Slide 1: One Care Implementation Council Duals 2.0 Contract Recommendations
February 11, 2020
Slide 2: IC recommendations fall into three buckets:
•	Care model
•	Data
•	Quality measures
Slide 3: Resources
•	Child and Adult Core Set Stakeholder Workgroup: Measures Suggested for Addition to the 2020 Core Sets 
•	Quality in Home and Community-Based Services to Support Community Living: Addressing Gaps in Performance Measurement
•	CAHPS home and community-based services survey
•	Application of Existing External Quality Review Protocols to Managed Long Term Services and Supports 
Slide 4: Data Not Available (NA)
•	The One Care plan examined its samples files for bias, and if any bias was detected, the plan has documentation describing efforts taken to correct for that bias.
•	Plans should consistently provide written notification to members of any adverse action. During quality monitoring of the service decision process, plans should include member notification as a review element.
Slide 5: Data Not Available (NA)
•	Plans should provide an extension when there are efforts to obtain additional documentation that may be in the member’s best interest. 
•	Plans should provide evidence of a formal strategy that includes the use of provider profiling to identify and manage outliers, a system to establish and measure progress toward meeting improvement goals, and conducting onsite visits for assessing meaningful compliance with ADA requirements.
•	Plans should implement a formal quality-of-care process to include the review, corrective action, and required reporting to CMS and MassHealth for complaints related to quality-of-care and medical errors.
Slide 6: Data Not Available (NA)
•	When determining improvement in performance between measurement periods, the One Care plan applies appropriate statistical methodology to determine levels of significance of changes. 	 
•	The One Care plan carried out medical record reviews and abstractions in a manner that facilitated the collection of complete, accurate, and valid data.
•	Record review staff were properly trained and supervised for the task.
Slide 7: Quality recommendations identified in assessment and performance improvement
•	How does your MCO assess the quality and appropriateness of care, including LTSS, furnished to enrollees with special health care needs? Provide examples.
•	How is LTSS incorporated in performance improvement projects? What performance improvement projects currently involving LTSS are in place?
•	What interventions are used or are anticipated to be used to improve LTSS quality? How will the interventions be evaluated for effectiveness? How will improvement be sustained or increased?
Slide 8: Issues identified
•	bPlans should provide members with clear guidelines and definitions of medical necessity denials versus administrative denials. 
•	Challenges within the plan utilization management process since the path of appeal options available to the member varies based on the designation of the denial as administrative or clinical. 
•	Plans should conduct an annual CAHPS survey. 
•	How do the MCOs monitor LTSS provider quality, appropriateness of care, compliance with state and plan requirements and enforce corrective action when necessary?
Slide 9: Recommendations to MassHealth
•	MassHealth should consider conducting focused case management file review on a sample of One Care members to better evaluate the effect of the overall model of care at the individual member level. A file review might provide more meaningful feedback in terms of strengths and actionable findings to further improve the delivery of care to members covered under the One Care model.
•	MassHealth should provide guidance to One Care plans on appeal procedures to increase consistency across plans to ensure that plans administer member appeal rights based on the service being denied under what benefit. 
•	MassHealth should provide clarity to One Care Plans on its expectations related to medical necessity and administrative denials.
Slide 10: Care model
•	Goal-directed, person-centered care planning and implementation
•	Shared decision making
•	Systems to coordinate acute care, long-term services and supports, and nonmedical community resources
•	Beneficiary sense of control/autonomy/self-determination
•	Psychosocial needs
•	Community integration/inclusion and participation
•	Optimal functioning (e.g., improving when possible, maintaining, managing decline)
Slide 11: Recommendations continued
•	Plans engage in more robust person-centered planning that advances member goals that goes beyond narrow medical necessity guidelines or benefit definitions while ensuring prior authorization processes that advance equity at the individual and population levels.
Slide 12: Data
•	Percentage of enrollees who have an LTS coordinator participate in their care planning and goal setting activities;
•	Percentage of enrollees receiving LTS coordination in any given quarter;
•	Duration of enrollee engagement with LTS coordinator;
•	Frequency of encounters with the LTS coordinator;
•	Types of services recommended by the LTS coordinator homemaking, home delivered meals, adult day programs and adaptive technology to make it easier for a person to take care of themselves;
•	Utilization of Recovery Coaches & CPS’s.