Health and Recovery Plan

The Health and Recovery Plan (HARP) is an amendment to the 1115 waiver that enables qualified Managed Care Organizations (MCO) throughout New York State (NYS) to comprehensively meet the needs of individuals with behavioral health needs. The State identifies individuals who are eligible for HARPs. The general HARP eligibility requirements are: aged 21+ years, insured by only Medicaid (no dual-eligibles), have serious mental illness and substance use disorder diagnoses having serious behavioral health issues.

Care management is an important part of being in a HARP. Individuals identified as HARP-eligible must be offered care management through a health home designated by NYS. A person-centered care plan is developed and care management provided for all services within the care plan, including the home and community based services (HCBS). HARP HCBS services are also available to eligible SNP enrollees.

The goal of HARPs is to manage the Medicaid services for people who need them, manage an enhanced benefit package of HCBS, and provide enhanced care management for members to help them coordinate all their physical health, behavioral health, and non-Medicaid support needs.

Behavioral health HCBS benefits for the member:

• Psychosocial Rehabilitation
• Community Support and Treatment
• Habilitation Services
• Family Support and Training
• Short-Term Crisis Respite
• Intensive Crisis Respite
• Education Support Services
• Peer Support Services
• Non-medical Transportation
• Pre-vocational Services
• Transitional Employment
• Intensive Supported Employment
• On-going Supported Employment
• Self-directed Care

HARPs are responsible to coordinate and provide physical and behavioral health care services to members. Health homes are utilized to coordinate these services. HARP members are encouraged, but not required, to join a health home.

Special Needs Plan

The HIV Special Needs Plan (SNP) is a health plan for Medicaid recipients who are living with HIV/AIDS, and their Medicaid eligible children, regardless of the child´s HIV/AIDS status. In addition, SNPs serve homeless persons, regardless of HIV status. When a HIV positive member joins a HIV SNP, that person is assessed for care management. Care management, also referred to as case management, is a multi-step process to ensure timely access to and coordination of medical and psycho-social services for a person living with HIV/AIDS and his or her family or close support system.

Care management activities are diverse. In addition to assisting clients to access and maintain specific services, care management activities may include negotiation and advocacy for services, consultation with providers, navigation through the service system, psychosocial support, supportive counseling, and general client education. SNPs provide the same services that are provided by other Medicaid managed care plans and cover additional specialty services important to people living with HIV/AIDS. In addition, HARP HCBS services are available to eligible SNP enrollees.

The goal of care management is to promote and support independence and self-sufficiency. As such, the care management process requires the consent and active participation of the client in decision-making, and supports a client's right to privacy, confidentiality, self-determination, dignity, respect, nondiscrimination, compassionate non-judgmental care, a culturally competent provider, and quality case management services.

The intended care management outcomes for persons living with HIV/AIDS include:

• Early access to and maintenance of comprehensive health care and social services
• Improved integration of services provided across a variety of settings
• Enhanced continuity of care
• Prevention of disease transmission and delay of HIV progression
• Increased knowledge of HIV disease
• Greater participation in and optimal use of the health and social service system
• Reinforcement of positive health behaviors
• Personal empowerment
• An improved quality of life

SNPs are responsible for helping to coordinate:

• All medical services
• Services not covered by regular Medicaid, but which support wellness (i.e., psychosocial case management, housing, counseling, peer support, legal assistance, etc.)
• Special programs for people experiencing substance use disorders, homelessness, and families affected by HIV/AIDS
• Services that are "carved out" or paid for through fee-for-service Medicaid

SNP providers (doctors, nurses, and other care providers who participate in SNPs) understand members may need help with:

• Taking medications
• Behavioral health issues including mental health and substance use disorders
• Talking to loved ones about HIV

HIV SNPs were created because studies show that when people living with HIV/AIDS receive care from providers experienced in HIV health care, they live longer, healthier lives. All HIV SNPs are required to meet the New York State Department of Health (DOH) AIDS Institute quality standards for HIV/AIDS care.

This report is principally based on two data sources, the Health Plan Care Management Assessment Reporting Tool (CMART) and the New York State Medicaid Data. These data provide information regarding which members received care management services; the scope and nature of those services; and claims, encounters, and demographic details. HARP and SNP members are continually enrolled in care management. Members may require routine monitoring or may have episodes with acute needs during the year. The Clinical DataMart is utilized to generate quality measures to better understand outcomes of members receiving HARP- or SNP-led care management.

The Health Plan CMART is submitted annually to DOH for HARP and SNP plans. This information documents the process of HARP- and SNP-led care management services which include:

• Acute/active episodes requiring care management
• Date acute/active episodes begin to receive care management
• For members with acute/active episodes in HARP-led or SNP-led care management, CMART includes:
  • Start and end date of care management
  • Type of care management service received
  • Number of interventions
  • Type of interventions: letter, phone, in-person intervention

No health home services are included.

The Medicaid Data contains all claims and encounters data as well as demographics, diagnoses, etc. regarding HARP and SNP members.

The Clinical DataMart is utilized to calculate quality measures consistent with Healthcare Effectiveness Data and Information Set (HEDIS®) quality measures from the National Committee for Quality Assurance, and Prevention Quality Indicators (PQIs) from the Agency for Healthcare Research and Quality. PQIs can be used to identify potential problem areas in health care quality. These quality measures and quality indicators are used to better understand the quality of care provided by HARP and SNP care management.

The tables provided in this report are for comparison to the total (All HARP or All SNP) rates/numbers only. These comparisons tell us many characteristics about the care managed recipients, however, the data does not tell us the reason(s) why the recipients are engaged in the care management program. Program variation between HARPs and between SNPs programs limits the ability to compare one HARP to another or one SNP to another. Each HARP and each SNP differ in how care management services are carried out. Trends over time for a single HARP or SNP may be useful, but because HARPs and SNPs can change their internal policies, discontinuities in the data may or may not reflect changes in practice. The variation in HARP- and SNP-led care management programs may create differences in results that would not be apparent.

Variation and/or extreme values in results are difficult to interpret where numbers are small. Therefore, results with fewer than 30 eligible individuals are reported in the tables as SS (small sample).

This report represents the HARP and SNP populations during 2016 and contains the following three sections:

• Outreach: Descriptive statistics and process measures for members contacted for acute/active care management services.
• Engagement: Descriptive statistics and process measures for members engaged in acute/active care management services.
• Quality Measures: Quality measures for members engaged in care management services at any point in the calendar year.

Data presented in Table 2 in this report are stratified by Clinical Risk Group (CRG). CRGs are a categorical clinical model (developed by 3M®) which assigns each member of a population to a single mutually exclusive risk category. The CRGs provide a way to consider illness and resource utilization of a full range of patient types, including low income, elderly, commercial beneficiaries and those with disabilities. CRGs use standard claims data and, when available, additional data such as pharmaceutical data and functional health status which is collected longitudinally. Each CRG is clinically meaningful and correlates with health care utilization and cost. The Standard Model set of CRGs was used, which removes the effects of pregnancy/delivery during the calendar year.

We have combined the Standard Model CRGs as shown below. Each CRG group is defined and includes examples of conditions which could qualify a member for that CRG group.

• Healthy: Non-User and CRG number 1 (Healthy)
  • Non-User: No medical care encounters
  • CRG #1: Uncomplicated upper respiratory infection
• Stable: CRG numbers 2 (Significant acute disease) and 3 (Single minor chronic disease)
  • CRG #2: Pneumonia
  • CRG #3: Migraine Headache
• Simple Chronic: CRG numbers 4 (Minor chronic disease in multiple organ systems) and 5 (Single dominant or moderate chronic disease)
  • CRG #4: Migraine Headache and Hyperlipidemia
  • CRG #5: Diabetes
• Complex Chronic: CRG numbers 6 (Pairs – significant chronic disease in multiple organ systems) and 7 (Triples – dominant chronic disease in three or more organ systems)
  • CRG #6: Diabetes and Congestive Heart Failure (CHF)
  • CRG #7: Diabetes and CHF and Chronic Obstructive Pulmonary Disorder
• Critical/HIV: CRG numbers 8 (Malignancies – dominant, metastatic, and complicated) and 9 (Catastrophic conditions/HIV)
  • CRG #8: Metastatic Colon Malignancy, under active treatment
  • CRG #9: History of Major Organ Transplant

HARP and SNP members are automatically enrolled in care management. Care managers typically monitor member health and needs via the telephone each month. When the care manager determines there are specific needs for the member, an acute/active episode is started. An episode is a distinct unit of acute/active care management with a begin date and an end date. A member may have more than one acute/active episode during a measurement year. The acute/active episodes that have a need for interventions are submitted on the CMART to DOH.

Table 1 shows the population of the HARP and SNP plans as of December 31, 2016, and the total number of care management acute/active episodes for the entire year of 2016.

Table 1: Plan enrollment and potential acute/active episodes for each HARP and SNP

Table 2 shows the number of care management acute/active episodes, stratified by CRG.

Table 2: Acute/active potential episodes by CRG for each HARP and SNP

Note: CRG % by plan may not sum to 100% because of missing data

HARP members in the Complex Chronic CRG, significant chronic disease in multiple organ systems and dominant chronic disease in three or more organ systems, account for approximately 73 percent of All HARPs acute/active episodes.

SNP members in the Critical/HIV CRG, which includes malignancies, catastrophic conditions, and HIV, explain 94 percent of All SNPs acute/active episodes.

Once the care managers are aware that a member of a HARP or a SNP has a need for an acute/active episode, the care manager contacts the member to verify the services needed. This is the outreach phase. Outreach is primarily conducted by phone, but is occasionally conducted in-person.

Table 3 shows the percentage of potential HARP and SNP care management acute/active episodes for which members were contacted. The percentage contacted is the number of members successfully contacted by the HARP or SNP plan divided by the number of potential HARP or SNP care management acute/active episodes during the calendar year. The percentage contacted same day, contacted 1-30 days, and contacted 31+ days is the number of members successfully contacted by the HARP or SNP plan in each time frame divided by the total number contacted.

Table 3: Acute/Active members contacted and the contact timing for each HARP and SNP

Note: MetroPlus Enhanced episodes were considered monitoring, therefore, no contact or engagement data was submitted

All HARPs demonstrate about 80 percent successful contact from the outreach efforts. The majority of contacts are within the first month after becoming eligible for an acute/active episode.

Across All SNPs, more than 70 percent of outreach efforts end in a successful contact. The three SNPs vary in how long it takes to have successful contact from the outreach efforts.

Once the HARP or the SNP contacts the member, the member may choose to engage in an acute/active care management episode or decline the offer. Table 4 shows the percentage of contacted members who engage in HARP- or SNP-led care management services. The percentage engaged is the number of members engaged by the HARP or SNP divided by the number successfully contacted during the calendar year. The percentage engaged same day, engaged 1-30 days, and engaged 31+ days is the number of members engaged by the HARP or SNP in each time frame divided by the total number successfully contacted.

Table 4: Member engagement and timing for each HARP and SNP

Note: MetroPlus Enhanced episodes were considered monitoring, therefore, no contact or engagement data was submitted
SS: Small Sample Size

Across All HARPs, most of the contacted members engaged in HARP-led care management. Almost 90 percent of the engaged members did so more than one month after the acute/active episode start date.

Across all SNPs, over 90 percent of the members contacted decided to participate in SNP-led care management. This decision was usually made the same day or more than one month after the acute/active episode start date.

Members who are engaged in acute/active care management receive interventions. Services and referrals made to the member engaged in acute/active care management are based on an individualized plan of care.

A member may engage in acute/active care management more than one time during the measurement year, or engage for a period longer than a year. Therefore, the annual files may capture multiple acute episodes or an episode that exceeds the measurement year for a member.

Services offered to members within the care management programs will differ by HARP, SNP, and member needs. These differences impact the duration of engagement and the number of interventions provided to engaged members.

Table 5 shows the number of engaged acute/active episodes that closed in the measurement year per HARP and SNP, median number of days engaged in each acute/active care management episode, and mean number of interventions per closed acute/active episode.

Table 5: Median number of days and mean interventions for all closed episodes for each HARP and SNP

N/A: No members of the plan closed episodes in the measurement year
Note: MetroPlus Enhanced episodes were considered monitoring, therefore, no contact or engagement data was submitted
Note: Only episodes that closed in the calendar year are included; episodes with the same enrolled and closed date are excluded from this table
SS: Small Sample

The HARPs and the SNPs vary in both the mean number of interventions and the median number of days engaged in acute/active care management episodes. The variation in successfully meeting care plan goals is largely driven by differences in members´ needs. One method used to determine the success of care management is to look at the reason the episode closed.

Table 6 shows the number and percentage of closed episodes by reason for closure, the median number of days, and the mean number of interventions for each reason for closure for the HARPs and the SNPs.

Table 6: Reasons for Closure

Note: Only episodes that closed in the calendar year are included; episodes with the same enrolled and closed date are excluded from this table

An episode that met program goals is considered a success. Table 7 shows the number of acute/active episodes that closed with program goals met. The total percentage of closure is the number of episodes that met program goals divided by the total number of episodes that closed.

Table 7: Episodes closed for met program goals for each HARP and SNP

N/A: No members of the plan closed episodes in 2016
Note: All episodes with the same enrolled and closed date are excluded from this table
Note: MetroPlus Enhanced episodes were considered monitoring, therefore, no contact or engagement data was submitted
SS: Small Sample Size

The HARPs and SNPs vary in the percentage of the closed episodes that met program goals. Please note, this does not include episodes that are not closed within the measurement year. There may be episodes which successfully meet goals and close in the subsequent year.

Quality measures and PQIs, used to measure performance across HARPs and SNPs, can also be used to identify problems, opportunities for improvement, and obtain a baseline assessment of current practices. They are used as a first step to establishing performance benchmarks for the care management group. Table 8 shows the performance for each quality measure among engaged care management members. These measures are expressed as the percentage of members meeting the quality measure criteria.

Table 8: Percent of members meeting quality measures

The measures in Table 9 are rates of potentially preventable hospitalizations for specific chronic conditions. These chronic conditions are prevalent for many of the members engaged in care management. The measures are expressed as the rate of events per 100,000 members.

Table 9: Prevention Quality Indicator Rates per 100,000 Engaged Members

Utilization of medical services is a major component of the total cost of health care. One of the goals of care management is to lower utilization cost by decreasing emergency department (ED) and inpatient use, while simultaneously increasing outpatient use. The utilization shift is expected to cost less and improve member outcomes. Tables 10 through 12 show the utilization rates of emergency department, inpatient care, and outpatient care for anytime during the calendar year that the acute/active episode occurred.

Emergency department utilization is defined as visits to the ED that do not transfer to an inpatient stay. Inpatient utilization is defined as hospitalizations in a calendar year. Outpatient utilization is defined as ambulatory visits to providers.

Table 10: Emergency Department Rates per 1,000 member years

Note: MetroPlus Enhanced episodes were considered monitoring, therefore, no contact or engagement data was submitted

Table 11: Inpatient Rates per 1,000 member years

Note: MetroPlus Enhanced episodes were considered monitoring, therefore, no contact or engagement data was submitted

Table 12: Outpatient Rates per 1,000 member years

Note: MetroPlus Enhanced episodes were considered monitoring, therefore, no contact or engagement data was submitted

Quality Measures

Improving Preventive Care

Adult BMI Assessment (ABA): Percent of members, with an outpatient visit, who had their BMI documented during the measurement year or the year prior to the measurement year.

Breast Cancer Screening (BCS): Percent of women who had one or more mammograms to screen for breast cancer at any time two years prior up through the measurement year.

Cervical Cancer Screening (CCS): Percent of women, who had cervical cytology performed every 3 years or who had cervical cytology/human papillomavirus co-testing performed every 5 years.

Chlamydia Screening (CHL): Percent of sexually active young women who had at least one test for Chlamydia during the measurement year.

Colorectal Cancer Screening (COL): Percent of adults who had appropriate screening for colorectal cancer during the measurement year.

Improving Disease-related Care for Chronic Conditions

Comprehensive Diabetes Care - HbA1c Test (CDC): The percent of members with diabetes who received at least one Hemoglobin A1c (HbA1c) test within the year.

HIV/AIDS Comprehensive Care - Syphilis Screening: The percent of members with HIV/AIDS who were screened for syphilis in the past year.

HIV/AIDS Comprehensive Care - Viral Load Monitoring: The percent of members with HIV/AIDS who had two viral load tests performed with at least one test during each half of the past year.

HIV/AIDS Comprehensive Care - Engaged in Care: The percent of members with HIV/AIDS who had two visits for primary care or HIV-related care with at least one visit during each half of the past year.

Medication Management for People with Asthma - 50% Days covered (MMA): The percent of members with persistent asthma who filled prescriptions for asthma controller medications during at least 50% of their treatment period.

Medication Management for People with Asthma - 75% Days covered (MMA): The percent of members with persistent asthma who filled prescriptions for asthma controller medications during at least 75% of their treatment period.

Improving Outcomes for Persons with Mental Illness

Antidepressant Medication Management - Acute Phase (84 days) (AMM): The percent of members who remained on antidepressant medication during the entire 12-week acute treatment phase.

Antidepressant Medication Management - Continuation Phase (180 days) (AMM): The percent of members who remained on antidepressant medication for at least six months.

Follow Up After Hospitalization for Mental Illness - 7 days (FUH): The percent of members who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 7 days of discharge.

Follow Up After Hospitalization for Mental Illness - 30 days (FUH): The percent of members who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 30 days of discharge.

Improving Outcomes for Persons with Substance Use Disorders

Initiation of Alcohol and Other Drug Dependence Treatment (IET): The percent of members who, after the first new episode of alcohol or drug dependence, initiated treatment within 14 days of the diagnosis.

Engagement of Alcohol and Other Drug Dependence Treatment (IET): The percent of members who, after the first new episode of alcohol or drug dependence, initiated treatment and had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.

Prevention Quality Indicators; Reducing Avoidable Hospitalizations

Diabetes Short-Term Complications Admission Rate (PQI #1): Admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population; excludes obstetric admissions.

Diabetes Long-Term Complications Admission Rate (PQI #3): Admissions for a principal diagnosis of diabetes with long-term complications (renal, eye, neurological, circulatory, or complications not otherwise specified) per 100,000 population; excludes obstetric admissions.

COPD or Asthma in Older Adults Admission Rate (PQI #5): Admissions with a principal diagnosis of COPD or asthma per 100,000 population, ages 40 and older; excludes obstetric admissions.

Hypertension Admission Rate (PQI #7): Admissions with a principal diagnosis of hypertension per 100,000 population; excludes kidney disease combined with dialysis access procedure admissions, cardiac procedure admissions, and obstetric admissions).

Heart Failure Admission Rate (PQI #8): Admissions with a principal diagnosis of heart failure per 100,000 population; excludes cardiac procedure admissions and obstetric admissions.

Dehydration Admission Rate (PQI #10): Admissions with a principal diagnosis of dehydration per 100,000 population; excludes obstetric admissions.

Bacterial Pneumonia Admission Rate (PQI #11): Admissions with a principal diagnosis of bacterial pneumonia per 100,000 population; excludes sickle cell or hemogobin-5 admissions, other indications of immunocompromised state admissions, and obstetric admissions.

Urinary Tract Infection Admission Rate (PQI #12): Admissions with a principal diagnosis of urinary tract infection per 100,000 population; excludes kidney or urinary tract disorder admissions, other indications of immunocompromised state admissions, and obstetric admissions.

Uncontrolled Diabetes Admission Rate (PQI #14): Admissions for a principal diagnosis of diabetes without mention of short-term (ketoacidosis, hyperosmolarity, or coma) or long-term (renal, eye, neurological, circulatory, or other unspecified) complications per 100,000 population; excludes obstetric admissions.

Asthma in Younger Adults Admission Rate (PQI #15): Admissions for a principal diagnosis of asthma per 100,000 population, ages 18 to 39 years; excludes admissions with an indication of cystic fibrosis or anomalies of the respiratory system and obstetric admissions.

Lower-Extremity Amputation among Patients with Diabetes Rate (PQI #16): Admissions for any-listed diagnosis of diabetes and any-listed procedure of lower-extremity amputation per 100,000 population; excludes any-listed diagnosis of traumatic lower-extremity amputation admissions, toe amputation admissions, and obstetric admissions.

Reducing Utilization Associated with Avoidable IP stays and ED visits

Reducing Utilization Associated with Avoidable IP stays and ED visits

Ambulatory Care - Emergency Department (AMB-ED): Utilization of ambulatory care ED visits per 1,000 member years. Does not include mental health- or chemical dependency-related services.

Ambulatory Care - Outpatient (AMB-OP): Utilization of ambulatory care OP visits per 1,000 member years. Does not include mental health- or chemical dependency-related services.

Inpatient Utilization (IPU): Utilization of total acute inpatient stays per 1,000 member years. Does not include mental health- or chemical dependency-related inpatient stays.

HARP and SNP Covered Counties

Counties in NYS each HARP & SNP cover
HARPs
Affinity Health Plan; Affinity Enriched Health
Bronx	New York	Richmond	Suffolk
Kings	Orange	Rockland	Westchester
Nassau	Queens
CDPHP; CDPHP
Albany	Fulton	Rensselaer	Schoharie
Broome	Greene	Saratoga	Tioga
Columbia	Montgomery	Schenectady	Washington
EmblemHealth (HIP); EmblemHealth Enhanced Care Plus
Bronx	Nassau	Queens	Suffolk
Kings	New York	Richmond	Westchester
Empire BlueCross BlueShield; HealthPlus Amerigroup
Bronx	Nassau	Putnam	Richmond
Kings	New York	Queens	Suffolk
Excellus; Blue Option Plus
Broome	Monroe	Orleans	Wayne
Herkimer	Oneida	Otsego	Yates
Livingston	Ontario	Seneca
Fidelis Care; HealthierLife
Albany	Franklin	Oneida	Schuyler
Allegany	Fulton	Onondaga	Seneca
Bronx	Genesee	Ontario	St. Lawrence
Broome	Greene	Orange	Steuben
Cattaraugus	Hamilton	Orleans	Suffolk
Cayuga	Herkimer	Oswego	Sullivan
Chautauqua	Jefferson	Otsego	Tioga
Chemung	Kings	Putnam	Tompkins
Chenango	Lewis	Queens	Ulster
Clinton	Livingston	Rensselaer	Warren
Columbia	Madison	Richmond	Washington
Cortland	Monroe	Rockland	Wayne
Delaware	Montgomery	Saratoga	Westchester
Dutchess	Nassau	Schenectady	Wyoming
Erie	New York	Schoharie	Yates
Essex	Niagara
HealthFirst; HealthFirst Personal Wellness Plan
Bronx	Nassau	Queens	Suffolk
Kings	New York	Richmond
Independent Health; Independent Health´s MediSource Connect
Erie	Niagara
MetroPlus Health Plan; MetroPlus Enhanced
Bronx	New York	Queens	Richmond
Kings
Molina Healthcare; Total Care Plus
Cortland	Onondaga	Tompkins
MVP Health Care; MVP Harmonious Health Care Plan
Albany	Lewis	Putnam	Sullivan
Columbia	Livingston	Rensselaer	Ulster
Dutchess	Monroe	Rockland	Warren
Genesee	Oneida	Saratoga	Washington
Greene	Ontario	Schenectady	Westchester
Jefferson	Orange
UnitedHealthcare; UnitedHealthcare Community Plan-Wellness4Me
Albany	Essex	Nassau	Rockland
Bronx	Fulton	New York	Seneca
Broome	Genesee	Niagara	St. Lawrence
Cayuga	Greene	Oneida	Suffolk
Chautauqua	Herkimer	Onondaga	Tioga
Chemung	Jefferson	Ontario	Ulster
Chenango	Kings	Orange	Warren
Clinton	Lewis	Oswego	Wayne
Columbia	Livingston	Queens	Westchester
Dutchess	Madison	Rensselaer	Wyoming
Erie	Monroe	Richmond
YourCare Health Plan; YourCare Option Plus
Allegany	Chautauqua	Monroe	Wyoming
Cattaraugus	Erie	Ontario
SNPs
Amida Care
Bronx	New York	Queens	Richmond
Kings
MetroPlus Health Plan Partnership in Care
Bronx	New York	Queens	Richmond
Kings
VNSNY CHOICE SelectHealth
Bronx	New York	Queens	Richmond
Kings