2016 Q1 ADvantage Quarterly Cumulative Report PDF Library... · DHS Medicaid Services Unit---AD vantage Administration 823 S Detroit Avenue, 4 th Floor Tulsa, Oklahoma 74120 P O Box

Q1 2016

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Contents

ADvantage Program History 1

Who are ADvantage Members? 2

Where in Oklahoma do ADvantage Members live? 2

What is the demographic composition of ADvantage Members? 3

Additional service options available to ADvantage Members 3

What is the full spectrum of services provided through ADvantage? 4

How does ADvantage membership demonstrate growth? 6

What causes ADvantage membership to fluctuate? 10

Informal Support Makes All the Difference 11

What if ADvantage is not appropriate? 12

The intent in making a Quarterly Cumulative Report available is to offer all interested partiesinformation that reflects an abbreviated overview of the status of services provided to olderadults and individuals with disabilities of Oklahoma through the ADvantage Program. This report is by no means intended to represent an exhaustive or detailed review of programoperations and service delivery. If the report prompts questions or the need for additionalinformation, recipients of the report are encouraged to contact the ADvantage Administrationlocated in Tulsa, Oklahoma.

Contact us:

DHS Medicaid Services Unit---ADvantage Administration

823 S Detroit Avenue, 4th Floor Tulsa, Oklahoma 74120

P O Box 50550, Tulsa, Oklahoma 74150-0550

918.933.4900

Prepared by MSU-AA based on data retrieved from the Waiver Management Information System

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# Served

ADvantage Program History

ADvantage, the Medicaid Home and Community-Based Services (HCBS) waiver program isauthorized in §1915(c) of the Social Security Act. This Act permits a state to furnish an array of home andcommunity-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver’s target population. Waiver services complement and/or supplement the services that areavailable to participants through the Medicaid State Plan Personal Care Program and other federal, stateand local public programs, as well as the supports that families and communities provide.

The ADvantage Program is operated by the Oklahoma Department of Human Services (DHS), AgingServices (AS), a separate agency of the State that is not a division/unit of the Medicaid agency. In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in theadministration and supervision of the waiver and issues policies, rules and regulations related to the waiver. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this policy is available through the Medicaid agency to CMS upon request. TheMedicaid Services Unit-ADvantage Administration (MSU-AA) serves as the administrative agent for theprogram services.

The Oklahoma Commission for Human Services approved the creation of the ADvantage Program in 1993 and by 1995 the program had expanded to ten counties in Oklahoma. In 1997 the program wasimplemented statewide. During the first 23 months of operation, 323 individuals received services. Today,approximately 20,000 Oklahomans receive services annually.

The MSU-AA’s Quarterly Cumulative Report presents the ongoing status of the ADvantage Program. Contents of this report were prepared by the MSU-AA. The variables included in the analysis are subjectto change daily, for example Member count. Please contact the MSU-AA at (918) 933-4900 for questionsregarding the interpretation of data.

ADvantage Program Members Served

The graph above represents the growth of the ADvantage Program since its inception in 1993.

1 Prepared by MSU-AA, based on data retrieved from the Waiver Management Information System

Who are ADvantage Members?

ADvantage Program services are available to the citizens of Oklahoma including frail elders 65 yearsand older and adults 21-64 that have been diagnosed with physical disabilities. A person must firstqualify for Medicaid, or low income services, and they must be assessed by a long term care nurse, priorto receiving ADvantage services. Once an individual is considered eligible, they become a “Member”,and the MSU-AA will process proposed service plans submitted by provider agencies for serviceauthorization.

Where in Oklahoma do ADvantage Members live? The state is divided into five regions where ADvantage services are received by persons eligible to

receive services or Members of ADvantage. The majority of Members live in the larger metropolitanareas including Oklahoma City and Tulsa.

Region 1st

Quarter 2nd

Quarter 3rd

Quarter 4th

Quarter Year to Date

I 2,155 2,155II 3,350 3,350III 3,384 3,384IV 5,603 5,603V 3,592 3,592

Total 18,084 18,084

ADvantage Members by DHS Region 1st Quarter

2,155

3,350 5,603

3,592


What is the demographic composition of ADvantage Members?

The frail elderly make up a disproportionate number of persons served by ADvantage. The Program isavailable to adults who have disabilities, but is not intended to serve persons who have both physical andintellectual disabilities. The Uniform Comprehensive Assessment Tool (UCAT) is used to assess which services an individual may need, both upon being admitted to the ADvantage Program and annuallyduring redetermination. The UCAT includes a mental status assessment, which is captured by the MentalStatus Questionnaire (MSQ). Functional assessment is yet another aspect of the UCAT where anindividual’s ability to perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living(IADLs) are measured for the purpose of supporting an individual to sustain independence in their home in the community.

Demography 1st

Quarter 2nd

Quarter 3rd

Quarter 4th

Quarter Year to Date

Average Member Age 67.8 67.8

Age 60+ 72.4% 72.4%

Age 65+ 59.2% 59.2%

Minority 24.9% 24.9%

Female 70.3% 70.3%

Lives Alone 51.9% 51.9%

UCAT Score 95.8 95.8

MSQ Score 4.9 4.9

ADLs 8.6 8.6

IADLs 14.9 14.9

Additional service options available to ADvantage Members

Consumer Directed Personal Assistance Services and Supports Q1 (CD-PASS)

CD-Pass Members Served

Current Active Members 964

New Members 108

YTD Members Served 964

The distinction with CD-PASS is that the Member, not a home care agency, directs the personal care services. Personal ServicesAssistance and/or Advanced Personal Services Assistance enable anindividual in need of assistance to reside in their home and in thecommunity of their choosing rather than in an institution and to carryout functions of daily living, self-care, and mobility. The Member

employs the Personal Services Assistant (PSA) and/or the Advanced Personal Services Assistant (APSA)and is responsible, with assistance from ADvantage Program Administrative Financial Management Services (FMS), for ensuring that the employment complies with State and Federal Labor Law requirements

Assisted Living Services Q4The Assisted Living service option provides housing and personalcare supports. Members reside in a home-like, non-institutionalsetting that includes 24-hour on-site response capability to meet scheduled or unpredictable resident needs and to providesupervision, safety and security.

Assisted Living Services

Current Active Members 193

YTD Members Served 193

Pending Members 2


What is the full spectrum of services provided through ADvantage?

Individuals who are eligible to receive ADvantage services may need supports in addition to CaseManagement. These needs are documented in a service plan, which outlines the services needed inorder to maintain health and safety in their home and community.

Provider by Type ADH 27 AL 8

CD-PASS 112

CM 112

DME 203

EM 14HDM 17

HH/SN 98

HOSPICE 77

RESPITE-NF 86

RESPITE IN-HOME93

THERAPY 10

Provider by Type Q1

AbbreviationType of Agency Number of

Providers

ADH Adult Day Health 27

AL Assisted Living Facility 8

CD-PASS Consumer Directed Personal Assistance Services and Supports 112

CM Case Management (includes agencies with multiple branch offices) 110

DME Durable Medical Equipment 203

EM Environmental Modifications 14

HDM Home Delivered Meals 17

HH/SN Home Care / Skilled Nursing (includes agencies with multiple branch offices)

98

Hospice Hospice 77

Respite In-Home In Home Respite 93

Respite-NF Nursing Facility Respite 86

Therapy Therapy 10

Overall Providers (# Reflects individual branches) 639


What level of service do ADvantage Members receive?

ADvantage Members receive case management (CM) services to assist Members in coordinating theirservices. Most Members are eligible to have personal care (PC) assistance to provide in-home servicesas needed. The level of CM and PC services authorized for each Member is determined after the Members Interdisciplinary Team (IDT) meets. The IDT generally includes the Member, Case Managerand others as deemed necessary. During the IDT meeting, assessments are reviewed and the IDTdiscusses how much service and what type of service the Member needs. The Case Manager will draft a service plan requesting the level of service or the number of units of service needed, which is thensubmitted to the MSU-AA for authorization. The graphs below represent services authorized to bedelivered for CM and PC for this quarter.

Authorized Services for Personal Care 1st Quarter

ADvantageMembers

Authorized toReceive Servicesfor this Quarter

Overall Total ofMembers for

Whom ClaimsPaid for PC this

Quarter

Overall Total ofHours of PC ServiceAuthorized for this

Quarter

Overall Total ofAuthorized Units of

PC Service Paid thisQuarter

Overall Amount of PCServices Paid for this

Quarter

OverallPercentageof ServicesPaid for that

wasAuthorized

15,120 13,209 1,689,856.7 1,104,317.4 $17,110,874.02 65.3%

Authorized Services for Case Management 1st Quarter

ADvantageMembers

Authorized toReceive Servicesfor this Quarter

Overall Total ofMembers for

Whom ClaimsPaid for CM this

Quarter

Overall Total ofHours of CM

Service Authorizedfor this Quarter

Overall Total ofAuthorized Units ofCM Service Paid

this Quarter

Overall Amount ofCM Services Paid for

this Quarter

OverallPercentage ofServices Paidfor that wasAuthorized

17,996 16,917 376,883.7 188,979.0 $11,466,680.70 50.1%

Note: These are conservative estimates since a small (but unknown) percentage of claims for the time period have not cleared for payment and some Members may have exited the Program but they may not have been recorded in the system so authorized units may be overstated.

While services were authorized, the claim may not have been submitted for payment; therefore, not all claims willbe reflected as paid during this quarter.


How does ADvantage membership demonstrate growth?

The ADvantage Program gains new Members monthly. After an individual has applied for ADvantageservices and they are determined eligible, the new Member has the choice to select from 100 (numberreflects all CM provider agencies and multiple branch offices) case management providers, some of which have multiple branch offices dispersed throughout the State. The prescribed method for a Memberto select a provider is to complete form 02CB001E, Member Consents and Rights, where they willdocument their choice of provider based on a list of those available in their county of residence. If theMember is unwilling or perhaps unable to make a provider selection, the Social Worker or other person assisting with completing their application will enter the Members choice as “Round Robin”. A selection indicated as Round Robin means that the agency will be randomly selected by a computer program.Member’s choice of provider is only limited by the availability of providers in the region in which theyreside, but every effort is made to ensure that the Member is given a choice in provider.

Market Share Analysis of Case Management Providers detailing ADvantage membership growth, Member choice/selection and availability of providers.

DHS Region

Average Total

Providers

Total NewMembers

Total RoundRobin New

Members

Total Choice

NewMembers

Percentage of Round

Robin Assignment

Percentage of Member

Choice

DHS Region: I 13.0 148 67 81 117 54.7%DHS Region: II 16.6 233 87 146 117 62.7%DHS Region: III 31.0 215 122 93 117 43.3%DHS Region: IV 21.5 417 124 293 117 70.3%DHS Region: V 23.6 221 87 134 117 60.6%Grand Total 1,234 487 747 117 60.5%

Definitions

Average Total Providers-- indicate the average number of providers covering the same DHS Region.New Members --are defined as any one person entering the ADvantage Program for the first time.Round Robin New Mbrs--represents the total # of new members assigned to the "on-referral" agency when acomputerized random assignment is chosen by Members as their provider selection.Choice New Mbrs --represents the total # of new Members who choose their case management agency through theFreedom of Choice form ADV 1.% of New Members: is the total # of new Members coming from either Round Robin or Member Choice divided by theTotal New Members for the report period.Prepared by OK DHS ADvantage Administration UnitSource: WMIS


CountyDHS Area

AverageProviders

TotalNew

Members

TotalRound Robin

TotalChoice

Selectionby Member

PercentageRoundRobin

Percentage MemberChoice

Adair IV 19 25 0 25 0.0% 100.0%Alfalfa I 7 0 0 0 0.0% 0.0%Atoka IV 19 13 7 6 53.8% 46.2%Beaver I 4 2 0 2 0.0% 100.0%Beckham I 10 9 0 9 0.0% 100.0%Blaine I 12 3 3 0 100.0% 0.0%Bryan IV 19 32 9 23 28.1% 71.9%Caddo II 18 11 2 9 18.2% 81.8%Canadian I 25 25 14 11 56.0% 44.0%Carter II 16 17 7 10 41.2% 58.8%Cherokee IV 23 22 0 22 0.0% 100.0%Choctaw IV 17 9 2 7 22.2% 77.8%Cimarron I 3 1 0 1 0.0% 100.0%Cleveland II 27 30 26 4 86.7% 13.3%Coal IV 20 5 1 4 20.0% 80.0%Comanche II 15 14 3 11 21.4% 78.6%Cotton II 11 1 1 0 100.0% 0.0%Craig V 17 2 0 2 0.0% 100.0%Creek IV 32 32 26 6 81.3% 18.8%Custer I 10 8 5 3 62.5% 37.5%Delaware V 19 16 5 11 31.3% 68.8%Dewey I 8 1 0 1 0.0% 100.0%Ellis I 8 1 0 1 0.0% 100.0%Garfield I 9 19 16 3 84.2% 15.8%Garvin II 22 11 6 5 54.5% 45.5%Grady II 24 10 3 7 30.0% 70.0%Grant I 9 1 1 0 100.0% 0.0%Greer II 12 3 0 3 0.0% 100.0%Harmon II 10 2 0 2 0.0% 100.0%Harper I 6 0 0 0 0.0% 0.0%Haskell IV 19 4 0 4 0.0% 100.0%Hughes IV 17 10 0 10 0.0% 100.0%Jackson II 13 13 2 11 15.4% 84.6%Jefferson II 9 12 4 8 33.3% 66.7%Johnston II 15 4 0 4 0.0% 100.0%Kay I 16 20 9 11 45.0% 55.0%


CountyDHS Area

AverageProviders

TotalNew

Members

TotalRound Robin

TotalChoice

Selectionby Member

PercentageRoundRobin

Percentage MemberChoice

Kingfisher I 15 3 2 1 66.7% 33.3%Kiowa II 13 5 0 5 0.0% 100.0%Latimer IV 17 5 2 3 40.0% 60.0%Leflore IV 15 44 24 20 54.5% 45.5%Lincoln II 27 16 2 14 12.5% 87.5%Logan I 24 12 5 7 41.7% 58.3%Love II 15 4 0 4 0.0% 100.0%Major I 10 1 0 1 0.0% 100.0%Marshall II 15 5 0 5 0.0% 100.0%Mayes V 28 22 3 19 13.6% 86.4%McClain II 20 7 6 1 85.7% 14.3%McCurtain IV 16 29 5 24 17.2% 82.8%McIntosh IV 23 23 1 22 4.3% 95.7%Murray II 17 3 1 2 33.3% 66.7%Muskogee IV 31 38 17 21 44.7% 55.3%Noble I 17 1 0 1 0.0% 100.0%Nowata V 20 4 0 4 0.0% 100.0%Okfuskee IV 20 10 7 3 70.0% 30.0%Oklahoma III 31 215 122 93 56.7% 43.3%Okmulgee IV 31 18 10 8 55.6% 44.4%Osage I 27 7 2 5 28.6% 71.4%Ottawa V 14 8 6 2 75.0% 25.0%Pawnee I 24 6 5 1 83.3% 16.7%Payne I 25 18 2 16 11.1% 88.9%Pittsburg IV 20 18 1 17 5.6% 94.4%Pontotoc IV 18 15 3 12 20.0% 80.0%Pottawatomie II 26 31 16 15 51.6% 48.4%Pushmataha IV 16 10 2 8 20.0% 80.0%Roger Mills I 6 0 0 0 0.0% 0.0%Rogers V 31 29 15 14 51.7% 48.3%Seminole IV 23 13 0 13 0.0% 100.0%Sequoyah IV 22 34 2 32 5.9% 94.1%Stephens II 12 25 7 18 28.0% 72.0%Texas I 3 1 0 1 0.0% 100.0%Tillman II 12 9 1 8 11.1% 88.9%Tulsa V 36 131 56 75 42.7% 57.3%


County DHS Area

Average

Providers

Total New

Members

Total

Round Robin

Total

Choice Selection

by Member

Percentage

Round Robin

Percentage

Member Choice

Wagoner IV 35 8 5 3 62.5% 37.5% Washington V 24 9 2 7 22.2% 77.8% Washita I 12 4 3 1 75.0% 25.0% Woods I 8 1 0 1 0.0% 100.0% Woodward I 8 4 0 4 0.0% 100.0%

Total 117 1,234 487 747 39.5% 60.5%

Definitions

Average Total Providers: Indicates the average number of providers covering the same DHS Region. Total New Members: Individuals entering the ADvantage Program for the first time. Total Round Robin New Members: Total number of Members who were assigned a case management

provider. Total Choice New Members: Total number of Members who selected their case management provider as indicated on the Member Consents and Rights, form 02CB001E. Percentage of Round Robin New Members: Percent of new Members who were assigned a case management provider (Total Round Robin New Members divided by Total ADvantage New Members). Percentage of Choice New Members: Percentage of new Members who choose their case management provider as indicated on the Member Consents and Rights, form 02CB001E (Total Choice New Members divided by Total New Members).


What causes ADvantage membership to fluctuate?

The number of Members served by ADvantage will tend to increase or decrease daily primarily basedon whether a Member remains eligible to receive services. There are a number of reasons an individualmay discontinue receiving ADvantage services, but most center on the fact that the services providedmust continue to be appropriate to meet the needs of the individual being served. For example, aMember's case may become “Inactive” or they may discontinue receiving services if they are “Not Nursing Facility Level of Care (Not NF LOC)”. One criterion for determining eligibility is to establish that a Members care in the community does not exceed the cost of care in a nursing facility. Attrition, as it relates ADvantage membership, occurs due to the following:

Inactive By Reason Q1

(Member Not Actively Receiving Services)

Reason Reason Defined Member # Average Age

Assisted Living Member moved to Assisted Living option, not ADvantage. 3 84.0

Medicare/HH 0 0

Death Member is deceased. 417 71.6

Disenrolled

Termination of Member services because, the State, as partof the waiver program approval authorization, assures CMS that each Member's health, safety or welfare can bemaintained in their home. If a Member's identified needscannot be met through provision of ADvantage Program or Medicaid State Plan services and other formal or informalservices are not in place or immediately available to meet those needs, the individual's health, safety or welfare in theirhome cannot be assured. [Policy reference 317:35-17-3.]

0 0

Financial Member is no longer eligible for financial reasons. 80 69.7

Hospice NotADvantage

Member was admitted to Hospice prior to start of ADvantageservices. 1 60.0

HospitalizedMember is hospitalized, therefore services havediscontinued. 0 0

Moved Member has moved. 82 68.2

Nursing FacilityPermanently

Member has entered a nursing facility permanently. 318 74.8

Not NursingFacility Level of

Care

Member no longer assessed to need the level of care that originally resulted in eligibility. 26 58.0

Non-compliance The necessary data to justify services cannot be obtained. 0 0

Other Atypical reason for Member‘s case to be inactive. 20 68.0

ProgramAppropriateness

ADvantage Services no longer meet Member’s needs; therefore, services are not appropriate. 0 0

Refusal of ServiceMember refuses to accept previously agreed upon servicesplan. 19 62.9

Unable to LocateMember is no longer found at the known location for servicedelivery. 16 55.7

WithdrawnMember has elected to discontinue from ADvantageservices. 69 67.3

Transition toPACE

Member leaves ADvantage and instead receives PACE 11 72.1

Total


Informal Support Makes All the Difference

A Member’s success in the ADvantage program is largely dependent upon whether or notthey receive informal supports. ADvantage services are not like institutional/facility services inso much as they are not intended to provide companion care or 24/7 supports. A Member canonly qualify for ADvantage if all of a Member’s health and safety needs can be met in thecommunity. Informal supports are put in place in order to complete a Member’s Service Planand to ensure they can live safely at home in the community. Informal supports added to aMembers Service Plan are related to what they may need to remain safe and healthy while intheir home in the community. Informal supports are services a Member receives that are notpaid for through the ADvantage Program but the services are included as part of the Service Plan. A Member’s Service Plan might include 15 hours of support in the form of meal prep,bathing, or provided by a relative or an informal care giver. There are also products ormedications they may receive in the form of informal support that is not met through the ADvantage services they are authorized to receive.

Most ADvantage recipients receive some level of informal support in the form of personalcare or they may receive some product they might need in order to have safe living. There were only 1,169 Members during the second quarter that did not receive some form of informalsupport. Clearly the success of program services is attributed to a combination of formal andinformal supports that allow our Members to remain safe in their homes in the community.


What if ADvantage is not appropriate?

Not everyone who applies for ADvantage services will be determined as eligible, but theymay still be in need of personal care. All applicants who submit a request for ADvantage aredually assessed to determine if they might qualify for another MSU program, State PlanPersonal Care (SPPC) services. SPPC services do not offer the same spectrum of supports butpersonal care, which is a primary support needed by most, is available. The medical andfinancial assessment differs somewhat to qualify for SPPC, however the medical eligibilitycriteria differs. Currently MSU serves 3,030 individuals through the SPPC program.

SPPC Services Provided

Assessment of need Development and oversight of a care plan Monitoring PCA services Personal Care Attendant (PCA) Personal Care Tasks Meal Tasks Housekeeping Tasks Laundry Tasks Shopping/Errand Tasks Specific Task (assist pay bills, frequent transfers, spoon feed

etc.)

SPPC Services Not Provided

Technical Services DME Case Management Frozen Meals Emergency alert response (EAR) Adult Day Health Assisted Living Respite


Documents

2016 Q1 ADvantage Quarterly Cumulative Report PDF Library... · DHS Medicaid Services Unit---AD vantage Administration 823 S Detroit Avenue, 4 th Floor Tulsa, Oklahoma 74120 P O Box