicaid Services (CMS) recently released a review of its effort to shift from intuitional care to HCBS. CMS cited ten states that have increased their shift to HCBS by twice the national average and can serve as instructive examples. The list is a classic example of community care strategy in action. The states, in the order of Medicaid HCBS expenditures as a percentage of total Medicaid LTSS expenditures for Fiscal Year 2016, include:

1: Massachusetts

2: Colorado

3: New York

4: Missouri

5: Nevada

6: Connecticut

7: Arkansas

8: Illinois

9: South Carolina

10: New Jersey

In citing the ten states as good examples, CMS considered a host of demographic, economic, and state budget database points. It is a lot of data to track and includes:

1: Demographic data included such traits as the share of each state’s population over 85 years old, had disabilities, was duly eligible for Medicare and Medicaid, or resided in a certified nursing facility.

2: Economic data indicators included employment and hourly wage in LTSS occupations, gross domestic product (GDP), personal income, and employment.

3: Budget data measures included total state revenue and expenditures for Medicaid, which can be considered a proxy for states’ flexibility to use funding to pay for new or different policies.

The study is the latest indication of the commitment CMS has to an HCBS LTSS strategy. Indeed, such HCBS LTSS strategies are part of CMS’s shift to value-based care to control costs and improve quality. Medicaid is the primary payer for the more than 13 million adults who need every day help to function and be productive. About 6 million people in this group are under the age of 65 with intellectual or developmental disabilities.

There are challenges, of course. According to a not-for-profit Center for Health Care Strategies analysis, much of the implementation is data collection and analysis related. These include:

1: Limited consensus on performance metrics. Unlike Medicaid core quality measure sets for adults and children, there is little consensus on commonly accepted measures of HCBS quality. Consequently, states need to decide which measures to link to financial incentives.

2: Ability to collect and report performance data. HCBS providers often have more limited capacity to collect and report data than acute and primary care providers or even nursing facilities. Many HCBS providers do not maintain electronic assessment, care planning, and service delivery records that can be easily transmitted to health plans and states. Also, self-reported data on quality of life, choice, and control may be subjective and thus more difficult to link to payment.

3: Source of potential savings. More than half of Medicaid LTSS users are dually eligible beneficiaries whose acute care services like hospitalizations and emergency department visits are paid for by Medicare. Savings from improving the quality of Medicaid-covered HCBS tend to accrue to Medicare. Without some sort of integration mechanism, there is limited opportunity for state Medicaid-only programs to access shared savings.

The key to a successful LTTS HCBS initiative is to find a data platform specifically designed to capture the metrics unique to each state program. Indeed a 2016 study published in Home Health Management reported touched on the need for community care, noting that a seamlessly connected and coordinated structure is a crucial capability:

“The home health agency of the future must be part of a seamless, connected and coordinated home-based care continuum, as well as being connected with primary care, and facility-based care.”

The evidence is clear that state programs and the people they serve are benefitting from the move to LTTS HCBS. A 2018 CMS from the 2009-2014 study revealed measurable benefits in reducing institutionalized care for people in HCBS state programs. For example, the study found that 73 percent of older adults who started with institutional care had stays of 91 days or more. However, just four percent of older-adult community-based LTSS initiators had long stays. Those adults in an LTSS HCBS are also less likely to have a repeat institutional stay.

Clearly, care coordination is a good strategy on many levels but is especially good for patients.

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