Analyzing Plans of Care from the Florida Statewide Medicaid Managed Care Program in Long-Term Care

Background and Purpose

In 2013-2014, approximately 83,000 Florida long-term care (LTC) Medicaid recipients were moved from the previous delivery model to a managed care model implemented by private managed care plans. Approximately 100,000 new Medicaid recipients have been enrolled since the state implemented the program. The program is administered through contracts with six private healthcare companies (i.e., Plans).

In 2016, Florida Medicaid contracted with Florida State University to conduct an independent assessment of the LTC program. Results from the first two years of the evaluation are published elsewhere. In contract year three, the FSU evaluation team was tasked with addressing the following Research Question:

How do case managers improve quality of care for NF enrollees based on reviews of plans of care and case notes?

Plans of care (POCs) are essential to identifying and providing appropriate services to enrollees. In addition to federally mandated assessments in nursing facilities, enrollees of the Florida Medicaid LTC program residing in NFs also are assessed using an assessment measure specific to Florida Medicaid, administered by case managers employed by Plans. These case managers, independent of facility staff, develop POCs based on state-authored assessments. Case managers visit residents monthly and maintain case notes for each visit.

Methods:

We completed a content analysis of 341 randomly-selected Plan-authored POCs and associated case notes comprising a representative sample of the population. We developed a template of characteristics consisting of six domains (timely, accurate, person-centered, unique, measureable, appropriate) based on extant literature, expert opinion, and government documents. We evaluated the degree to which the POC and associated case notes represented the stated domain, using a rating system of not at all, somewhat, or completely. Interrater reliability was calculated using Cohen’s Kappa. Raters had sufficient agreement; Kappas ranged from .80 to 1.00.

Results

When evaluated as completely in compliance, all Plans had low levels of achievement (≤ 10%) regarding timeliness. Most Plans were successful (≥ 70%) in accuracy and appropriateness. Plans were less successful (≤ 33%) in person-centeredness and uniqueness, with no Plan exceeding 50% for either domain. Overall, Plans produced POCs and case notes that were at least somewhat accurate.

Person-centered POCs and case notes were a problem for most Plans, even when the categories of “completely” and “somewhat” were collapsed. Person-centered care is the gold standard for healthcare delivery. We also examined individual Plans and found only one Plan effective in all domains.

Conclusions and Implications

While Plans succeeded in some areas, person-centered care is an obvious failure. The literature supports a direct relationship between quality of care and person-centered, individualized care, making this focus for high quality care. Most enrollees’ POC goals were appropriate. The essence of the care planning process is to use the assessment to identify issues and address those issues through appropriate goals. Overall the Plans are doing this. As more states employ managed care, these findings are important. Case manager education data were not available, this is an area of future study.