A Study of Critical Access to HCBS in Minnesota Presentation to the HCBS Partners Panel August 15, 2014

A Study of Critical Access to HCBS in Minnesota

Presentation to the HCBS Partners Panel

August 15, 2014

Abt Associates | pg 2

Purpose

Examine Minnesota residents’ critical access to HCBS at both the local and community level, by;

– Working with DHS and the HCBS Partners Panel to more accurately define and quantify “critical access” using service planning, assessment, claims and county survey data; and

– Examining access issues among certain subpopulations who may face particular access challenges (e.g., persons with dementia, persons with complex physical and behavioral health needs) who likely “cut across” broader service recipient and disability categories

Suggest strategies for addressing these gaps.


Relationship to Other Projects

Abt will be coordinating with the service access study contractor to complement, not duplicate, their work

– Critical access is one component of larger access study

– Critical access analyses may include broader population and services focus

Abt will also be coordinating with the Gaps Analysis contractor responsible for the county survey

– Initial analyses to inform topic areas for survey in 2015

– Previous survey results provide direction and data for examining critical access

Analysis will build off of the MA Reform Study findings when relevant


DHS Areas of Interest

1) The relationship between the number of people receiving publicly-funded HCBS with potential total demand for these services;

2) The size and nature of the population eligible for HCBS waiver programs who do not currently receive these services;

3) More granular geographic (regional) and community-level service utilization trends, including specific subpopulations; and

4) Critical access correlates, such as provider mix and geographic and political configuration.


DHS Populations Included in Study

Categories of Recipients:

– Older adults;

– Children and adults with disabilities (physical, behavioral and cognitive);

– Children and youth with mental health conditions; and

– Adults living with mental illness.


DHS Populations Included in Study

Additional subpopulations of interest

– Individuals with dementia/Alzheimers

– “Frequent flyers” (e.g., high use of emergency/crisis services)

– Racial/ethnic groups

– Individuals with sensory deprivation

• Deaf, blind, hard-of-hearing

– “High need” users (e.g., individuals eligible for HCBS who also have co-occurring mental or behavioral health conditions)

– Individuals not eligible for Community First Services and Supports but with a mental health diagnosis


Defining Relevant Services

Could include:

Services covered by a Medicaid 1915c/HCBS waiver, including community residential

State plan services, e.g., PCA, PDN and CSG

Alternative Care

Essential Community Supports

Community First Services and Supports

Mental and behavioral health services

– CTSS, IRTS, ARMHS, Rule 5, ACT

Other related services

– Primary health care, inpatient, ER


Analytic Approach

Data Sources

– MN Base File (MMIS, MAXIS and assessment data)

– Provider File

– Service Agreement data

– Gaps and other county data

– American Community Survey

Expert input

– DHS programmatic and subject matter experts

– HCBS Partners Panel


Analytic Approach

Assess critical access issues through examination of both HCBS supply and demand. (Focus Areas 1 and 2)

Potential Demand Factors

– The extent to which individuals eligible for MA HCBS waiver services are “taking-up” services

– The number of individuals currently served by MA HCBS programs (i.e., actual demand) relative to potential demand (as culled from existing data sources)

– Waiting list information


Analytic Approach

Potential Supply Factors:

– Geographic distribution of key provider types, stratified by various subpopulations

– Self-assessments of “preparedness” to provide HCBS services from Gaps Survey data from county-level providers


Analytic Approach

Create definition(s) of critical access to more accurately capture the key services and “bundle of providers” needed to provide comprehensive services for each subpopulation (Focus Areas 3 and 4)

Other potential measures of critical access gaps

– Service use outside of county of residence

– Average driving distance to provider

– Institutionalization

– Self-reported access/availability data from the county survey

– Discrepancies between authorized and used service amounts

– Utilization levels and services not used

Examine determinants of utilization and critical access through multivariate analysis


Defining Critical Access

Seeking Partners Panel input on how to define and operationalize this construct

– Utilization rates and amounts

– Discrepancy between authorized and used services

– Combinations of local providers

– Geographic accessibility of providers

Potential correlates or drivers of critical access

– Demographics, including diagnosis

– Location, e.g., county or Rural Urban Commuting Area (RUCA) category

– Assessed need

– Number and type of registered providers


Defining Critical Access

Seeking Partners Panel input on potential areas or groups with suspected constrained critical access

– Does your experience and feedback from constituents suggest particular pockets of concern:

• Areas of the State

• Disability subgroups

• Users of specific HCBS services

• Provider supply

• Other factors, such as limited English proficiency, immigrant status or race/ethnicity


Potential Analyses

Matched case cohort analysis

– Construct cohorts or analytic groups matching on multiple variables, such as assessment data (e.g., number and type of ADLs, behaviors), diagnosis and demographics

– Goal is to examine differences in utilization or other factors, such as institutionalization or use of certain provider types, between “similar” individuals

– Variations by RUCA category or Census tract

– Allows us to explore correlates of critical access


Potential Analyses

Examine supply and demand for specific services and groups

– Define key service and provider needs for specific subpopulations

• Respite providers and children and adolescents with behavioral health needs

– Compare to actual number of users and potential demand

– Compare with other state and national ratios, as feasible


Simple Caseload Example

RUCA CategoryAverage Recipient per

PCA

1: Urban 4.4

2: Small Town 4.1

3: Rural 3.5

4: Isolated 3.6

5: Missing 2.8

Average PCA Provider Caseload by RUCA, FY2012


Potential Analyses: Geography

Actual distance analysis

– Match recipient and provider addresses to individual claims, for select services

– Can calculate actual driving distance by service type, using SAS and Google Maps

– Examine variation by subpopulation, service and geography

Potential driving distance for all providers in a certain service category

– For example, average distance between older adults with certain assessed needs and PDN agencies

Analyze substitute services used when no “close” providers are available

Examine “outcomes,” such as institutionalization, for those with constrained geographic access


Potential Analyses: Geographic

Examine utilization and utilization trends by:

– RUCA

– Census tract

– Service-specific, e.g., customized living

– Subpopulation specific, e.g., individuals with dementia

– Combination of location, service and population


Simple Utilization Example

Total Services Average per PersonRUCA Days Hours Days Hours

1: Urban 5,968,029 30,177,997.6 241.4 1,220.92: Small Town 478,967 2,794,043.1 201.1 1,173.03: Rural 286,874 1,819,372.3 190.0 1,204.94: Isolated 587,131 3,548,170.5 210.4 1,271.35: Missing 305,556 1,373,512.0 210.9 947.9

Total and per person PCA utilization by RUCA Category, FY2012*

*Not adjusted for number of eligibility days


Potential Analyses: Frequent Flyer

Create a profile (in the form of a bundle of common characteristics) of a “frequent flyer”, or high utilizer of services (e.g., ED services, behavioral crisis intervention services, etc.)

– Similar to “crisis user” analysis under MA Reform

– Assess potentially missing or underutilized services, such as certain therapies or respite

– Assess supply gaps for these services, by geographic location and subpopulation


Potential Analyses: CFSS

Examine population not eligible for Community First Services and Supports (CFSS) (i.e., individuals with no ADLs or Level 1 Behaviors but who may have a mental health diagnosis).

– What are they receiving now?

– How does this match what they need?

This would be coordinated with other ongoing efforts to evaluate CFSS


Potential Analyses: High Need

Create consensus definition of a “high need” population

– Physical and mental health disabilities

– Cognitive and mental health disabilities

– Complex medical needs

Examine variations in utilization, supply and demand

– What are they receiving now?

– How does this match what they need?

– How does this vary across the state and by subpopulation?


Questions and Feedback

Suggested focus areas

– Populations

– Services

– Providers

Suggested research questions


Contacts

Mary Olsen Baker, DHS

[email protected]

Sara Galantowicz, Abt Associates

[email protected]

mailto:[email protected]

mailto:[email protected]

Documents

A Study of Critical Access to HCBS in Minnesota Presentation to the HCBS Partners Panel August 15, 2014