EXHIBIT A-4-c
LTC SUBMISSION REQUIREMENTS
AND EVALUATION CRITERIA (10-2-17)
RESPONDENT NAME:
A. RESPONDENT BACKGROUND / EXPERIENCE
LTC SRC# 1 – Participant Direction of Services (Statewide):
The respondent shall describe its experience with participant direction of services (also referred to as self-directed or consumer-directed) by specifying the model(s) of participant direction used in the states in which the respondent currently operates and previously operated (e.g., agency with choice or fiscal employer agent). The respondent shall include a flowchart depicting how services are authorized and delivered through the participant direction programs referenced in the response. The description shall include:
· Whether the model(s) includes the use of employer authority, budget authority, or both;
· The target population (ABD, DD, general aging population, etc.);
· The number of participants in each participant direction program;
· The services provided through its participant direction programs;
· The monitoring approach used to prevent and detect waste and abuse, specifically over-utilization of services;
· The lessons learned from implementing participant direction programs; and
· The innovations it has deployed to enhance the delivery of services through the participant direction program.
Response:
Evaluation Criteria:
1. The extent to which the respondent’s description includes experience with managing a participant direction of service delivery model.
2. The extent to which the respondent’s flowchart provides a description that addresses the following components:
(a) Care planning;
(b) Service authorization;
(c) Involvement of the Fiscal Employer Agent;
(d) Electronic Visit Verification;
(e) Claims processing;
(f) Claims payment; and
(g) Encounter data submission.
3. The extent to which lessons learned have been utilized to improve the respondent’s participant direction of service delivery model.
4. The extent to which the described experience demonstrates past innovations or planned innovations in participant direction of services (e.g., mobile telephone applications, implementation of electronic access/training to complete required forms, and electronic visit verification).
5. The extent to which the respondent’s monitoring approach ensures that fraud, waste and abuse is monitored and prevented, including over utilization of services.
Score: This section is worth a maximum of 55 raw points with each of the above components being worth a maximum of 5 points each.
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LTC SRC# 2 – Performance Measures (Statewide):
a. The respondent shall describe its experience in measuring performance and achieving quality standards with populations similar to the target population for the long-term care (LTC) component of the SMMC program. Describe experience with and performance on measures of the following elements of LTC:
(1) Comprehensive LTC assessment and update (the percentage of LTC plan enrollees who have documentation of a comprehensive assessment within the appropriate time frame);
(2) Comprehensive LTC Care Plan (the percentage of LTC enrollees who have documentation of a Comprehensive LTC Care Plan within the appropriate time frame);
(3) Shared Care Plan (the percentage of LTC plan enrollees with a care plan for whom all or part of the care plan was transmitted to key LTC providers and the primary care provider within the appropriate time frame);
(4) Re-Assessment and Care Plan Update after Discharge (the percentage of discharges from inpatient facilities in the measurement year for LTC plan enrollees resulting in a re-assessment and care plan update within 30 days of discharge);
(5) Admission to an Institution from the Community among LTC enrollees (the percentage of LTC enrollee admissions to an institution (nursing facility or intermediate care facility for individuals with intellectual disabilities (ICF/IID)) from the community that result in a short-term or long-term stay during the measurement year);
(6) Successful Transition after Short-Term Institutional Stay among LTC enrollees (the percentage of LTC enrollee institutional admissions that result in successful discharge to the community (community residence for 30 or more days) within 100 days of admission); and
(7) Successful Transition after Long-Term Institutional Stay among LTC enrollees (the percentage of LTC enrollees who are long-term residents (101 days or more) of institutions who are successfully discharged to the community (community residence for 30 or more days)).
b. The respondent shall describe any instances of failure to meet Contract-required quality standards for these types of measures, actions taken to improve performance, and how improvement was measured. (See Section 409.966(3)(a)2., Florida Statutes)
c. The respondent shall describe its experience with and performance on other LTC performance measures, any instances of failure to meet Contract-required quality standards for these measures, actions taken to improve performance, and how improvement was measured.
d. The respondent shall describe the data sources used for collecting and reporting LTC performance measures.
e. The respondent shall describe how the respondent has obtained data needed to track measures related to care plan updates after hospital admissions and discharges, and emergency department visits.
Response:
Evaluation Criteria:
1. The extent of experience (e.g., number of Contracts, enrollees or years) in achieving quality standards with similar target populations, for measures related to the elements of LTC identified as number a.(1) through a.(7).
2. The extent of experience (e.g., number of Contracts, enrollees, or years) in achieving quality standards with similar target populations for other LTC performance measures.
3. The extent to which the described experience demonstrates the ability to effectively measure quality improvement.
4. The extent to which the described experience demonstrates the ability to improve quality in a meaningful way.
5. The extent to which the respondent met all quality measures or successfully remediated all failures.
6. The extent to which the respondent has used multiple data sources and has obtained data needed to collect and report on LTC performance measures, including those that require information related to care plan updates after hospital admissions and discharges, and emergency department visits.
Score: This section is worth a maximum of 30 raw points with each of the above components being worth a maximum of 5 points each.
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B. AGENCY GOALS
LTC SRC# 3 – Transitions of Care (Statewide):
The respondent shall describe how it will address transition and discharge planning for an enrollee going from a hospital or nursing facility rehabilitation setting and returning to a community setting. The respondent should identify specific strategies for ensuring that transition and discharge planning incorporates assessment of appropriate supports in the home, provision of supplies and home care/nursing services. The respondent shall include an example of an effective transition plan with appropriate timeframes for each step of the process.
Response:
Evaluation Criteria:
1. The extent to which the respondent’s process and example address the following components of transition and discharge planning:
(a) Assessment criteria for ensuring the enrollee can be served safely in the community;
(b) Collaboration with providers’ discharge planning staff (e.g., hospitals, institutional settings, assisted living facilities, ancillary providers);
(c) Referral and scheduling assistance;
(d) Coordination with home and community-based providers, including DME and home health providers as appropriate to meet the enrollee’s needs; and
(e) Processes to prevent unnecessary hospital or nursing facility readmissions.
2. The extent to which the respondent’s process and example ensure the protection of the enrollee’s privacy consistent with confidentiality requirements.
3. The extent to which the respondent’s example provides appropriate timeframes for each step of the transition and discharge planning process.
Score: This section is worth a maximum of 35 raw points with each of the above components being worth a maximum of 5 points each.
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LTC SRC# 4 – Provider Network Agreements/Contracts (Regional):
The Agency has identified some the key network provider types that will be critical in order for the respondent to promote the Agency’s goals.
The respondent shall demonstrate its progress with executing agreements or contracts it had with providers in the region by submitting Exhibit A-4-c-1, Provider Network Agreements/Contracts (Regional) (10-2-2017):
Response:
Evaluation Criteria:
For each service type the respondent may receive up to 60 points as described below. There are four (4) service types available in a region.
Percentage of agreements/contracts for each service type / Points0.0% / 0
1.0% - 25% / 15
25.1% - 50% / 30
50.1% - 75% / 45
75.1% or greater / 60
Score: This section is worth a maximum of 240 raw points based on the above point scale.
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C. RECIPIENT EXPERIENCE
LTC SRC# 5 – Transition from Nursing Facility to Community (Statewide):
The respondent shall describe its experience with transitioning individuals from institutional to community settings and strategies to ensure individuals maintain successful community placement including:
a. Experience and strategies pertaining to deploying transitional care teams and using evidence-based practices with support from other clinical resources and community-based organizations.
b. Experience and strategies pertaining to individuals who reside in an institutional setting for rehabilitation, or have otherwise resided in a facility for less than one year.
c. Experience and strategies pertaining to individuals who have resided in an institutional setting for more than one year.
Response:
Evaluation Criteria:
1. The extent to which the respondent identifies how it will coordinate care with all individuals and/or entities necessary.
2. The extent to which the respondent assesses potential caregiver willingness and availability in supporting the transition.
3. The extent to which the respondent’s description addresses transitioning enrollees with special circumstances or medical conditions (e.g., complex needs); enrollees with ongoing needs; and enrollees who at the time of their transition have existing prior authorization or approval for ancillary services.
4. The extent to which the respondent demonstrates through data its success rate at transitioning individuals from institutional to community settings.
5. The extent to which the respondent demonstrates through data its success rate at maintaining individuals who have transitioned from an institutional placement to community placements.
Score: This section is worth a maximum of 25 raw points with each of the above components being worth a maximum of 5 points each.
LTC SRC# 6 – Care Planning (Statewide):
The respondent shall provide a flowchart depicting how it will use the information contained in the State of Florida approved assessment (Florida Department of Elder Affairs 701B Comprehensive Assessment), the respondent’s supplemental assessment (if applicable), and any additional information collected in its utilization and case management processes for LTC services, in order to properly complete the initial care planning process for a recipient in a facility-based setting and in a community-based setting.
Response:
Evaluation Criteria:
1. The extent to which the flowchart outlines specific data components it will use from the State of Florida approved assessment in the development of the plan of care for enrollees.
2. The extent to which the flowchart outlines specific data components it will use from the respondent’s supplemental assessment, and/or any additional informational sources, in the development of the plan of care for enrollees.
3. The extent to which the flowchart incorporates specific data components it will use to ensure a person-centered approach is achieved in the care planning process, including documenting personal goals.
4. The extent to which the respondent uses the caregiver assessment to determine the availability of family/informal support systems, and the amount of assistance the existing support systems are able to provide the enrollee, in making authorization decisions.
Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each.
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LTC SRC# 7 – Freedom of Choice & Residential Settings (Statewide):
The respondent shall describe how it will address the enrollee’s preference in residential settings (i.e., home, adult family care home, assisted living, or nursing facility). The respondent shall describe the safeguards it will have in place during the implementation of the re-procurement of the SMMC program to ensure enrollees do not have to move out of their current residence, by residential setting.
Response:
Evaluation Criteria:
1. The extent to which the respondent’s description addresses the process it will use to ensure enrollees are educated about their choice in residential setting, including freedom of choice.
2. The extent to which the respondent describes initial or ongoing case manager training to confirm enrollee preference in residential setting.
3. The extent to which the respondent’s description addresses how all residential settings are considered for enrollee placement.
4. The extent to which the respondent’s description includes safeguards the respondent has in place to ensure enrollees will not have to move out of their current residence, by residential setting.
Score: This section is worth a maximum of 20 raw points with each of the above components being worth a maximum of 5 points each.
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D. PROVIDER EXPERIENCE
LTC SRC# 8 Home and Community-Based Services (HCBS) Performance and Credentialing (Statewide):
The respondent shall describe how its staff will create, collect, report and use internal provider performance measures and/or criteria for home and community-based, residential, and participant direction provider types. The respondent shall include how the performance measures will improve network quality and be utilized in recredentialing activities, and if/how the respondent will use the internally-developed performance measures to limit its provider networks pursuant to Section 409.982(1)(c), Florida Statutes.
Response:
Evaluation Criteria:
1. The extent to which the respondent’s description includes a plan to create, collect, report and use provider performance measures.
2. The extent to which the respondent describes how performance measures are reported and trended for each participating provider type and incorporates utilization data, quality of care concerns, performance measure scoring, and provider and enrollee satisfaction in recredentialing activities.
3. The extent to which the respondent’s description includes a plan to communicate the performance measure results to providers, including any provider incentives or alternative payment methodology opportunities available.
4. The extent to which the respondent’s description includes the establishment of data-based targets to determine the completion of provider corrective action plans and utilization of these targets pursuant to Section 409.982(1), Florida Statutes, including the ability for providers to be notified of performance issues prior to termination.