Slide 1: Implementation Council
Oct 12, 2021
Tufts Health Unify
Slide 2: One Care Rating Categories| Definitions
Data is shown by rating category in this presentation. See rating category definitions below for reference:

F1 - Facility-based Care. Individuals identified as having a long-term facility stay of more than 90 days

C3- Community Tier 3- High Community Need. Individuals who have a daily skilled need; two or more Activities of Daily Living (ADL) limitations AND three days of skilled nursing need; and individuals with 4 or more ADL limitations
-	In CY2014, C3 split into two subsets:
		C3B: for C3 individuals with certain diagnoses (e.g., quadriplegia, ALS, Muscular Dystrophy and Respirator dependence) leading to costs considerably above the average for current C3
		C3A: for remaining C3 individuals

C2 - Community Tier 2 - Community High Behavioral Health. Individuals who have a chronic and ongoing Behavioral Health diagnosis that indicates a high level of service need
- In CY2014, C2 split into two subsets
		C2B: for C2 individuals with co-occurring diagnoses of substance abuse and serious mental illness
		C2A: for remaining C2 individuals

C1 - Community Tier 1 Community Other. Individuals in the community who do not meet F1, C2 or C3 criteria
Footer:  CONFIDENTIAL – For Policy Development Purposes Only
Slide 3: UM Process Slide
Tufts Health Unify approaches UM by ensuring there are close connections between Cityblock Health (delegated for Unify care management) and the Tufts Health UM team to ensure decisions are rooted in holistic understanding of member needs. 

Note: the following information was shown in a flowchart with each item in a box with an arrow in between it pointing to the next box which illustrates movement from one step to the next. The chart uses colors and shapes to distinguish which task is related to which group. The groups are CHB Care Team, LTSS vendor and THPP UM.

•	Identify LTSS needs1
•	Refer to LTSS vendor
•	Complete LTSS assessment 
•	 LTS-C and CBH co develop LTSS service plan
•	Submit service request to THPP
•	Review request and member care plan and assessments2
•	Make service determination and notify member, CBH, and PCM
•	Implement services (as applicable)
•	Follow up with member
•	Ongoing collaboration

1.	LTSS needs are identified through comprehensive assessment, MDS, and the care planning process 
2.	THPP UM can request additional information if gaps in information are found through an RFMI (request for more information) process 
3.	THPP UM shares daily reporting with Cityblock that provides detail on authorizations 
4.	Member follow-up includes overview on how to file appeal and grievances and care manager advocacy to support member filing an appeal or grievance (as needed).

Key 
Blue=CBH, Orange=LTSS vendor, Green=CBH/LTSS, Teal=THPP UM
Slide 4: 99% of all PCA PA decisions are Approved
Of the 1913 PCA requests received by THPP since 2018*:
•	~99% were Approved
o	97% were approved without modification
o	3% were approved with modification
o	All modifications are downgrades and considered “partial approvals”
•	<1% were denied

Note: the following information was shown in a pie chart.

Approved without modification	97%
Approved with modification	3%
Denied	0%

*Data reflects the time period 2018- July 2021 
Slide 5: 99% of all PCA PA decisions are Approved
Note: the following information was shown in a table.

2021 YTD
Approved Without Modification 	315 (84%)
Approved With Modification 	55 (15%)
Denied 	4 (1%)
Total Requests 	374

2020
Approved Without Modification 	788 (100%)
Approved With Modification 	1 (0%)
Denied 	0 (0%)
Total Requests 	789

2019
Approved Without Modification 	414 (99%)
Approved With Modification 	1 (0%)
Denied 	3(1%)
Total Requests 	418

2018
Approved Without Modification 	332 (100%)
Approved With Modification 	0 (0%)
Denied 	0 (0%)
Total Requests 	332

Grand Total
Approved Without Modification 	1849 (97%)
Approved With Modification 	57 (3%)
Denied 	7 (0%)
Total Requests 	1913

Volume of PCA Requests by Final Decision and Year

Note: the following information was shown in a bar chart.

2021 YTD
Approved without Modification	315
Approved with Modification	55
Denied	4

2020
Approved without Modification	788
Approved with Modification	0
Denied	1

2019
Approved without Modification	414
Approved with Modification	1
Denied	3

2018
Approved without Modification	332
Approved with Modification	0
Denied	0

*2021 YTD reflects data through July 2021

Slide 6:
PCA Decisions- Rating Category

The vast majority of PCA requests are for C3A members.
•	C1: 3%
•	C2: 3%
o	C2A: 3%
o	C2B: <1%
•	C3: 94%
o	C3A: 90%
o	C3B: 4%
•	F1: <1%

Volume of PCA Requests by Year and Rating Category

Note: the following information was shown in a bar chart.

DC1
2018	14
2019	2
2020	26
2021YTD	16

DC2A
2018	20
2019	7
2020	18
2021YTD	5

DC2B
2018	3
2019	2
2020	1
2021YTD	4

DC3A
2018	283
2019	389
2021	709
2021YTD	331

DC3B
2018	11
2019	14
2021	28
2021YTD	15

DF1
2018	0
2019	4
2020	7
2021YTD	3
Slide 7: PCA Decisions – Rating Category
PCA Requests by Rating Category* and Year

Note: the following information was shown in a bar chart.

2018, N: C1 = 14, C2 = 23, C3 = 294
Approved Without Modification
C1	14
C2 	23
C3 	294
Approved With Modification
C1 	0
C2 	0
C3 	0
Denied
C1	0
C2 	0
C3 	0

2019, N: C1 = 2, C2 = 9, C3 = 403
Approved Without Modification
C1 	2
C2 	9
C3 	399
Approved With Modification
C1 	0
C2 	0
C3 	3
Denied
C1 	0
C2 	0
C3 	0

2020, N: C1 = 26, C2 = 19, C3 = 737
Approved Without Modification
C1 	26
C2 	19
C3 	736
Approved With Modification
C1 	0
C2 	0
C3 	1
Denied
C1 	0
C2 	0
C3 	0

2021YTD, N: C1 = 16, C2 = 9, C3 = 346
Approved Without Modification
C1 	14
C2 	7
C3 	291
Approved With Modification
C1 	2
C2 	2
C3 	51
Denied
C1 	0
C2 	0
C3 	4

*F1 members excluded due to low volume (<1%)
Slide 8: 82% of decreases were modifications of <40%
•	All PCA Approvals with modifications1 since 2018 have been reductions.
•	For 82% of PCA modifications, the decrease was less than 40%
Magnitude of Service Level Modifications with Decreases

Note: the following information was shown in a bar chart.

2019
0-10%	0%
11-20%	0%
21-30%	1%
31-40%	0%
41-50%	0%
>50%	0%

2020
0-10%	0%
11-20%	1%
21-30%	0%
31-40%	0%
41-50%	0%
>50%	0%

2021YTD
0-10%	5 (9%)
11-20%	21 (37%)
21-30%	11 (19%)
31-40%	10 (18%)
41-50%	5 (9%)
>50%	5 (9%)

1Examples of Common Reasons for PCA Modifications include: 1) Comprehensive assessment not yet completed or overdue 2) Current services already address member needs, 3) Time Requested exceeds allocated time based on member’s level of functioning and internal standards

Slide 9: PCM Agency Modification Rates
•	PCA Modifications constitute ~3% of all decisions
•	PCM agencies range in modification rates.
•	No PCM has had more than 10% of PCA decisions as modifications

Approvals with Modifications as a % of All Decisions by PCM*

Note: the following information was shown in a bar chart.

A = 10%
B = 8%
C = 7%
D = 4%
E = 2%
F = 1%
G = 0%
H = 0%
I = 0%
J = 0%
K = 0%

*PCMs with less than 5 PCA PA requests excluded