First Interim Evaluation of California’s Health Homes Program (HHP) Prepared for: California Department of Health Care Services (DHCS) September 2020 First Interim Evaluation of California’s Health Homes Program (HHP) Nadereh Pourat, PhD Xiao Chen, PhD Brenna O’Masta, MPH Leigh Ann Haley, MPP Anna Warrick Weihao Zhou, MS Hanqing Yao UCLA Center for Health Policy Research Health Economics and Evaluation Research Program September 2020 This evaluation was supported by funds received from The California Endowment and the California Department of Health Care Services. The analyses, interpretations, and conclusions contained within this evaluation are the sole responsibility of the authors. This report contains analysis of data available up to September 30, 2019. Acknowledgments The authors would like to thank Azeem Banatwala, Brendon Chau, Maria Ditter, and Wafeeq Ridhuan for their hard work and support of HHP evaluation activities. Suggested Citation Pourat N, Chen X, O’Masta B, Haley LA, Warrick A, Zhou W, and Yao H. First Interim Evaluation of California’s Health Homes Program (HHP). Los Angeles, CA: UCLA Center for Health Policy Research, September 2020. UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Contents First Interim Evaluation of California’s Health Homes Program (HHP) ............................ 1 Executive Summary ...................................................................................................... 15 Health Homes Program Overview ............................................................................. 15 Evaluation Methods ................................................................................................... 16 Results....................................................................................................................... 16 HHP Implementation and Infrastructure ............................................................. 16 HHP Enrollment and Enrollment Patterns .......................................................... 17 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization ... 18 HHP Service Utilization Among HHP Enrollees .................................................. 19 HHP Outcomes................................................................................................... 20 Conclusion and Next Steps ....................................................................................... 20 Introduction ................................................................................................................... 22 Health Homes Program Overview ............................................................................. 22 HHP Implementation Plan ......................................................................................... 22 HHP Services ............................................................................................................ 24 HHP Target Populations ............................................................................................ 26 Funding and Payment Methodology .......................................................................... 27 UCLA HHP Evaluation ............................................................................................... 27 Conceptual Framework ...................................................................................... 27 Evaluation Questions and Data Sources ............................................................ 29 HHP Implementation and Infrastructure ........................................................................ 31 HHP Delivery Models................................................................................................. 33 HHP Delivery Networks ............................................................................................. 37 HHP Staffing .............................................................................................................. 38 Staffing Requirements ........................................................................................ 38 HHP Team Composition ............................................................................................ 40 Care Coordinators .............................................................................................. 41 HHP Directors..................................................................................................... 41 Housing Navigators, Clinical Consultants, and Optional Staff ............................ 41 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Data Sharing ..................................................................................................... 42 Data Sharing Technologies for Care Management and Care Coordination ........ 42 Dynamic versus Static Health Action Plan .......................................................... 44 Real-Time Notifications of Hospitalizations and ED Visits .................................. 44 MCP Approach to Targeting Patients for HHP Enrollment ................................. 44 Predictive Modeling to Identify Enrollees and Risk Grouping ............................. 45 Communication with HHP Enrollees .......................................................................... 46 Frequency of Outreach to Potential Enrollees .................................................... 47 Outreach to Homeless HHP Eligible Beneficiaries ............................................. 48 HHP Enrollment and Enrollment Patterns ..................................................................... 51 Enrollment Size.......................................................................................................... 52 Growth in HHP Enrollment by SPA..................................................................... 52 Growth in HHP Enrollment among Homeless by SPA ........................................ 53 Enrollment Size by Group and County ............................................................... 54 Enrollment Size Compared to Eligible Beneficiary Population ............................ 54 Enrollment Patterns ................................................................................................... 55 Enrollment Churn................................................................................................ 55 Enrollment Length .............................................................................................. 55 MCP Exclusions of Specific HHP Eligible Populations .............................................. 57 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization .............. 58 Demographics of HHP Enrollees at Time of Enrollment ............................................ 59 Health Status of HHP Enrollees Prior to Enrollment .................................................. 61 Health Care Utilization of HHP Enrollees Prior to Enrollment .................................... 62 Payments Associated with Health Care Utilization Prior to HHP Enrollment ............. 65 HHP Service Utilization among HHP Enrollees ............................................................. 66 HHP Services ............................................................................................................ 67 Estimated Overall HHP Service Delivery to HHP Enrollees ....................................... 69 Estimated Types of HHP Services Received ............................................................. 70 Estimated HHP Core Services by Modality and Staff Type ....................................... 71 HHP Housing Services .............................................................................................. 72 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Expenditures ..................................................................................................... 73 Outcomes ...................................................................................................................... 74 Process Metrics ......................................................................................................... 74 Outcome Metrics........................................................................................................ 76 HHP Costs .................................................................................................................... 80 Conclusions................................................................................................................... 81 Next Steps ................................................................................................................. 82 Appendix A: HHP Data Sources and Analytic Methods................................................. 84 Readiness Documents............................................................................................... 84 Enrollment Reports and MCP Quarterly HHP Reports .............................................. 84 Medi-Cal Enrollment and Claims ............................................................................... 84 Medi-Cal Health Homes Program Rate Range Summary.......................................... 84 Analytic Methods ....................................................................................................... 85 Readiness Documents ....................................................................................... 85 Enrollment Reports and MCP Quarterly HHP Reports ....................................... 85 Medi-Cal Enrollment and Claims ........................................................................ 87 Limitations ................................................................................................................. 95 Readiness Documents ....................................................................................... 95 Enrollment Reports and MCP Quarterly HHP Reports ....................................... 96 Medi-Cal Enrollment and Claims ........................................................................ 96 Appendix B: UCLA HHP Evaluation Design .................................................................. 97 Appendix C: HHP Enrollees Enrolled Less Than 31 Days .......................................... 107 Appendix D: Supplemental Data Tables...................................................................... 110 Homeless Enrollment by Group ............................................................................... 110 Appendix E: MCP- Level Data ..................................................................................... 111 Aetna Better Health of California ............................................................................. 111 HHP Implementation and Infrastructure ........................................................... 111 HHP Enrollment and Enrollment Patterns ........................................................ 112 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 115 HHP Service Utilization among HHP Enrollees ................................................ 118 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Alameda Alliance for Health .................................................................................... 121 HHP Implementation and Infrastructure ........................................................... 121 HHP Enrollment and Enrollment Patterns ........................................................ 122 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 125 HHP Service Utilization among HHP Enrollees ................................................ 128 Anthem Blue Cross of California Partnership Plan, Inc............................................ 131 HHP Implementation and Infrastructure ........................................................... 131 HHP Enrollment and Enrollment Patterns ........................................................ 132 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 136 HHP Service Utilization among HHP Enrollees ................................................ 140 Blue Shield of California Promise Health Plan ......................................................... 144 HHP Implementation and Infrastructure ........................................................... 144 HHP Enrollment and Enrollment Patterns ........................................................ 145 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 148 HHP Service Utilization among HHP Enrollees ................................................ 152 California Health & Wellness ................................................................................... 155 HHP Implementation and Infrastructure ........................................................... 155 HHP Enrollment and Enrollment Patterns ........................................................ 156 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 159 HHP Service Utilization among HHP Enrollees ................................................ 162 CalOptima ................................................................................................................ 165 HHP Implementation and Infrastructure ........................................................... 165 HHP Enrollment and Enrollment Patterns ........................................................ 166 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 169 HHP Service Utilization among HHP Enrollees ................................................ 172 Community Health Group Partnership Plan ............................................................. 175 HHP Implementation and Infrastructure ........................................................... 175 HHP Enrollment and Enrollment Patterns ........................................................ 176 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 179 HHP Service Utilization among HHP Enrollees ................................................ 182 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Net ................................................................................................................ 185 HHP Implementation and Infrastructure ........................................................... 185 HHP Enrollment and Enrollment Patterns ........................................................ 186 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 190 HHP Service Utilization among HHP Enrollees ................................................ 195 Inland Empire Health Plan ....................................................................................... 199 HHP Implementation and Infrastructure ........................................................... 199 HHP Enrollment and Enrollment Patterns ........................................................ 200 HHP Service Utilization among HHP Enrollees ................................................ 203 HHP Service Utilization among HHP Enrollees ................................................ 207 Kaiser Permanente .................................................................................................. 210 HHP Implementation and Infrastructure ........................................................... 210 HHP Enrollment and Enrollment Patterns ........................................................ 211 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 214 HHP Service Utilization among HHP Enrollees ................................................ 218 Kern Health Systems ............................................................................................... 221 HHP Implementation and Infrastructure ........................................................... 221 HHP Enrollment and Enrollment Patterns ........................................................ 222 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 225 HHP Service Utilization among HHP Enrollees ................................................ 229 L.A Care Health Plan ............................................................................................... 232 HHP Implementation and Infrastructure ........................................................... 232 HHP Enrollment and Enrollment Patterns ........................................................ 233 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 236 HHP Service Utilization among HHP Enrollees ................................................ 240 Molina Healthcare of California Partner Plan, Inc. ................................................... 243 HHP Implementation and Infrastructure ........................................................... 243 HHP Enrollment and Enrollment Patterns ........................................................ 244 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 248 HHP Service Utilization among HHP Enrollees ................................................ 255 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program San Francisco Health Plan ...................................................................................... 259 HHP Implementation and Infrastructure ........................................................... 259 HHP Enrollment and Enrollment Patterns ........................................................ 260 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 263 HHP Service Utilization among HHP Enrollees ................................................ 267 Santa Clara Family Health Plan ............................................................................... 270 HHP Implementation and Infrastructure ........................................................... 270 HHP Enrollment and Enrollment Patterns ........................................................ 271 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 274 HHP Service Utilization among HHP Enrollees ................................................ 278 UnitedHealthcare Community Plan of California, Inc. .............................................. 281 HHP Implementation and Infrastructure ........................................................... 281 HHP Enrollment and Enrollment Patterns ........................................................ 282 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization . 286 HHP Service Utilization among HHP Enrollees ................................................ 290 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Table of Figures Exhibit 1: General Health Homes Program Acronyms and Definitions .......................... 13 Exhibit 2: Managed Care Plans Acronyms/Abbreviations and Definitions ..................... 14 Exhibit 3: Timeline of HHP Implementation by Group and SPA .................................... 23 Exhibit 4: MCPs that Implemented HHP across California, by Group and County ........ 24 Exhibit 5: HHP Services Provided through MCPs and CB-CMEs ................................. 25 Exhibit 6: HHP Eligibility Inclusion and Exclusion Criteria ............................................. 26 Exhibit 7: HHP Evaluation Conceptual Framework ....................................................... 28 Exhibit 8: Health Homes Program Evaluation Questions and Data Sources ................. 29 Exhibit 9: Distribution of California Counties by Health Homes Program Implementation Group and MCPs Implementing Health Homes Program by County ............................. 32 Exhibit 10: Health Homes Program Delivery Models ..................................................... 33 Exhibit 11: Health Homes Program Delivery Models Employed and Primary Model Employed by MCP, Implementation Group, and Counties ............................................ 34 Exhibit 12: Selected Illustrative Examples of Implementation of Health Homes Program Delivery Models by MCPs ............................................................................................. 35 Exhibit 13: Health Homes Program CB-CME Network by Organization Type as of September 2019 ............................................................................................................ 37 Exhibit 14: Total Health Homes Program Anticipated Capacity by CB-CME Organization Type ............................................................................................................................. 38 Exhibit 15: DHCS Recommendation for Health Homes Program Multidisciplinary Team Composition at CB-CMEs ............................................................................................. 39 Exhibit 16: Selected Illustrative Examples of Health Homes Program Data Sharing Technologies between MCPs and CB-CMEs for Comprehensive Care Management and Care Coordination ......................................................................................................... 43 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 17: Selected Illustrative Examples of Predictive Modeling Approaches Used by MCPs ............................................................................................................................ 45 Exhibit 18: Planned Alternative Approaches to Outreach Frequency by Health Homes Program MCPs .............................................................................................................. 47 Exhibit 19: Illustrative Examples of Planned Outreach Approaches to Health Homes Program Eligible Homeless or At-Risk-of-Homeless MCP Members ............................ 48 Exhibit 20: Unduplicated Monthly and Cumulative Enrollment in HHP by SPA, July 1, 2018 to September 30, 2019 ......................................................................................... 52 Exhibit 21: Unduplicated Monthly and Cumulative Enrollment of HHP Homeless Enrollees by SPA, July 1, 2018 to September 30, 2019 ................................................ 53 Exhibit 22: Unduplicated Cumulative HHP Enrollment by Group and County as of September 30, 2019 ...................................................................................................... 54 Exhibit 23: Enrollment and Disenrollment Patterns in HHP as of September 30, 2019 . 55 Exhibit 24: Average Length of Enrollment in Months in HHP by Group as of September 30, 2019 ........................................................................................................................ 56 Exhibit 25: Number of Eligible Beneficiaries Excluded by Exclusion Rationale as of September 30, 2019 ...................................................................................................... 57 Exhibit 26: HHP Enrollee Demographics, Overall, and by SPA, at the Time of HHP Enrollment ..................................................................................................................... 60 Exhibit 27: Top Ten Most Frequent Physical and Mental Health Conditions among HHP Enrollees, 24 Months Prior to HHP Enrollment ............................................................. 61 Exhibit 28: Complexity of HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment ............................................................................................................ 62 Exhibit 29: Average Health Care Utilization by SPA, 24 Months Prior to HHP Enrollment ...................................................................................................................................... 62 Exhibit 30: Utilization Levels of HHP Enrollees, 24 Months Prior to HHP Enrollment ... 64 Exhibit 31: Utilization Level of HHP Enrollees by Specific Chronic Condition Criteria, 24 Months Prior to HHP Enrollment ................................................................................... 64 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 32: HHP Services .............................................................................................. 67 Exhibit 33: Estimated Overall HHP Services Received by HHP Enrollees by SPA, July 1, 2018 to June 31, 2019............................................................................................... 69 Exhibit 34: Estimated Average Number of HHP Services Provided to HHP Enrollees by Service Type and SPA, July 1, 2018 to June 30, 2019 ................................................. 70 Exhibit 35: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 .................................................... 71 Exhibit 36: Housing Services among HHP Enrollees by SPA and Group, HHP Q3 from July 1 to September 30, 2019 ....................................................................................... 72 Exhibit 37: Estimated HHP Supplemental Expenditures by Enrollee Type and Group, July 1, 2018 to September 30, 2019 ............................................................................. 73 Exhibit 38: Proportion of HHP Enrollees Who Were Assessed for Body Mass Index, Pre- and Post-HHP, Group 1 SPA 1 ..................................................................................... 75 Exhibit 39: Proportion of HHP Enrollees with Initiation of Alcohol and Other Drug Abuse or Dependence Treatment, Pre- and Post-HHP, Group 1 SPA 1 .................................. 75 Exhibit 40: Proportion of HHP Enrollees with Engagement of Alcohol and Other Drug Abuse or Dependence Treatment, Pre- and Post-HHP, Group 1 SPA 1 ....................... 76 Exhibit 41: Proportion of HHP Enrollees with All-Cause 30-Day Readmission, Pre- and Post-HHP, Group 1 SPA 1 ............................................................................................ 76 Exhibit 42: Number of PQIs per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 ............................................................................................................................ 77 Exhibit 43: Number of Ambulatory Care: Emergency Department Visits per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 .................................................. 77 Exhibit 44: Inpatient Visits per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 ............................................................................................................................ 78 Exhibit 45: Average Inpatient Length of Stay in Number of Days, Pre- and Post-HHP, Group 1 SPA 1 .............................................................................................................. 78 Exhibit 46 Number of Short-Term Nursing Facility Admissions per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 ................................................................ 79 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 47: Evaluation Questions and Data Sources ..................................................... 85 Exhibit 48: Beneficiary-Level Variables ......................................................................... 86 Exhibit 49: Demographic Indicators ............................................................................... 87 Exhibit 50: Health Status Indicators .............................................................................. 88 Exhibit 51: Healthcare Utilization Indicators .................................................................. 89 Exhibit 52: HHP Service Utilization Indicators ............................................................... 90 Exhibit 53: HHP Services .............................................................................................. 91 Exhibit 54: HHP Metrics, Definitions, and Reporting Status .......................................... 92 Exhibit 55: Evaluation Conceptual Framework .............................................................. 98 Exhibit 56: Evaluation Questions and Data Sources ..................................................... 99 Exhibit 57: Evaluation Timeline and Deliverables ........................................................ 106 Exhibit 58: HHP Enrollee Demographics at the Time of HHP Enrollment ................... 107 Exhibit 59: Top Ten Most Frequent Physical Health and Mental Health Conditions among HHP Enrollees ................................................................................................. 108 Exhibit 60: Proportion of HHP Enrollees that met Eligibility Criteria, Overall and by SPA, at the Time of HHP Enrollment .................................................................................... 109 Exhibit 61: Unduplicated Monthly and Cumulative Enrollment of HHP Homeless Enrollees by Group, July 1, 2018 to September 30, 2019 ........................................... 110 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 1 defines acronyms and terms referenced throughout the report. Exhibit 1: General Health Homes Program Acronyms and Definitions Acronym Definition AB Assembly Bill ACO Accountable Care Organization AHF AIDS Healthcare Foundation AHS Alameda Health Systems BMI Body Mass Index CB-CME Community-Based Care Management Entity CBO Community Based Organizations CCA Clinical Care Advance CCW Chronic Condition Warehouse CDPS Chronic Illness and Disability Payment System Risk Score CKD Chronic Kidney Disease CM Care Management COPD Chronic Obstructive Pulmonary Disease CSH Corporation for Supportive Housing DHCS California Department of Health Care Services E&M Evaluation & Management ED Emergency Department EHR Electronic Health Record ER Emergency Room FMAP Federal Medical Assistance Percentage FQHC Federally Qualified Health Center GRM General Risk Model HAP Health Action Plan HCPCS Healthcare Common Procedure Coding System HCSA Alameda County Health Care Services Agency HEDIS Healthcare Effectiveness Data and Information Set HHP Health Homes Program HIE Health Information Exchange HIT Health Information Technology HMIS Homeless Management Information Session ICD International Classification of Diseases LA Los Angeles LCSW Licensed Clinical Social Worker MCP Managed Care Plan MFT Marriage and Family Therapist NPI National Provider Identifier NPPES National Plan and Provider Enumeration System PACE Program of All-Inclusive Care for the Elderly PCP Primary Care Provider PMPM Per Member per Month RN Registered Nurse UCLA Evaluation | Glossary 13 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Acronym Definition SCAN Senior Care Action Network SFTP Secure File Transfer Protocol SMI Severe Mental Illness SNF Skilled Nursing Facility SPA State Plan Amendment SUD Substance Use Disorder SW Social Worker TEL Targeted Engagement List UCLA University of California, Los Angeles Center for Health Policy Research UOS Unit of Service Exhibit 2 defines acronyms and full names of participating Managed Care Plans. Exhibit 2: Managed Care Plans Acronyms/Abbreviations and Definitions Acronym/Abbreviations Managed Care Plan Full Name ABHCA Aetna Better Health of California AAH Alameda Alliance for Health Anthem Anthem Blue Cross of California Partnership Plan, Inc. BSCPHP Blue Shield of California Promise Health Plan CHW California Health & Wellness CalOptima CalOptima CHG Community Health Group Partnership Plan HNCS Health Net Community Solutions, Inc. IEHP Inland Empire Health Plan Kaiser Kaiser Permanente KHS Kern Health Systems L.A. Care L.A. Care Health Plan MHC Molina Healthcare of California Partner Plan, Inc. SFHP San Francisco Health Plan SCFHP Santa Clara Family Health Plan UnitedHealthcare UnitedHealthcare Community Plan of California, Inc. 14 Glossary | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Executive Summary Health Homes Program Overview The California Department of Health Care Services (DHCS) implemented the Medi-Cal Health Homes Program (HHP) to serve eligible Medi-Cal beneficiaries with complex needs and chronic conditions. HHP was authorized under California Assembly Bill 361 and approved by Centers for Medicare and Medicaid Services under Section 2703 of the 2010 Patient Protection and Affordable Care Act. The overarching goal of HHP was to achieve the “triple aim” of better care, better health, and lower costs by improving member outcomes through care coordination and reducing avoidable health care costs. HHP was designed to provide six core services for eligible enrollees: (1) comprehensive care management; (2) care coordination; (3) health promotion; (4) comprehensive transitional care; (5) individual and family support; and (6) referral to community and social support services. DHCS selected 12 California counties where 16 Medi-Cal managed care plans (MCPs) would implement HHP for MCP enrollees who met certain chronic condition and acuity criteria. HHP was implemented in phases by county groupings and two subsets of enrollees, with the first group implementing in July 2018 and the last group implementing in September 2020. Subsets of enrollees included those with chronic physical health conditions or substance use disorders (SUD) referred to as SPA 1 (State Plan Amendment 1) and those with severe mental illness (SMI) referred to as SPA 2. MCPs implemented SPA 2 six months after SPA 1 within each county grouping. DHCS published a program guide to ensure uniform HHP implementation, delivery of services, and reporting across all MCPs. MCPs were expected to contract with Community-Based Care Management Entities (CB-CMEs), or in instances where contracting with local CB-CMEs was not feasible, to deliver services directly to HHP enrollees. CB-CMEs could include primary care providers (PCPs), Federally Qualified Health Centers (FQHCs), and other service providers. CB-CMEs could also work with Community Based Organizations (CBOs) to provide linkages to community and social support services, as needed. This evaluation report is the first of a series of three planned evaluation reports of HHP and focuses on the initial implementation efforts and infrastructure development of HHP MCPs, health status and utilization of enrollees prior to HHP implementation, as well as some early trends for key health outcomes and utilization metrics for Group 1 SPA 1 enrollees. UCLA Evaluation | Executive Summary 15 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Evaluation Methods The University of California, Los Angeles (UCLA) Center for Health Policy Research was selected to evaluate HHP and developed a conceptual framework and evaluation questions to conduct a rigorous assessment of the program. The framework anticipated that the HHP program would lead to better care delivery by establishing the necessary infrastructure and delivery of HHP services, which in turn would lead to better health as measured by specific utilization and health outcome metrics. Both better care and better health would lead to lower overall Medi-Cal health care expenditures. UCLA used all available data for the evaluation. These included MCP Readiness Documents that contained MCP’s HHP policies and procedures for implementation and delivery of services; Targeted Engagement Lists (TEL) created every six months by DHCS to identify potentially eligible HHP enrollees per MCP; MCP enrollment and quarterly reports that included enrollee level enrollment data and homeless status; and Medi-Cal enrollment and claims data for all HHP enrollees with information on demographics, health status, and use of health services. In this first report, UCLA used readiness documents to describe HHP implementation efforts including composition of HHP networks, types of staff, data sharing, enrollee outreach and engagement, and HHP service delivery approaches. UCLA used TEL, MCP enrollment and utilization reports, and Medi-Cal data to assess HHP enrollment patterns, demographics, health status, HHP service use, and health care service utilization. Results HHP Implementation and Infrastructure • HHP was implemented by 16 MCPs in 12 counties, with six MCPs implementing in more than one county. • MCP HHP implementation plans outlined in Readiness Documents were used to examine MCP intentions at the beginning of HHP, even though the plans may have changed during implementation. These plans indicated that 15 (of 16) MCPs used delivery Model I, where CB-CMEs were typically medical providers that hired and housed HHP staff, including care coordinators. When HHP enrollees’ medical providers were not able to take on these responsibilities, MCPs utilized Models II and III to deliver services centrally or regionally. • In their Quarterly HHP Reports, MCPs reported that they had developed HHP delivery networks with 212 CB-CMEs by September 2019. These CB-CMEs were primarily community health centers or clinics (70%), followed by primary care or specialty providers (14%), or care coordination or case management providers 16 Executive Summary | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program (13%). MCPs reported that they anticipated that these CB-CMEs had an enrollment capacity of approximately 47,010 enrollees. • MCPs ensured that CB-CMEs had adequate staffing to deliver HHP services by requiring certain staffing types such as care coordinators, HHP directors, clinical consultants, and housing navigators. • In Readiness Documents, 11 MCPs (of 16), including all of the MCPs that implemented in more than one County, indicated that they planned to hire certain HHP staff internally to improve efficiency and effectiveness. These roles most often included directors, program managers, and housing specialists. • Seven MCPs planned to use a SFTP or dedicated email and six MCPs planned to use electronic health records (EHR), care management platforms, or health information exchange (HIE) data sharing technologies. • Both CB-CMEs and MCPs planned to use data sharing technologies to provide timely access to information. Eight MCPs (of 16) planned to provide access to a dynamic Health Action Plan (HAP) to allow access to up-to-date information and five MCPs planned to provide real-time and automated notifications of HHP hospital admissions or emergency department visits to CB-CMEs. • MCPs developed plans for identifying and targeting individuals for HHP enrollment including use of predictive modeling and risk grouping of eligible beneficiaries. • MCPs most often planned to use newsletters (nine of 16) and websites (nine) to communicate with eligible beneficiaries and developed plans on how often they would outreach to eligible beneficiaries. • MCPs planned to use a mix of approaches to target individuals experiencing homelessness. These approaches included collaborating with CB-CMEs or community-based organizations that specialized in working with these individuals and leveraging existing infrastructure developed under Whole Person Care to provide outreach. HHP Enrollment and Enrollment Patterns • A total of 15,527 individuals enrolled in HHP between July 1, 2018 and September 30, 2019, with 14,380 enrolled in SPA 1 and 1,147 enrolled in SPA 2. The highest HHP enrollment in a given group and county was 4,791 corresponding to an earlier implementation. • There was a steady growth in the number of homeless enrollees over time. As of September 2019, 510 HHP enrollees (3.5%) were reported as ever homeless at any point during HHP enrollment, 472 from SPA 1 (3.4%) and 38 from SPA 2 (3.5%). There was variation in the number of homeless enrollees by Group, with Group 2 having the largest proportion of homeless enrollees (4.4%) and Group 1 UCLA Evaluation | Executive Summary 17 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program having the smallest proportion of homeless enrollees (less than 2%). Due to data limitations, these numbers are likely to underestimate the size of homeless enrollees in HHP. • Group 1 MCPs began enrollment in July 2018, and enrolled 12% of potentially eligible beneficiaries from their respective TELs. Group 2 MCPs began enrollment in January 2019, and enrolled 18% of potentially eligible beneficiaries. Group 3 MCPs began enrollment in July 2019, and had enrolled 3% of potentially eligible beneficiaries by September 30, 2019. • Ninety percent of HHP enrollees were continuously enrolled, 9.9% enrolled for a shorter time, and 0.1% enrolled multiple times in the program. The average length of enrollment in Group 1 was 7.5 months for SPA 1 enrollees and 5.1 months for SPA 2 enrollees. Overall, the average length of enrollment was 5 months for Group 2 and 1.6 months for Group 3 enrollees. • Among the 245,330 potentially eligible beneficiaries identified in the TEL, MCPs reported excluding 9,442 beneficiaries because they were not MCP members, 6,340 because of unsuccessful engagement, and 5,229 because the eligible beneficiary declined to participate. HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization • The great majority of HHP enrollees (15,522) were enrolled for over 30 days. • The majority of HHP enrollees were between 50 and 64 years old, female, and spoke English. Nearly 45% were Latino. SPA 2 enrollees were more often between 18 and 49 years old and more often female in comparison to SPA 1 enrollees. • Prior to enrollment, the most common chronic conditions among all HHP enrollees and SPA 1 enrollees were hypertension (72.8%) and diabetes (53.4%). The most common condition among SPA 2 enrollees was depression (71.0%). • MCPs enrolled Medi-Cal managed care beneficiaries with multiple chronic health conditions, consistent with HHP’s requirements. For example, 60.5% had hypertension along with chronic obstructive pulmonary disease, diabetes, coronary artery disease, and/or chronic or congestive heart failure and 43.4% had a combination of very complex conditions such as chronic renal (kidney) disease, chronic liver disease, traumatic brain injury, and a more common condition. • Consistent with HHP requirements, HHP enrollees had high levels of utilization of acute services, 1.2 hospitalizations and 4.1 emergency department (ED) visits in the 24 months prior to HHP enrollment on average. SPA 2 enrollees had more ED visits in the 24 months prior to HHP enrollment (5.1) compared to SPA 1 18 Executive Summary | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program enrollees (4.0). SPA 1 enrollees had more primary care services visits in the 24 months prior to HHP enrollment than SPA 2 enrollees. • UCLA examined the utilization levels of ED visits and hospitalizations for HHP enrollees 24 months prior to enrollment and identified three categories, one including those with the highest use of either service. The highest utilizers (25% of HHP enrollees) had 13.9 ED visits and 4.6 hospitalizations on average. These individuals also had the highest level of severity, estimated by using an independent measure risk called the Chronic Illness and Disability Payment System (CDPS) based on presence of high cost conditions. HHP Service Utilization Among HHP Enrollees • MCPs provided HHP engagement services, core HHP services, and other HHP services. Services were provided by clinical and non-clinical CB-CME providers. Core HHP services were provided in-person or through telehealth. Each service was reported in 15-minute increments or units of service (UOS). Multiple units of service per each claim were allowed and services from clinical and non-clinical staff in tandem were allowed. • MCPs were required to report HHP services to DHCS in Medi-Cal claims data starting on July 1, 2018 using HCPCS codes. However, HCPCS codes were not present in claims data for many enrollees and appeared to be under-reported by CB-CMEs to MCPs. In discussions with DHCS, MCPs reported challenges in obtaining data on provision of all services including housing services from their CB-CMEs, which they were addressing by providing technical assistance to improve reporting. Sixteen percent of HHP enrollees lacked any HCPCS codes and 38.7% of HHP enrollees lacked HCPCS codes for some months during their enrollment. Rates of under-reporting varied by type of service with a higher rate for core services and a lower rate for engagement services. UCLA calculated HHP service use for the months that HCPCS codes were present as an estimate of type of services provided under HHP. • Data showed an estimated total of 31,183 UOS, averaging to 1.9 UOS per HHP enrollee per month. SPA 2 enrollees had an average of 3.5 UOS per HHP enrollee per month, while SPA 1 had an average of 1.8. The estimated number of UOS per enrollee per month was higher for core HHP services (1.7), than engagement (1.3) and other HHP services (1.4). The estimated number of UOS per enrollee per month per type of service was higher for SPA 2 than SPA 1 enrollees for all three service types. • SPA 2 enrollees were estimated to receive more telehealth services (2.2 UOS) compared to in-person services (1.4 UOS). Similarly, estimated number of services by non-clinical staff (2.9 UOS) were higher than clinical staff (1.5 UOS) for SPA 2 enrollees. UCLA Evaluation | Executive Summary 19 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program • MCPs reported that 3.8% of enrollees were homeless or at risk for homelessness between July 1, 2019, and September 30, 2019, and 38.0% of these enrollees received housing navigation and transition services. Due to data limitations, these numbers are likely to underestimate both the size of homeless enrollees in HHP and the quantity of housing services received. • Data showed that estimated HHP supplemental payments by the end of Q3 2019 totaled $30.8 million and that average monthly HHP expenditure was $488 per enrollee. HHP Outcomes • HHP outcomes were only measured for Group 1 SPA 1 enrollees because this was the only group with complete claims data for the first year of HHP implementation. Changes in selected metrics for Group 1 SPA 1 enrollees in San Francisco were examined before and after each individual’s enrollment in HHP. • For Group 1 SPA 1 enrollees, Assessment and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment increased significantly from a rate of 45% in Pre-HHP Year 1 (or 12 months prior to HHP enrollment) to 55% after HHP Year 1 (or 12 months of enrollment in HHP). • For Group 1 SPA 1 enrollees, the rate of Emergency Department (ED) visits showed a steady increase 24 months prior to HHP enrollment. Pre-HHP Year 2 (or 24 months prior to HHP enrollment) the rate of ED visits was 315 per 1,000 enrollee months and increased to a rate of 404 in pre-HHP Year 1 (or 12 months prior to HHP enrollment). The ED visits rate decreased significantly after one year of HHP enrollment, or HHP Year 1, to a rate of 285. • For Group 1 SPA 1 enrollees, inpatient utilization or the rate of hospitalizations, showed a steady increase 24 months prior to HHP enrollment. In pre-HHP Year 2, the rate was 92 inpatient visits per 1,000 enrollee months and increased to a rate of 134 in Pre-HHP Year 1. The rate of hospitalizations decreased significantly after one year of HHP enrollment, or HHP Year 1, to a rate of 91. Conclusion and Next Steps These findings provide evidence that MCPs had developed comprehensive plans to build the needed infrastructure and to deliver HHP services as required by HHP; successfully enrolled eligible Medi-Cal beneficiaries in participating counties; targeted appropriate beneficiaries based on their complexity of health status and very high use of ED and hospitalization prior to HHP enrollment; and delivered substantial HHP services to enrollees. 20 Executive Summary | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program This report highlights the interim progress made by MCPs under the first 15 months of HHP, including early and preliminary analyses of trends in key health outcomes and utilization metrics among HHP enrollees. This report was limited in reporting of HHP outcomes due to lags in comprehensive claims data and short length of enrollment for HHP enrollees in Groups 2 and 3. The next two evaluation reports will assess longer term outcomes and utilization trends using more recent enrollment and claims data. These reports will include data on changes in pre-defined outcomes and Medi-Cal payments for HHP enrollees and a comparable control group of Medi-Cal beneficiaries after an adequate period of enrollment. Pre-defined outcomes will include measures of health services utilization, such as emergency department visits and indicators of quality of care, such as all-cause readmissions and initiation and engagement of alcohol and other drug abuse or dependence treatment. UCLA Evaluation | Executive Summary 21 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Introduction Health Homes Program Overview The Health Homes Program (HHP) was created and implemented under the statutory authority of California Assembly Bill (AB) 361. The legislation authorizes the California Department of Health Care Services (DHCS) to create HHP under Section 2703 of the 2010 Patient Protection and Affordable Care Act. Section 2703 allows states to create Medicaid health homes to coordinate the full range of physical health, behavioral health, and community-based long-term services and supports needed by Medi-Cal enrollees with chronic conditions. Twelve California counties chose to implement HHP and all Medi-Cal Managed Care Plans (MCPs) in those participating counties were required to participate in HHP. HHP is focused on enrollees who meet certain chronic condition and acuity criteria. HHP has a phased implementation schedule, and individuals with chronic physical health conditions or substance use disorders (SUD) are included in State Plan Amendment (SPA) 1 (i.e., Phase 1) and those with severe mental illness (SMI) are included in SPA 2 (i.e., Phase 2). The primary goals of HHP are to improve member outcomes through care coordination and reduce avoidable health care costs. MCPs are expected to deliver HHP services directly or through contracted community-based care management entities (CB-CMEs), which could include primary care providers (PCPs), Federally Qualified Health Centers (FQHCs), and other service providers. CB-CMEs work with Community Based Organizations (CBOs) to provide linkages to community and social support services, as needed. HHP Implementation Plan The HHP implementation schedule is displayed in Exhibit 3. The 12 counties implementing HHP were divided into four groups, with Group 1 scheduled to begin implementation on July 1, 2018, and Group 4 to implement the final phase on July 1, 2020. Each Group would first implement HHP for SPA 1 enrollees (those with chronic physical health conditions and/or SUD), followed six months later by SPA 2 enrollees (those with SMI). 22 Introduction | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 3: Timeline of HHP Implementation by Group and SPA Source: Adapted from HHP Implementation Schedule. HHP Managed Care Plans. Note: SPA is State Plan Amendment. A total of 16 MCPs implemented HHP across the 12 counties (Exhibit 4). MCPs were responsible for the overall administration of HHP and expected to fulfill HHP requirements by leveraging existing infrastructure, communication, and reporting capabilities. MCP responsibilities included (1) perform regular auditing and monitoring activities; (2) train, support, and qualify CB-CMEs; (3) provide CB-CMEs with timely information on admissions, discharges, and other key utilization and health condition information; (4) connect members experiencing homelessness to housing navigation services and identify permanent housing solutions; and (5) fulfill HHP care management requirements. UCLA Evaluation | Introduction 23 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 4: MCPs that Implemented HHP across California, by Group and County Group County Managed Care Plan 1 San Francisco Anthem Blue Cross of California Partnership Plan, Inc. San Francisco Health Plan 2 Riverside Inland Empire Health Plan Molina Healthcare of California Partner Plan, Inc. San Bernardino Inland Empire Health Plan Molina Healthcare of California Partner Plan, Inc. 3 Alameda Alameda Alliance for Health Anthem Blue Cross of California Partnership Plan, Inc. Imperial California Health & Wellness Molina Healthcare of California Partner Plan, Inc. Kern Health Net Community Solutions, Inc. Kern Health Systems Los Angeles Health Net Community Solutions, Inc. L.A. Care Health Plan Sacramento Aetna Better Health of California Anthem Blue Cross of California Partnership Plan, Inc. Health Net Community Solutions, Inc. Kaiser Permanente Molina Healthcare of California Partner Plan, Inc. San Diego Aetna Better Health of California Blue Shield of California Promise Health Plan Community Health Group Partnership Plan Health Net Community Solutions, Inc. Kaiser Permanente Molina Healthcare of California Partner Plan, Inc. UnitedHealthcare Community Plan of California, Inc. Santa Clara Anthem Blue Cross of California Partnership Plan, Inc. Santa Clara Family Health Plan Tulare Anthem Blue Cross of California Partnership Plan, Inc. Health Net Community Solutions, Inc. 4 Orange CalOptima Source: DHCS. Notes: MCP is Managed Care Plan and DHCS is the California Department of Health Care Services. HHP Services The overarching goal of HHP was to achieve the “triple aim” of better care, better health, and lower costs. To achieve these goals, MCPs provided HHP services most 24 Introduction | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program often through community-rooted CB-CMEs. These services included (1) comprehensive care management, (2) care coordination, (3) health promotion, (4) comprehensive transitional care, (5) individual and family support services, and (6) referrals to community and social support services. Exhibit 5 displays detailed descriptions of these services. Exhibit 5: HHP Services Provided through MCPs and CB-CMEs Service Description Comprehensive care • Engage MCP members to participate in HHP management • Collaborate with HHP enrollees and their family/support persons to develop a Health Action Plan (HAP) within 90 days of enrollment that is comprehensive and person-centered • Reassess HAP as needed and track referrals • Case conferencing to support continuous and integrated care among all service providers Care coordination • Provide enrollee support to implement HAP and attain enrollee goals • Coordinate referrals and follow-ups, share information to all involved parties, and facilitate communication • Frequent, in-person contact between HHP enrollees and care coordinators • Appointment with primary care physician within 60 days of enrollment encouraged • Identify and address enrollee gaps in care • Maintain an appointment reminder system for enrollees as appropriate • Link eligible enrollees who are homeless or experiencing housing instability to permanent housing Health promotion • Encourage and support HHP enrollees to make lifestyle choices based on health behavior • Encourage and support health education • Assess and motivate enrollees and family/support person understanding of health condition and motivation to engage in self-management Comprehensive • Facilitate HHP enrollees’ transition from and among transitional care treatment facilities • Provide medication information and reconciliation • Plan follow-up appointments and anticipate care or place to stay post-discharge UCLA Evaluation | Introduction 25 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Service Description Individual and family • Ensure HHP enrollees and family/support persons support services are educated about the enrollee’s conditions to improve treatment and medical adherence Referrals to community • Determine appropriate services to meet HHP and social support enrollee’s needs services • Identify and refer enrollees to available community resources Source: Adapted from Health Homes Program Guide. Notes: MCP is Managed Care Plan and CB-CME is Community-Based Care Management Entity. HHP Target Populations The eligibility criteria defined by DHCS for HHP was based on the presence of specific chronic conditions and evidence of high acuity (Exhibit 6). These criteria aimed to identify the Medi-Cal population who may benefit the most from HHP services. DHCS identified a Targeted Engagement List (TEL) of Medi-Cal MCP enrollees in the 12 participating counties who were likely to be eligible for HHP services based on specific inclusion and exclusion criteria. The exclusion criteria were designed to limit enrollment to eligible enrollees who were not receiving similar services in other programs and were more likely to benefit from HHP than other interventions, among other reasons. Due to data limitations, the TEL did not identify the inclusion criteria of chronic homelessness or some exclusion criteria, such as enrollees who would benefit from alternative care management programs. DHCS provided the TEL to MCPs as an initial list of potentially eligible HHP members, but MCPs had the responsibility of engaging and enrolling HHP eligible members and could use other eligibility identification strategies, subject to DHCS approval. Exhibit 6: HHP Eligibility Inclusion and Exclusion Criteria Eligibility Requirement Criteria Details Met at least one chronic • At least two of the following: chronic obstructive condition criteria pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders • Hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure • One of the following: major depression disorders, bipolar disorder, psychotic disorders (including schizophrenia) • Asthma 26 Introduction | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Eligibility Requirement Criteria Details Met at least one • Has at least three or more of the HHP eligible acuity/complexity criteria chronic conditions • At least one inpatient hospital stay in the last year • Three or more emergency department (ED) visits in the last year • Chronic homelessness Did not meet one of the • Hospice recipient or skilled nursing home resident exclusion criteria • Enrolled in specialized MCPs (e.g., Program of All- Inclusive Care for the Elderly (PACE), Senior Care Action Network (SCAN) and AIDS Healthcare Foundation (AHF)) • Fee-for-service rather than managed care • Sufficiently well managed through self-management or another program • More appropriate for alternative care management programs • Behavior or environment is unsafe for CB-CME staff Source: Adapted from Health Homes Program Guide. Funding and Payment Methodology Under federal rules, DHCS would receive a 90% enhanced Federal Medical Assistance Percentage (FMAP) for HHP services for the first two years of each phase of implementation. However, the federal portion will revert to the 50% FMAP after this period. DHCS used grant funds provided by The California Endowment to pay for the state’s share of HHP services. MCPs received a supplemental per member per month (PMPM) payment for HHP services and reimbursed CB-CMEs based on claims for services under contractual agreements. DHCS also created an HHP-specified Healthcare Common Procedure Coding System (HCPCS) procedure code and modifiers to report HHP services. These codes are described later in this report in the HHP Service Utilization among HHP Enrollees chapter. UCLA HHP Evaluation AB 361 required an independent evaluation of HHP and submission of a report to the legislature after two years of implementation. Two interim evaluation reports will be developed after 18 and 30 months of implementation and a final evaluation report will be developed after 54 months of implementation. The UCLA Center for Health Policy Research (UCLA) was selected as the evaluator of the HHP program. Conceptual Framework UCLA Evaluation | Introduction 27 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program UCLA developed a conceptual framework for the evaluation of HHP (Exhibit 7). Following the HHP program goals and structure, the framework indicated that better care is achieved when MCPs establish the necessary infrastructure and deliver HHP services. Delivery of HHP services will in turn lead to better health indicated by reduced utilization of health care services that are associated with negative health outcomes as well as improvements in population health indicators. Better care and better health will lead to lower overall health care expenditures. Exhibit 7: HHP Evaluation Conceptual Framework •Infrastructure: HHP network composition, organization model of community-based care management, care coordination staffing, health information technology (HIT) and data sharing approach, patient enrollment approach •Process: provide comprehensive care management, coordinate care, deliver health promotion services, provide comprehensive transitional care, provide individual and family support Better Care services, refer to community and social support services •Health care utilization: reduce emergency department visits, reduce inpatient hospitalizations, reduce length of stay, increase outpatient follow-up care post admission, reduce nursing facility admissions, increase use of substance use treatment •Patient outcomes: control blood pressure, screen for depression, assess body mass index Better (BMI), reduce all-cause readmissions, reduce inpatient admission for ambulatory care sensitive chronic conditions Health •Health care expenditures: reduce overall expenditures by lower spending on acute care services and higher spending on needed outpatient services •Cost neutrality: maintain cost neutrality by insuring HHP service expenditures do not lead to higher overall expenditures Lower Costs •Return on investment: show return on investment due to HHP program implementation 28 Introduction | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Evaluation Questions and Data Sources Exhibit 8 displays the evaluation questions and data sources that were used to answer those questions. The evaluation questions were aligned with the components of the conceptual framework. Questions 1-7 examined the infrastructure established by MCPs including the composition of their networks, populations enrolled, and the services delivered. Questions 8-13 examined the impact of HHP service delivery on multiple indicators of health services utilization as well as patient health indicators. Questions 14 and 15 examined the impact of HHP on lowering costs of the Medi-Cal program. Exhibit 8: Health Homes Program Evaluation Questions and Data Sources Evaluation Questions Data Sources Better Care Infrastructure 1. What was the composition of HHP • MCP Readiness Documentation networks? • MCP Quarterly HHP Reports 2. Which HHP network model was employed? 3. When possible, what types of staff provided HHP services? 4. What was the data sharing approach? 5. What was the approach to targeting patients for enrollment per HHP network? Process 6. What were the demographics of program • MCP Enrollment Reports enrollees? What was the acuity level of the • MCP Quarterly HHP Reports enrollees including health and health risk • TEL profile indicators, such as aggregate • Medi-Cal Enrollment and inpatient, ED, and rehab skilled nursing Encounter Data facility (SNF) utilization? What proportion of eligible enrollees were enrolled? How did enrollment patterns change over time? What proportion of enrollees are homeless? 7. Were Health Home services provided in- person or telephonically? Were Health Home services provided by clinical or non- clinical staff? How many enrollees received engagement services? How many homeless enrollees received housing services? Better Health Health care utilization UCLA Evaluation | Introduction 29 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Evaluation Questions Data Sources 8. How did patterns of health care service use • Medi-Cal Enrollment and Claims among HHP enrollees change before and Data after HHP implementation? 9. Did rates of acute care services, length of stay for hospitalizations, nursing home admissions and length of stay decline? 10. Did rates of other services such as substance use treatment or outpatient visits increase? Patient outcomes 11. How did HHP core health quality measures • MCP Quarterly HHP Reports improve before and after HHP • Medi-Cal Enrollment and Claims implementation? Data 12. Did patient outcomes (e.g., controlled blood pressure, screening for clinical depression) improve before and after HHP implementation? 13. How many homeless enrollees were housed? Lower Costs Health care expenditures 14. Did Medi-Cal expenditures for health • Medi-Cal Enrollment and Claims services decline after HHP implementation? Data 15. Did Medi-Cal expenditures for needed outpatient services increase? Note: TEL is Targeted Engagement List. Detailed descriptions of the data sources and analytic methods used in the evaluations can be found in Appendix A: HHP Data Sources and Analytic Methods and Appendix B: UCLA HHP Evaluation Design. 30 Introduction | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Implementation and Infrastructure This section addresses the following HHP evaluation questions: 1. What was the composition of HHP networks? 2. Which HHP network model was employed? 3. When possible, what types of staff provided HHP services? 4. What was the data sharing approach? 5. What was the approach to targeting patients for enrollment per HHP network? UCLA relied on two data sources to address these questions: (1) MCP Readiness Documents, which outlined MCPs’ plans to develop and implement HHP under the guidelines set by DHCS, and (2) the MCP Quarterly HHP Reports, which detailed the networks developed by the MCP during each quarter of the program. Readiness documents may differ from the actual implementation approach employed by MCPs. Therefore, the information from these documents primarily reflect the intentions of MCPs at the start of HHP implementation and may not provide a comprehensive understanding of implementation to date. A total of 16 MCPs implemented HHP across California, submitting both Readiness Documents and Quarterly HHP Reports. The time period of this report covers data through September 30, 2019 and includes implementations for MCPs in Groups 1, 2, and 3. Data from CalOptima, a Group 4 MCP was also available in Readiness Documents and is included here. UCLA aimed to answer the HHP evaluation questions by identifying and analyzing the strategies that each MCP planned to implement and by providing selected illustrative examples of these strategies. Further analytic approach details can be found in Appendix A: HHP Data Sources and Analytic Methods. UCLA Evaluation | HHP Implementation and Infrastructure 31 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 9 displays the participating HHP counties by their respective implementation groups and the MCPs implementing HHP in each county. Of the 12 counties implementing HHP, four counties were in Northern California, two in Central California, and the remaining six were in Southern California. A total of 16 MCPs were operating across the state with six MCPs (Aetna, Anthem, Health Net, Inland Empire, Kaiser Permanente, and Molina) operating in multiple counties. Exhibit 9: Distribution of California Counties by Health Homes Program Implementation Group and MCPs Implementing Health Homes Program by County Source: Adapted from Health Homes Program Guide. Note: MCP is Managed Care Plan. 32 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Delivery Models MCPs could choose one or more of three HHP delivery models that were designed by DHCS. Each model varied in delegation of care management delivery responsibility to CB-CMEs, type of CB-CME, and geographic location. Exhibit 10 describes these three models. Model I was the DHCS preferred model. DHCS recommended that MCPs only use Models II and III in areas that were rural, had a low-volume of HHP eligible members, or low-volume of medical providers. The only MCP that did not use the delivery models designed by DHCS was Kaiser Permanente, which used its established integrated delivery system to house HHP staff with medical providers without contracting with external CB-CMEs. Exhibit 10: Health Homes Program Delivery Models Mode Description Use and Rationale l I HHP care management services Utilized where most HHP enrollees were provided by care coordinators were served by high-volume medical hired by the contracted CB-CMEs. providers in urban areas with the The care coordinators acted as capacity to hire and house HHP staff. designated HHP staff and were embedded on-site in the CB-CME offices. II HHP care management services Utilized where most HHP enrollees were provided by either the staff of an received care from low-volume external community-based medical providers without capacity for organization or MCP acting as CB- hiring and housing HHP staff on-site. CME, with care coordinators not always located on-site. III HHP care management services Utilized where HHP enrollees lived in were provided by MCP acting as a rural areas and were served by low- CB-CME, which hired HHP staff and volume providers without capacity for located them in regional offices hiring and housing HHP staff on-site. that are geographically close to rural enrollees and enrollees assigned to solo practitioners with limited HHP enrollment and capacity to hire HHP staff. Source: Adapted from Health Homes Program Guide. Notes: CB-CME is Community-Based Care Management Entity and MCP is Managed Care Plan. UCLA Evaluation | HHP Implementation and Infrastructure 33 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Of the 15 MCPs using these models, all 15 indicated that they planned to use the Model I care management delivery model for the majority of their HHP enrollees in their Readiness Documents. However, MCPs planned to use the other models as needed, including 12 who planned to use Model II and three who planned to use Model III. Exhibit 11 displays the HHP delivery models employed by each MCP. Exhibit 11: Health Homes Program Delivery Models Employed and Primary Model Employed by MCP, Implementation Group, and Counties Managed Care Plan Groups Counties Models Employed Aetna Better Health of 3 Sacramento, San Diego I, II California Alameda Alliance for Health 3 Alameda I, II Anthem Blue Cross of 1, 3 Alameda, Sacramento, San I, II California Partnership Plan, Francisco, Santa Clara, Inc. Tulare Blue Shield of California 3 San Diego I, II, III Promise Health Plan California Health & Wellness 3 Imperial I CalOptima 4 Orange I Community Health Group 3 San Diego I, II Partnership Plan Health Net Community 3 Kern, Los Angeles, I Solutions, Inc. Sacramento, San Diego, Tulare Inland Empire Health Plan 2 Riverside, San Bernardino I, II, III Kaiser Permanente 3 Sacramento, San Diego Kaiser’s Integrated Medical Model Kern Health Systems 3 Kern I, II L.A. Care Health Plan 3 Los Angeles I, II Molina Healthcare of 2, 3 Imperial, Riverside, San I, II, III California Partner Plan, Inc. Bernardino, Sacramento, San Diego San Francisco Health Plan 1 San Francisco I, II Santa Clara Family Health 3 Santa Clara I, II Plan UnitedHealthcare 3 San Diego I, II Community Plan of California, Inc. Source: MCP Readiness Documents. Notes: MCP is Managed Care Plan. 34 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 12 provides specific examples of how MCPs implemented each HHP delivery model. CB-CMEs in Model I were typically FQHCs, PCPs, and primary care clinics, which expanded their staff and/or developed additional partnerships (e.g., working with CBOs) to provide HHP services. Under Models II and III, MCPs often stepped in to fulfill responsibilities that providers couldn’t provide on their own. Exhibit 12: Selected Illustrative Examples of Implementation of Health Homes Program Delivery Models by MCPs HHP Delivery Managed Care Plan Implementation Approach Model Model I Alameda Alliance for AAH embedded care coordinators in Health (AAH) CB-CMEs to serve the majority of their members. Their CB-CMEs included a partnership with Alameda Health Systems (AHS) under Model I. AHS was comprised of three acute care hospitals, a psychiatric hospital, an acute rehabilitation facility, and an FQHC with four medical homes. This partnership leveraged AHS’ resources (i.e., complex care management teams) to deliver HHP services for enrollees. San Francisco Health SFHP served the majority of its Plan (SFHP) members with Model I. All CB-CMEs under Model I were located at primary care clinics and were responsible for providing care management activities such as counseling, access to substance use disorder treatment services, and chronic disease management. UnitedHealthcare UnitedHealthcare worked to integrate Community Plan of the two largest Whole Person Care California, Inc. providers in San Diego County to (UnitedHealthcare) provide care management and housing support services through Model I. These providers employed their own staff to deliver HHP services. The remaining CB-CMEs under Model I were FQHCs and Accountable Care Organizations (ACO). Model II Kern Health Systems KHS employed Model II to cover (KHS) enrollees who weren’t assigned to a safety net or FQHC organization that used Model I. For enrollees under UCLA Evaluation | HHP Implementation and Infrastructure 35 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Delivery Managed Care Plan Implementation Approach Model Model II, Dignity Health and Premier Medical Group, which both have experience with providing HHP-like services, were contracted to act as the HHP CB-CME and provide care management services. Santa Clara Family SCFHP allowed Model II to be used if a Health Plan (SCFHP) CB-CME couldn’t provide sufficient care management services. An internal team was also formed to work with members who were previously assigned to an external CB-CME that later chose not to participate. Model III Blue Shield of California BSCPHP used Model III for enrollees Promise Health Plan who were patients of low-volume (BSCPHP) providers in the rural areas of San Diego county. Enrollees received services from care coordinators where they lived. Inland Empire Health IEHP used Model III to create regional, Plan (IEHP) MCP-staffed CB-CMEs that would deliver HHP services to HHP enrollees that were patients of typically three providers in a designated geographic area. Source: MCP Readiness Documents. Notes: CB-CME is Community-Based Care Management Entity and MCP is Managed Care Plan. 36 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Delivery Networks HHP delivery networks were composed of CB-CMEs who either used their own staff or sub-contracted with other community-based organizations to deliver care management (CM) services. CB-CMEs were certified by the MCPs using DHCS general guidelines and requirements. CB-CMEs were required to maintain a strong and direct connection with the HHP enrollee and their primary care physician, the latter being applicable when CB-CMEs were not medical providers. An MCP’s goals in developing their CB-CME network included: (1) ensuring CM delivery at point of care, (2) experience with high utilizing and homeless populations, and (3) building upon existing CM infrastructure within the county. In their Quarterly HHP Reports, MCPs reported developing contracts with 212 CB- CMEs by September 2019. Using the CB-CME’s National Provider Identifier (NPI) number, only 174 unique CB-CMEs were identified. There were 27 CB-CMEs that were reported more than once either because they overlapped between MPC networks or multiple sites under the same NPI were included separately. Of the 212 reported CB- CMEs, most (70%) were community health clinics or centers (Exhibit 13). Other common organization types included primary care or specialty practices (14%), care coordination or case management providers such as community-based organizations with case management accreditation, (13%), and managed care plans (7%). Exhibit 13: Health Homes Program CB-CME Network by Organization Type as of September 2019 Community Health Center/Clinic 70% Primary Care or Specialty Practice 14% Care Coordination or Case Management 13% Managed Care Plan 7% Hospital 6% Behavioral Health or Mental Health Provider 6% Other 4% Source: MCP Quarterly HHP Reports from September 2019. Note: CB-CME is Community-Based Care Management Entity, MCP is Managed Care Plan, and NPI is National Provider Identifier. A total of 212 CB-CMEs were reported and their primary taxonomy classifications associated with their NPI were used to categorize them into distinct organization types. CB-CMEs in the “Other” category included a charity and home health organization. MCPs were required to report an estimated anticipated capacity for each CB-CME in their Quarterly HHP Reports. CB-CMEs were asked to estimate the maximum caseload of HHP enrollees that they could manage for either SPA 1 or SPA 2. DHCS encouraged UCLA Evaluation | HHP Implementation and Infrastructure 37 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program CB-CMEs to consider their ability to serve including the HHP care manager ratio requirements and certification requirements. For example, CB-CMEs had to have the ability to provide appropriate and timely in-person care coordination, telephonic communication, and accompany HHP enrollees to critical appointments. As of September 2019, MCPs reported a total of 212 CB-CMEs and an anticipated capacity of approximately 47,010 HHP enrollees, with a median of 200 enrollees per CB-CME (Exhibit 14). The median anticipated capacity at an individual CB-CME was largest among hospitals and behavioral health providers (200 enrollees) and smallest at CB-CMEs in the community health centers or clinics (103 enrollees). Exhibit 14: Total Health Homes Program Anticipated Capacity by CB-CME Organization Type Mean Median Anticipated Total Anticipated Anticipated CB-CME Type N Enrollee Enrollee Capacity Enrollee Capacity Capacity per per CB-CME CB-CME Total 212 47,010 200 222 Community Health Center/Clinic 122 22,903 103 188 Primary Care or Specialty Practice 25 4,659 178 186 Care Coordination or Case Management Provider 23 4,771 179 207 Managed Care Plan 13 3,605 185 277 Hospital 11 6,530 200 594 Behavioral Health Provider 11 2,835 200 258 Other 7 1,707 125 244 Source: MCP Quarterly HHP Reports from September 2019. Notes: CB-CME is Community-Based Care Management Entity, MCP is Managed Care Plan, and NPI is National Provider Identifier. A total of 212 CB-CMEs were reported and their primary taxonomy classifications associated with their NPI were used to categorize them into distinct organization type. CB-CMEs in the “Other” category included a charity and home health organization. HHP Staffing Staffing Requirements DHCS required that MCPs ensure CB-CMEs have an HHP enrollee-to-care coordinator ratio of at least 60 for their overall enrolled population. In addition, DHCS required that 38 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program MCPs verify that contracted CB-CMEs had or could develop multidisciplinary teams with specific roles to provide HHP services. Exhibit 15 displays the required and recommended multidisciplinary team members including team staff titles, qualifications, and their roles and responsibilities at CB-CMEs. DHCS recommended that these team members be primarily located at the CB-CMEs but allowed flexibility in location of different team members to accommodate HHP delivery model and CB-CME capacity. DHCS allowed for some roles to be centralized at the MCP and utilized across multiple CB-CMEs. This approach was used mostly for low-volume CB-CMEs and for HHP director and clinical consultant roles. Additional team members, such as a pharmacist or nutritionist, could also be included on the multi-disciplinary care team in order to meet the HHP member’s individual care coordination needs. Exhibit 15: DHCS Recommendation for Health Homes Program Multidisciplinary Team Composition at CB-CMEs Title Qualifications Roles and Responsibilities HHP Director Ability to manage • Overall responsibility for management and multidisciplinary operations of the multidisciplinary team care teams • Responsible for quality measures and reporting for the team Clinical Primary care or • Review and inform health action plan Consultant specialist physician, • Act as clinical resource for care coordinator psychiatrist, • Facilitate access to primary care and psychologist, behavioral health providers pharmacist, registered nurse, advanced practice nurse, nutritionist, licensed clinical social worker, or other behavioral health care professional Care Paraprofessional or • Oversee provision of HHP services and Coordinator licensed care implementation of health action plan coordinator, social • Offer services where the HHP enrollee lives, worker, or nurse seeks care, or finds most easily accessible and within MCP guidelines • Connect HHP enrollee to needed social services • Advocate on behalf of enrollee with health care professionals • Work with hospital staff on the discharge plan UCLA Evaluation | HHP Implementation and Infrastructure 39 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Title Qualifications Roles and Responsibilities • Accompany HHP enrollee to office visits, as needed and according to MCP guidelines • Monitor treatment adherence (including medication) • Provide health promotion and self‐ management training • Arrange transportation as needed • Call HHP member to facilitate care coordination visits Housing Paraprofessional or • Form and foster relationships with housing Navigator other qualification agencies and permanent housing providers, based on including supportive housing providers experience and • Connect and assist the HHP member to get knowledge of the available permanent housing population and • Coordinate with HHP member in the most processes easily accessible setting, within MCP guidelines Community Paraprofessional or • Provide administrative support to care Health peer advocate coordinator Workers • Engage eligible HHP beneficiaries (Optional) • Arrange transportation and, when needed, accompany HHP enrollees to office visits • Health promotion and self-management training • Assist with linkage to social supports • Distribute health promotion materials • Call HHP enrollees to facilitate HHP visits • Connect HHP enrollee to needed social services • Advocate on behalf of enrollee with health care professionals • Use motivational interviewing, trauma- informed care, and harm-reduction practices • Monitor treatment adherence (including medications) Source: Adapted from Health Homes Program Guide. Notes: CB-CME is Community-Based Care Management Entity and MCP is Managed Care Plan. HHP Team Composition MCPs included information on team composition in their Readiness Documents. MCPs either planned to hire staff members internally or required CB-CMEs to hire HHP staff and follow certain qualifications. Eleven MCPs (data not shown) planned to hire internal 40 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program MCP staff for centralized roles overseeing multiple CB-CMEs. MCPs intended to hire staff when CB-CMEs had insufficient staff or were otherwise unable to fulfill HHP requirements, frequently in rural and other areas with low-volume providers. Reasons for planning to hire internal MCP staff varied between MCPs and included efficiency and effectiveness. All MCPs that implemented HHP in multiple counties (six MCPs; data not shown) planned to hire internal staff. These MCPs typically had larger HHP enrollment. Hiring internal staff could facilitate larger enrollments and, in some cases, allow for the MCP to focus on specific populations. For example, Kaiser Permanente intended to hire Pediatric Health Care Coordinators to focus on their pediatric population in addition to their Health Care Coordinators. Further information on specific staffing plans are described below. Care Coordinators Care coordinators were required staff for every CB-CME, and three MCPs hired care coordinators internally. Twelve MCPs reported specific qualifications for care coordinators (data not shown). Common qualifications across MCPs included a minimum education level such as a high school diploma, and 1 to 5 years of experience. Seven MCPs also required certification/licensure, such as registered nurse (RN) and licensed clinical social worker (LCSW). MCPs used different titles such as “health care coordinators” and “care coordinator extender” for individuals providing care coordination. HHP Directors All MCPs required CB-CMEs to hire an HHP director, with eight MCPs planning to hire these directors internally. Readiness Documents indicated that seven MCPs required a minimum education level of either Bachelor’s or Master’s, and five specified certification/licenses, with LCSW being most common. Nine MCPs indicated a minimum number of years of experience in Readiness Documents, which ranged from one to eight years (data not shown). Housing Navigators, Clinical Consultants, and Optional Staff According to Readiness Documents, all MCPs required CB-CMEs to hire housing navigators to serve members experiencing homelessness, and three MCPs intended to hire their housing navigators internally. All MCPs were required to hire clinical consultants. Two MCPs reported specific qualification requirements for clinical consultants, although submission of qualifications was not required by DHCS. Both MCPs required that CB-CMEs have a physician available and a licensed professional with expertise in behavioral health for clinical consult. These MCPs cited complexity of patient care needs as the primary motivator for imposing these additional requirements. UCLA Evaluation | HHP Implementation and Infrastructure 41 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program MCPs also indicated in Readiness Documents whether the optional role of community health worker was included in the CB-CME’s multidisciplinary teams. Ten (data not shown) intended to include community health workers, though in some cases only as outreach specialists, rather than in a care coordination role. HHP Data Sharing DHCS specifically required that MCPs ensure they had shared data with CB-CMEs, met certain data sharing criteria, and conducted specific activities to the extent possible. MCPs were expected to (1) attribute HHP enrollees to CB-CMEs, (2) ensure CB-CMEs could fulfill all required CB-CME duties, (3) notify CB-CMES of inpatient admission and ED visits, and (4) track and share enrollee health history. Through an examination of the MCP Readiness Documents, UCLA identified data sharing technologies utilized by MCPs to communicate and share data with their CB-CMEs; whether the latest updated HAPs were available; and whether CB-CMEs received real-time notifications of hospital admissions and ED visits. Data Sharing Technologies for Care Management and Care Coordination MCPs reported planning to use a variety of data sharing technologies with CB-CMEs, with various levels of detail. Overall, as indicated in Readiness Documents, MCPs said they would share a list of prioritized HHP eligible beneficiaries along with data on risk groupings and utilization with their CB-CMEs to be used for care management. MCPs also described data sharing technologies that could be used to facilitate care coordination. Seven MCPs (data not shown) indicated they would use a secure file transfer protocol (SFTP) and/or dedicated email to share data between the MCP and CB-CME. Six MCPs (data not shown) had established electronic health records (EHR), care management platforms or health information exchanges (HIE) that they planned to utilize by their CB-CMEs to share these data. Three MCPs (data not shown) indicated that data sharing would be determined by the capabilities and infrastructure in place at each CB-CME contracting with the MCP individually. The MCP verified that the systems and protocols in place at each CB-CME were sufficient during the CB-CME verification process. Exhibit 16 provides illustrative examples of these data sharing technologies used by MCPs. 42 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 16: Selected Illustrative Examples of Health Homes Program Data Sharing Technologies between MCPs and CB-CMEs for Comprehensive Care Management and Care Coordination Data Sharing Approach MCP Example Secure File Transfer California CB-CMEs received their TEL assigned Protocol (SFTP)/ Health & eligible beneficiaries along with assigned Dedicated Email Wellness risk grouping of each individual monthly (CHW) via provider portal or SFTP site from CHW. CB-CMEs developed and shared HAPs with CHW to track progress via the provider portal, SFTP, or by secure email depending on their capability. Electronic Health Record/ Molina Contracted CB-CMEs accessed and Care Management Healthcare of documented all HHP activities and Platform/ California services in MHC’s electronic care Health Information Partner Plan, management platform, Clinical Care Exchange Inc. (MHC) Advance (CCA). Direct access to the system allowed for efficient and timely updates to the enrollee’s record, facilitated the sharing of information, such as the HAP, and enabled standardized reporting. CB-CMEs that did not have the IT infrastructure or capability to access CCA were assessed on an individual basis to establish the best method of data exchange. Alternate methods of data exchange included SFTP, secure email, and/or fax. Data exchanged by alternate methods were loaded to CCA. CB-CME Dependent San Francisco SFHP employed multiple modes of Approach Health Plan health information technology to provide (SFHP) comprehensive care management. For CB-CMEs participating in Model I, SFHP assessed data sharing capacities via the CB-CME readiness assessment and site visits to understand CB-CME capabilities before specifying data sharing methods. Additionally, SFHP planned to use the web-based care management tool PreManage to facilitate data sharing. Source: MCP Readiness Documents. Notes: CB-CME is Community-Based Care Management Entity and MCP is Managed Care Plan. UCLA Evaluation | HHP Implementation and Infrastructure 43 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Dynamic versus Static Health Action Plan Dynamic HAPs are accessible in real-time and modifiable for key healthcare and service providers, typically as part of an EHR or care management platform. By having up-to-date information on the HAP available as soon as possible, providers can make the most informed decisions about enrollee’s care. MCPs were required to ensure that CB-CMEs had the capability to share the HAP with the MCPs, but they did not have to share HAPs in real-time or allow the MCP to modify the HAP. As indicated in Readiness Documents, eight MCPs (50%; data not shown) provided evidence that the care management and care coordination teams, including both MCP and CB-CME staff, would have access to a dynamic HAP as compared to seven MCPs that indicated they would have access to a static HAP. One MCP did not provide sufficient information to determine if their HAP access would be dynamic or static. Static HAPs were sent to MCPs typically as a PDF through email, SFTP or similar data sharing technology, frequently at monthly or other set intervals. Real-Time Notifications of Hospitalizations and ED Visits Of the 16 MCPs, five MCPs indicated in Readiness Documents that they planned to have real-time and automated systems in place to notify CB-CMEs of when HHP enrollees were admitted to the hospital or emergency department. These real-time systems relied on specialized health information technology or were built into the EHR or care management platforms used by the MCPs. In addition, eight MCPs indicated that they would share admission and discharge data with CB-CMEs “in a timely manner” or “as soon as it was available” but did not indicate if these notifications would be in real-time or automated. Three MCPs indicated that such real-time notifications to CB- CMEs would not be possible with current data sharing infrastructure. MCP Approach to Targeting Patients for HHP Enrollment All MCPs received the TEL developed by DHCS to identify HHP-eligible beneficiaries. However, MCPs did not solely rely on their TELs because they had additional and more recent information on eligible beneficiaries in their own administrative data sources. More specifically, MCPs could identify eligible beneficiaries that met criteria not available in Medi-Cal enrollment and claims data such as homelessness or acuity data. Furthermore, MCPs could use provider referrals to identify eligible beneficiaries that were not identified using administrative data sources. MCPs were required to develop a priority engagement group to ensure that those targeted for HHP services had the greatest potential for improvement in outcomes, such as reduction in avoidable utilization. Once eligible beneficiaries would provide their 44 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program consent to participate in HHP, MCPs also had to stratify enrollees into at least three risk groups, which would determine the appropriate level of intervention for each enrollee. Predictive Modeling to Identify Enrollees and Risk Grouping Predictive modeling includes methods to identify eligible HHP beneficiaries and/or predict intensity of care based on risk groups using administrative and historical data prior to acute events or high use of services during HHP. All MCPs were required to develop methods for risk grouping within their eligible population and ensure that services are provided based on level of risk. All MCPs outlined their risk grouping strategies in their Readiness Documents, and 12 MCPs specifically indicated using some form of predictive modeling with techniques and tools such as data mining and risk screening. MCPs used demographic, socioeconomic, medical and behavioral diagnoses, procedures, and prescription data in these models. Exhibit 17 provides illustrative examples of predictive modeling by MCPs for these purposes. Exhibit 17: Selected Illustrative Examples of Predictive Modeling Approaches Used by MCPs Approach to Predictive Modeling Managed Care Plan Example Identifying Aetna Better Health of ABHCA used internal data mining to Eligible California (ABHCA) estimate the amount of HHP eligible Beneficiaries beneficiaries among their members and applied geo-analysis to estimate the necessary capacity and staffing of CB- CMEs. ABHCA specified that key chronic conditions, including asthma, diabetes, and heart failure, were included in their modeling tools. Blue Cross of California Anthem identified at-risk individuals Partnership Plan, Inc. eligible for HHP with their initial risk (Anthem) screening and predictive modeling tools. In addition to these, risk stratification tools were also used to group eligible members based on acuity levels. Members stratified by acuity levels allowed Anthem to better coordinate interventions in accordance with their chronic illnesses and likelihood of inpatient admission. Risk Grouping Blue Cross of California Anthem’s General Risk Model (GRM) Partnership plan, Inc. identified members at risk for high cost (Anthem) and/or high utilization based on medical, behavioral, laboratory and UCLA Evaluation | HHP Implementation and Infrastructure 45 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Approach to Predictive Modeling Managed Care Plan Example pharmacy diagnoses, and claims data. Members were stratified by risk in order to prioritize high-risk members and deliver the information directly to health plans through their care management software. Blue Shield of California BSCPHP utilized their predictive engine Promise Health Plan tool, ImpactPro, to categorize eligible (BSCPHP) members as high or low risk members based on repeating acuity factors through two years of prior health data. These factors included emergency room (ER) visits, hospital stays, and homelessness. Kaiser Permanente Kaiser utilized a risk stratification tool to (Kaiser) identify eligible members based on utilization, diagnostic, and medication history. The tool is also used to stratify members into four levels of need based on utilization, risk, and complexity. The four levels identified the timing of enrollment outreach and predicted the intensity of care required for an eligible member. Kern Health Systems KHS relied on the John Hopkins (KHS) Adjusted Clinical Groups risk assessment tool to generate a risk score of eligible members based on their risk of a hospitalization within the next six months. Members scoring above 50% were scored as high risk and members scoring below 50% were scored as low risk. Source: MCP Readiness Documents. Notes: CB-CME is Community-Based Care Management Entity and MCP is Managed Care Plan. Communication with HHP Enrollees MCPs outlined their plans for communicating in Readiness Documents, which included newsletters (nine of 16), websites (nine), letters (six), and welcome packets (six) to communicate with HHP eligible members and enrollees. MCPs planned to use 46 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program newsletters and websites to facilitate ongoing communication with enrollees regarding program eligibility criteria and HHP services. Letters and welcome packets were sent to potential enrollees identified as eligible for HHP as a part of the MCPs’ initial outreach protocol. Frequency of Outreach to Potential Enrollees DHCS recommended that MCPs conduct at least five outreach attempts for HHP enrollment within 90 days. As indicated in Readiness Documents, nine MCPs (of 16) planned to follow this recommendation, four reported planning three attempts within 90 days, and three planned less frequent attempts (data not shown). The latter three planned alternative approaches in frequency of outreach attempts as shown in Exhibit 18. Exhibit 18: Planned Alternative Approaches to Outreach Frequency by Health Homes Program MCPs Managed Care Plan Approach Inland Empire Health Plan IEHP indicated that outreach attempts would be (IEHP) completed within 90 days. However, the minimum number of attempts for members differed by risk group. • Tier 1: Weekly outreach attempts • Tier 2: Biweekly outreach attempts • Tier 3: Monthly outreach attempts Molina Healthcare of MHC indicated outreach would consist of a minimum of California Partner Plan, Inc. five attempts. However, they did not specify a timeline (MHC) for these attempts. San Francisco Health Plan SFHP expected their care managers to conduct one (SFHP) outreach attempt per week for three months. SFHP also outlined multiple strategies for reaching out to eligible members during each week if previous attempts were unsuccessful. • Weeks 1-2: Notify members of eligibility for HHP by phone or in-person. If necessary, SFHP recommended a call or email to a member’s PCP. • Week 3: Send a letter. • Week 4: Outreach to eligible members by call, email, or another method. SFHP also recommended reaching out to a member’s PCP. • Week 5: Outreach to a member’s collateral (e.g., community social worker, IHSS, caregiver, etc.). UCLA Evaluation | HHP Implementation and Infrastructure 47 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Managed Care Plan Approach • Week 6: SFHP recommended care managers review information from electronic medical records for additional or updated information before conducting additional outreach. Source: MCP Readiness Documents. Notes: MCP is Managed Care Plan. Outreach to Homeless HHP Eligible Beneficiaries DHCS expected MCPs to develop policies and procedures for outreach to homeless eligible beneficiaries. As indicated in Readiness Documents, most MCPs relied on CB- CMEs with experience in serving homeless populations to identify these members through field-based outreach and partnerships with local agencies. CB-CMEs that could not locate individuals could reach out to MCPs for additional assistance. Specific examples of how MCPs planned to outreach to homeless/at-risk-of-homelessness members are outlined in Exhibit 19. Exhibit 19: Illustrative Examples of Planned Outreach Approaches to Health Homes Program Eligible Homeless or At-Risk-of-Homeless MCP Members Approach to Homeless Individuals Managed Care Plan Example Collaboration Blue Cross of California Anthem’s Housing Program Manager with Local Partnership Plan, Inc. and Housing Specialist worked with CB- Agencies (Anthem) CMEs to develop partnerships with local housing/homeless service providers. These partnerships will utilize strategic field-based approaches to engage homeless individuals. This includes reaching out to individuals by visiting homeless shelters, jails/prisons, and community locations. Inland Empire Health IEHP worked with the IEHP Housing Plan (IEHP) Initiative to assess homeless members for housing and tenancy support. The IEHP Housing Initiative also partnered with a subcontractor to provide tenancy support. Kern Health Systems The Kern County Homeless coalition, (KHS) comprised of the Kern County’s CBO and Kern County Housing Authority, will work with their Health Homes Social Worker to provide case management 48 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Approach to Homeless Individuals Managed Care Plan Example services and match homeless members with available resources. Experienced CB- Santa Clara Family SCFHP assigned members to CB- CMEs Health Plan (SCFHP) CMEs based on their experience working with homeless individuals. CB- CMEs are also expected to have progressive community outreach experience and conduct on the ground outreach in locating members. UnitedHealthcare UnitedHealthcare partnered with Community Plan of community-based organizations that California, Inc. had experience in addressing the needs (UnitedHealthcare) and challenges of their target populations. This included a collaboration with the Corporation for Supportive Housing (CSH) to identify members who were homeless or at risk of homelessness. Integrating California Health & CHW planned to integrate community Community Wellness (CHW) entities focused on addressing Entities homelessness into their care model and their multi-disciplinary care team. Leverage Aetna Better Health of ABHCA expanded the structure of Existing California (ABHCA) Whole Person Care pilots into HHP and Infrastructure utilized relationships established in Whole Person Care to work with more homeless and housing unstable members. CB-CMEs were expected to provide housing transition, tenancy support, and sustaining services for members. Alameda Alliance for Alameda County’s Health Care Health (Alameda) Services Agency (HCSA) approved a plan to create one network of community-based care management providers and one model of care for members enrolled in Whole Person Care and HHP. As a result, Alameda invested heavily in expanding health analytics, improving the management of encounter data, and deployed an enterprise data warehouse. UCLA Evaluation | HHP Implementation and Infrastructure 49 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Approach to Homeless Individuals Managed Care Plan Example L.A. Care Health Plan L.A. Care worked with CB-CMEs to (L.A. Care) ensure they’re prepared to assist homeless members. These included partnering with local housing/homeless service providers, conduct collaborative learning sessions, and providing access to the Homeless Management Information System (HMIS). UnitedHealthcare UnitedHealthcare worked with the two Community Plan of largest Whole Person Care providers in California, Inc. San Diego County to provide care (UnitedHealthcare) management and housing support services. They were appropriately staffed to deliver HHP services and become Model I providers in accordance with HHP requirements. Source: MCP Readiness Documents. Notes: CB-CME is Community-Based Care Management Entity and MCP is Managed Care Plan. 50 HHP Implementation and Infrastructure | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns This section addresses the following HHP evaluation questions: 1. How did enrollment patterns change over time? 2. What proportion of enrollees are homeless? 3. What proportion of eligible enrollees were enrolled? From July 1, 2018 to July 31, 2019, MCPs reported data on individual-level enrollment in ad hoc Enrollment Reports requested by DHCS. Beginning in the third quarter of 2019, MCPs reported on individual enrollment data in their Quarterly HHP Reports. Both reports included monthly enrollment status by individual, along with individual level SPA data. Homeless status was only reported by MCPs at the member level in Quarterly HHP Reports beginning in Quarter 3 of 2019 (July 1, 2019 to September 30, 2019). Therefore, enrollment growth and patterns among homeless enrollees was not available for enrollees who had disenrolled prior to this time. UCLA used these data from July 1, 2018, to September 30, 2019, to examine how enrollment changed over time for the overall HHP population, by SPA, and for homeless enrollees. Due to staggered HHP implementation over time, data was available for Group 1 (SPA 1 and 2), Group 2 (SPA 1 and 2), and Group 3 (SPA 1) counties at the time of this report. Further details can be found in Appendix A: HHP Data Sources and Analytic Methods. A small number of HHP enrollees (246) were enrolled for less than 31 days and were excluded from these analyses. MCPs received PMPM payments for one month, but no longer received payments if those individuals could no longer be enrolled in the program. MCPs did not provide other services to this group. Comparison of these enrollees with those enrolled for longer than 30 days indicated the groups had similar demographics, health status, and health care utilization prior to HHP. Further details about this group can be found in Appendix C: HHP Enrollees Enrolled Less Than 31 Days. UCLA Evaluation | HHP Enrollment and Enrollment Patterns 51 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Growth in HHP Enrollment by SPA Enrollment in HHP began with Group 1, SPA 1 in San Francisco in July 2018 and expanded rapidly when Groups 2 and 3 began enrollment in January and July 2019, respectively. By the end of September 2019, a total of 15,527 members had ever enrolled in HHP with 2,356 new enrollees in that month. Examining HHP enrollment by SPA showed rapid growth in SPA 1 enrollees (Exhibit 20) starting with Group 2 implementation in January 2019. By the end of September 2019, MCPs had enrolled 14,380 SPA 1 members and 1,147 SPA 2 members. The slower growth in SPA 2 enrollment was due to fewer eligible populations, later implementation compared to SPA 1, and lack of SPA 2 implementation from Group 3 MCPs as of September 2019. Exhibit 20: Unduplicated Monthly and Cumulative Enrollment in HHP by SPA, July 1, 2018 to September 30, 2019 14,380 SPA 2 Enrollees SPA 1 Enrollees Group 3 Starts Group 2 Starts Group 2 Group 1 Group 1 Starts Starts Starts 1,147 Apr-19 Dec-18 Jan-19 May-19 Oct-18 Apr-19 May-19 19-Jan Aug-18 Mar-19 Jun-19 Aug-19 Mar-19 Jun-19 Aug-19 Nov-18 Jul-18 Sep-18 Feb-19 Jul-19 Sep-19 Feb-19 Jul-19 Sep-19 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q1 2019 Q2 2019 Q3 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from 52 HHP Enrollment and Enrollment Patterns | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Growth in HHP Enrollment among Homeless by SPA MCPs began reporting homeless data per enrollee in Quarter 3 of 2019 (Q3; July 1 to September 30) HHP Quarterly Reports. UCLA used the identifier indicating enrollees who were ever homeless and the enrollment dates of these enrollees to show the patterns of enrollment over time. However, these data underestimate the size of homeless enrollees in HHP because they exclude those who had disenrolled in previous quarters and did not reenroll in HHP. Data showed a steady growth in the number of homeless enrollees over time (Exhibit 21). As of September 2019, 510 HHP enrollees (3.5%) were reported as ever homeless, including 472 from SPA 1 (3.4%) and 38 from SPA 2 (3.5%). There was variation in number of homeless enrollees by Group, which can be seen in Appendix D: Supplemental Data Tables, Exhibit 61. Data showed a steady growth in the number of homeless enrollees over time for Group 2. As of September 2019, 345 HHP enrollees were reported as homeless from Group 2 and 159 from Group 3. Exhibit 21: Unduplicated Monthly and Cumulative Enrollment of HHP Homeless Enrollees by SPA, July 1, 2018 to September 30, 2019 SPA 1 Enrollees SPA 2 Enrollees 472 New Enrollees per Month Existing Enrollees per Month Group 3 Cumulative Enrollment Starts Group 2 Starts Group Group 2 38 Group 1 1 Starts Starts Starts Apr-19 May-19 Feb-19 Mar-19 Jul-19 Aug-19 Sep-19 Jan-19 Jun-19 May-19 Jul-18 Feb-19 Mar-19 Apr-19 Jul-19 Oct-18 Nov-18 Dec-18 Aug-18 Sep-18 Jan-19 Jun-19 Aug-19 Sep-19 2019 Q1 2019 Q2 2019 Q3 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 UCLA Evaluation | HHP Enrollment and Enrollment Patterns 53 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Source: MCP Quarterly HHP Reports. Enrollment was limited to available data for the period between July 2018 and September 2019. Notes: MCP is Managed Care Plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Monthly enrollment of less than 11 was recorded as 11. Excludes HHP enrollees that were designated as homeless and were disenrolled prior to Q3. Includes homeless enrollees that were included in Q3 HHP Quarterly Reports. Enrollment Size by Group and County Exhibit 22 shows enrollment by group and county as of September 2019. Enrollment varied by county. Riverside and San Bernardino in Group 2 had implemented on January 1, 2019 and had the largest enrollment with 4,791 enrollees and 3,614 enrollees, respectively. Group 3 counties had implemented on July 1, 2019 and the numbers enrolled varied by County. Exhibit 22: Unduplicated Cumulative HHP Enrollment by Group and County as of September 30, 2019 4,791 3,614 2,642 2,363 724 457 444 177 150 129 33 RIVERSIDE IMPERIAL ALAMEDA LOS ANGELES KERN SAN DIEGO SACRAMENTO TULARE SANTA CLARA SAN FRANCISCO SAN BERNARDINO Group 1 Group 2 Group 3 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: MCP is Managed Care Plan. Those enrolled for less than 31 days were excluded from this analysis. Group 1 implemented HHP on July 1, 2018, Group 2 implemented HHP on January 1, 2019, and Group 3 implemented HHP on July 1, 2019. Enrollment Size Compared to Eligible Beneficiary Population 54 HHP Enrollment and Enrollment Patterns | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program UCLA measured the proportion of all potentially eligible HHP beneficiaries who were enrolled from the TEL, calculated using total HHP enrollees over the total potentially eligible beneficiaries identified in the TEL. The data was measured as of September 30, 2019, and showed variation between groups. Group 2 MCPs had the highest rate of enrollment from their respective TELs (18%), followed by Group 1 (12%) and Group 3 (3%; data not shown). Group 3 implementation began in July 2019, limiting the available data to a three-month period that only included SPA 1 enrollees who were enrolled by September 2019. Enrollment Patterns Enrollment Churn The majority of HHP enrollees were continuously enrolled as of September 2019 (Exhibit 23). Overall, 9.9% of HHP enrollees disenrolled from the program and remained disenrolled and 0.1% of members re-enrolled after disenrollment. When comparing churn by SPA, there was less churn among SPA 2 enrollees, but this was likely due to the limited length of observation and recent enrollment in this group. Exhibit 23: Enrollment and Disenrollment Patterns in HHP as of September 30, 2019 Total Continuously Disenrolled Enrolled Multiple Enrollment Enrolled Once Times Overall 15,527 90.0% 9.9% 0.1% SPA 1 14,380 89.4% 10.4% 0.1% SPA 2 1,147 96.6% 3.4% 0.0% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: MCP is Managed Care Plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Length The average length of enrollment as of September 2019 is provided in Exhibit 24 and was commensurate with the Group and SPA implementation dates. In other words, the length of enrollment was shorter for Groups 2 and 3 compared to Group 1 and shorter for SPA 2 compared to SPA 1. UCLA Evaluation | HHP Enrollment and Enrollment Patterns 55 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 24: Average Length of Enrollment in Months in HHP by Group as of September 30, 2019 Overall 6.8 Group 1 SPA 1 7.5 SPA 2 5.1 Overall 5 Group 2 SPA 1 5.4 SPA 2 1.5 Group 3 Overall 1.6 SPA 1 1.6 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 56 HHP Enrollment and Enrollment Patterns | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program MCP Exclusions of Specific HHP Eligible Populations MCPs were able to use standardized criteria to exclude some of the 245,330 eligible beneficiaries identified on their respective TELs and were required to report the reason for such exclusions in their Quarterly HHP Reports in the aggregate. Exhibit 25 displays the total number of eligible beneficiaries that were excluded by MCPs by reasons for such exclusions. The most common reason for exclusion was that the eligible beneficiary was not an MCP member (9,442). At the time the TEL was constructed, these individuals may have been members of the MCP, but were no longer members when the MCP began enrollment either due to enrollment in another MCP or disenrollment from Medi-Cal. Other common reasons for exclusion were unsuccessful engagement (6,340) and eligible enrollee declined to participate (5,229; Exhibit 25). Exhibit 25: Number of Eligible Beneficiaries Excluded by Exclusion Rationale as of September 30, 2019 Excluded because not enrolled in Medi-Cal at MCP 9,442 Excluded because of unsuccessful engagement 6,340 Excluded because declined to participate 5,229 Excluded because duplicative program 2,188 Excluded because not eligible - well-managed 1,030 Externally referred but excluded 207 Excluded because unsafe behavior or environment 24 Source: MCP Quarterly HHP Reports from September 1, 2018 to September 30, 2019. Notes: MCP is Managed Care Plan and TEL is Targeted Engagement List. A total of 245,330 eligible beneficiaries were identified on MCP TELs from May 28, 2019. Those enrolled for less than 31 days were excluded from this analysis. UCLA Evaluation | HHP Enrollment and Enrollment Patterns 57 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization This section addresses the following HHP evaluation questions: 1. What were the demographics of program enrollees? 2. What was the acuity level of the enrollees including health and health risk profile indicators, such as aggregate inpatient, ED, and rehab SNF utilization? 3. What proportion of enrollees are homeless? UCLA used demographic information from the Medi-Cal enrollment data, homeless status from MCP Quarterly HHP Reports, and Medi-Cal claims data to construct measures of health status and healthcare utilization prior to enrollment in HHP. Medi- Cal data included both managed care and fee-for-service encounters. UCLA used a look-back period of 24 months for these measures in line with the HHP Program Guide. The exception to this was calculation of enrollee demographics, which was based on an enrollee’s HHP enrollment date. Measures of chronic conditions and acuity eligibility criteria were created based on definitions in the HHP Program Guide and the Centers for Medicare and Medicaid Service’s Chronic Condition Warehouse condition categories, using primary and secondary diagnosis codes in each Medi-Cal claim. Further details can be found in Appendix A: HHP Data Sources and Analytic Methods. UCLA reported demographics, health status, and healthcare utilization for (1) all enrollees, (2) SPA 1 enrollees, (3) SPA 2 enrollees, and when appropriate, (4) by prior healthcare utilization. Enrollees fell into one of three tiers of prior healthcare utilization; the top 15% at the highest level of either emergency department (ED) visits or hospitalizations (IP), the bottom 50% at the lowest level of both ED visits and hospitalizations, and the middle 35% with varying combinations of utilization. Of the 15,527 HHP enrollees (see HHP Enrollment and Enrollment Patterns), five enrollees were missing Medi-Cal data prior to HHP enrollment and were not included in these analyses. HHP enrollees enrolled for less than 31 days (246 enrollees) were excluded from these analyses. DHCS defined inclusion and exclusion eligibility criteria for HHP enrollees and used these criteria to identify eligible Medi-Cal beneficiaries to be included in the TEL, which was then distributed to MCPs in six-month intervals. However, DHCS did not have access to all eligibility criteria in Medi-Cal enrollment and claims data. Specifically, DHCS lacked information on “chronic homelessness” acuity criteria and three exclusion criteria including “sufficiently well managed through self-management or another program”, “more appropriate for alternative care management programs,” and “behavior 58 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program or environment is unsafe for CB-CME staff” (Exhibit 25). In addition to lack of data, the TEL was based on retrospective claims data used to define acuity criteria of “at least one inpatient hospital stay in the last year” and “three or more emergency department (ED) visits in the last year”. Nearly all the exclusion criteria were also retrospective and may have changed prior to enrollment by the MCPs. For example, individuals in a skilled nursing facility, enrolled in specialized MCPs, or enrolled in fee-for-service Medi- Cal may have been discharged back to the community, disenrolled from a specialized MCP, or enrolled in managed care outside of the TEL defined timeline, respectively. In addition, DHCS issued the TEL every six months based on adjudicated Medi-Cal claims data, while MCPs had and used more recent data on diagnoses and service utilization. MCPs were likely to have access to electronic medical records that contain more comprehensive diagnoses and information on health problems and needs of patients. Furthermore, MCPs had the option to enroll members that were referred by providers that may not have matched the HHP eligibility criteria in Medi-Cal data. Ultimately, MCPs prioritized some TEL enrollees based on severity, complexity, or risk- status using information not available to DHCS. Demographics of HHP Enrollees at Time of Enrollment As of September 2019, MCPs had enrolled 15,522 individuals for over 30 days, with 14,375 in SPA 1 and 1,147 in SPA 2. Overall, HHP enrollees were most often 50 to 64 years old, female and Hispanic. When comparing SPA 1 and SPA 2 enrollees, the former group were more often older, less likely to be White, and less likely to speak English. 3.5% of HHP enrollees were ever homeless during HHP enrollment (Exhibit 26), and rates varied by group with under 2% for Group 1, 4.4% for Group 2, and over 2.4% for Group 3 (data not shown). UCLA Evaluation | HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization 59 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 26: HHP Enrollee Demographics, Overall, and by SPA, at the Time of HHP Enrollment SPA 1 SPA 2 Total Enrollees Enrollees Enrollment N 15,522 14,375 1,147 Age (at time of % 0-17 5.4% 5.6% 3.7% enrollment) % 18-34 11.8% 11.1% 20.1% % 35-49 22.5% 22.1% 27.3% % 50-64 54.0% 54.8% 45.0% % 65+ 6.3% 6.5% 3.8% Gender % male 40.5% 40.8% 37.2% Race/Ethnicity % White 23.2% 22.8% 27.4% % Hispanic 44.3% 44.7% 39.5% % African American 17.2% 17.4% 14.7% % Asian American and Pacific Islander 5.4% 5.4% -- % American Indian and Alaska Native 0.4% 0.4% -- % other 2.4% 2.2% -- % unknown 7.2% 7.1% 7.5% Language % speak English 75.1% 74.7% 80.3% Enrolled in Average number Medi-Cal full- of months scope during the year prior to enrollment 11.9 11.9 11.8 Homelessness Proportion ever homeless during HHP enrollment 3.5% 3.4% 3.5% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019, and homelessness is only reported for enrollees who were active as of July 2019. Demographics at the time of HHP enrollment were obtained from Medi- Cal enrollment data from July 1, 2016 to June 30, 2019. Notes: MCP is Managed Care Plan. “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Homeless data was not reported for 720 enrollees. 60 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Status of HHP Enrollees Prior to Enrollment UCLA examined the proportion of enrollees with the top ten most frequent physical health and mental health conditions in the 24 months prior to enrollment. Data showed high rates of hypertension (72.8%) and diabetes (53.4%) among HHP enrollees (Exhibit 27). When comparing SPA 1 and SPA 2, SPA 2 enrollees were more likely to have mental health conditions, including depression (71.0%), anxiety (49.2%), and bipolar disorder (27.3%) compared to SPA 1. Exhibit 27: Top Ten Most Frequent Physical and Mental Health Conditions among HHP Enrollees, 24 Months Prior to HHP Enrollment Total SPA 1 Enrollees SPA 2 Enrollees N=15,522 N=14,375 N=1,147 Hypertension (72.8%) Hypertension (74.1%) Depression (71.0%) Depressive Disorders Diabetes (53.4%) Diabetes (55.2%) (66.4%) Hyperlipidemia (45.9%) Hyperlipidemia (46.9%) Hypertension (56.3%) Obesity (41.7%) Obesity (42.3%) Anxiety (49.2%) Chronic Kidney Disease Chronic Kidney Disease Fibromyalgia, Chronic Pain (39.9%) (40.8%) and Fatigue (35.7%) Depression (37.5%) Depression (34.8%) Obesity (35.0%) Depressive Disorders Depressive Disorders Hyperlipidemia (33.2%) (34.6%) (32.1%) Fibromyalgia, Chronic Pain Fibromyalgia, Chronic Pain Diabetes (30.5%) and Fatigue (32.0%) and Fatigue (31.7%) Chronic Kidney Disease Anxiety (30.6%) Asthma (30.0%) (27.7%) Asthma (28.8%) Anxiety (29.1%) Bipolar Disorder (27.3%) Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Chronic and other chronic health, mental health, and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: MCP is managed care plan. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. In order to further examine the level of complexity of health status of HHP enrollees, UCLA examined the proportion of HHP enrollees that met each of the four HHP eligibility criteria outlined in the HHP Program Guide in the 24 months prior to enrollment. Exhibit 28 shows that 60.5% of HHP enrollees had hypertension along with chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure (Criteria 2). Nearly equal proportions of enrollees had serious mental health conditions (Criteria 3) or a combination of very complex conditions such as chronic renal (kidney) disease, chronic liver disease, traumatic brain injury and a UCLA Evaluation | HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization 61 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program more common condition (Criteria 1). A smaller proportion of HHP enrollees (28.8%) had asthma (Criteria 4). Consistent with HHP program goals, more SPA 2 enrollees had major depression disorder, bipolar disorder, or psychotic disorders (Criteria 3) than SPA 1 enrollees (84.7% versus 38.6%). Exhibit 28: Complexity of HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment SPA 1 SPA 2 Total Enrollees Enrollees Number of HHP Enrollees N=15,522 N=14,375 N=1,147 Two specific conditions (Criteria 1) 43.4% 44.8% 25.7% Hypertension and another specific condition (Criteria 2) 60.5% 62.7% 33.3% Serious Mental Health Conditions (Criteria 3) 42.0% 38.6% 84.7% Asthma (Criteria 4) 28.8% 30.0% 13.4% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 29 displays average health care utilization 24 months prior to enrollment for all HHP enrollees and by SPA. HHP enrollees had on average 1.2 hospitalizations and 4.1 ED visits in the 24 months prior to HHP enrollment. SPA 2 enrollees had 5.1 ED visits on average compared to 4.0 for SPA 1 enrollees. HHP enrollees received on average 19.9 primary care and 11.6 specialty services in the 24 months prior to enrollment, and SPA 1 enrollees had more primary care services while SPA 2 enrollees had slightly more specialty services. Exhibit 29: Average Health Care Utilization by SPA, 24 Months Prior to HHP Enrollment SPA 1 SPA 2 Total Enrollees Enrollees Number of HHP Enrollees N=15,522 N=14,375 N=1,147 Number of hospitalizations 1.2 1.2 1.3 62 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program SPA 1 SPA 2 Total Enrollees Enrollees Number of emergency department visits 4.1 4.0 5.1 Number of long-term skilled nursing facility stays TBD TBD TBD Number of short-term skilled nursing facility stays TBD TBD TBD Number of primary care services 19.9 20.1 17.4 Number of specialty services 11.6 11.6 12.2 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: TBD indicated data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Primary care and specialty services include visits and procedures. UCLA examined the utilization levels of HHP enrollees 24 months prior to enrollment by identifying those at the highest level of either emergency department (ED) visits or hospitalizations (15th percentile or higher), those at the lowest level of both ED visits and hospitalizations (up to 50th percentile) and those in the middle with varying combinations of utilization (between 50th and 15th percentile; Exhibit 30). Data showed that 25% of enrollees were the highest utilizers of either ED visits or hospitalizations and 32% were the lowest utilizers of both ED and hospital care. The remaining 43% of enrollees were in the middle with varying levels of use of these services. These levels of utilization were aligned with an independent measure of severity called the Chronic Illness and Disability Payment System (CDPS). CDPS is constructed using ICD diagnoses in Medi-Cal claims data and creates a score for each beneficiary based on specific chronic condition categories and their association with future health care expenditures. Therefore, higher CDPS scores represent higher risk for health expenditures. The distribution of the score is specific to the population of interest. Exhibit 30 shows that the highest utilizers had 13.9 ED visits and 4.6 hospitalizations on average. These rates corresponded to an average CDPS score of 3.8. In contrast, lowest utilizers had 1.1 ED visits, 0 hospitalizations, and a CDPS score of 1.5 on average. UCLA Evaluation | HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization 63 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 30: Utilization Levels of HHP Enrollees, 24 Months Prior to HHP Enrollment Percent of Average Number Average Number Average Enrollees of ED Visits of Hospitalizations CDPS Score Highest 25% 13.9 4.6 3.8 Utilization Middle 43% 4.2 0.9 2.0 Utilization Lowest 32% 1.1 0.0 1.5 Utilization Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: CDPS is Chronic Disability Payment System. “Highest utilization” refers to HHP enrollees who had the highest (15th percentile or higher) level of either emergency department (ED) visits or hospitalizations; “Middle utilization” refers to HHP enrollees who were in the middle (between 15th and 50th percentile) with varying levels of these services; “Lowest utilization” refers to HHP enrollees who had the lowest (up to 50th percentile) level of both ED visits and hospitalizations. Exhibit 31 shows the intersection of health status complexity and high utilization of ED visits or hospitalizations among HHP enrollees. Data showed that highest utilization was more prevalent (31.7%) among enrollees who had very complex conditions such as chronic renal (kidney) disease, chronic liver disease, traumatic brain injury, or substance use disorders along with more common conditions such as chronic or congestive heart failure (Criteria 1). In contrast, enrollees with hypertension and another condition such as diabetes (Criteria 2) frequently had lowest level of utilization (35.5%). Exhibit 31: Utilization Level of HHP Enrollees by Specific Chronic Condition Criteria, 24 Months Prior to HHP Enrollment Enrollees with Enrollees Enrollees hypertension with serious Enrollees with two All and another mental with specific Enrollees specific health asthma conditions condition conditions (Criteria 4) (Criteria 1) (Criteria 2) (Criteria 3) N=15,522 N=6,729 N=9,394 N=6,522 N=4,464 Highest Utilization 25% 31.7% 25.2% 28.4% 28.1% Middle Utilization 43% 36.8% 39.3% 39.9% 47.8% Lowest Utilization 32% 31.5% 35.5% 31.7% 24.1% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 64 HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: “Highest utilization” refers to HHP enrollees who had the highest (15th percentile or higher) level of either emergency department (ED) visits or hospitalizations; “Middle utilization” refers to HHP enrollees who were in the middle (between 15th and 50th percentile) with varying levels of these services; “Lowest utilization” refers to HHP enrollees who had the lowest (up to 50th percentile) level of both ED visits and hospitalizations. Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization 65 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees This section addresses the following HHP evaluation questions: 1. Were HHP services provided in-person or telephonically? 2. Were HHP services provided by clinical or non-clinical staff? 3. How many homeless enrollees received housing services? MCPs were required to report HHP services to DHCS in Medi-Cal claims data starting on July 1, 2018. Two different procedure codes with unique modifiers that further indicated type and modality of services as well as type of providers were used. DHCS required HCPCS code G0506 from July 1, 2018 to September 30, 2018, but discontinued it because it led to denial of claims where a provider had submitted more than one unit of service per date of service. Therefore, DHCS adopted HCPCS code G9008 starting on October 1, 2018. Both codes were used to report HHP services in this report. HCPCS code G0506 was only reported by two MCPs who implemented HHP as part of Group 1, SPA 1. Prior to Q3 2019, MCPs reported on the number of HHP enrollees that were homeless or at risk of homelessness and the provision of housing services to these beneficiaries in the aggregate and per quarter. This data could not be used to assess trends since it lacked information on each individual member and changes in their status. MCPs began reporting this data at the member level starting in Q3 2019, representing July 1 through September 30, 2019. Therefore, this report describes the size of enrollment and receipt of housing services for homeless and at-risk-of-homelessness beneficiaries in HHP during this quarter. Trends in this data will be reported in future reports. UCLA used all available data to examine the type and frequency of HHP services received by enrollees at the SPA level. Due to the phased implementation schedule of HHP, only four MCPs (Inland Empire Health Plan, San Francisco Health Plan, Anthem Blue Cross Partnership Plan, and Molina Healthcare Plan of California) in three counties (San Francisco, San Bernardino, and Riverside) were included in the HHP services analysis in this report. Further details can be found in Appendix A: HHP Data Sources and Analytic Methods. 66 HHP Service Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Services MCPs were required to report HHP services, defined as “coordinated care fee, physician coordinated care oversight services.” MCPs were required to use HCPCs code modifiers to represent three unique services including type of service, provider, and service modality (Exhibit 32). MCPs were expected to use at least one modifier per claim to define an HHP service. For example, a single visit where an enrollee receives HHP core services in-person by both clinical and non-clinical staff would use two modifiers (U1 and U4). Multiple units of service (UOS) were allowed, where one UOS was equivalent to 15 minutes of time to provide the service. Clinical staff included licensed medical professionals such as physicians, nurse practitioners, LCSWs, and medical assistants, while non-clinical staff included employees working in administrative or technical roles. In-person visits could occur at a variety of locations (e.g., home, office, or clinic). Telehealth allowed for remote patient monitoring (e.g., vitals and blood pressure), allowing enrollee care, reminders, and education to occur through telephone and electronic communications. Exhibit 32: HHP Services Provider Modifier Modality Definition Type Engagement Services Provider U7 Not Active outreach such as direct Type Not specified communications with member (e.g., face-to- Specified face, mail, electronic, and telephone), follow- up if the member presents to another partner in the HHP network or using claims data to contact providers the member is known to use. Providers must show active, meaningful, and progressive attempts at member engagement each month until the member is engaged. Examples of acceptable engagement include: (1) letter to member followed by phone call to member; (2) phone call to member, outreach to care delivery partners and social service partners; (3) and street level outreach, including, but not limited to, where the member lives or is accessible. UCLA Evaluation | HHP Service Utilization 67 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Provider Modifier Modality Definition Type Core Services Provided by U1 In-person Comprehensive care management, care Clinical Staff coordination, health promotion, U2 Telehealth comprehensive transitional care, individual and family support services, and referral to Provided by U4 In-person community and social supports Non-Clinical Staff U5 Telehealth Other Services Provided by U3 Not Case notes, case conferences, tenant Clinical Staff specified supportive services, and driving to Provided by U6 Not appointments Non-Clinical specified Staff Source: Adapted from Health Homes Program Guide. Notes: HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan, and UOS is Unit of Service. Service use was reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 1, 2018 to September 30, 2018) and HCPCS code G9008 (October 1, 2018 to June 30, 2019) to specify the service. Telehealth includes phone and other forms of remote communication. Housing navigation and transition services included activities such as conducting tenant screenings, developing an individualized housing plan, assisting with move-in, and assisting with the housing search and application process. UCLA’s examination of claims data revealed that HCPCS codes were missing for some enrollees. DHCS reported identifying deficiencies in reporting of data both in claims and MCP reports. In discussions with DHCS, MCPs reported challenges in reporting of HHP service provided in claims data by CB-CMEs. The same problem was also observed by MCPs for provision of housing services to enrollees who were homeless or at-risk of homelessness, which were only available in MCP reports to DHCS. DHCS provided technical support to MCPs to address these problems. MCPs also reported to DHCS that they were providing technical assistance to CB-CMEs to improve reporting for all data. This was likely due to under-reporting of this data by CB-CMEs to MCPs, a problem that MCPs are working to address. An examination of the extent of this under-reporting showed that 16.1% of HHP enrollees lacked any HCPCS codes and 38.7% of HHP 68 HHP Service Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program enrollees lacked HCPCS codes for some months during their enrollment (data not shown). Further analysis showed that the rate of under-reporting varied by type of service with a higher rate for core services and a lower rate for engagement services. Therefore, UCLA calculated the average number of HHP services during months when HCPCS codes were present for each enrollee rather than calculating HHP services across all months of enrollment. The latter methodologies would have been based on the incorrect assumption that HHP enrollees did not receive HHP services when HCPCS codes were missing. Due to the limitations of data on HHP services and the methodology employed by UCLA, the data presented in this chapter are considered estimates of HHP services. Under-reporting of HCPCS codes did not impact MCPs’ PMPM payments because these payments were based on capitation and independent of the volume of HHP encounters provided to program enrollees. Estimated Overall HHP Service Delivery to HHP Enrollees Exhibit 33 shows estimated service utilization for any HHP service (modifiers U1-U7), regardless of provider type and modality between July 1, 2018 and June 30, 2019. Among MCPs who had implemented HHP within this period, available data showed that a total of 31,183 UOS (in 15-minute increments) were received during this time period, averaging to 1.9 UOS per enrollee per month. Comparison of services received by HHP enrollees by SPA showed enrollees in SPA 2 had more UOS than SPA 1 (3.5 UOS versus 1.8 UOS per month per enrollee in months that HHP services were received) on average. The higher number of total UOS delivered to SPA 1 enrollees corresponded to a higher number of enrollees in this SPA. Exhibit 33: Estimated Overall HHP Services Received by HHP Enrollees by SPA, July 1, 2018 to June 31, 2019 SPA 1 SPA 2 All HHP Enrollees Enrollees Enrollees (n=7,023) (n=6,856) (n=167) Total number of units of service received 31,183 29,585 1,598 Average number of units of service per enrollee per month 1.9 1.8 3.5 Median number of units of service per enrollee per month 1 1 2 Source: Medi-Cal Claims data from June 1, 2018 to June 30, 2019. UCLA Evaluation | HHP Service Utilization 69 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Notes: HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan, and UOS is Unit of Service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 1, 2018 to September 30, 2018) and HCPCS code G9008 (October 1, 2018 to June 30, 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. MCPs and SPAs included in HHP service analysis between July 1, 2018 and June 30, 2019 include: Inland Empire Health Plan – Riverside – SPA 1; Inland Empire Health Plan – San Bernardino – SPA 1; San Francisco Health Plan – San Francisco – SPA 1 and 2; Anthem Blue Cross Partnership Plan – San Francisco – SPA 1 and 2; Molina Healthcare of California Partner Plan – Riverside – SPA 1 and 2; and Molina Healthcare of California Partner Plan – San Bernardino – SPA 1 and 2. Estimated Types of HHP Services Received Exhibit 34 shows estimated average number of units of service for HHP services by type of service from July 1, 2018 to June 30, 2019. The average number of UOS received per enrollee per month was higher for core HHP services (1.7) than engagement (1.3) and other HHP services (1.4). The average number of UOS per enrollee per month per type of service was higher for SPA 2 than SPA 1 enrollees for all three service types. Exhibit 34: Estimated Average Number of HHP Services Provided to HHP Enrollees by Service Type and SPA, July 1, 2018 to June 30, 2019 Service Type All HHP Enrollees SPA 1 Enrollees SPA 2 Enrollees (n=7,023) (n=6,856) (n=167) Engagement Services (U7) 1.3 1.3 1.8 Core HHP Services (U1, U2, U4, or U5) 1.7 1.7 2.5 Other Health Homes Services (U3 or U6) 1.4 1.3 2.1 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Data show estimated average number of units of services per enrollee during months that specific service was received. HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan, and UOS is Unit of Service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 1, 2018 to September 30, 2018), HCPCS code G9008 (October 1, 2018 to June 30, 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. MCPs and SPAs included in HHP service analysis between July 1, 2018 and June 30, 2019 include: Inland Empire Health Plan – Riverside – SPA 1; Inland Empire 70 HHP Service Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Plan – San Bernardino – SPA 1; San Francisco Health Plan – San Francisco – SPA 1 and 2; Anthem Blue Cross Partnership Plan – San Francisco – SPA 1 and 2; Molina Healthcare of California Partner Plan – Riverside – SPA 1 and 2; and Molina Healthcare of California Partner Plan – San Bernardino – SPA 1 and 2. Estimated HHP Core Services by Modality and Staff Type MCPs were required to report the modality of HHP core services including in-person or through telehealth. However, DHCS did not require reporting modality for other HHP services or engagement services. Exhibit 35 shows the average number of telehealth services received per enrollee during months that telehealth services were received (1.5 UOS) was higher than the average number of in-person services received per enrollee during months that in-person services were received (1.3 UOS). SPA 2 enrollees received more telehealth services (2.2 UOS) compared to in-person services (1.4 UOS) in the months where each modality of service was received. MCPs were required to report the types of staff that provided core and other HHP services. The average number of services received from non-clinical staff (2.9 UOS) were higher than clinical staff (1.5 UOS) for SPA 2 in the months where services from each staff type were received. Exhibit 35: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 All HHP Enrollees SPA 1 Enrollees SPA 2 Enrollees (n=7,023) (n=6,856) (n=167) Modality In-Person (U1 or U4) 1.3 1.3 1.4 Telehealth (U2 or U5) 1.5 1.5 2.2 Staff Type Clinical Staff (U1, U2, or U3) 1.6 1.6 1.5 Non-Clinical Staff (U4, U5, or U6) 1.5 1.5 2.9 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Data show estimated average number of units of services per enrollee during months that service was received. HCPCS is Healthcare Common Procedure Coding System, MCP is Managed Care Plan, and UOS is Unit of Service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 1, 2018 to September 30, 2018) and HCPCS code G9008 (October 1, 2018 to June 30, 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. MCPs and SPAs included in HHP service analysis between July 1, 2018 and June 30, 2019 include: Inland Empire Health Plan – Riverside – SPA 1; Inland Empire UCLA Evaluation | HHP Service Utilization 71 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Plan – San Bernardino – SPA 1; San Francisco Health Plan – San Francisco – SPA 1 and 2; Anthem Blue Cross Partnership Plan – San Francisco – SPA 1 and 2; Molina Healthcare of California Partner Plan – Riverside – SPA 1 and 2; and Molina Healthcare of California Partner Plan – San Bernardino – SPA 1 and 2. HHP Housing Services MCPs began reporting enrollee level data on homeless status and delivery of housing services in Q3 2019 (July 1 through September 30, 2019). In this period, MCPs reported those who were homeless or at risk of homelessness during Q3 2019, those who were no longer homeless during Q3 2019, and those who received housing services in Q3 2019. CB-CMEs had 90 days to assess an enrollee’s homeless status, which may lead to smaller estimates in the data reported below. As noted earlier in this chapter, data were also likely to have been underreported. Using this information, UCLA estimated that 3.8% of enrollees were homeless or at risk- of homelessness in Q3 and 38.0% of these enrollees received housing navigation and transition services (Exhibit 36). Examination of this data by SPA indicated a larger proportion of SPA 2 than SPA 1 enrollees were homeless or at risk-of homelessness in Q3 but a slightly smaller proportion of the former group had received housing services by September 2019. Exhibit 36: Housing Services among HHP Enrollees by SPA and Group, HHP Q3 from July 1 to September 30, 2019 All HHP SPA 1 SPA 2 Enrollees Enrollees Enrollees (n=14,769) (n=13,695) (n=1,074) Proportion of HHP Enrollees that were homeless or at risk of homelessness 3.8% 3.8% 4.2% Among those who were homeless or at risk of homelessness: All HHP SPA 1 SPA 2 Enrollees Enrollees Enrollees (n=566) (n=521) (n=45) Proportion of above HHP enrollees that received housing services 38.0% 38.0% 37.8% Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. Seven MCPs had sufficient data for examination of this information by county. These data showed that Inland Empire Health Plan in Riverside had the largest number of homeless or at risk for homelessness with 180 HHP enrollees, and provided housing services to 40.6% of these enrollees. Three months into their HHP implementation, LA 72 HHP Service Utilization | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Care had the second largest enrollment with 66 enrollees who were homeless or at risk for homelessness. Detailed MCP data can be found in Appendix E: MCP- Level Data. HHP Expenditure UCLA examined per-member per-month (PMPM) HHP supplemental payments to participating MCPs and calculated the estimated total and average per-enrollee HHP expenditures per month from quarter three of 2018 to quarter three of 2019. PMPM payments varied by MCP and county and changed each fiscal year, and per-enrollee expenditures were dependent on the number of months each member was enrolled. Rates were also lower for enrollees who were covered by both Medicare and Medi-Cal, referred to as dually eligible. Using the rates and the number of enrolled months per member, UCLA calculated estimated total expenditures and the average per-enrollee monthly expenditures for all HHP enrollees and by group and dual status. Data showed that total estimated HHP expenditures by end of Q3 of 2019 were $30,818,333 and average monthly per enrollee expenditure was $488 (Exhibit 37). The overall estimated expenditures for duals were lower ($494,472) than non-duals ($30,323,861), as were average monthly per person expenditures. Exhibit 37: Estimated HHP Supplemental Expenditures by Enrollee Type and Group, July 1, 2018 to September 30, 2019 Total Cumulative Average Monthly Per Expenditures Enrollee Expenditure Overall $30,818,333 $488 Group 1 $2,507,871 $498 Total HHP Group 2 $20,909,613 $446 Group 3 $7,400,849 $541 Overall $494,472 $134 Group 1 $76,880 $123 Dual Group 2 $323,674 $138 Group 3 $93,918 $123 Overall $30,323,861 $522 Group 1 $2,430,991 $549 Non-dual Group 2 $20,585,939 $464 Group 3 $7,306,932 $566 Source: Medi-Cal HHP Rate Range Summary. UCLA Evaluation | HHP Service Utilization 73 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Outcomes UCLA calculated selected pre- and post-metrics for Group 1 SPA 1 HHP enrollees with the most complete claims data for the first year of HHP implementation (July 1, 2018 to June 30, 2019). Group 1 included Anthem Blue Cross – San Francisco (Anthem) and San Francisco Health Plan (SFHP) in San Francisco County. These preliminary findings do not include control group comparisons and whether the findings are solely due to HHP enrollment. The following evaluation questions will be addressed by UCLA in future reports: 1. How did patterns of health care service use among HHP enrollees change before and after HHP implementation? 2. Did rates of acute care services, length of stay for hospitalizations, nursing home admissions and length of stay decline? 3. Did rates of other services such as substance use treatment or outpatient visits increase? 4. How did HHP core health quality measures improve before and after HHP implementation? 5. Did patient outcomes (e.g., controlled blood pressure, screening for clinical depression) improve before and after HHP implementation? 6. How many homeless enrollees were housed? All metrics were reported in the aggregate and included data for two years prior to and one year following each individual’s enrollment in HHP. HHP metrics were calculated based on HHP metric specifications in CMS’s Core Set of Health Care Quality Measures for Medicaid Health Home Programs. HHP metrics were grouped by whether they measured process of care delivery or patient outcomes. Process Metrics The exhibits below display process metrics, including adult BMI assessment, initiation of alcohol and other drug abuse or dependence treatment, and engagement of alcohol and other drug abuse or dependence treatment. Significant changes over time were observed for BMI screenings prior to HHP enrollment and for engagement of alcohol and other drug abuse or dependence treatment after HHP enrollment. 74 Outcomes| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 38: Proportion of HHP Enrollees Who Were Assessed for Body Mass Index, Pre- and Post-HHP, Group 1 SPA 1 21%* 20% 17% Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Note: * Change from Pre-HHP Year 2 to Pre-HHP Year 1 was significant at p<0.05, otherwise change was not significant. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. Exhibit 39: Proportion of HHP Enrollees with Initiation of Alcohol and Other Drug Abuse or Dependence Treatment, Pre- and Post-HHP, Group 1 SPA 1 51% 45% 36% Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Note: Changes from Pre-HHP Year 2 to Pre-HHP Year 1 and from Pre-HHP Year 1 to HHP Year 1 were not significant at p<0.05. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. UCLA Evaluation | HHP Outcomes 75 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 40: Proportion of HHP Enrollees with Engagement of Alcohol and Other Drug Abuse or Dependence Treatment, Pre- and Post-HHP, Group 1 SPA 1 55%* 45% 37% Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Note: * Change from Pre-HHP Year 1 to HHP Year 1 was significant at p<0.05, otherwise change was not significant. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. Outcome Metrics The exhibits below display changes in outcome metrics over time. Significant changes were observed for PQI prior to HHP enrollment, ED visits and inpatient utilization prior to and after HHP enrollment, and inpatient length of stay prior to HHP enrollment. Exhibit 41: Proportion of HHP Enrollees with All-Cause 30-Day Readmission, Pre- and Post-HHP, Group 1 SPA 1 38% 34% 32% Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. 76 Outcomes| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Note: Changes from Pre-HHP Year 2 to Pre-HHP Year 1 and from Pre-HHP Year 1 to HHP Year 1 were not significant at p<0.05. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. Exhibit 42: Number of PQIs per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 34* 29 26 Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Notes: * Change from Pre-HHP Year 2 to Pre-HHP Year 1 was significant at p<0.05, otherwise change was not significant. PQI is Prevention Quality Indicator. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. Exhibit 43: Number of Ambulatory Care: Emergency Department Visits per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 404* 315 285* Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Note: * Changes from Pre-HHP Year 2 to Pre-HHP Year 1 and from Pre-HHP Year 1 to HHP Year 1 were significant at p<0.05. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. UCLA Evaluation | HHP Outcomes 77 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 44: Inpatient Visits per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 134* 92 91* Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Note: * Changes from Pre-HHP Year 2 to Pre-HHP Year 1 and from Pre-HHP Year 1 to HHP Year 1 were significant at p<0.05. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. Exhibit 45: Average Inpatient Length of Stay in Number of Days, Pre- and Post-HHP, Group 1 SPA 1 6.1 5.2* 4.6 Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Note: * Change from Pre-HHP Year 2 to Pre-HHP Year 1 was significant at p<0.05, otherwise change was not significant. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. 78 Outcomes| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 46: Number of Short-Term Nursing Facility Admissions per 1,000 Enrollee Months, Pre- and Post-HHP, Group 1 SPA 1 2.6 2.0 1.1 Pre-HHP Year 2 Pre-HHP Year 1 HHP Year 1 Source: UCLA analysis of Medi-Cal enrollment and claims data from July 2016 to June 2019. Note: Changes from Pre-HHP Year 2 to Pre-HHP Year 1 and from Pre-HHP Year 1 to HHP Year 1 were not significant at p<0.05. “Short-term” is defined less than 101 days. Group 1 includes San Francisco Health Plan and Anthem Blue Cross – San Francisco. UCLA Evaluation | HHP Outcomes 79 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Costs The following evaluation questions will be addressed by UCLA in future reports: 1. Did Medi-Cal expenditures for health services decline after HHP implementation? 2. Did Medi-Cal expenditures for needed outpatient services increase? 3. When possible, did HHP have the opportunity during the time period studied to achieve cost neutrality in the delivery of HHP services, in that the overall Medi- Cal expenditures after HHP implementation remained in line with the expected patterns of growth in utilization and cost prior to HHP program implementation? 4. When possible, did HHP program operations lead to cost savings? 5. When possible, what was the ratio of program expenditures to cost savings? 80 HHP Costs | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Conclusions This interim report presented the findings of HHP evaluation in California for the first 15 months of implementation. The report describes: (1) the MCP’s proposed HHP implementation plans; (2) HHP enrollment patterns; (3) HHP enrollee demographics, health status, and health care utilization prior to enrollment; and (4) HHP services delivered by MCPs and contracted CB-CMEs. We found evidence that MCPs had developed comprehensive plans to build the needed infrastructure and to deliver HHP services as well as some evidence of adhering to these plans. This included frequently placing HHP staff within CB-CMEs that were health care providers, requiring specific staffing and qualifications, and establishing and using functional data sharing across MCP networks. In addition, we found evidence of plans to utilize effective strategies, such as predictive modeling and risk grouping methods to target and prioritize members for HHP enrollment and use multiple communication methods and frequent outreach attempts to successfully communicate and engage eligible members. Various aspects of these plans promoted goals of HHP. For example, placing HHP staff with providers should promote efficient care integration and access to needed social services. Functional data sharing capacity should promote proactive management of patients and the ability for timely interventions when patients visit emergency departments or are hospitalized. Our assessment of HHP implementation was limited by lack of data on approaches MCPs ultimately used in implementing these plans. We found an enrollment of 15,527 in HHP primarily in SPA 1, attributable to lower prevalence of SMI among eligible enrollees and later implementation of SPA 2, which was for those who met SMI eligibility criteria. Enrollment size also varied by MCP and County, attributable to phased implementation of HHP in groups of counties and enrollment capacity of MCP networks. For example, the lower enrollment in Group 1 reflected HHP implementation only in San Francisco and the larger enrollment in Group 2 reflected HHP implementation in several larger counties including San Bernardino, Riverside, Kern, and Los Angeles Counties by large MCPs such as Inland Empire Health Plan, Kern Health Systems, and LA Care. Our findings indicated that HHP enrollees had high rates of common chronic conditions, which were often complicated by the presence of additional very complex conditions or mental health diagnoses prior to enrollment. Our findings also indicated very high rates of ED visits and hospitalizations and corresponding high rates of severity among some enrollees prior to HHP enrollment. Our assessment of health status and utilization levels of HHP enrollees had some limitations. We lacked additional detail on health status and utilization of HHP enrollees available in specific administrative MCP data, such as UCLA Evaluation | Conclusions 81 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program factors that disqualified beneficiaries from enrollment and complete information on homeless status. We also lacked more recent information on health status and utilization available to MCPs during and after enrollment. The assessment of HHP services received during this early HHP enrollment period indicated extensive delivery of services commensurate with the needs of HHP enrollees and indicated by SPA. HHP enrollees received the core HHP services from a mix of clinical and non-clinical providers, where most of the care was provided by non-clinical services and using telehealth modalities. Further assessment also indicated that the more complex SPA 2 enrollees received more core services but also more engagement and other HHP services. Data also showed a small proportion of HHP enrollees were homeless and that many of these enrollees received housing support services. Our assessment of receipt of HHP services were restricted to enrollees that had adequate information in their claims in each month of enrollment. We identified significant under- reporting of this data during early HHP implementation. Our assessment of homelessness status and homeless support services was also limited by availability of individual level data prior to Q3 in 2019. Preliminary analyses of HHP metrics for Group 1, SPA 1 enrollees showed improvements in selected process and outcome metrics after HHP enrollment. However, further analyses and inclusion of control group data are required to determine if these changes were attributable solely to HHP. Next Steps This report highlights the interim progress made by MCPs in the first 15 months of HHP implementation by 15 MCPs in 11 counties (i.e., data does not include Orange County due to a later implementation schedule). Additionally, at the time of this report, only San Francisco, Riverside, and San Bernardino had implemented for both SPA 1 and SPA 2. By the end of this program, a total of 16 MCPs in 12 counties will have implemented HHP in both SPA 1 and SPA 2 for an adequate period of time when the program impact on a number of pre-defined outcomes and Medi-Cal payments could be measured. The interim findings of this report indicated substantial enrollment of eligible Medi-Cal beneficiaries and delivery of HHP services to those enrollees. Further data on changes in pre-defined outcomes and Medi-Cal payments will be provided in the next two evaluation reports. These include comparison of patterns of pre-defined outcomes among HHP enrollees and a control group of Medi-Cal beneficiaries before and after HHP enrollment. These outcomes will include: • Emergency department visits, • Hospitalizations, • All-Cause Readmissions, • Skilled nursing facility stays, 82 Conclusions | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program • Adult Body Mass Index Assessment, • Controlled High Blood Pressure, • Screening for Clinical Depression and Follow-Up, • Initiation and Engagement of Alcohol and Other Drug Abuse or Dependent Treatment, • Prevention Quality Indicator 92: Chronic Conditions Composite • Frequency of HHP enrollees receiving Health Action Plans within 90 days of enrollment, • Proportion of homeless enrollees that were housed, and • Medi-Cal payments for health services for HHP enrollees and the control group. UCLA Evaluation | Conclusions 83 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Appendix A: HHP Data Sources and Analytic Methods Readiness Documents UCLA used the Readiness Documents from 16 MCPs submitted to DHCS to report on MCP implementation of HHP. In these readiness documents, MCPs reported on topics including organizational model, staffing, health information technology, HHP services, HHP network, and HHP operations. Enrollment Reports and MCP Quarterly HHP Reports UCLA used MCP Enrollment Reports and Quarterly HHP Reports to analyze HHP enrollment. Enrollee-level HHP enrollment data was only available in MCP Enrollment Reports prior to July 2019. All four MCPs (Anthem Blue Cross of California Partnership Plan, San Francisco Health Plan, Inland Empire Health Plan, and Molina Healthcare of California Partner Plan) that implemented HHP by July 2019 submitted an Enrollment Report to DHCS in August 2019, covering the period of July 1, 2018 to June 30, 2019. All MCPs except CalOptima submitted Quarterly HHP Reports during the time they had implemented HHP from July 1, 2018 to September 30, 2019. Starting in July 2019, MCP Quarterly HHP Reports included enrollee-level data on both enrollment, homelessness, and housing status. CalOptima had not implemented HHP as of September 2019 and did not submit a report. Additionally, UCLA used MCP Quarterly HHP Reports to report on MCP and CB-CME characteristics in this report. These two data sources had some differences, which resulted in UCLA only being able to analyze enrollment at a monthly level. Staggered implementation of the program by county resulted in MCPs with different reporting lengths. Therefore, data was often limited to one quarter, July 1 to September 30, 2019, that included MCPs with any HHP enrollment at the time of the report. Medi-Cal Enrollment and Claims UCLA used Medi-Cal enrollment and claims data from July 1, 2016 to September 30, 2019 to create demographic health status indicators, health care utilization indicators, and preliminary metrics used in this report. Claims data included both managed care and fee-for-service encounters. Medi-Cal Health Homes Program Rate Range Summary 84 Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program UCLA used the Medi-Cal Health Homes Program Rate Range Summary, which provided per member per month (PMPM) HHP rates, to calculate total expenditures per quarter and average per enrollee expenditures. Rates varied by MCP and County, and whether the enrollee was dual (covered by Medi-Cal and Medicare) or non-dual (covered only by Medi-Cal). Analytic Methods Readiness Documents UCLA reviewed all Readiness Documents to answer the UCLA evaluation questions detailed in Exhibit 47. MCPs varied in the level of detail in their documents. UCLA identified and tabulated relevant information to the extent possible given this variation by MCP. Information from Readiness Documents were cross-checked with other data including MPC Quarterly HHP Reports to improve accuracy when possible. Exhibit 47: Evaluation Questions and Data Sources Evaluation Question Location in Readiness Documents 1. Which HHP network model was employed? Organizational Model 2. What was the composition of HHP networks? Organizational Model MCP Duties/Responsibilities 3. What types of staff provide HHP services? Organizational Model Staffing 4. What was the data sharing approach? Health Information Technology/Data and Information Sharing 5. What was the approach to targeting patients Member Engagement for enrollment into HHP? Member Notices Risk Grouping Housing Services Source: UCLA Health Homes Program Evaluation Design, 2019. Enrollment Reports and MCP Quarterly HHP Reports Exhibit 48 shows the enrollment data obtained from these reports. Monthly enrollment data from the MCP Enrollment Reports and Quarterly HHP Reports were combined to determine monthly enrollment status by individual enrollee. If there were conflicting data for individual enrollees between the two data sources, UCLA used the more recent data from the Quarterly HHP Reports. Nineteen enrollees that switched counties or plans during their enrollment were excluded from further analysis. Beneficiaries who were enrolled on any date during a given month were considered enrolled for the whole month. Beneficiaries that were disenrolled for less than 30 days in between enrolled Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation 85 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program months were considered enrolled in the program for that month. However, 246 beneficiaries who were only enrolled for less than 31 days were excluded from the analyses of enrollment patterns. UCLA used the MCP Quarterly HHP Reports to analyze data on enrollee’s housing status and housing service utilization as of September 2019. Enrollee-level housing services data were included in the Quarterly HHP Reports starting in July 2019, which limited the analysis of housing services to July 1 through September 30, 2019. Exhibit 48: Beneficiary-Level Variables Data Elements Definitions SPA Enrolled in SPA 1 vs. SPA 2. Dual Status Enrollee in both Medicare and Medi-Cal during HHP enrollment. County County in which enrollee is enrolled. Monthly Enrollment Indicator for HHP enrollment status for a particular month. Status Enrollment Date The date an enrollee starts to enroll in HHP. Enrollment date reported prior to 2019 Quarter 3 always begins on the first day of the initially enrolled month. Enrollment date reported after June 30, 2019 is the exact date. Disenrollment Date The date an enrollee disenrolled from HHP. Disenrollment date reported prior to July 1, 2019 is the last day of the month. Disenrollment date reported after June 30, 2019 is an exact date. Number of Times The number of times each enrollee disenrolled from the MCP Disenrolled throughout their enrollment. Length of Enrollment The differences between disenrollment date and enrollment date. If an enrollee enrolls in and disenrolls from HHP on the same date, the length of enrollment will be one day. Day count was divided by 30 to estimate length of enrollment in months. Ever Homeless Data only available from Quarterly HHP Reports. Indicates during HHP whether enrollee was ever homeless during HHP enrollment. Homeless or at Risk Data only available from Quarterly HHP Reports. Enrollee is for Homelessness homeless or at risk for homelessness from July 1, 2019 to September 30, 2019. Received Housing Data only available from Quarterly HHP Reports. Enrollee Services received housing services from July 1, 2019 to September 30, 2019. Housed by Data only available from Quarterly HHP Reports. Indicator of September 2019 whether enrollee was housed by September 30, 2019. Notes: Data from MCP Enrollment Reports from July 1, 2018 to June 30, 2019 and MCP Quarterly HHP Reports from July 1, 2019 to September 30, 2019. 86 Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program From the MCP Quarterly HHP Reports, UCLA reported on CB-CME networks by county and aggregate excluded eligible beneficiary counts by county as of September 2019. The HHP Program Guide provided specifications of the elements from in the Quarterly HHP Reports. Briefly, UCLA reported on the number of eligible beneficiaries excluded from HHP for seven exclusion rationales defined by DHCS. MCPs reported individual CB-CMEs, identified by the National Plan and Provider Enumeration System (NPPES) NPI, serving HHP enrollees and the estimated anticipated enrollment of each CB-CME. UCLA used the NPI Registry to identify characteristics of unique CB-CMEs in MCP networks. The anticipated enrollment was reported as of September 30, 2019, although only limited variation by quarter was reported by CB-CME. Medi-Cal Enrollment and Claims Demographic Indicators Exhibit 49 displays demographic indicators created by UCLA using Medi-Cal monthly enrollment data. UCLA calculated age based on an enrollee’s HHP enrollment date. On the rare occasion enrollment data included more than one birthday for an enrollee, UCLA used the latest birthday reported. While not common, if the Medi-Cal enrollment data contained conflicting data for gender, race, or language for an HHP enrollee, UCLA used the most frequently reported category. Exhibit 49: Demographic Indicators Indicators Definitions Age Enrollee’s final age in years at the time of HHP enrollment. Gender Indicates whether an enrollee is male or female. Race The race label for an enrollee: White, Hispanic, African American, Asian American and Pacific Islander, American Indian and Alaska Native, other, or unknown. Speaks English Indicating whether an enrollee is an English speaker or not. Number of Full scope coverage is defined as at enrollment in at least one Months with Full dental MCP and another non-dental MCP during the eligible date Scope Coverage period. The number of months that an enrollee is full scope is reported for the year prior to the enrollee’s initial enrollment in HHP. Health Status Indicators UCLA used Medi-Cal claims data from July 1, 2016 to September 30, 2019 to assess health status of HHP enrollees prior to their enrollment in HHP. UCLA followed chronic condition and acuity eligibility criteria developed by DHCS for HHP as described in the HHP Program Guide (Exhibit 50). According to these criteria, chronic conditions were present if an enrollee had two or more services on different dates for the specified Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation 87 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program condition during the two years prior to HHP enrollment. UCLA also used the criteria set by CMS’s Chronic Condition Warehouse to obtain a complete list of chronic condition and potentially chronic or disabling condition categories. Exhibit 50: Health Status Indicators Indicators Definition Chronic Conditions Chronic Condition The percentage of enrollees that meet chronic condition Criteria 1: Two criteria 1. An enrollee satisfies chronic condition criteria 1 if the specific conditions enrollee has at least two of the following HHP eligible chronic and SUD conditions: chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, dementia, substance use disorder. Chronic Condition The percentage of enrollees that meet chronic condition Criteria 2: criteria 2. An enrollee satisfies chronic condition criteria 2 if the Hypertension and enrollee has hypertension and one of the following HHP another specific eligible chronic conditions: chronic obstructive pulmonary comorbidity disease, diabetes, coronary artery disease, chronic or congestive heart failure. Chronic Condition The percentage of enrollees that meet chronic condition Criteria 3: Serious criteria 3. An enrollee satisfies chronic condition criteria 3 if the Mental Illness (SMI) enrollee has one of the following HHP eligible chronic conditions: major depression disorders, bipolar disorder, psychotic disorders (including schizophrenia. Chronic Condition The percentage of enrollees that meet chronic condition Criteria 4: Asthma criteria 4. An enrollee satisfies chronic condition criteria 4 if the enrollee has the HHP eligible chronic condition asthma. Acuity Acuity Criteria 1: The percentage of enrollees that meet acuity criteria 1. An Three or more enrollee satisfies acuity criteria 1 if the enrollee has at least chronic conditions three of the following HHP eligible chronic conditions: chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, dementia, substance use disorder. Acuity Criteria 2: The percentage of enrollees that meet acuity criteria 2. An One or more enrollee satisfies acuity criteria 2 if the enrollee has at least Hospitalizations one inpatient hospital stay during one year prior to HHP enrollment. Acuity Criteria 3: The percentage of enrollees that meet acuity criteria 3. An Three or more ED enrollee satisfies acuity criteria 3 if the enrollee has at least Visits three or more emergency department visits during one year prior to HHP enrollment. 88 Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Indicators Definition Chronic Condition The percentage of enrollees meeting each of the CCW Warehouse (CCW) condition category criteria in the period prior to HHP Conditions enrollment. CDPS (Chronic The mean, median, and standard deviation of CDPS among all Illness and Disability enrollees. The CDPS is calculated based on the International Payment System Classification of Diseases (ICD) diagnosis codes in Medi-Cal Risk Score) claims data. Healthcare Utilization Indicators UCLA also created healthcare utilization indicators using Healthcare Effectiveness Data and Information Set (HEDIS) 2019 Volume 2 definitions. Exhibit 51 displays these indicators. Exhibit 51: Healthcare Utilization Indicators Indicators Definitions Number of Hospitalizations The number of inpatient hospitalization visits during the service month. Length of hospitalization The total lengths measured in number of total days of (days) all hospitalizations during the service month. Number of ED Visits The number of ED visits during the service month. Number of Primary Care The number primary care provider services during the Services service month. Number of Specialty Services The number of specialty services during the service month. Number of Evaluation and The number of evaluation and management services Management Visits during the service month. Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation 89 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Services HHP Services were only reported for four plans in limited counties and SPAs due to the phased implementation schedule of HHP. Plans and counties that were included were Anthem Blue Cross Partnership Plan – San Francisco – SPA 1 and 2, Inland Empire Health Plan – Riverside- SPA 1, Inland Empire Health Plan – San Bernardino – SPA 1, Molina Healthcare of California Partner Plan – Riverside – SPA 1 and 2, Molina Healthcare of California Partner Plan – San Bernardino – SPA 1 and 2, and San Francisco Health Plan – San Francisco – SPA 1 and 2. Exhibit 52 displays indicators of utilization of HHP services reported by MCPs in Medi-Cal claims data. Exhibit 52: HHP Service Utilization Indicators Indicators Definitions Proportion of enrollees that ever received The percent of enrollees that ever an HHP service received the service. Proportion of enrolled months that The percent months with services services were provided per enrollee received out of the number of months enrolled in HHP among HHP enrollees that have ever received the service. Average number of units of service per The average of each HHP enrollee’s enrollee per month during months that monthly average number of service units services were provided for the received service each month among HHP enrollees that have ever received the service. Units of service are defined as 15-minutes of service; multiple units of service are possible. Median number of units of service per The median of each HHP enrollee’s enrollee during months that service was monthly number of service units for the provided received service each month among HHP enrollees that have ever received the service. Units of service are defined as 15-minutes of service; multiple units of service are possible. 90 Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program UCLA used the HHP designated HCPCS codes and modifiers to identify encounters that included HHP services, defined in Exhibit 53. HCPCS code G0506 and modifier codes U1 to U7 were used July 1, 2018 through September 30, 2018, and HCPCS code G9008 and modifier codes U1 to U7 were used October 1, 2018 through June 30, 2019. Exhibit 53: HHP Services Provider Modifier Modality Definition Type Engagement Services Provider U7 Not Active outreach such as direct Type Not specified communications with member (e.g., face-to- Specified face, mail, electronic, and telephone), follow- up if the member presents to another partner in the HHP network or using claims data to contact providers the member is known to use. Providers must show active, meaningful, and progressive attempts at member engagement each month until the member is engaged. Examples of acceptable engagement include: (1) letter to member followed by phone call to member; (2) phone call to member, outreach to care delivery partners and social service partners; (3) and street level outreach, including, but not limited to, where the member lives or is accessible. Core Services Provided by U1 In-person Comprehensive care management, care Clinical Staff coordination, health promotion, U2 Telehealth comprehensive transitional care, individual and family support services, and referral to Provided by U4 In-person community and social supports Non-Clinical Staff U5 Telehealth Other Services Provided by U3 Not Case notes, case conferences, tenant Clinical Staff specified supportive services, and driving to Provided by U6 Not appointments Non-Clinical specified Staff Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation 91 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Preliminary Metrics Preliminary metrics were presented for Anthem Blue Cross – San Francisco (Anthem) and San Francisco Health Plan (SFHP) only. Metrics were restricted to Group 1 SPA 1 because more comprehensive and adjudicated claims data were available for the entire year (July 1, 2018 to June 30, 2019). All metrics were reported in the aggregate and included data for two years prior to and one year following each individual’s enrollment in HHP. Control group data were not available for this report. Therefore, changes from pre- to post-HHP may be due to factors other than HHP enrollment and cannot be attributed to HHP solely. HHP metrics were calculated based on HHP metric specifications in CMS’s Core Set of Health Care Quality Measures for Medicaid Health Home Programs. HHP metrics were grouped by whether they measured process of care delivery or patient outcomes. Exhibit 54 includes descriptions of all HHP metrics, how changes in the metric are to be interpreted, and whether they were included in this report. Exhibit 54: HHP Metrics, Definitions, and Reporting Status Improvement Reporting Measured by Metric Description Status and Increase or Limitations Decrease Adult Body Mass Percentage of Health Home Increase Reported Index (BMI) enrollees ages 18 to 74 who had an Assessment outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. Follow-Up After Percentage of discharges for Health Increase Not Hospitalization Home enrollees age 6 and older reported for Mental Illness who were hospitalized for treatment due to within 30 days of selected mental illness diagnoses under- and who had a follow-up visit with a reporting of mental health practitioner within 30 related days. codes Follow-Up After Percentage of discharges for Health Increase Not Hospitalization Home enrollees age 6 and older reported 92 Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Improvement Reporting Measured by Metric Description Status and Increase or Limitations Decrease for Mental Illness who were hospitalized for treatment due to within 7 days of selected mental illness diagnoses under- and who had a follow-up visit with a reporting of mental health practitioner within 7 related days. codes Screening for Percentage of Health Home Increase Not Depression and enrollees age 12 and older reported Follow-Up Plan screened for clinical depression on due to use the date of the encounter, and if of positive, a follow-up plan is alternative documented on the date of the codes positive screen Initiation of Percentage of enrollees who initiate Increase Reported Alcohol and treatment through within 14 days of Other Drug the diagnosis Abuse or Dependence Treatment Engagement of Percentage of enrollees who initiate Increase Reported Alcohol and treatment and who had two or more Other Drug additional AOD services or MAT Abuse or within 34 days of the initiation visit. Dependence Treatment Controlling High Percentage of Health Home Increase Not Blood Pressure enrollees ages 18 to 85 who had a reported diagnosis of hypertension (HTN) due to and whose blood pressure (BP) was under- adequately controlled during the reporting of measurement year. codes Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation 93 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Improvement Reporting Measured by Metric Description Status and Increase or Limitations Decrease Plan All-Cause For Health Home enrollees ages 18 Decrease Reported Readmissions to 64, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Prevention Number of inpatient hospital Decrease Reported Quality Indicator admissions for ambulatory care (PQI) 92: sensitive chronic conditions per Chronic 100,000 enrollee months for Health Conditions Home enrollees age 18 and older. Composite This measure includes adult hospital admissions for diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, or heart failure without a cardiac procedure. Ambulatory Rate of emergency department (ED) Decrease Reported Care: visits per 1,000 enrollee months Emergency among Health Home enrollees. Department (ED) Visits Inpatient Rate of acute inpatient care and Decrease Reported Utilization services (total, maternity, mental and behavioral disorders, surgery, and medicine) per 1,000 enrollee 94 Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Improvement Reporting Measured by Metric Description Status and Increase or Limitations Decrease months among Health Home enrollees Inpatient Length All approved days from admission to Decrease Reported of Stay discharge. Long-Term The number of admissions to a Decrease Not Nursing Facility nursing facility from the community reported; Utilization that result in a long-term stay will appear (greater than or equal to 101 days) in during the measurement year per subsequent 1,000 enrollee months. reports Short-Term The number of admissions to a Decrease Reported Nursing Facility nursing facility from the community Utilization that result in a short term (less than 101 days) stays during the measurement year per 1,000 enrollee months. Source: Detailed information for each metric is available in HHP Metric Specifications. Limitations Readiness Documents The MCP readiness documents represented MCP plans for HHP implementation and may not reflect the final implementation approach by MCPs. Several MCPs submitted periodically revised readiness documents during HHP implementation. These documents included drafts, revisions, and communications with DHCS regarding further revisions and/or clarifications. In addition, MCPs provided variable amounts of detail on planned implementation, which may have led to a limited understanding of MCPs’ final approach. The MCPs maximum estimated HHP enrollment overall and by CB-CME in readiness documents and their responsibilities are unlikely to align with actual quarterly enrollment data. Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation 95 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Reports and MCP Quarterly HHP Reports UCLA analyzed the enrollment data provided by MCPs. Given that enrollee-level data in the MCP Quarterly Report were not required until July 2019, UCLA had to combine these data with MCP Enrollment Reports from July 1, 2018 to June 30, 2019 to examine enrollment and enrollment patterns. These two data sources had some differences, which resulted in UCLA only being able to analyze enrollment at a monthly level. Staggered implementation of the program by county resulted in MCPs with different reporting lengths. Therefore, data was often limited to one quarter, July 1, 2019 to September 30, 2019, that included MCPs with any HHP enrollment at the time of the report. Medi-Cal Enrollment and Claims One of the acuity criteria set by DHCS in the HHP Program Guide was chronic homelessness. However, Medi-Cal Enrollment and Claims data do not provide sufficient data to identify individuals that are chronically homelessness. As a result, UCLA could not report on this acuity criteria. Medi-Cal claims data takes at least six months to mature, resulting in the incomplete reporting of claims if the data is collected less than six months after the relevant date of service. UCLA collected data for this report at the end of January 2020, which resulted in potentially incomplete claims for the period of August to September 2019. The identification of chronic conditions relied on the primary and secondary diagnoses associated with each service. Any error in reporting of these diagnoses could result in under or over reporting of chronic conditions. The HCPCS code G0506 with modifiers that was initially used to identify HHP services was found to be in conflict with National Correct Coding Initiative rules (i.e., if a provider submitted more than one unit per date of service, the claim would be denied), and not all MCPs reported encounters using the HHP HCPCS code. These factors resulted in probable under reporting of HHP services. MCPs that did not report any encounters with the HHP HCPCS code included Aetna Better Health of California, UnitedHealthcare Community Plan of California, Community Health Group Partnership Plan, and Kaiser Permanente. 96 Appendix A: HHP Data Sources and Analytic Methods | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Appendix B: UCLA HHP Evaluation Design Introduction The Health Homes Program (HHP) is created and implemented under the statutory authority of California AB 361. The legislation authorizes the California Department of Health Care Services (DHCS) to create HHP under the Section 2703 of the 2010 Patient Protection and Affordable Care Act. Section 2703 allows states to create Medicaid health homes to coordinate the full range of physical health, behavioral health, and community-based long-term services and supports needed by members with chronic conditions. The program is subject to cost-neutrality requirements regarding the State General Funds and federal financial participation. AB 361 requires an evaluation of the program. AB 361 also required that DHCS submit a report to the Legislature within two years after implementation of the program. The overarching goal of HHP is to achieve the Triple Aim of Better Care, Better Health, and Lower Costs. These goals are to be achieved by providing (1) comprehensive care management, (2) care coordination, (3) health promotion, (4) comprehensive transitional care, (5) individual and family support services, and (6) referrals to community and social support services. The program is implemented by Medi-Cal managed care plans (MCPs) to their members. MCPs form contractual or non- contractual relationships with Community-Based organizations or entities, forming an HHP network for delivery of services. HHP is scheduled to be implemented in 14 California counties, with four groups of counties implanting HHP in five consecutive time periods. In addition to staggered implementation by county, MCPs incorporate the subset of patients with serious mental illness (SMI) and serious emotional disturbance (SED) six months after the program start date (phase 2) for other eligible populations with program criterion of physical health/substance use disorder (SUD) (phase 1). The first county has implemented the first phase of the program in July 2018 and the last counties will implement the second phase in July 2020. The target population of the program is a small subset (3-5%) of the state’s Medi-Cal population. This subset requires an intensive set of services and the highest levels of care coordination. Eligibility for HHP includes having chronic conditions that fit one of several predetermined categories and evidence of high acuity/complexity. There are program exclusions criteria for those receiving care management such as: (1) hospice recipients and skilled nursing home residents, (2) enrollees in specialized MCPs (e.g., Program of All-Inclusive Care for the Elderly (PACE), Senior Care Action Network (SCAN) and AIDS Healthcare Foundation (AHF)), (3) MCP members sufficiently well managed through self-management or another program, and (4) members determined to be more appropriate for alternative care management programs, etc. Appendix B: UCLA HHP Evaluation Design | UCLA Evaluation 97 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Evaluation Conceptual Framework and Questions The UCLA Center for Health Policy Research (UCLA) is the evaluator of the HHP program. UCLA has developed a conceptual framework for the evaluation of HHP (Exhibit 1). According to the framework, better care is achieved when HHP network providers establish the necessary infrastructure and deliver HHP services. Delivery of HHP services will in turn lead to better health indicated by reduced utilization of health care services that are associated with negative health outcomes as well as improvements in population health indicators. Better care and better health will lead to lower overall health care expenditures. Exhibit 55: Evaluation Conceptual Framework •Infrastructure: HHP network composition, organization model of community-based care management, care coordination staffing, HIT and data sharing approach, patient enrollment approach •Process: provide comprehensive care management, coordinate care, deliver health promotion services, provide comprehensive transitional care, provide individual and family support Better Care services, refer to community and social support services •Health care utilization: reduce emergency department visits, reduce inpatient hospitalizations, reduce length of stay, increase outpatient follow-up care post admission, reduce nursing facility admissions, increase use of substance use treatment Better •Patient outcomes: control blood pressure, screen for depression, assess BMI, reduce all-cause readmissions, reduce inpatient admission for ambulatory care sensitive chronic conditions Health •Health care expenditures: reduce overall expenditures by lower spending on acute care services and higher spending on needed outpatient services •Cost neutrality: maintain cost neutrality by insuring HHP service expenditures do not lead to higher overall expenditures Lower Costs •Return on investment: show return on investment due to HHP program implementation Exhibit 56 displays the evaluation questions and data sources that will be used to answer those questions. The evaluation questions are aligned with the components of the conceptual framework. Questions 1-7 examine the infrastructure established by HHP networks, population enrolled, and the services delivered. Questions 8-13 examine the impact of HHP service delivery on multiple indicators of healthcare service utilization as well as patient health indicators. Question 14-17 examine the impact of HHP on lowering costs or cost savings for the Medi-Cal program. 98 Appendix B: UCLA HHP Evaluation Design| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 56: Evaluation Questions and Data Sources Evaluation Questions Data Sources Better Care Infrastructure 16. What was the composition of HHP MCP Reports networks? 17. Which HHP network model was employed? 18. When possible, what types of staff provided HHP services? 19. What was the data sharing approach? 20. What was the approach to targeting patients for enrollment per HHP network? Process 21. What were the demographics of program MCP Reports enrollees? What was the acuity level of the TEL: demographic and eligibility enrollees including health and health risk criteria of targeted MCP members profile indicators, such as aggregate Medi-Cal Claims and Encounter inpatient, ED, and rehab SNF utilization? Data: demographics and service What proportion of eligible enrollees were use enrolled? How did enrollment patterns Quarterly HHP Enrolled CIN File: change over time? What proportion of HHP enrollees enrollees are homeless? 22. Were Health Home services provided in- person or telephonically? Were Health Home services provided by clinical or non- clinical staff? How many enrollees received engagement services? How many homeless enrollees received housing services? Better Health Health care utilization 23. How did patterns of health care service use TEL: demographic and eligibility among HHP enrollees change before and criteria of targeted MCP members after HHP implementation? Medi-Cal Claims and Encounter 24. Did rates of acute care services, length of Data: demographics and service stay for hospitalizations, nursing home use admissions and length of stay decline? 25. Did rates of other services such as substance use treatment or outpatient visits increase? Patient outcomes Appendix B: UCLA HHP Evaluation Design | UCLA Evaluation 99 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Evaluation Questions Data Sources 26. How did HHP core health quality measures MCP Reports: core measures improve before and after HHP Medi-Cal Claims and Encounter implementation? Data: conditions and service use 27. Did patient outcomes (e.g., controlled blood pressure, screening for clinical depression) improve before and after HHP implementation? 28. How many homeless enrollees were housed? Lower Costs Health care expenditures 29. Did Medi-Cal expenditures for health Medi-Cal Claims and Encounter services decline after HHP implementation? Data: conditions and service use 30. Did Medi-Cal expenditures for needed HHP Payment Files: HHP services outpatient services increase? and payments for those services Cost neutrality 31. When possible, did HHP have the Medi-Cal Claims and Encounter opportunity during the time period studied to Data: Service use and expenditures achieve cost neutrality in the delivery of HHP Payment Files: HHP services HHP services, in that the overall Medi-Cal and payments for those services expenditures after HHP implementation remained in line with the expected patterns of growth in utilization and cost prior to HHP program implementation? Return on Investment 32. When possible, did HHP program Medi-Cal Claims and Encounter operations lead to cost savings? What was Data: Service use and expenditures the ratio of program expenditures to cost HHP Payment Files: HHP services savings? and payments for those services Notes: TEL is Targeted Engagement List. Data Sources As indicated in Exhibit 56, UCLA will receive four data sources from DHCS including (1) reports filed by each MCP, (2) TEL (Targeted Engagement List) created every six months by DHCS, (3) Medi-Cal Claims and Encounter Data for all program beneficiaries and comparison group, and (4) monthly HHP payments files submitted by MCPs. These data sources allow for a qualitative and quantitative approach to the HHP evaluation. The ability of UCLA to address the evaluation questions is dependent on the content of these datasets and the type of analyses will be dependent on availability of data. MCP reports include the readiness deliverables and required quarterly reporting. The readiness deliverables include HHP policies and procedures describing infrastructure, 100 Appendix B: UCLA HHP Evaluation Design| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program services, network and operations, engagement plans, and HHP network composition. The quarterly reporting will include aggregate semi-annual and annual health outcome measures. The quarterly reports will also identify enrollees that are experiencing homelessness and whether or not they received housing services and were successfully housed. TEL is created every six months by DHCS to identify enrollees of participating MCPs who are potentially eligible for enrollment in HHP based on the HHP inclusion and exclusion criteria. These data include patient demographics and health status indicators. Medi-Cal fee-for-service (FFS) claims and managed care encounter data include comprehensive information on use of services by eligible and enrolled HHP patients. UCLA will receive two years of data prior to implementation of HHP to establish baseline trends, and a minimum of one year of data during HHP implementation. These data include diagnoses, service use, and provider payments for fee-for-service (FFS) claims. HHP payment files will be submitted monthly by the MCPs to DHCS. They are expected to include enrollment lists, the enrollee’s State Plan Amendment (SPA) assignment, enrollee’s status as a dual-enrollee and monthly DHCS payments to MCPs. UCLA will maintain all data in a secure environment. UCLA anticipates receiving a preliminary enrollment and encounter data from DHCS within six months of program implementation to evaluate the data for completeness and accuracy and to conduct preliminary analyses. The final and complete data for the first year of the program are anticipated no later than six months after the end of the first year of program implementation. Methods UCLA will analyze all available data to evaluate HHP impact. The evaluation will include a quantitative assessment of program impact on enrollment, health care utilization, and cost indicators. In addition, the evaluation will also include a qualitative assessment of HHP infrastructure and implementation process through analysis of the HHP readiness deliverables. The quantitative analyzes will range from more descriptive analyses of enrollees, enrollment trends, self-reported metrics, and health outcomes, to advanced methods to assess changes in utilization and costs. The descriptive analyses will use descriptive statistics to examine basic enrollee demographics, health conditions and acuity, and healthcare utilization both historically and during the period of the program. The Appendix B: UCLA HHP Evaluation Design | UCLA Evaluation 101 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program advanced methods include use of regression models and quasi-experimental analytic design including pre-post, intervention-comparison group design and difference-in- difference (DD) methodology when possible. The quasi-experimental design is desirable due to its rigor in isolating the impact of HHP services. In order to study the impact of the HHP by county and MCP, the evaluation will use small area estimation to stratify all relevant outcomes by county and MCP combinations. This will be accomplished by including MCP and county as random effects in the models, thereby allowing for the measurement of these factors on the overall estimate even among small counties and MCPs. The final measures will be presented for the overall program and stratified by these groups. Selection of the comparison group is necessary for the quasi-experimental design and allows for elimination of the impact of contextual determinants of health care utilization and costs. UCLA has identified two possible methods of identifying a comparison group including: 1) participating MCP members that are on the TEL but either were not targeted or yet to be targeted by MCPs or did not opt-in; and 2) MCP members in counties not implementing HHP that fit the TEL criteria. As enrollment in HHP will change over the course of the program and inclusion on the TEL will also change over time, the comparison group will have to be created during multiple time points during the course of the evaluation. If needed to create a sufficiently large enough group, the comparison group may be composed of individuals from both methods. Both methods to identify the comparison group have significant limitations. HHP enrollment among the eligible beneficiaries is not random as MCPs target beneficiaries based on additional criteria and their knowledge of patient utilization and costs. In addition, HHP enrollees have to choose to opt-in and those who do not are likely to have different characteristics. Therefore, the first comparison group is subject to selection bias. UCLA will be unable to identify which members on the TEL chose not to opt-in versus those that were not contacted. The second comparison group is not subject to selection bias, but there are potential differences in health system characteristics, population demographics, and patterns of health care utilization in other counties. For both comparison groups, HHP eligible patients may be enrolled in the Whole Person Care pilot programs which provides a number of similar services to HHP. Enrollment in WPC will not be known among either the treatment or comparison group members. UCLA will create these comparison groups and will closely examine the size and characteristics of each group to assess the utility of each group for the DD analyses, in addition to exploring modeling tools that account for selection bias. If an appropriate comparison group is not possible, an alternative strategy to assess the impact of HHP is to compare pre- and post-trends in health care utilization and expenditures for HHP enrollees, using regression models to project trends in the post 102 Appendix B: UCLA HHP Evaluation Design| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program period assuming no HHP services are provided (counterfactual trends), and measure the change between the observed and projected trends in the post period. The difference in these trends will estimate the potential reduction in utilization or expenditures that can be attributed to HHP. The Medi-Cal managed care encounter data used for assessing HHP impact does not have enough information on expenditures, which will be needed to demonstrate potential savings, cost neutrality and return-on-investment. Possible methods that UCLA will use to attribute expenditures to managed care encounters include using FFS expenditure data and the Medi-Cal Fee Schedule. If possible, the Medi-Cal fee schedule will be used to attribute a fee to each service provided during managed care encounters. UCLA will also compare the fee schedule to the FFS claims to assess the accuracy of using the fee schedule. If the fee schedule does not have sufficient information, ULCA will examine the patterns of care among FFS beneficiaries and managed care HHP enrollees to assess whether the FFS claims will be suitable for estimating expenditures. UCLA anticipates population and health care use differences between the two groups. UCLA’s ability to estimate cost neutrality and return-on- investment is dependent on being able to estimate expenditures for managed care encounters. If the FFS data and fee schedule do not provide all necessary estimated expenditures, UCLA will calculate the individual acuity factors over time based on the prospective Medicaid Rx model for the HHP enrollees and derive change over time to draw inference on how HHP works. UCLA will collaborate with DHCS to examine the HHP encounter submissions. UCLA will use the DD analytic technique when available to measure potential reduction in total expenditures that can be attributed to HHP. Total expenditures will include the HHP payments. The potential reduction in expenditures will represent the savings associated with delivery of HHP services. UCLA will then calculate the return on investment by assessing the amount of savings per each dollar spent on the HHP program. In addition to calculating changes in HHP enrollee utilization and expenditures, UCLA will independently assess changes in self-reported HHP metrics during the program when possible. UCLA will also independently assess the CMS recommended Core Set of health care quality measures for HHP using Medi-Cal data whenever possible. These measures include both health outcome and utilizations measures that are endorsed by organizations such as National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), National Committee for Quality Assurance (NCQA), and/or CMS that have detailed measure specifications. Appendix B: UCLA HHP Evaluation Design | UCLA Evaluation 103 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program The evaluation will further focus on creating metrics and utilization measures that are likely to be the outcome of HHP services. For example, care coordination and wrap around services are likely to reduce hospital and emergency department visits because of availability of timely and appropriate outpatient care. Therefore, UCLA will assess the changes in the annual rates of emergency department and hospital visits in the pre- and post-periods and compare these changes to the comparison groups or the counterfactual trends. Alternatively, care coordination services are likely to increase use of outpatient medical and substance use services for some enrollees. Therefore, UCLA will examine the change in delivery of these services using the same methodology. HHP interventions to improve care transitions are expected to increase the rate of post- admission outpatient follow up and reduce readmissions. Thus, UCLA will assess the delivery of outpatient follow up post-discharge, number of hospital readmissions, and potential association of outpatient follow ups on readmissions. UCLA will also create additional measures that are specific to common subpopulations in HHP when possible. For example, many of the HHP enrollees will have common chronic conditions such as diabetes or asthma or will be homeless. UCLA will use Medi- Cal data to create measures that evaluate the program impact on subgroups with conditions such as asthma or diabetes or the homeless. Examples of the measures may include frequency of HbA1c lab tests among patients with diabetes and the rate of asthma prescriptions filled among patients with asthma. UCLA will also create metrics and measures for homeless patients including the most common conditions and service use patterns among the homeless. Other subpopulations of interest may include pediatric patients, SPA groups and recent Medi-Cal enrollees. Limitations External contextual factors may impact individual MCP results, such as other local or state initiatives that were ongoing or newly embarked on in the geographic areas that are served by HHP networks. These challenges will be met through use of DD analyses and comparing the HHP enrollee results with selected comparison groups or the counterfactual trends. There are limitations to UCLA’s ability to independently assess all HHP self-reported metrics. UCLA anticipates that metrics such as all-cause hospitalizations and emergency department visits can be independently assessed using Medi-Cal enrollment and claims data. However, measures of use of some services such as screening for clinical depression are only available in self-reported data. Similarly, information on implementation of care coordination policies and procedures are limited to self-reported data. 104 Appendix B: UCLA HHP Evaluation Design| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program UCLA anticipated some error in attributing expenditures to managed care encounters due to anticipated differences in characteristics of FFS and managed care enrollees, systematic differences in health care delivery, and potential lack of detailed encounter data or fee schedule data. These limitations will lead to under or overestimates of actual expenditures attributed to encounter data but do not negatively impact estimates of changes in utilizations or savings. This is because the error in attributing expenditures is consistently and systematically applied to all encounters. Due to the staggered rollout of the program, with the majority of counties implementing SPA 2 in January 2020, UCLA anticipates that enrollment numbers will be low for the initial June 2020 report and that there will be insufficient time to observe the comprehensive impact of the program. Furthermore, due to a lag of at least six months in adjudicated Medi-Cal claims data, the data available for the first evaluation report will be limited to the first county to implement the program, San Francisco County. Two additional reports will follow this first report (Exhibit 57), which allows for all counties to implement HHP and an adequate time period to observe an impact of HHP on health and utilization trends and outcomes. For some of the outcomes of interest, UCLA anticipates that HHP’s impact may not be realized during the evaluation timeframe. Appendix B: UCLA HHP Evaluation Design | UCLA Evaluation 105 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Timeline Exhibit 57 indicates the evaluation deliverables and anticipated dates. Exhibit 57: Evaluation Timeline and Deliverables Deliverable Description Due Date(s) Draft evaluation Draft evaluation methodology for managed September 30, design and care plan/stakeholder review and comment 2018 methods Revised Revised evaluation methodology November 16, evaluation design 2018 and methods Final evaluation Final evaluation methodology December 31, design and 2018 methods First draft interim First draft interim evaluation report to be May 22, 2020 evaluation report completed after the first 18 months of HHP implementation Final first interim Final first interim evaluation report June 20, 2020 evaluation report Second draft Second draft interim evaluation report to be August 22, 2021 interim evaluation completed after 30 months of HHP report implementation Final second Final second interim evaluation report September 30, interim evaluation 2021 report Draft Final Draft final evaluation report May 1, 2023 Evaluation Report Final Evaluation Final evaluation report June 23, 2023 Report 106 Appendix B: UCLA HHP Evaluation Design| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Appendix C: HHP Enrollees Enrolled Less Than 31 Days There were 246 HHP enrollees enrolled for less than 31 days due to unsuccessful engagement among other unknown factors. This group was reported exclusively in this appendix. MCPs received PMPM payments for one month for these enrollees, but payments ceased if those individuals could no longer be enrolled in the program. MCPs did not provide other services to this group. Comparison of these enrollees with those enrolled for longer than 30 days indicated these groups had similar demographics, health status, and health care utilization prior to HHP. Demographics for those enrolled longer than 30 days and those enrolled less than 31 days showed similar trends. Enrollees from both groups were most often 50-64 years old, female, and Hispanic (Exhibit 58). Exhibit 58: HHP Enrollee Demographics at the Time of HHP Enrollment Enrolled less than 31 days Total Enrollment N 246 Age (at time of % 0-17 8.5% enrollment) % 18-34 13.4% % 35-49 18.3% % 50-64 50.8% % 65+ 8.9% Gender % male 49.2% Race/Ethnicity % White 21.5% % Hispanic 48.0% % African American 17.1% % Asian American and Pacific Islander -- % American Indian and Alaska Native -- % other -- % unknown 8.1% Language % speak English 73.2% Enrolled in Medi-Cal Average number of full-scope during the months year prior to enrollment 11.9 Appendix C: HHP Enrollees Enrolled Less Than 31 Days| UCLA Evaluation 107 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrolled less than 31 days Total Homelessness Proportion ever homeless during HHP enrollment -- Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019, and homelessness is only reported for enrollees who were active as of July 2019. Demographics at the time of HHP enrollment were obtained from Medi- Cal enrollment data from July 1, 2016 to June 30, 2019. Notes: MCP is Managed Care Plan. “--" indicates unreported data due to less than 11 enrollees. The top ten most frequent conditions among those enrolled less than 31 days were similar to the top ten conditions for those enrolled over 30 days, with hypertension and diabetes as the most common conditions (Exhibit 59). Exhibit 59: Top Ten Most Frequent Physical Health and Mental Health Conditions among HHP Enrollees Enrolled less than 31 days Top Ten Conditions Total Condition 1 (%) Hypertension (67.9%) Condition 2 (%) Diabetes (44.3%) Condition 3 (%) Hyperlipidemia (42.7%) Condition 4 (%) Obesity (36.2%) Condition 5 (%) Chronic Kidney Disease (35.8%) Condition 6 (%) Depression (34.1%) Condition 7 (%) Depressive Disorders (32.1%) Condition 8 (%) Rheumatoid Arthritis / Osteoarthritis (27.2%) Condition 9 (%) Fibromyalgia, Chronic Pain and Fatigue (26.8%) Condition 10 (%) Anxiety (24.8%) Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Chronic and other chronic health, mental health, and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: MCP is managed care plan. Similarly to enrollees enrolled longer than 30 days, among those enrolled less than 31 days Criteria 2 (hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure) was the most common, followed by Criteria 1, Criteria 3, and Criteria 4 (Exhibit 60). 108 Appendix C: HHP Enrollees Enrolled Less Than 31 Days | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 60: Proportion of HHP Enrollees that met Eligibility Criteria, Overall and by SPA, at the Time of HHP Enrollment Enrolled less than 31 days Total Two specific conditions (Criteria 1) 41.5% Hypertension and another specific condition (Criteria 2) 55.3% Serious Mental Health Conditions (Criteria 3) 38.6% Asthma (Criteria 4) 23.6% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Medi-Cal claims data from July 1, 2016 to September 30, 2019 was used to identify eligibility criteria defined in the HHP Program Guide. Notes: MCP is Managed Care Plan. Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Appendix C: HHP Enrollees Enrolled Less Than 31 Days| UCLA Evaluation 109 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Appendix D: Supplemental Data Tables Homeless Enrollment by Group Exhibit 61 displays the date of HHP enrollment for individuals reported as ever homeless during HHP by Group, using data available in the Q3 2019 Quarterly Report. Exhibit 61: Unduplicated Monthly and Cumulative Enrollment of HHP Homeless Enrollees by Group, July 1, 2018 to September 30, 2019 Group 1 Group 2 Group 3 18-Jul Group 1 Implementation 0 0 0 18-Aug 0 0 0 18-Sep 0 0 0 18-Oct 0 0 0 18-Nov 0 0 0 18-Dec 0 0 0 19-Jan Group 2 Implementation 0 76 0 19-Feb 0 110 0 19-Mar 0 153 0 19-Apr 0 192 0 19-May 0 229 0 19-Jun 0 271 0 19-Jul Group 3 Implementation < 11 302 59 19-Aug < 11 327 117 19-Sep < 11 345 159 Source: MCP Quarterly HHP Reports. Enrollment was limited to available data for the period between July 2018 and September 2019. Notes: MCP is Managed Care Plan. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Excludes HHP enrollees that were designated as homeless and were disenrolled prior to Q3. Includes homeless enrollees that were recorded in Q3 HHP Quarterly Report as “ever homeless during HHP”. 110 Appendix D: Supplemental Data Tables| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Appendix E: MCP- Level Data Aetna Better Health of California This appendix provides information about the implementation and evaluation findings of HHP by Aetna Better Health of California (Aetna), which began operating as a Medi-Cal managed care plan in January 2018. This section outlines Aetna’s implementation schedule and infrastructure, as well as Aetna enrollment trends, demographics, health status, and HHP service utilization as of September 2019. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Aetna enrollees. Aetna carried out HHP implementation in Sacramento and San Diego counties in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 62: Aetna’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Sacramento Group 3 7/1/2019 1/1/2020 San Diego Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Aetna Better Health of California 111 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 63: Cumulative Total Enrollment in Aetna, July 1, 2018 to September 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 18-Jul 0 0 0 0 18-Aug 0 0 0 0 18-Sep 0 0 0 0 18-Oct 0 0 0 0 18-Nov 0 0 0 0 18-Dec 0 0 0 0 19-Jan 0 0 0 0 19-Feb 0 0 0 0 19-Mar 0 0 0 0 19-Apr 0 0 0 0 19-May 0 0 0 0 19-Jun 0 0 0 0 19-Jul 20 0 17 0 Group 3 SPA 1 Implementation 19-Aug 30 0 23 0 19-Sep 38 0 30 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 112 Appendix E: Aetna Better Health of California | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 64: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Aetna by Group and County, as of September 30, 2019 Group 3 Sacramento San Diego Enrollment as of September 2019 38 30 Potential Eligible Beneficiaries on TEL 267 257 % of TEL Enrolled 14.2% 11.7% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 65: HHP Continuous Enrollment in Aetna as of September 30, 2019 by Group and County Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Total Enrollment 38 0 30 0 % of Enrollees Continuously Enrolled 100.0% 0.0% 100.0% 0.0% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Aetna Better Health of California 113 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 66: HHP Length of Enrollment (in Months) for Aetna Enrollees as of September 30, 2019 by Group and County Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=38) (n=0) (n=30) (n=0) Average 2 -- 2 -- Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 67: Number of HHP Eligible Beneficiaries Excluded in Aetna by Reason for Exclusion as of September 30, 2019 Group 3 Sacramento San Diego Reason for Exclusion (n=38) (n=30) Excluded because unsafe behavior or environment -- -- Externally referred but excluded -- -- Excluded because not eligible - well-managed 27 11 Excluded because duplicative program -- -- Excluded because declined to participate 25 55 Excluded because of unsuccessful engagement 14 -- Excluded because not enrolled in Medi-Cal at MCP 66 60 Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to less than 11 enrollees. 114 Appendix E: Aetna Better Health of California | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 68: Aetna HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Enrollment N 38 0 30 0 % 0-17 -- 0 -- 0 Age (at time of % 18-64 -- 0 -- 0 enrollment) % 65+ -- 0 -- 0 Gender % male 50.0% 0 40.0% 0 % White -- 0 -- 0 % Hispanic -- 0 -- 0 Race/Ethnicity % African American -- 0 -- 0 % other/unknown -- 0 -- 0 Language % speak English -- 0 100.0% 0 Medi-Cal full-scope Average number of during the year prior months to enrollment 11.8 0 11.5 0 Proportion ever Homelessness homeless during HHP enrollment -- 0 -- 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Aetna Better Health of California 115 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 69: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Aetna’s HHP Enrollees Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Top Ten Conditions (n=38) (n=0) (n=30) (n=0) Condition 1 (%) -- 0 -- 0 Condition 2 (%) -- 0 -- 0 Condition 3 (%) -- 0 -- 0 Condition 4 (%) -- 0 -- 0 Condition 5 (%) -- 0 -- 0 Condition 6 (%) -- 0 -- 0 Condition 7 (%) -- 0 -- 0 Condition 8 (%) -- 0 -- 0 Condition 9 (%) -- 0 -- 0 Condition 10 (%) -- 0 -- 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: -- indicates unreported data due to samples of less than 100 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Exhibit 70: Complexity of Aetna’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=38) (n=0) (n=30) (n=0) Two specific conditions (Criteria 1) 31.6% 0 40.0% 0 Hypertension and another specific condition (Criteria 2) 39.5% 0 50.0% 0 Serious Mental Health Conditions (Criteria 3) 60.5% 0 46.7% 0 Asthma (Criteria 4) 34.2% 0 -- 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: -- indicates unreported data due to samples of less than 100 enrollees. Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver 116 Appendix E: Aetna Better Health of California | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 71: Average Health Care Utilization by SPA of Aetna’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=38) (n=0) (n=30) (n=0) Number of hospitalizations per enrollee 0.7 0 1.1 0 Number of emergency department visits per enrollee 4.2 0 3.0 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 TBD 0 Number of primary care services per enrollee 11.7 0 9.8 0 Number of specialty services per enrollee 6.4 0 7.9 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: -- indicates unreported data due to samples of less than 100 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: Aetna Better Health of California 117 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 72: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=0) (n=0) Total number of units of service provided 0 0 0 0 Average number of units of service per enrollee 0 0 0 0 Median number of units of service per enrollee 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 118 Appendix E: Aetna Better Health of California | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 73: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Service Type (n=0) (n=0) (n=0) (n=0) Engagement Services (U7) 0 0 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 0 0 Other Health Homes Services (U3 or U6) 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Aetna Better Health of California 119 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 74: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Modality (n=0) (n=0) (n=0) (n=0) In-Person (U1 or U4) 0 0 0 0 Phone/Telehealth (U2 or U5) 0 0 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Housing Services Exhibit 75: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 0 0 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0 0 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 120 Appendix E: Aetna Better Health of California | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Alameda Alliance for Health This appendix provides information about the implementation and evaluation findings of HHP by Alameda Alliance for Health (Alameda Alliance) as of September 2019. It outlines Alameda Alliance’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Alameda Alliance enrollees. Alameda Alliance carried out HHP implementation in Alameda County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 76: Alameda Alliance’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 Alameda 7/1/2019 1/1/2020 Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Alameda Alliance for Health 121 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 77: Cumulative Total Enrollment in Alameda Alliance, July 1, 2018 to September 30, 2019 Group 3 Alameda SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 48 0 Group 3 SPA 1 Implementation 19-Aug 93 0 19-Sep 126 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 122 Appendix E: Alameda Alliance for Health | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 78: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Alameda Alliance by Group and County, as of September 30, 2019 Group 3 Alameda Enrollment as of September 2019 126 Potential Eligible Beneficiaries on TEL 11,614 % of TEL Enrolled 1.1% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 79: HHP Continuous Enrollment in Alameda Alliance as of September 30, 2019 by Group and County Group 3 Alameda SPA 1 SPA 2 Total Enrollment 126 0 % of Enrollees Continuously Enrolled 98.4% 0.0% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Percent of enrollees continuously enrolled could not be calculated for counties with one or more SPAs with enrollment less than 11 and were recorded as “N/A.” SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Alameda Alliance for Health 123 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 80: HHP Length of Enrollment (in Months) for Alameda Alliance Enrollees as of September 30, 2019 by Group and County Group 3 Alameda SPA 1 SPA 2 (n=26) (n=0) Average 2 -- Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 81: Number of HHP Eligible Beneficiaries Excluded in Alameda Alliance by Reason for Exclusion as of September 30, 2019 Group 3 Alameda Reason for Exclusion (n=126) Excluded because unsafe behavior or environment 0 Externally referred but excluded -- Excluded because not eligible - well-managed 11 Excluded because duplicative program 216 Excluded because declined to participate 42 Excluded because of unsuccessful engagement -- Excluded because not enrolled in Medi-Cal at MCP 386 Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to less than 11 enrollees. 124 Appendix E: Alameda Alliance for Health | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 82: Alameda Alliance HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Alameda SPA 1 SPA 2 Enrollment N 126 0 % 0-17 0.0% 0 Age (at time of enrollment) % 18-64 78.6% 0 % 65+ 21.4% 0 Gender % male 38.9% 0 % White 11.1% 0 % Hispanic 30.2% 0 Race/Ethnicity % African American 29.4% 0 % other/unknown 29.4% 0 Language % speak English 65.1% 0 Medi-Cal full-scope during the Average number of months year prior to enrollment 11.9 0 Proportion ever homeless Homelessness during HHP enrollment 16.7% 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Alameda Alliance for Health 125 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 83: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Alameda Alliance’s HHP Enrollees Group 3 Alameda SPA 1 SPA 2 Top Ten Conditions (n=126) (n=0) Condition 1 (%) Hypertension (78.6%) 0 Condition 2 (%) Diabetes (47.6%) 0 Chronic Kidney Disease Condition 3 (%) 0 (46.0%) Condition 4 (%) Depression (42.1%) 0 Condition 5 (%) Depressive Disorder (36.5%) 0 Condition 6 (%) Obesity (33.3%) 0 Condition 7 (%) Hyperlipidemia (32.5%) 0 Condition 8 (%) Heart Failure (29.4%) 0 Ischemic Heart Disease Condition 9 (%) 0 (29.4%) Condition 10 (%) Anemia (27.8%) 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Exhibit 84: Complexity of Alameda Alliance’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Alameda SPA 1 SPA 2 (n=126) (n=0) Two specific conditions (Criteria 1) 55.6% 0 Hypertension and another specific condition (Criteria 2) 67.5% 0 Serious Mental Health Conditions (Criteria 3) 42.9% 0 Asthma (Criteria 4) 20.6% 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use 126 Appendix E: Alameda Alliance for Health | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 85: Average Health Care Utilization by SPA of Alameda Alliance’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Alameda SPA 1 SPA 2 (n=126) (n=0) Number of hospitalizations per enrollee 1.3 0 Number of emergency department visits per enrollee 5.2 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 Number of primary care services per enrollee 16.0 0 Number of specialty services per enrollee 17.0 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: Alameda Alliance for Health 127 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 86: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Alameda SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 87: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Alameda SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 128 Appendix E: Alameda Alliance for Health | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Type Exhibit 88: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Alameda SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth(U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Alameda Alliance for Health 129 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 89: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Alameda SPA 1 SPA 2 (n=126) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 24.6% 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services -- 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 130 Appendix E: Alameda Alliance for Health | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Anthem Blue Cross of California Partnership Plan, Inc. This appendix provides information about the implementation and evaluation findings of HHP by Anthem Blue Cross of California Partnership Plan, Inc. (Anthem) as of September 2019. It outlines Anthem’s implementation schedule and infrastructure, as well as Anthem enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Anthem enrollees. Anthem operates in five counties and began HHP implementation in San Francisco County with Group 1, launching SPA 1 in July 2018 and SPA 2 in January 2019. Implementation in Alameda, Sacramento, Santa Clara, and Tulare counties followed in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 90: Anthem’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 1 San Francisco 7/1/2018 1/1/2019 Alameda Sacramento Group 3 7/1/2019 1/1/2020 Santa Clara Tulare Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. 131 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 91: Cumulative Total Enrollment in Anthem, July 1, 2018 to September 30, 2019 Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 18-Jul 0 0 0 0 0 0 0 0 0 0 Group 1 SPA 1 Implementation 18-Aug -- 0 0 0 0 0 0 0 0 0 18-Sep 11 0 0 0 0 0 0 0 0 0 18-Oct 23 0 0 0 0 0 0 0 0 0 18-Nov 26 0 0 0 0 0 0 0 0 0 18-Dec 32 -- 0 0 0 0 0 0 0 0 19-Jan 46 -- 0 0 0 0 0 0 0 0 Group 1 SPA 2 Implementation 19-Feb 51 -- 0 0 0 0 0 0 0 0 19-Mar 54 -- 0 0 0 0 0 0 0 0 19-Apr 55 -- 0 0 0 0 0 0 0 0 19-May 59 -- 0 0 0 0 0 0 0 0 19-Jun 63 -- 0 0 0 0 0 0 0 0 19-Jul 66 -- 0 0 0 0 0 0 -- -- Group 3 SPA 1 Implementation 19-Aug 71 -- -- 0 -- -- -- -- 33 29 19-Sep 74 -- -- 0 79 67 12 -- 64 71 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 132 Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 92: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Anthem by Group and County, as of September 30, 2019 Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare Enrollment as of September 2019 85* 11* 146 23* 135 Potential Eligible Beneficiaries on TEL 940 2,447 7,814 1,981 2,701 % of TEL Enrolled 9.0% 0.4% 1.9% 1.2% 5.0% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. *Total enrollment in counties with less than 11 enrollees in one or more SPA groups were calculated using 11 enrollees for those SPA groups. UCLA Evaluation | Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. 133 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Patterns Enrollment Continuity Exhibit 93: HHP Continuous Enrollment in Anthem as of September 30, 2019 by Group and County Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Total Enrollment 74 -- -- 0 79 67 12 -- 64 71 % of Enrollees 64.0% -- -- 0 100.0% 100.0% 100.0% -- 100.0% 100.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. Enrollment Length Exhibit 94: HHP Length of Enrollment (in Months) for Anthem Enrollees as of September 30, 2019 by Group and County Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=74) (n=<11) (n=<11) (n=0) (n=79) (n=67) (n=12) (n=<11) (n=64) (n=71) Average 7 4 2 0 0 0 1 1 1 1 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 134 Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 95: Number of HHP Eligible Beneficiaries Excluded in Anthem by Reason for Exclusion as of September 30, 2019 Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare Reason for Exclusion (n=85*) (n=11*) (n=146) (n=23*) (n=135) Excluded because unsafe 0 0 0 0 -- behavior or environment Externally referred but -- -- -- 0 -- excluded Excluded because not 39 0 -- 0 0 eligible - well-managed Excluded because -- 0 -- 0 0 duplicative program Excluded because declined 164 -- 132 38 61 to participate Excluded because of 28 0 0 -- 0 unsuccessful engagement Excluded because not 18 0 -- -- 0 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. *Total enrollment in counties with less than 11 enrollees in one or more SPA groups were calculated using 11 enrollees for those SPA groups. UCLA Evaluation | Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. 135 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 96: Anthem HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Enrollment N 74 <11 <11 0 79 67 12 <11 64 71 % 0-17 -- -- -- 0 -- -- -- -- -- -- Age (at time of % 18-64 68.9% -- -- 0 67.1% 92.5% -- -- -- -- enrollment) % 65+ -- -- -- 0 -- -- -- -- -- -- Gender % male 68.9% -- -- 0 50.6% 25.4% -- -- 29.7% 28.2% % White 20.3% -- -- 0 24.1% 19.4% -- -- -- 39.4% % Hispanic -- -- -- 0 26.6% 31.3% -- -- -- 47.9% % African 0 Race/Ethnicity American -- -- -- 25.3% 20.9% -- -- -- 2.8% % other/ 0 unknown -- -- -- 24.1% 28.4% -- -- -- 9.9% % speak 0 Language English 71.6% -- -- 74.7% 73.1% -- -- 73.4% 81.7% Medi-Cal full- Average scope during number of the year prior months to enrollment 12.0 -- -- 0 11.8 11.9 12.0 -- 12.0 11.9 Proportion ever Homelessness homeless during HHP enrollment 0 -- -- 0 -- -- -- -- -- -- Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. 136 Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. HHP Enrollee Health Status Exhibit 97: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Anthem’s HHP Enrollees Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Top Ten Conditions (n=74) (n=<11) (n=<11) (n=0) (n=79) (n=67) (n=12) (n=<11) (n=64) (n=71) Condition 1 (%) -- -- -- 0 -- -- -- -- -- -- Condition 2 (%) -- -- -- 0 -- -- -- -- -- -- Condition 3 (%) -- -- -- 0 -- -- -- -- -- -- Condition 4 (%) -- -- -- 0 -- -- -- -- -- -- Condition 5 (%) -- -- -- 0 -- -- -- -- -- -- Condition 6 (%) -- -- -- 0 -- -- -- -- -- -- Condition 7 (%) -- -- -- 0 -- -- -- -- -- -- Condition 8 (%) -- -- -- 0 -- -- -- -- -- -- Condition 9 (%) -- -- -- 0 -- -- -- -- -- -- Condition 10 (%) -- -- -- 0 -- -- -- -- -- -- Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. UCLA Evaluation | Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. 137 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 98: Complexity of Anthem's HHP Enrollees' Health Status by SPA, 24 Months Prior to HHP Enrollment Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=74) (n=<11) (n=<11) (n=0) (n=79) (n=67) (n=12) (n=<11) (n=64) (n=71) Two specific conditions (Criteria 1) 50.0% -- -- 0 31.6% 35.8% -- -- 51.6% 45.1% Hypertension and another specific condition (Criteria 2) 55.4% -- -- 0 36.7% 31.3% -- -- 62.5% 60.6% Serious Mental Health Conditions (Criteria 3) 43.2% -- -- 0 -- 70.1% -- -- -- 76.1% Asthma (Criteria 4) 21.6% -- -- 0 43.0% 17.9% -- -- 32.8% 21.1% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 138 Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 99: Average Health Care Utilization by SPA of Anthem’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=74) (n=<11) (n=<11) (n=0) (n=79) (n=67) (n=12) (n=<11) (n=64) (n=71) Number of hospitalizations per enrollee 1.3 -- -- 0 1.3 2.5 0.3 -- 1.3 1.8 Number of emergency department visits per enrollee 4.3 -- -- 0 5.2 8.3 6.3 -- 3.4 3.9 Number of long-term skilled nursing facility stays per enrollee TBD TBD TBD 0 TBD TBD TBD TBD TBD TBD Number of short-term skilled nursing facility stays per enrollee TBD TBD TBD 0 TBD TBD TBD TBD TBD TBD Number of primary care services per enrollee 9.9 -- -- 0 7.7 8.8 12.3 -- 15.4 17.9 Number of specialty services per enrollee 13.4 -- -- 0 8.2 12.2 11.7 -- 8.9 11.3 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. UCLA Evaluation | Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. 139 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 100: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=63) (n=<11) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Total number of units of service provided 206 9 0 0 0 0 0 0 0 0 Average number of units of service per enrollee per month 1.3 1.0 0 0 0 0 0 0 0 0 Median number of units of service per enrollee per month 1 1 0 0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. “--" indicates unreported data due to samples of less than 11 enrollees. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 140 Appendix C: Anthem Blue Cross of California Partnership Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 101: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Service Type (n=63) (n=<11) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Engagement Services (U7) 1.2 1.0 0 0 0 0 0 0 0 0 Core HHP Services (U1, U2, U4 or U5) 1.2 1.0 0 0 0 0 0 0 0 0 Other Health Homes Services (U3 or U6) 1.0 0.0% 0 0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. 141 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 102: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality SPA, July 1, 2018 to June 30, 2019 Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Modality (n=63) (n=<11) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) In-Person (U1 or U4) 1.3 0.0 0 0 0 0 0 0 0 0 Phone/Telehealth (U2 or U5) 1.1 1.0 0 0 0 0 0 0 0 0 Staff Type Clinical Staff (U1, U2 or U3) 1.2 1 0 0 0 0 0 0 0 0 Non-Clinical Staff (U4, U5 or U6) 1.2 1 0 0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. “--" indicates unreported data due to samples of less than 11 enrollees. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 142 Appendix E: Anthem Blue Cross of California Partnership Plan, Inc.| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 103: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 1 Group 3 San Francisco Alameda Sacramento Santa Clara Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=47) (n=<11) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 0.0% -- 0 0 0 0 0 0 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0.0% -- 0 0 0 0 0 0 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to samples of less than 11 enrollees. UCLA Evaluation | Appendix E: Anthem Blue Cross of California Partnership Plan, Inc. 143 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Blue Shield of California Promise Health Plan This appendix provides information about the implementation and evaluation findings of HHP by Blue Shield of California Promise Health Plan (Blue Shield) as of September 2019. It outlines Blue Shield’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Blue Shield enrollees. Blue Shield carried out HHP implementation in San Diego County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in the Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 104: Blue Shield’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 San Diego 7/1/2019 1/1/2020 Source: Health Homes Program Guide. 144 Appendix C: Blue Shield of California Promise Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 105: Cumulative Total Enrollment in Blue Shield, July 1, 2018 to September 30, 2019 Group 3 San Diego SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 34 0 Group 3 SPA 1 Implementation 19-Aug 101 0 19-Sep 132 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Blue Shield of California Promise Health Plan 145 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 106: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Blue Shield by Group and County, as of September 30, 2019 Group 3 San Diego Enrollment as of 132 September 2019 Potential Eligible 3,818 Beneficiaries on TEL % of TEL Enrolled 3.5% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 107: HHP Continuous Enrollment in Blue Shield as of September 30, 2019 by Group and County Group 3 San Diego SPA 1 SPA 2 Total Enrollment 132 0 % of Enrollees 99.2% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Percent of enrollees continuously enrolled could not be calculated for counties with one or more SPAs with enrollment less than 11 and were recorded as “N/A.” SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 146 Appendix E: Blue Shield of California Promise Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 108: HHP Length of Enrollment (in Months) for Blue Shield Enrollees as of September 30, 2019 by Group and County Group 3 San Diego SPA 1 SPA 2 (n=132) (n=0) Average 1 -- Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 109: Number of HHP Eligible Beneficiaries Excluded in Blue Shield by Reason for Exclusion as of September 30, 2019 Group 3 San Diego Reason for Exclusion (n=132) Excluded because unsafe 0 behavior or environment Externally referred but -- excluded Excluded because not 0 eligible - well-managed Excluded because -- duplicative program Excluded because declined 11 to participate Excluded because of -- unsuccessful engagement Excluded because not -- enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. UCLA Evaluation | Appendix E: Blue Shield of California Promise Health Plan 147 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 110: Blue Shield HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 San Diego SPA 1 SPA 2 Enrollment N 132 0 % 0-17 -- 0 Age (at time of % 18-64 85.6% 0 enrollment) % 65+ -- 0 Gender % male 47.7% 0 % White 31.8% 0 % Hispanic 32.6% 0 Race/Ethnicity % African American 10.6% 0 % other/unknown 25.0% 0 Language % speak English 81.8% 0 Medi-Cal full- scope during Average number the year prior of months to enrollment 11.9 0 Proportion ever Homelessness homeless during HHP enrollment 15.9% 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “—" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 148 Appendix E: Blue Shield of California Promise Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 111: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Blue Shield’s HHP Enrollees Group 3 San Diego SPA 1 SPA 2 Top Ten Conditions (n=132) (n=0) Condition 1 (%) Hypertension (61.4%) 0 Condition 2 (%) Depression (54.5%) 0 Depressive Disorder Condition 3 (%) 0 (51.5%) Condition 4 (%) Obesity (40.2%) 0 Condition 5 (%) Diabetes (39.4%) 0 Anxiety Disorders Condition 6 (%) 0 (37.9%) Fibromyalgia, Chronic Condition 7 (%) Pain and Fatigue 0 (37.1%) Drug User Disorders Condition 8 (%) 0 (34.8%) Chronic Kidney Condition 9 (%) 0 Disease (31.8%) Hyperlipidemia Condition 10 (%) 0 (31.8%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Blue Shield of California Promise Health Plan 149 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 112: Complexity of Blue Shield’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 San Diego SPA 1 SPA 2 (n=132) (n=0) Two specific conditions (Criteria 1) 45.5% 0 Hypertension and another specific condition (Criteria 2) 46.2% 0 Serious Mental Health Conditions (Criteria 3) 62.9% 0 Asthma (Criteria 4) 26.5% 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. 150 Appendix E: Blue Shield of California Promise Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 113: Average Health Care Utilization by SPA of Blue Shield’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 San Diego SPA 1 SPA 2 (n=132) (n=0) Number of hospitalizations per enrollee 1.8 0 Number of emergency department visits per enrollee 4.8 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 Number of primary care services per enrollee 20.6 0 Number of specialty services per enrollee 14.0 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Blue Shield of California Promise Health Plan 151 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 114: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 152 Appendix E: Blue Shield of California Promise Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 115: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Blue Shield of California Promise Health Plan 153 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 116: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Housing Services Exhibit 117: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 San Diego SPA 1 SPA 2 (n=131) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 25.2% 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 66.7% 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 154 Appendix E: Blue Shield of California Promise Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program California Health & Wellness This appendix provides information about the implementation and evaluation findings of HHP by California Health & Wellness as of September 2019. It outlines California Health & Wellness’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for California Health & Wellness enrollees. California Health & Wellness carried out HHP implementation in Imperial County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 118: California Health & Wellness’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 Imperial 7/1/2019 1/1/2020 Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: California Health & Wellness 155 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 119: Cumulative Total Enrollment in California Health & Wellness, July 1, 2018 to September 30, 2019 Group 3 Imperial SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 0 0 Group 3 SPA 1 Implementation 19-Aug 0 0 19-Sep 0 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 156 Appendix E: California Health & Wellness | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 120: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in California Health & Wellness by Group and County, as of September 30, 2019 Group 3 Imperial Enrollment as of 0 September 2019 Potential Eligible 2,948 Beneficiaries on TEL % of TEL Enrolled 0.0% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 121: HHP Continuous Enrollment in California Health & Wellness as of September 30, 2019 by Group and County Group 3 Imperial SPA 1 SPA 2 Total Enrollment 0 0 % of Enrollees 0.0% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Percent of enrollees continuously enrolled could not be calculated for counties with one or more SPAs with enrollment less than 11 and were recorded as “--.” SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: California Health & Wellness 157 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 122: HHP Length of Enrollment (in Months) for California Health & Wellness Enrollees as of September 30, 2019 by Group and County Group 3 Imperial SPA 1 SPA 2 (n=0) (n=0) Average 0 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 123: Number of HHP Eligible Beneficiaries Excluded in California Health & Wellness by Reason for Exclusion as of September 30, 2019 Group 3 Imperial Reason for Exclusion (n=0) Excluded because unsafe 0 behavior or environment Externally referred but 0 excluded Excluded because not 0 eligible - well-managed Excluded because 0 duplicative program Excluded because declined 0 to participate Excluded because of 0 unsuccessful engagement Excluded because not 0 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. 158 Appendix E: California Health & Wellness | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 124: California Health & Wellness HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Imperial SPA 1 SPA 2 Enrollment N 0 0 % 0-17 0 0 Age (at time of % 18-64 0 0 enrollment) % 65+ 0 0 Gender % male 0 0 % White 0 0 % Hispanic 0 0 Race/Ethnicity % African American 0 0 % other/unknown 0 0 Language % speak English 0 0 Medi-Cal full- scope during Average number of the year prior months to enrollment 0 0 Proportion ever Homelessness homeless during HHP enrollment 0 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: California Health & Wellness 159 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 125: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among California Health & Wellness’s HHP Enrollees Group 3 Imperial SPA 1 SPA 2 Top Ten Conditions (n=0) (n=0) Condition 1 (%) 0 0 Condition 2 (%) 0 0 Condition 3 (%) 0 0 Condition 4 (%) 0 0 Condition 5 (%) 0 0 Condition 6 (%) 0 0 Condition 7 (%) 0 0 Condition 8 (%) 0 0 Condition 9 (%) 0 0 Condition 10 (%) 0 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Exhibit 126: Complexity of California Health & Wellness’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Imperial SPA 1 SPA 2 (n=0) (n=0) Two specific conditions (Criteria 1) 0 0 Hypertension and another specific condition (Criteria 2) 0 0 Serious Mental Health Conditions (Criteria 3) 0 0 Asthma (Criteria 4) 0 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic 160 Appendix E: California Health & Wellness | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 127: Average Health Care Utilization by SPA of California Health & Wellness’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Imperial SPA 1 SPA 2 (n=0) (n=0) Number of hospitalizations per enrollee 0 0 Number of emergency department visits per enrollee 0 0 Number of long-term skilled nursing facility stays per enrollee 0 0 Number of short-term skilled nursing facility stays per enrollee 0 0 Number of primary care services per enrollee 0 0 Number of specialty services per enrollee 0 0 Number of evaluation and management visits per enrollee 0 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: California Health & Wellness 161 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 128: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Imperial SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 129: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Imperial SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims 162 Appendix E: California Health & Wellness | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Exhibit 130: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Imperial SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: California Health & Wellness 163 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 131: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Imperial SPA 1 SPA 2 (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 164 Appendix E: California Health & Wellness | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program CalOptima This appendix provides information about the implementation and evaluation findings of HHP by CalOptima as of September 2019. It outlines CalOptima’s implementation schedule and infrastructure, as well as CalOptima enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for CalOptima enrollees. CalOptima carried out HHP implementation in Orange County in Group 4, with SPA 1 beginning January 2020 and SPA 2 beginning July 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 132: CalOptima’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 4 Orange 1/1/2020 7/1/2020 Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: CalOptima 165 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 133: Cumulative Total Enrollment in CalOptima, July 1, 2018 to September 30, 2019 Group 4 Orange SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 0 0 19-Aug 0 0 19-Sep 0 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 166 Appendix E: CalOptima| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 134: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in CalOptima by Group and County, as of September 30, 2019 Group 4 Orange Enrollment as of 0 September 2019 Potential Eligible 0 Beneficiaries on TEL % of TEL Enrolled 0 Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 135: HHP Continuous Enrollment in CalOptima as of September 30, 2019 by Group and County Group 4 Orange SPA 1 SPA 2 Total Enrollment 0 0 % of Enrollees 0.0% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Percent of enrollees continuously enrolled could not be calculated for counties with one or more SPAs with enrollment less than 11 and were recorded as “--”. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: CalOptima 167 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 136: HHP Length of Enrollment (in Months) for CalOptima Enrollees as of September 30, 2019 by Group and County Group 4 Orange SPA 1 SPA 2 (n=0) (n=0) Average 0 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 137: Number of HHP Eligible Beneficiaries Excluded in CalOptima by Reason for Exclusion as of September 30, 2019 Group 4 Orange Reason for Exclusion (n=0) Excluded because unsafe 0 behavior or environment Externally referred but 0 excluded Excluded because not 0 eligible - well-managed Excluded because 0 duplicative program Excluded because declined 0 to participate Excluded because of 0 unsuccessful engagement Excluded because not 0 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. 168 Appendix E: CalOptima| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 138: CalOptima HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 4 Orange SPA 1 SPA 2 Enrollment N 0 0 % 0-17 0 0 Age (at time of % 18-64 0 0 enrollment) % 65+ 0 0 Gender % male 0 0 % White 0 0 % Hispanic 0 0 Race/Ethnicity % African American 0 0 % other/unknown 0 0 Language % speak English 0 0 Medi-Cal full- scope during Average number the year prior of months to enrollment 0 0 Proportion ever Homelessness homeless during HHP enrollment 0 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: CalOptima 169 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 139: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among CalOptima’s HHP Enrollees Group 4 Orange SPA 1 SPA 2 Top Ten Conditions (n=0) (n=0) Condition 1 (%) 0 0 Condition 2 (%) 0 0 Condition 3 (%) 0 0 Condition 4 (%) 0 0 Condition 5 (%) 0 0 Condition 6 (%) 0 0 Condition 7 (%) 0 0 Condition 8 (%) 0 0 Condition 9 (%) 0 0 Condition 10 (%) 0 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Exhibit 140: Complexity of CalOptima’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 4 Orange SPA 1 SPA 2 (n=0) (n=0) Two specific conditions (Criteria 1) 0 0 Hypertension and another specific condition (Criteria 2) 0 0 Serious Mental Health Conditions (Criteria 3) 0 0 Asthma (Criteria 4) 0 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic 170 Appendix E: CalOptima| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 141: Average Health Care Utilization by SPA of CalOptima’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 4 Orange SPA 1 SPA 2 (n=0) (n=0) Number of hospitalizations per enrollee 0 0 Number of emergency department visits per enrollee 0 0 Number of long-term skilled nursing facility stays per enrollee 0 0 Number of short-term skilled nursing facility stays per enrollee 0 0 Number of primary care services per enrollee 0 0 Number of specialty services per enrollee 0 0 Number of evaluation and management visits per enrollee 0 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: CalOptima 171 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 142: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 4 Orange SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 143: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 4 Orange SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include 172 Appendix E: CalOptima| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Type Exhibit 144: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 4 Orange SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: CalOptima 173 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 145: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 4 Orange SPA 1 SPA 2 (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 174 Appendix E: CalOptima| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Community Health Group Partnership Plan This appendix provides information about the implementation and evaluation findings of HHP by Community Health Group Partnership Plan as of September 2019. It outlines Community Health Group’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Community Health Group enrollees. Community Health Group carried out HHP implementation in San Diego County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 146: Community Health Group’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 San Diego 7/1/2019 1/1/2020 Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Community Health Group Partnership Plan 175 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 147: Cumulative Total Enrollment in Community Health Group, July 1, 2018 to September 30, 2019 Group 3 San Diego SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul Group 3 SPA 1 Implementation 31 0 19-Aug 105 0 19-Sep 210 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 176 Appendix E: Community Health Group Partnership Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 148: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Community Health Group by Group and County, as of September 30, 2019 Group 3 San Diego Enrollment as of 210 September 2019 Potential Eligible 12,357 Beneficiaries on TEL % of TEL Enrolled 1.7% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 149: HHP Continuous Enrollment in Community Health Group as of September 30, 2019 by Group and County Group 3 San Diego SPA 1 SPA 2 Total Enrollment 210 0 % of Enrollees 100.0% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Percent of enrollees continuously enrolled could not be calculated for counties with one or more SPAs with enrollment less than 11 and were recorded as “--". SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Community Health Group Partnership Plan 177 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 150: HHP Length of Enrollment (in Months) for Community Health Group Enrollees as of September 30, 2019 by Group and County Group 3 San Diego SPA 1 SPA 2 (n=210) (n=0) Average 1 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 151: Number of HHP Eligible Beneficiaries Excluded in Community Health Group by Reason for Exclusion as of September 30, 2019 Group 3 San Diego Reason for Exclusion (n=210) Excluded because unsafe 0 behavior or environment Externally referred but 0 excluded Excluded because not 38 eligible - well-managed Excluded because 0 duplicative program Excluded because declined 120 to participate Excluded because of 0 unsuccessful engagement Excluded because not -- enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. 178 Appendix E: Community Health Group Partnership Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 152: Community Health Group HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 San Diego SPA 1 SPA 2 Enrollment N 210 0 % 0-17 8.1% 0 Age (at time of % 18-64 86.6% 0 enrollment) % 65+ 5.3% 0 Gender % male 32.5% 0 % White 18.7% 0 % Hispanic 41.6% 0 Race/Ethnicity % African American 11.5% 0 % other/unknown 28.2% 0 Language % speak English 70.8% 0 Medi-Cal full- scope during Average number of the year prior months to enrollment 11.9 0 Proportion ever Homelessness homeless during HHP enrollment 8.6% 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Community Health Group Partnership Plan 179 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 153: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Community Health Group’s HHP Enrollees Group 3 San Diego SPA 1 SPA 2 Top Ten Conditions (n=210) (n=0) Condition 1 (%) Hypertension (75.2%) 0 Condition 2 (%) Obesity (66.2%) 0 Condition 3 (%) Diabetes (57.6%) 0 Condition 4 (%) Depression (52.4%) 0 Hyperlipidemia 0 Condition 5 (%) (49.0%) Depressive Disorder 0 Condition 6 (%) (48.6%) Anxiety Disorders 0 Condition 7 (%) (41.4%) Rheumatoid Arthritis / 0 Condition 8 (%) Osteoarthritis (41.0%) Fibromyalgia, Chronic 0 Condition 9 (%) Pain and Fatigue (39.5%) Chronic Kidney 0 Condition 10 (%) Disease (39.0%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 180 Appendix E: Community Health Group Partnership Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 154: Complexity of Community Health Group’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 San Diego SPA 1 SPA 2 (n=210) (n=0) Two specific conditions (Criteria 1) 53.3% 0 Hypertension and another specific condition (Criteria 2) 64.3% 0 Serious Mental Health Conditions (Criteria 3) 57.6% 0 Asthma (Criteria 4) 31.0% 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 155: Average Health Care Utilization by SPA of Community Health Group’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 San Diego SPA 1 SPA 2 (n=210) (n=0) Number of hospitalizations per enrollee 1.3 0 Number of emergency department visits per enrollee 4.0 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 Number of primary care services per enrollee 16.5 0 Number of specialty services per enrollee 20.2 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Community Health Group Partnership Plan 181 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 156: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 182 Appendix E: Community Health Group Partnership Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 157: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Community Health Group Partnership Plan 183 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 158: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Housing Services Exhibit 159: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 San Diego SPA 1 SPA 2 (n=210) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 8.6% 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 100.0% 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to less than 11 enrollees. 184 Appendix E: Community Health Group Partnership Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Net This appendix provides information about the implementation and evaluation findings of HHP by Health Net Community Solutions, Inc. (Health Net) as of September 2019. It outlines Health Net’s implementation schedule and infrastructure, as well as Health Net enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Health Net enrollees. Health Net carried out HHP implementation in Kern, Los Angeles, Sacramento, San Diego, and Tulare counties. All five counties were in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 160: Health Net’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Kern Los Angeles Group 3 Sacramento 7/1/2019 1/1/2020 San Diego Tulare Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Health Net 185 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 161: Cumulative Total Enrollment in Health Net, July 1, 2018 to September 30, 2019 Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 18-Jul 0 0 0 0 0 0 0 0 0 0 18-Aug 0 0 0 0 0 0 0 0 0 0 18-Sep 0 0 0 0 0 0 0 0 0 0 18-Oct 0 0 0 0 0 0 0 0 0 0 18-Nov 0 0 0 0 0 0 0 0 0 0 18-Dec 0 0 0 0 0 0 0 0 0 0 19-Jan 0 0 0 0 0 0 0 0 0 0 19-Feb 0 0 0 0 0 0 0 0 0 0 19-Mar 0 0 0 0 0 0 0 0 0 0 19-Apr 0 0 0 0 0 0 0 0 0 0 19-May 0 0 0 0 0 0 0 0 0 0 19-Jun 0 0 0 0 0 0 0 0 0 0 19-Jul 0 0 14 0 0 0 0 0 -- 0 Group 3 SPA 1 Implementation 19-Aug 0 0 83 0 0 0 0 0 -- 0 19-Sep 0 0 267 0 0 0 0 0 15 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 186 Appendix E: Health Net | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 162: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Health Net by Group and County, as of September 30, 2019 Group 3 Kern Los Angeles Sacramento San Diego Tulare Enrollment as of September 2019 0 267 0 0 15 Potential Eligible Beneficiaries on TEL 2,890 27,911 4,425 1,440 3,535 % of TEL Enrolled 0.0% 1.0% 0.0% 0.0% 0.4% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 163: HHP Continuous Enrollment in Health Net as of September 30, 2019 by Group and County Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Total Enrollment 0 0 267 0 0 0 0 0 15 0 % of Enrollees 0.0% 0.0% 99.3% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Percent of enrollees continuously enrolled could not be calculated for counties with one or more SPAs with enrollment less than 11 and were recorded as “--.” SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Health Net 187 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 164: HHP Length of Enrollment (in Months) for Health Net Enrollees as of September 30, 2019 by Group and County Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=267) (n=0) (n=0) (n=0) (n=0) (n=0) (n=15) (n=0) Average 0 0 1 0 0 0 0 0 2 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 188 Appendix E: Health Net | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 165: Number of HHP Eligible Beneficiaries Excluded in Health Net by Reason for Exclusion as of September 30, 2019 Group 3 Kern Los Angeles Sacramento San Diego Tulare Reason for Exclusion (n=0) (n=267) (n=0) (n=0) (n=15) Excluded because unsafe 0 0 0 0 0 behavior or environment Externally referred but 0 14 0 0 0 excluded Excluded because not 0 30 0 0 0 eligible - well-managed Excluded because 0 -- 0 0 -- duplicative program Excluded because declined 0 185 0 0 -- to participate Excluded because of 0 -- 0 0 0 unsuccessful engagement Excluded because not 0 0 0 0 0 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. UCLA Evaluation | Appendix E: Health Net 189 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 166: Health Net HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Enrollment N 0 0 267 0 0 0 0 0 15 0 % 0-17 0 0 16.5% 0 0 0 0 0 0.0% 0 Age (at time of % 18-64 0 0 77.5% 0 0 0 0 0 100.0% 0 enrollment) % 65+ 0 0 6.0% 0 0 0 0 0 0.0% 0 Gender % male 0 0 43.4% 0 0 0 0 0 -- 0 % White 0 0 8.2% 0 0 0 0 0 -- 0 % Hispanic 0 0 39.0% 0 0 0 0 0 -- 0 Race/ % African -- Ethnicity American 0 0 36.7% 0 0 0 0 0 0 % other/ -- unknown 0 0 16.1% 0 0 0 0 0 0 % speak -- Language English 0 0 74.9% 0 0 0 0 0 0 Medi-Cal full- Average scope during number of the year prior months to enrollment 0 0 12.0 0 0 0 0 0 12.0 0 Proportion ever homeless Homelessness during HHP enrollment 0 0 4.1% 0 0 0 0 0 -- 0 190 Appendix E: Health Net | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Health Net 191 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 167: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Health Net’s HHP Enrollees Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Top Ten (n=0) (n=0) (n=267) (n=0) (n=0) (n=0) (n=0) (n=0) (n=15) (n=0) Conditions 0 0 Hypertension 0 0 0 0 0 0 Condition 1 (%) -- (65.5%) Condition 2 (%) 0 0 Diabetes (49.8%) 0 0 0 0 0 -- 0 Condition 3 (%) 0 0 Asthma (49.1%) 0 0 0 0 0 -- 0 Condition 4 (%) 0 0 Obesity (46.8%) 0 0 0 0 0 -- 0 0 0 Hyperlipidemia 0 0 0 0 0 0 Condition 5 (%) -- (39.3%) 0 0 Chronic Kidney 0 0 0 0 0 0 Condition 6 (%) -- Disease (30.7%) 0 0 Depression 0 0 0 0 0 0 Condition 7 (%) -- (23.2%) 0 0 Depressive 0 0 0 0 0 0 Condition 8 (%) -- Disorder (22.5%) 0 0 Chronic 0 0 0 0 0 0 Obstructive Condition 9 (%) -- Pulmonary Disease (18.4%) 0 0 Fibromyalgia, 0 0 0 0 0 0 Condition 10 (%) Chronic Pain and -- Fatigue (17.2%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic 192 Appendix E: Health Net | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to samples of less than 100 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Exhibit 168: Complexity of Health Net’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=267) (n=0) (n=0) (n=0) (n=0) (n=0) (n=15) (n=0) Two specific conditions (Criteria 1) 0 0 32.2% 0 0 0 0 0 80.0% 0 Hypertension and another specific condition (Criteria 2) 0 0 60.3% 0 0 0 0 0 93.3% 0 Serious Mental Health Conditions (Criteria 3) 0 0 31.8% 0 0 0 0 0 -- 0 Asthma (Criteria 4) 0 0 49.1% 0 0 0 0 0 -- 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. UCLA Evaluation | Appendix E: Health Net 193 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 169: Average Health Care Utilization by SPA of Health Net’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=267) (n=0) (n=0) (n=0) (n=0) (n=0) (n=15) (n=0) Number of hospitalizations per enrollee 0 0 1.5 0 0 0 0 0 2.3 0 Number of emergency department visits per enrollee 0 0 4.4 0 0 0 0 0 3.9 0 Number of long-term skilled nursing facility stays per enrollee 0 0 TBD 0 0 0 0 0 TBD 0 Number of short-term skilled nursing facility stays per enrollee 0 0 TBD 0 0 0 0 0 TBD 0 Number of primary care services per enrollee 0 0 13.1 0 0 0 0 0 11.3 0 Number of specialty services per enrollee 0 0 9.0 0 0 0 0 0 45.3 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to samples of less than 100 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 194 Appendix E: Health Net | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 170: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Total number of units of service provided 0 0 0 0 0 0 0 0 0 0 Average number of units of service per enrollee per month 0 0 0 0 0 0 0 0 0 0 Median number of units of service per enrollee per month 0 0 0 0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Health Net 195 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 171: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Service Type (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Engagement Services (U7) 0 0 0 0 0 0 0 0 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 0 0 0 0 0 0 0 0 Other Health Homes Services (U3 or U6) 0 0 0 0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 196 Appendix E: Health Net | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 172: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Modality (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) In-Person (U1 or U4) 0 0 0 0 0 0 0 0 0 0 Phone/Telehealth (U2 or U5) 0 0 0 0 0 0 0 0 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 0 0 0 0 0 0 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 0 0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Health Net 197 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 173: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Kern Los Angeles Sacramento San Diego Tulare SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=267) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 0 0 4.1% 0 0 0 0 0 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0 0 -- 0 0 0 0 0 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to samples of less than 11 enrollees. 198 Appendix E: Health Net | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Inland Empire Health Plan This appendix provides information about the implementation and evaluation findings of HHP by Inland Empire Health Plan as of September 2019. It outlines Inland Empire Health Plan’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Inland Empire Health Plan enrollees. Inland Empire Health Plan carried out HHP implementation in Riverside and San Bernardino counties in Group 2, with SPA 1 beginning January 2019 and SPA 2 beginning July 2019. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 174: Inland Empire Health Plan’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Riverside Group 2 1/1/2019 7/1/2019 San Bernardino Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Inland Empire Health Plan 199 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 175: Cumulative Total Enrollment in Inland Empire Health Plan, July 1, 2018 to September 30, 2019 Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 18-Jul 0 0 0 0 18-Aug 0 0 0 0 18-Sep 0 0 0 0 18-Oct 0 0 0 0 18-Nov 0 0 0 0 18-Dec 0 0 0 0 19-Jan 976 0 983 0 Group 2 SPA 1 Implementation 19-Feb 1,332 0 1,246 0 19-Mar 2,107 0 1,482 0 19-Apr 2,822 0 1,845 0 19-May 3,261 0 2,164 0 19-Jun 3,519 0 2,402 0 19-Jul Group 2 SPA 2 Implementation 3,686 102 2,638 85 19-Aug 3,853 250 2,810 182 19-Sep 3,984 347 2,913 214 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 200 Appendix E: Inland Empire Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 176: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Inland Empire Health Plan by Group and County, as of September 30, 2019 Group 2 San Riverside Bernardino Enrollment as of 4,331 3,127 September 2019 Potential Eligible 21,108 24,143 Beneficiaries on TEL % of TEL Enrolled 20.5% 13.0% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Excludes enrollees enrolled for less than 31 days because their eligibility could not be verified. Enrollment Patterns Enrollment Continuity Exhibit 177: HHP Continuous Enrollment in Inland Empire Health Plan as of September 30, 2019 by Group and County Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 Total Enrollment 3,984 347 2,913 214 % of Enrollees 84.2% 98.0% 85.9% 99.1% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Percent of enrollees continuously enrolled could not be calculated for counties with one or more SPAs with enrollment less than 11 and were recorded as “--.” SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Inland Empire Health Plan 201 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 178: HHP Length of Enrollment (in Months) for Inland Empire Health Plan Enrollees as of September 30, 2019 by Group and County Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 (n=3,984) (n=347) (n=2,913) (n=214) Average 6 2 5 2 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 179: Number of HHP Eligible Beneficiaries Excluded in Inland Empire Health Plan by Reason for Exclusion as of September 30, 2019 Group 2 Riverside San Bernardino Reason for Exclusion (n=4,331) (n=3,127) Excluded because unsafe -- -- behavior or environment Externally referred but 38 83 excluded Excluded because not 105 49 eligible - well-managed Excluded because 256 169 duplicative program Excluded because declined 1,324 845 to participate Excluded because of 661 470 unsuccessful engagement Excluded because not 3,122 3,294 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. 202 Appendix E: Inland Empire Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 180: Inland Empire Health Plan HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 Enrollment N 3984 347 2913 214 % 0-17 1.8% -- 6.4% -- Age (at time of % 18-64 93.5% 96.0% 89.5% 92.1% enrollment) % 65+ 4.7% -- 4.1% -- Gender % male 40.4% 36.0% 36.8% 30.8% % White 29.7% 32.0% 21.7% 27.1% % Hispanic 46.4% 45.5% 49.6% 44.4% Race/Ethnicity % African American 12.2% 10.1% 17.9% 20.1% % other/unknown 11.7% 12.4% 10.9% 8.4% Language % speak English 77.0% 83.0% 80.2% 82.2% Medi-Cal full-scope Average number of during the year months prior to enrollment 11.9 11.7 11.9 11.8 Proportion ever Homelessness homeless during HHP enrollment 4.2% 6.3% 5.5% -- Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Inland Empire Health Plan 203 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 181: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Inland Empire Health Plan’s HHP Enrollees Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 Top Ten (n=3,984) (n=347) (n=2,913) (n=214) Conditions Hypertension Depression Hypertension Depression Condition 1 (%) (79.0%) (72.3%) (74.7%) (68.2%) Depressive Depressive Diabetes Diabetes Condition 2 (%) Disorder Disorder (59.7%) (56.8%) (68.3%) (63.1%) Anxiety Hyperlipidemia Obesity Hypertension Condition 3 (%) Disorders (48.7%) (45.7%) (55.6%) (56.2%) Chronic Anxiety Kidney Hypertension Hyperlipidemia Condition 4 (%) Disorders Disease (50.4%) (44.7%) (45.8%) (43.0%) Fibromyalgia, Chronic Obesity Chronic Pain Kidney Obesity Condition 5 (%) (41.1%) and Fatigue Disease (42.1%) (39.8%) (42.1%) Depression Obesity Depression Hyperlipidemia Condition 6 (%) (40.2%) (32.9%) (35.5%) (37.9%) Fibromyalgia, Fibromyalgia, Depressive Hyperlipidemia Chronic Pain Chronic Pain Condition 7 (%) Disorder (32.3%) and Fatigue and Fatigue (37.1%) (34.1%) (34.6%) Anxiety Alcohol Use Bipolar Asthma Condition 8 (%) Disorders Disorders Disorder (33.0%) (35.9%) (31.7%) (29.0%) Fibromyalgia, Rheumatoid Depressive Chronic Pain Arthritis / Diabetes Condition 9 (%) Disorder and Fatigue Osteoarthritis (27.6%) (32.8%) (35.7%) (28.2%) Schizophrenia Rheumatoid Bipolar Anxiety and Other Arthritis / Condition 10 (%) Disorder Disorders Psychotic Osteoarthritis (28.2%) (27.7%) Disorders (29.7%) (24.8%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and 204 Appendix E: Inland Empire Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Exhibit 182: Complexity of Inland Empire Health Plan’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 (n=3,984) (n=347) (n=2,913) (n=214) Two specific conditions (Criteria 1) 48.0% 18.2% 45.1% 14.5% Hypertension and another specific condition (Criteria 2) 67.1% 23.3% 64.1% 26.2% Serious Mental Health Conditions (Criteria 3) 43.7% 84.4% 40.3% 83.6% Asthma (Criteria 4) 25.8% 7.5% 32.9% 11.7% Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. UCLA Evaluation | Appendix E: Inland Empire Health Plan 205 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 183: Average Health Care Utilization by SPA of Inland Empire Health Plan’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 (n=3,984) (n=347) (n=2,913) (n=214) Number of hospitalizations per enrollee 1.1 1.0 1.5 1.1 Number of emergency department visits per enrollee 3.8 3.5 4.6 4.6 Number of long- term skilled nursing facility stays per enrollee TBD TBD TBD TBD Number of short- term skilled nursing facility stays per enrollee TBD TBD TBD TBD Number of primary care services per enrollee 21.0 17.4 23.2 20.2 Number of specialty services per enrollee 11.4 10.8 11.8 11.2 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. 206 Appendix E: Inland Empire Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 184: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 (n=3,519) (n=0) (n=2,402) (n=0) Total number of units of service provided 11,083 0 10,546 0 Average number of units of service per enrollee 1.6 0 1.8 0 Median number of units of service per enrollee 1.0 0 1.0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 185: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 Service Type (n=3,519) (n=0) (n=2,402) (n=0) Engagement Services (U7) 1.0 0 1.1 0 Core HHP Services (U1, U2, U4 or U5) 1.6 0 1.6 0 Other Health Homes Services (U3 or U6) 1.2 0 1.2 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October UCLA Evaluation | Appendix E: Inland Empire Health Plan 207 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Type Exhibit 186: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 Modality (n=3,519) (n=0) (n=2,402) (n=0) In-Person (U1 or U4) 1.3 0 1.3 0 Phone/Telehealth (U2 or U5) 1.4 0 1.5 0 Staff Type Clinical Staff (U1, U2 or U3) 1.5 0 1.5 0 Non-Clinical Staff (U4, U5 or U6) 1.4 0 1.4 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. “--" indicates unreported data due to samples of less than 11 enrollees. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 208 Appendix E: Inland Empire Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 187: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 (n=3,785) (n=347) (n=2,703) (n=214) Proportion of HHP Enrollees that were homeless or at risk for homelessness 4.2% 6.3% 5.5% -- Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 38.0% 59.1% 38.7% -- Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to samples of less than 11 enrollees. UCLA Evaluation | Appendix E: Inland Empire Health Plan 209 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Kaiser Permanente This appendix provides information about the implementation and evaluation findings of HHP by Kaiser Permanente (Kaiser) as of September 2019. It outlines Kaiser’s implementation schedule and infrastructure, as well as Kaiser enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Kaiser enrollees. Kaiser carried out HHP implementation in Sacramento and San Diego counties in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 188: Kaiser’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Sacramento Group 3 7/1/2019 1/1/2020 San Diego Source: Health Homes Program Guide. 210 Appendix E: Kaiser Permanente | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 189: Cumulative Total Enrollment in Kaiser, July 1, 2018 to September 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 18-Jul 0 0 0 0 18-Aug 0 0 0 0 18-Sep 0 0 0 0 18-Oct 0 0 0 0 18-Nov 0 0 0 0 18-Dec 0 0 0 0 19-Jan 0 0 0 0 19-Feb 0 0 0 0 19-Mar 0 0 0 0 19-Apr 0 0 0 0 19-May 0 0 0 0 19-Jun 0 0 0 0 19-Jul 17 -- 0 0 Group 3 SPA 1 Implementation 19-Aug 74 -- 0 0 19-Sep 132 12 -- 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. UCLA Evaluation | Appendix E: Kaiser Permanente 211 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 190: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Kaiser by Group and County, as of September 30, 2019 Group 3 Sacramento San Diego Enrollment as of 144 11* September 2019 Potential Eligible 2,740 1,270 Beneficiaries on TEL % of TEL Enrolled 5.3% 0.9% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. *Total enrollment in counties with less than 11 enrollees in one or more SPA groups were calculated using 11 enrollees for those SPA groups. Enrollment Patterns Enrollment Continuity Exhibit 191: HHP Continuous Enrollment in Kaiser as of September 30, 2019 by Group and County Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Total Enrollment 132 12 -- 0 % of Enrollees 97.7% 91.7% -- 0 Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 212 Appendix E: Kaiser Permanente | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 192: HHP Length of Enrollment (in Months) for Kaiser Enrollees as of September 30, 2019 by Group and County Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=132) (n=12) (n=<11) (n=0) Average 1 1 0 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 193: Number of HHP Eligible Beneficiaries Excluded in Kaiser by Reason for Exclusion as of September 30, 2019 Group 3 Sacramento San Diego Reason for Exclusion (n=144) (n=<11) Excluded because unsafe 0 0 behavior or environment Externally referred but 0 0 excluded Excluded because not 15 11 eligible - well-managed Excluded because -- -- duplicative program Excluded because declined 103 -- to participate Excluded because of 0 536 unsuccessful engagement Excluded because not 81 23 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. UCLA Evaluation | Appendix E: Kaiser Permanente 213 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 194: Kaiser HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Enrollment N 132 12 <11 0 % 0-17 -- -- -- 0 Age (at time of % 18-64 71.2% -- -- 0 enrollment) % 65+ -- -- -- 0 Gender % male 48.5% -- -- 0 % White 24.2% -- -- 0 % Hispanic 9.8% -- -- 0 Race/Ethnicity % African American 40.2% -- -- 0 % other/unknown 25.8% -- -- 0 Language % speak English -- 100.0% -- 0 Medi-Cal full- scope during Average number of the year prior months to enrollment 11.9 12.0 -- 0 Proportion ever Homelessness homeless during HHP enrollment -- -- -- 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 214 Appendix E: Kaiser Permanente | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 195: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Kaiser’s HHP Enrollees Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Top Ten (n=132) (n=12) (n=<11) (n=0) Conditions Condition 1 (%) Asthma (59.8%) -- -- 0 Hypertension 0 Condition 2 (%) -- -- (50.0%) Condition 3 (%) Diabetes (41.7%) -- -- 0 Chronic Kidney Condition 4 (%) -- -- Disease (31.1%) 0 Condition 5 (%) Obesity (30.3%) -- -- 0 Hyperlipidemia 0 Condition 6 (%) -- -- (28.0%) Fibromyalgia, Condition 7 (%) Chronic Pain and -- -- 0 Fatigue (27.3%) Rheumatoid Arthritis / 0 Condition 8 (%) -- -- Osteoarthritis (25.0%) Condition 9 (%) Anemia (18.9%) -- -- 0 Anxiety Disorders 0 Condition 10 (%) -- -- (18.2%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. UCLA Evaluation | Appendix E: Kaiser Permanente 215 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 196: Complexity of Kaiser’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=132) (n=12) (n=<11) (n=0) Two specific conditions (Criteria 1) 41.7% 0 -- 0 Hypertension and another specific condition (Criteria 2) 44.7% 100.0% -- 0 Serious Mental Health Conditions (Criteria 3) 10.6% 0 -- 0 Asthma (Criteria 4) 59.8% 0 -- 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. 216 Appendix E: Kaiser Permanente | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 197: Average Health Care Utilization by SPA of Kaiser’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=132) (n=12) (n=<11) (n=0) Number of hospitalizations per enrollee 1.3 0.8 -- 0 Number of emergency department visits per enrollee 7.8 16.1 -- 0 Number of long- term skilled nursing facility stays per enrollee TBD TBD TBD 0 Number of short- term skilled nursing facility stays per enrollee TBD TBD TBD 0 Number of primary care services per enrollee 13.2 10.8 -- 0 Number of specialty services per enrollee 25.8 29.9 -- 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: Kaiser Permanente 217 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 198: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=0) (n=0) (n=0) (n=0) Total number of units of service provided 0 0 0 0 Average number of units of service per enrollee 0 0 0 0 Median number of units of service per enrollee 0 0 0 0 Source: Medi-Cal Claims data from July 2018 to June 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 199: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Service Type (n=0) (n=0) (n=0) (n=0) Engagement Services (U7) 0 0 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 0 0 Other Health Homes Services (U3 or U6) 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include 218 Appendix E: Kaiser Permanente | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Type Exhibit 200: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 Modality (n=0) (n=0) (n=0) (n=0) In-Person (U1 or U4) 0 0 0 0 Phone/Telehealth (U2 or U5) 0 0 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Kaiser Permanente 219 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 201: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 (n=130) (n=0) (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 10.0% 0 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services -- 0 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to samples of less than 11 enrollees. 220 Appendix E: Kaiser Permanente | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Kern Health Systems This appendix provides information about the implementation and evaluation findings of HHP by Kern Health Systems (Kern) as of September 2019. It outlines Kern’s implementation schedule and infrastructure, as well as Kern enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Kern enrollees. Kern carried out HHP implementation in Kern County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 202: Kern’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 Kern 7/1/2019 1/1/2020 Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Kern Health Systems 221 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 203: Cumulative Total Enrollment in Kern, July 1, 2018 to September 30, 2019 Group 3 Kern SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 1,842 0 Group 3 SPA 1 Implementation 19-Aug 2,212 0 19-Sep 2,363 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 222 Appendix E: Kern Health Systems | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 204: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Kern by Group and County, as of September 30, 2019 Group 3 Kern Enrollment as of 2,363 September 2019 Potential Eligible 10,044 Beneficiaries on TEL % of TEL Enrolled 23.5% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 205: HHP Continuous Enrollment in Kern as of September 30, 2019 by Group and County Group 3 Kern SPA 1 SPA 2 Total Enrollment 2,363 0 % of Enrollees 98.2% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Kern Health Systems 223 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 206: HHP Length of Enrollment (in Months) for Kern Enrollees as of September 30, 2019 by Group and County Group 3 Kern SPA 1 SPA 2 (n=2,363) (n=0) Average 2 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 207: Number of HHP Eligible Beneficiaries Excluded in Kern by Reason for Exclusion as of September 2019 Group 3 Kern Reason for Exclusion (n=2,363) Excluded because unsafe -- behavior or environment Externally referred but 0 excluded Excluded because not 16 eligible - well-managed Excluded because -- duplicative program Excluded because declined 79 to participate Excluded because of 207 unsuccessful engagement Excluded because not 43 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. “--" indicates unreported data due to samples of less than 11 enrollees. 224 Appendix E: Kern Health Systems | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 208: Kern HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Kern SPA 1 SPA 2 Enrollment N 2,363 0 % 0-17 -- 0 Age (at time of % 18-64 93.2% 0 enrollment) % 65+ -- 0 Gender % male 35.0% 0 % White 32.1% 0 % Hispanic 48.1% 0 Race/Ethnicity % African American 9.3% 0 % other/unknown 10.5% 0 Language % speak English 75.1% 0 Medi-Cal full- scope during Average number of the year prior months to enrollment 11.9 0 Proportion ever Homelessness homeless during HHP enrollment -- 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Kern Health Systems 225 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 209: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Kern’s HHP Enrollees Group 3 Kern SPA 1 SPA 2 Top Ten (n=2,363) (n=0) Conditions Hypertension Condition 1 (%) 0 (76.4%) Hyperlipidemia 0 Condition 2 (%) (58.8%) Condition 3 (%) Diabetes (52.8%) 0 Condition 4 (%) Obesity (47.9%) 0 Rheumatoid Arthritis / 0 Condition 5 (%) Osteoarthritis (43.8%) Depression 0 Condition 6 (%) (41.9%) Fibromyalgia, Condition 7 (%) Chronic Pain and 0 Fatigue (41.9%) Anxiety Disorders 0 Condition 8 (%) (41.8%) Chronic Kidney Condition 9 (%) Disease (39.0%) 0 Depressive Condition 10 (%) Disorder (37.2%) 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 226 Appendix E: Kern Health Systems | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 210: Complexity of Kern’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Kern SPA 1 SPA 2 (n=2,363) (n=0) Two specific conditions (Criteria 1) 40.1% 0 Hypertension and another specific condition (Criteria 2) 59.5% 0 Serious Mental Health Conditions (Criteria 3) 44.2% 0 Asthma (Criteria 4) 24.5% 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. UCLA Evaluation | Appendix E: Kern Health Systems 227 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 211: Average Health Care Utilization by SPA of Kern’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Kern SPA 1 SPA 2 (n=2,363) (n=0) Number of hospitalizations per enrollee 0.9 0 Number of emergency department visits per enrollee 3.9 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 Number of primary care services per enrollee 19.7 0 Number of specialty services per enrollee 11.5 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. 228 Appendix E: Kern Health Systems | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 212: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Kern SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 213: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Kern SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include UCLA Evaluation | Appendix E: Kern Health Systems 229 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Type Exhibit 214: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Kern SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 230 Appendix E: Kern Health Systems | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 215: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Kern SPA 1 SPA 2 (n=2,363) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness -- 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to less than 11 enrollees. UCLA Evaluation | Appendix E: Kern Health Systems 231 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program L.A Care Health Plan This appendix provides information about the implementation and evaluation findings of HHP by L.A. Care Health Plan (L.A. Care) as of September 2019. It outlines L.A. Care’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for L.A. Care enrollees. L.A. Care carried out HHP implementation in Los Angeles County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 216: L.A. Care’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 Los Angeles 7/1/2019 1/1/2020 Source: Health Homes Program Guide. 232 Appendix E: L.A Care Health Plan| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 217: Cumulative Total Enrollment in L.A. Care, July 1, 2018 to September 30, 2019 Group 3 Los Angeles SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 556 0 Group 3 SPA 1 Implementation 19-Aug 1,521 0 19-Sep 2,375 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes Those enrolled for less than 31 days were excluded from this analysis. Enrollment of less than 11 enrollees was censored. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: L.A Care Health Plan 233 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 218: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in L.A. Care by Group and County, as of September 30, 2019 Group 3 Los Angeles Enrollment as of 2,375 September 2019 Potential Eligible 69,265 Beneficiaries on TEL % of TEL Enrolled 3.4% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 219: HHP Continuous Enrollment in L.A. Care as of September 30, 2019 by Group and County Group 3 Los Angeles SPA 1 SPA 2 Total Enrollment 2,375 0 % of Enrollees 98.8% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 234 Appendix E: L.A Care Health Plan| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 220: HHP Length of Enrollment (in Months) for L.A. Care Enrollees as of September 30, 2019 by Group and County Group 3 Los Angeles SPA 1 SPA 2 (n=2,375) (n=0) Average 1 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 221: Number of HHP Eligible Beneficiaries Excluded in L.A. Care by Reason for Exclusion as of September 30, 2019 Group 3 Reason for Exclusion Los Angeles (n=2,375) Excluded because unsafe -- behavior or environment Externally referred but 41 excluded Excluded because not 65 eligible - well-managed Excluded because 1,281 duplicative program Excluded because declined 1,097 to participate Excluded because of 1,954 unsuccessful engagement Excluded because not 2,027 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. UCLA Evaluation | Appendix E: L.A Care Health Plan 235 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 222: L.A. Care HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Los Angeles SPA 1 SPA 2 Enrollment N 2375 0 % 0-17 7.3% 0 Age (at time of % 18-64 83.6% 0 enrollment) % 65+ 9.1% 0 Gender % male 43.4% 0 % White 10.4% 0 % Hispanic 45.8% 0 Race/Ethnicity % African American 28.5% 0 % other/unknown 15.3% 0 Language % speak English 67.8% 0 Medi-Cal full- scope during Average number the year prior of months to enrollment 12.0 0 Proportion ever Homelessness homeless during HHP enrollment 2.2% 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 236 Appendix E: L.A Care Health Plan| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 223: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among L.A. Care’s HHP Enrollees Group 3 Los Angeles Top Ten SPA 1 Enrollees SPA 2 Enrollees Conditions (n=2,375) (n=0) Condition 1 (%) Hypertension (71.5%) 0 Condition 2 (%) Diabetes (55.1%) 0 Condition 3 (%) Hyperlipidemia (44.8%) 0 Condition 4 (%) Obesity (44.1%) 0 Chronic Kidney Disease Condition 5 (%) 0 (40.3%) Condition 6 (%) Depression (36.0%) 0 Depressive Disorder Condition 7 (%) 0 (34.7%) Condition 8 (%) Asthma (30.7%) 0 Rheumatoid Arthritis / Condition 9 (%) 0 Osteoarthritis (24.0%) Fibromyalgia, Chronic Condition 10 (%) 0 Pain and Fatigue (21.8%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: L.A Care Health Plan 237 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 224: Complexity of L.A. Care’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Los Angeles SPA 1 SPA 2 Enrollees Enrollees (n=2,375) (n=0) Two specific conditions (Criteria 1) 41.8% 0 Hypertension and another specific condition (Criteria 2) 61.3% 0 Serious Mental Health Conditions (Criteria 3) 41.1% 0 Asthma (Criteria 4) 30.6% 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. 238 Appendix E: L.A Care Health Plan| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 225: Average Health Care Utilization by SPA of L.A. Care’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Los Angeles SPA 1 Enrollees SPA 2 Enrollees (n=2,375) (n=0) Number of hospitalizations per enrollee 1.1 0 Number of emergency department visits per enrollee 3.3 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 Number of primary care services per enrollee 19.0 0 Number of specialty services per enrollee 10.3 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: L.A Care Health Plan 239 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 226: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Los Angeles SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 227: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Los Angeles SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and 240 Appendix E: L.A Care Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Type Exhibit 228: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Los Angeles SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: L.A Care Health Plan 241 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 229: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Los Angeles SPA 1 SPA 2 (n=2,358) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 2.1% 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 36.7% 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 242 Appendix E: L.A Care Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Molina Healthcare of California Partner Plan, Inc. This appendix provides information about the implementation and evaluation findings of HHP by Molina Healthcare of California Partner Plan, Inc. (Molina) as of September 2019. It outlines Molina’s implementation schedule and infrastructure, as well as Molina enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Molina enrollees. Molina operates in five counties and began HHP implementation in Riverside and San Bernardino counties with Group 2, launching SPA 1 in January 2019 and SPA 2 in July 2019. Implementation in Imperial, Sacramento, and San Diego counties followed in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 230: Molina’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Riverside Group 2 San 1/1/2019 7/1/2019 Bernardino Imperial Group 3 Sacramento 7/1/2019 1/1/2020 San Diego Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 243 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 231: Cumulative Total Enrollment in Molina, July 1, 2018 to September 30, 2019 Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 18-Jul 0 0 0 0 0 0 0 0 0 0 18-Aug 0 0 0 0 0 0 0 0 0 0 18-Sep 0 0 0 0 0 0 0 0 0 0 18-Oct 0 0 0 0 0 0 0 0 0 0 18-Nov 0 0 0 0 0 0 0 0 0 0 18-Dec 0 0 0 0 0 0 0 0 0 0 19-Jan Group 2 SPA 1 13 0 -- -- 0 0 0 0 0 0 Implementation 19-Feb 50 -- 62 -- 0 0 0 0 0 0 19-Mar 116 -- 168 -- 0 0 0 0 0 0 19-Apr 155 -- 203 11 0 0 0 0 0 0 19-May 197 -- 221 12 0 0 0 0 0 0 19-Jun 241 -- 257 13 0 0 0 0 0 0 19-Jul Group 2 SPA 2 and Group 3 298 17 320 21 -- 0 18 0 -- 0 SPA 1 Implementation 19-Aug 327 64 346 51 -- 0 80 -- 37 0 19-Sep 347 115 373 115 33 0 127 -- 64 -- Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall 244 Appendix E: Molina Healthcare of California Partner Plan, Inc.| UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. Enrollment Size Compared to Eligible Beneficiary Population Exhibit 232: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Molina by Group and County, as of September 30, 2019 Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego Enrollment as of September 2019 462 488 33 138* 75* Potential Eligible Beneficiaries on TEL 1,443 1,277 662 2,619 9,921 % of TEL Enrolled 32.0% 38.2% 5.0% 5.3% 0.8% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. “--" indicates unreported data due to samples of less than 11 enrollees. *Total enrollment in counties with less than 11 enrollees in one or more SPA groups were calculated using 11 enrollees for those SPA groups. UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 245 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Patterns Enrollment Continuity Exhibit 233: HHP Continuous Enrollment in Molina as of September 30, 2019 by Group and County Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Total Enrollment 347 115 373 115 33 0 127 <11 64 <11 % of Enrollees 76.9% 98.3% 70.5% 95.7% 100.0% 0.0% 99.2% -- 100.0% -- Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. Enrollment Length Exhibit 234: HHP Length of Enrollment (in Months) for Molina Enrollees as of September 30, 2019 by Group and County Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=347) (n=115) (n=373) (n=115) (n=33) (n=0) (n=127) (n=<11) (n=64) (n=<11) Average 4 1 4 1 1 0 1 1 1 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 246 Appendix E: Molina Healthcare of California Partner Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 235: Number of HHP Eligible Beneficiaries Excluded in Molina by Reason for Exclusion as of September 30, 2019 Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego Reason for Exclusion (n=462) (n=488) (n=33) (n=138*) (n=75*) Excluded because unsafe behavior or 0 0 0 0 0 environment Externally referred but 0 0 0 0 0 excluded Excluded because not 215 192 -- 22 13 eligible - well-managed Excluded because 27 37 -- -- -- duplicative program Excluded because 105 265 -- 19 -- declined to participate Excluded because of unsuccessful 680 1,527 0 52 -- engagement Excluded because not enrolled in Medi-Cal at 0 0 0 0 0 MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. *Total enrollment in counties with less than 11 enrollees in one or more SPA groups were calculated using 11 enrollees for those SPA groups. UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 247 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 236: Molina HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 2 Group 3 San Riverside Imperial Sacramento San Diego Bernardino SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Enrollment N 345 115 371 115 33 0 127 <11 64 <11 % 0-17 23.2% 12.2% 16.4% -- -- 0 -- -- -- -- Age (at time of % 18-64 70.7% 87.8% 76.5% -- -- 0 -- -- -- -- enrollment) % 65+ 6.1% 0.0% 7.0% -- -- 0 -- -- -- -- Gender % male 50.1% 44.3% 50.4% 33.0% -- 0 44.1% -- 60.9% -- % White 18.6% 26.1% 13.5% 21.7% -- 0 29.9% -- 23.4% -- % Hispanic 47.0% 48.7% 49.1% 52.2% -- 0 14.2% -- 35.9% -- % African Race/Ethnicity American 15.9% 9.6% 18.6% -- -- 0 43.3% -- -- -- % other/ unknown 18.6% 15.7% 18.9% -- -- 0 12.6% -- -- -- % speak Language English 72.2% 82.6% 70.6% 82.6% 21.2% 0 90.6% -- 70.3% -- Medi-Cal full- Average scope during number of the year prior to months enrollment 11.9 11.8 11.9 12.0 11.8 0 12.0 -- 11.8 -- Proportion ever Homelessness homeless during HHP enrollment -- -- -- -- -- 0 11.8% -- -- -- 248 Appendix E: Molina Healthcare of California Partner Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 249 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 237: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Molina’s HHP Enrollees, Group 2 Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 Top Ten (n=345) (n=115) (n=371) (n=115) Conditions Condition 1 (%) Hypertension (62.6%) Depression (76.5%) Hypertension (66.1%) Hypertension (67.0%) Depressive Disorder Condition 2 (%) Diabetes (52.5%) Diabetes (51.6%) Depression (65.2%) (71.3%) Hypertension Hyperlipidemia Depressive Disorder Condition 3 (%) Asthma (41.7%) (50.4%) (42.2%) (58.3%) Hyperlipidemia Anxiety Disorders Condition 4 (%) Asthma (40.1%) Hyperlipidemia (44.3%) (41.2%) (48.7%) Chronic Kidney Chronic Kidney Condition 5 (%) Obesity (33.9%) Obesity (41.7%) Disease (39.7%) Disease (38.4%) Anxiety Disorders Condition 6 (%) Obesity (29.0%) Diabetes (31.3%) Obesity (35.8%) (37.4%) Fibromyalgia, Chronic Rheumatoid Arthritis / Alcohol Use Alcohol Use Disorders Condition 7 (%) Pain and Fatigue Osteoarthritis (20.6%) Disorders (31.3%) (19.6%) (33.9%) Ischemic Heart Hyperlipidemia Chronic Kidney Condition 8 (%) Anemia (18.0%) Disease (17.7%) (30.4%) Disease (32.2%) Chronic Kidney Ischemic Heart Condition 9 (%) Anemia (16.5%) Diabetes (27.8%) Disease (27.0%) Disease (18.0%) 250 Appendix E: Molina Healthcare of California Partner Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Group 2 Riverside San Bernardino SPA 1 SPA 2 SPA 1 SPA 2 Top Ten (n=345) (n=115) (n=371) (n=115) Conditions Chronic Obstructive Fibromyalgia, Chronic Bipolar Disorder Rheumatoid Arthritis / Condition 10 (%) Pulmonary Disease Pain and Fatigue (26.1%) Osteoarthritis (24.3%) (16.5%) (17.2%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to samples of less than 100 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Exhibit 238: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Molina’s HHP Enrollees, Group 3 Group 3 Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Top Ten Conditions (n=33) (n=0) (n=127) (n=<11) (n=64) (n=<11) Condition 1 (%) -- 0 Hypertension (78.0%) -- -- -- Condition 2 (%) -- 0 Diabetes (47.2%) -- -- -- Condition 3 (%) -- 0 Obesity (44.1%) -- -- -- Condition 4 (%) -- 0 Asthma (37.0%) -- -- -- Chronic Kidney Disease Condition 5 (%) -- 0 -- -- -- (36.2%) Condition 6 (%) -- 0 Hyperlipidemia (34.6%) -- -- -- UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 251 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Group 3 Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Top Ten Conditions (n=33) (n=0) (n=127) (n=<11) (n=64) (n=<11) Fibromyalgia, Chronic Condition 7 (%) -- 0 Pain and Fatigue -- -- -- (30.7%) Ischemic Heart Disease Condition 8 (%) -- 0 -- -- -- (29.1%) Chronic Obstructive Condition 9 (%) -- 0 Pulmonary Disease -- -- -- (26.8%) Condition 10 (%) -- 0 Heart Failure (26.0%) -- -- -- Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to samples of less than 100 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 252 Appendix E: Molina Healthcare of California Partner Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 239: Complexity of Molina’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=345) (n=115) (n=371) (n=115) (n=33) (n=0) (n=127) (n=<11) (n=64) (n=<11) Two specific conditions (Criteria 1) 39.1% 21.7% 43.0% 23.5% 66.7% 0 43.3% -- 64.1% -- Hypertension and another specific condition (Criteria 2) 58.0% 37.4% 58.9% 40.0% 81.8% 0 67.7% -- 62.5% -- Serious Mental Health Conditions (Criteria 3) 3.8% 89.6% 5.4% 76.5% -- 0 9.4% -- -- -- Asthma (Criteria 4) 41.7% 11.3% 39.8% 20.0% -- 0 37.0% -- 29.7% -- Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 253 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 240: Average Health Care Utilization by SPA of Molina’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Number of hospitalizations per enrollee 0.8 1.5 0.8 1.0 0.4 0 1.1 -- 1.3 -- Number of emergency department visits per enrollee 3.3 4.1 3.1 3.6 3.5 0 4.8 -- 3.5 -- Number of long-term skilled nursing facility stays per enrollee TBD TBD TBD TBD TBD 0 TBD TBD TBD TBD Number of short- term skilled nursing facility stays per enrollee TBD TBD TBD TBD TBD 0 TBD TBD TBD TBD Number of primary care services per enrollee 19.8 20.7 19.3 18.4 14.4 0 13.1 -- 24.3 -- Number of specialty services per enrollee 10.0 10.6 8.8 9.2 14.0 0 10.2 -- 8.4 -- Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: “--" indicates unreported data due to samples of less than 100 enrollees. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Data errors in Group 3, SPA 2 may result in enrollment prior to implementation. 254 Appendix E: Molina Healthcare of California Partner Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 241: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=239) (n=<11) (n=256) (n=13) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Total number of units of service provided 946 19 1,161 67 0 0 0 0 0 0 Average number of units of service per enrollee 2.0 1.6 2.2 2.2 0 0 0 0 0 0 Median number of units of service per enrollee 2.0 1.5 2.0 2.0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. “--" indicates unreported data due to samples of less than 11 enrollees. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 255 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 242: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Service Type (n=239) (n=<11) (n=256) (n=13) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) Engagement Services (U7) 1.4 1.4 1.4 1.75 0 0 0 0 0 0 Core HHP Services (U1, U2, U4 or U5) 1.8 1.6 1.8 2.0 0 0 0 0 0 0 Other Health Homes Services (U3 or U6) 0 0 1.0 0 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. “--" indicates unreported data due to samples of less than 11 enrollees. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 256 Appendix E: Molina Healthcare of California Partner Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 243: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 Modality (n=239) (n=<11) (n=256) (n=13) (n=0) (n=0) (n=0) (n=0) (n=0) (n=0) In-Person (U1 or U4) 1.1 1 1.0 1.2 0 0 0 0 0 0 Phone/Telehealth (U2 or U5) 1.7 1.5 1.8 1.9 0 0 0 0 0 0 Staff Type Clinical Staff (U1, U2 or U3) 2.6 1.2 2.4 1.8 0 0 0 0 0 0 Non-Clinical Staff (U4, U5 or U6) 1.6 1.375 1.4 1.775 0 0 0 0 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under- reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. “--" indicates unreported data due to samples of less than 11 enrollees. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Molina Healthcare of California Partner Plan, Inc. 257 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 244: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 2 Group 3 Riverside San Bernardino Imperial Sacramento San Diego SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 SPA 1 SPA 2 (n=307) (n=114) (n=317) (n=112) (n=0) (n=0) (n=127) (n=0) (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness -- -- -- -- 0 0 -- 0 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0 -- 0 0 0 0 -- 0 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to samples of less than 11 enrollees. 258 Appendix E: Molina Healthcare of California Partner Plan, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program San Francisco Health Plan This appendix provides information about the implementation and evaluation findings of HHP by San Francisco Health Plan as of September 2019. It outlines San Francisco Health Plan’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for San Francisco Health Plan enrollees. San Francisco Health Plan carried out HHP implementation in San Francisco County in Group 1, with SPA 1 beginning July 2018 and SPA 2 beginning January 2019. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 245: San Francisco Health Plan’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 1 San Francisco 7/1/2018 1/1/2019 Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: San Francisco Health Plan 259 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 246: Cumulative Total Enrollment in San Francisco Health Plan, July 1, 2018 to September 30, 2019 Group 1 San Francisco SPA 1 SPA 2 18-Jul 68 0 Group 1 SPA 1 Implementation 18-Aug 124 0 18-Sep 172 0 18-Oct 208 0 18-Nov 231 0 18-Dec 254 0 19-Jan 279 16 Group 1 SPA 2 Implementation 19-Feb 318 73 19-Mar 341 111 19-Apr 357 123 19-May 368 135 19-Jun 377 144 19-Jul 394 153 19-Aug 443 171 19-Sep 455 187 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 260 Appendix E: San Francisco Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 247: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in San Francisco Health Plan by Group and County, as of September 30, 2019 Group 1 San Francisco Enrollment as of 642 September 2019 Potential Eligible 5,265 Beneficiaries on TEL % of TEL Enrolled 12.2% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 2018 and September 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 248: HHP Continuous Enrollment in San Francisco Health Plan as of September 30, 2019 by Group and County Group 1 San Francisco SPA 1 SPA 2 Total Enrollment 455 187 % of Enrollees 67.7% 88.2% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: San Francisco Health Plan 261 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 249: HHP Length of Enrollment (in Months) for San Francisco Health Plan Enrollees as of September 30, 2019 by Group and County Group 1 San Francisco SPA 1 SPA 2 (n=455) (n=187) Average 8 5 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 250: Number of HHP Eligible Beneficiaries Excluded in San Francisco Health Plan by Reason for Exclusion as of September 30, 2019 Group 1 Reason for Exclusion San Francisco (n=642) Excluded because unsafe -- behavior or environment Externally referred but -- excluded Excluded because not 61 eligible - well-managed Excluded because 86 duplicative program Excluded because declined 514 to participate Excluded because of 173 unsuccessful engagement Excluded because not 30 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 2018 to September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. 262 Appendix E: San Francisco Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 251: San Francisco Health Plan HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 1 San Francisco SPA 1 SPA 2 Enrollment N 455 187 % 0-17 14.3% -- Age (at time of % 18-64 74.9% 89.3% enrollment) % 65+ 10.8% -- Gender % male 58.9% 53.5% % White 9.9% 21.9% % Hispanic 13.0% 12.3% Race/Ethnicity % African American 26.2% 19.3% % other/unknown 51.0% 46.5% Language % speak English 60.0% 70.6% Medi-Cal full- scope during Average number the year prior of months to enrollment 11.9 11.9 Proportion ever Homelessness homeless during HHP enrollment -- -- Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: San Francisco Health Plan 263 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 252: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among San Francisco Health Plan’s HHP Enrollees Group 1 San Francisco SPA 1 SPA 2 Top Ten (n=455) (n=187) Conditions Condition 1 (%) Hypertension (66.4%) Depression (79.1%) Condition 2 (%) Diabetes (45.9%) Depressive Disorder (75.9%) Chronic Kidney Disease Condition 3 (%) Hypertension (63.1%) (43.7%) Condition 4 (%) Asthma (37.1%) Anxiety Disorders (44.4%) Condition 5 (%) Hyperlipidemia (31.4%) Drug Use Disorders (43.9%) Condition 6 (%) Anemia (29.7%) Diabetes (35.8%) Fibromyalgia, Chronic Pain and Condition 7 (%) Drug Use Disorders (27.0%) Fatigue (35.3%) Chronic Obstructive Schizophrenia and Other Condition 8 (%) Pulmonary Disease (26.2%) Psychotic Disorders (35.3%) Condition 9 (%) Heart Failure (24.2%) Tobacco Use (35.3%) Fibromyalgia, Chronic Pain Condition 10 (%) Bipolar Disorder (34.2%) and Fatigue (23.7%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 264 Appendix E: San Francisco Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 253: Complexity of San Francisco Health Plan’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 1 San Francisco SPA 1 SPA 2 (n=455) (n=187) Two specific conditions (Criteria 1) 56.0% 45.5% Hypertension and another specific condition (Criteria 2) 60.2% 43.9% Serious Mental Health Conditions (Criteria 3) 18.7% 95.7% Asthma (Criteria 4) 37.1% 18.2% Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 2016 to September 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: San Francisco Health Plan 265 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 254: Average Health Care Utilization by SPA of San Francisco Health Plan’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 1 San Francisco SPA 1 SPA 2 (n=455) (n=187) Number of hospitalizations per enrollee 2.7 1.7 Number of emergency department visits per enrollee 5.3 9.2 Number of long-term skilled nursing facility stays per enrollee TBD TBD Number of short-term skilled nursing facility stays per enrollee TBD TBD Number of primary care services per enrollee 19.6 14.7 Number of specialty services per enrollee 14.5 18.1 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 2018 and September 2019. Utilization data was calculated using Medi-Cal claims data from July 2016 to September 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. 266 Appendix E: San Francisco Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 255: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, June 1, 2018 to June 30, 2019 Group 1 San Francisco SPA 1 SPA 2 (n=377) (n=144) Total number of units of service provided 5,643 1,503 Average number of units of service per enrollee 3.4 3.8 Median number of units of service per enrollee 2 2 Source: Medi-Cal Claims data from June 2018 to June 2019. Note: Only includes counties and SPAs with implementation timelines between June 2018 and June 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Types of HHP Services Delivered Exhibit 256: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, June 1, 2018 to June 30, 2019 Group 1 San Francisco SPA 1 SPA 2 Service Type (n=377) (n=144) Engagement Services (U7) 1.5 1.9 Core HHP Services (U1, U2, U4 or U5) 2.4 2.6 Other Health Homes Services (U3 or U6) 2.0 2.1 Source: Medi-Cal Claims data from June 2018 to June 2019. Notes: Only includes counties and SPAs with implementation timelines between June 2018 and June 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS UCLA Evaluation | Appendix E: San Francisco Health Plan 267 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Core Services by Modality and Staff Type Exhibit 257: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, June 1, 2018 to June 30, 2019 Group 1 San Francisco SPA 1 SPA 2 Modality (n=377) (n=144) In-Person (U1 or U4) 1.4 1.4 Phone/Telehealth (U2 or U5) 2.0 2.3 Staff Type Clinical Staff (U1, U2 or U3) 1.4 1 Non-Clinical Staff (U4, U5 or U6) 2.8 3.0 Source: Medi-Cal Claims data from June 2018 to June 2019. Notes: Only includes counties and SPAs with implementation timelines between June 2018 and June 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 268 Appendix E: San Francisco Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Housing Services Exhibit 258: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 1 San Francisco SPA 1 SPA 2 (n=336) (n=169) Proportion of HHP Enrollees that were homeless or at risk for homelessness -- -- Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services -- -- Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. “--" indicates unreported data due to samples of less than 11 enrollees. UCLA Evaluation | Appendix E: San Francisco Health Plan 269 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Santa Clara Family Health Plan This appendix provides information about the implementation and evaluation findings of HHP by Santa Clara Family Health Plan as of September 2019. It outlines Santa Clara Family Health Plan’s implementation schedule and infrastructure, as well as their enrollment trends, demographics, health status, and HHP service utilization. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for Santa Clara Family Health Plan enrollees. Santa Clara Family Health Plan carried out HHP implementation in Santa Clara County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 259: Santa Clara Family Health Plan’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 Santa Clara 7/1/2019 1/1/2020 Source: Health Homes Program Guide. 270 Appendix E: Santa Clara Family Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 260: Cumulative Total Enrollment in Santa Clara Family Health Plan, July 1, 2018 to September 30, 2019 Group 3 Santa Clara SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 79 0 Group 3 SPA 1 Implementation 19-Aug 128 0 19-Sep 158 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. When enrollment in one SPA was less than 11 enrollees, an enrollment range was reported for the overall population. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Santa Clara Family Health Plan 271 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 261: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in Santa Clara Family Health Plan by Group and County, as of September 30, 2019 Group 3 Santa Clara Enrollment as of 158 September 2019 Potential Eligible 7,861 Beneficiaries on TEL % of TEL Enrolled 2.0% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 1, 2018 and September 30, 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. Enrollment Patterns Enrollment Continuity Exhibit 262: HHP Continuous Enrollment in Santa Clara Family Health Plan as of September 30, 2019 by Group and County Group 3 Santa Clara SPA 1 SPA 2 Total Enrollment 158 0 % of Enrollees 96.8% 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness 272 Appendix E: Santa Clara Family Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 263: HHP Length of Enrollment (in Months) for Santa Clara Family Health Plan Enrollees as of September 30, 2019 by Group and County Group 3 Santa Clara SPA 1 SPA 2 (n=158) (n=0) Average 2 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 264: Number of HHP Eligible Beneficiaries Excluded in Santa Clara Family Health Plan by Reason for Exclusion as of September 30, 2019 Group 3 Reason for Exclusion Santa Clara Excluded because unsafe 0 behavior or environment Externally referred but -- excluded Excluded because not 114 eligible - well-managed Excluded because 82 duplicative program Excluded because declined 109 to participate Excluded because of 20 unsuccessful engagement Excluded because not 360 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 1, 2018 to September 30, 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. UCLA Evaluation | Appendix E: Santa Clara Family Health Plan 273 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 265: Santa Clara Family Health Plan HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 Santa Clara SPA 1 SPA 2 Enrollment N 158 0 % 0-17 -- 0 Age (at time of % 18-64 70.3% 0 enrollment) % 65+ -- 0 Gender % male 50.6% 0 % White 15.8% 0 % Hispanic 35.4% 0 Race/Ethnicity % African American -- 0 % other/unknown -- 0 Language % speak English 59.5% 0 Medi-Cal full- scope during Average number the year prior of months to enrollment 11.9 0 Proportion ever Homelessness homeless during HHP enrollment 11.4% 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 2016 to June 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--” indicates unreported data due to samples of less than 100 enrollees. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 274 Appendix E: Santa Clara Family Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 266: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among Santa Clara Family Health Plan’s HHP Enrollees Group 3 Santa Clara SPA 1 SPA 2 Top Ten (n=158) (n=0) Conditions Hypertension Condition 1 (%) 0 (72.8%) Condition 2 (%) Diabetes (54.4%) 0 Hyperlipidemia Condition 3 (%) 0 (44.3%) Chronic Kidney Condition 4 (%) 0 Disease (39.2%) Condition 5 (%) Asthma (31.6%) 0 Chronic Obstructive Condition 6 (%) 0 Pulmonary Disease (22.8%) Tobacco Use Condition 7 (%) 0 (21.5%) Rheumatoid Arthritis / Condition 8 (%) 0 Osteoarthritis (20.9%) Heart Failure Condition 9 (%) 0 (20.3%) Ischemic Heart Condition 10 (%) 0 Disease (20.3%) Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: Santa Clara Family Health Plan 275 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 267: Complexity of Santa Clara Family Health Plan’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 Santa Clara SPA 1 SPA 2 (n=158) (n=0) Two specific conditions (Criteria 1) 50.0% 0 Hypertension and another specific condition (Criteria 2) 62.0% 0 Serious Mental Health Conditions (Criteria 3) 20.9% 0 Asthma (Criteria 4) 31.6% 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. 276 Appendix E: Santa Clara Family Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 268: Average Health Care Utilization by SPA of Santa Clara Family Health Plan’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 Santa Clara SPA 1 SPA 2 (n=158) (n=0) Number of hospitalizations 1.1 per enrollee 0 Number of emergency department visits per 3.7 enrollee 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 Number of primary care 12.5 services per enrollee 0 Number of specialty 9.7 services per enrollee 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: Santa Clara Family Health Plan 277 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 269: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Santa Clara SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 278 Appendix E: Santa Clara Family Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 270: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 Santa Clara SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. UCLA Evaluation | Appendix E: Santa Clara Family Health Plan 279 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 271: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 Santa Clara SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Housing Services Exhibit 272: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 Santa Clara SPA 1 SPA 2 (n=158) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 24.1% 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 44.7% 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 280 Appendix E: Santa Clara Family Health Plan | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program UnitedHealthcare Community Plan of California, Inc. This appendix provides information about the implementation and evaluation findings of HHP by UnitedHealthcare Community Plan of California, Inc. (United), which began operating as a Medi-Cal managed care plan in October 2017. It outlines United’s implementation schedule and infrastructure, as well as United enrollment trends, demographics, health status, and HHP service utilization as of September 2019. The information in this appendix is organized and presented similarly to data provided in the main body of the report. The primary difference is presentation of data at the group, county, and SPA levels for United enrollees. United carried out HHP implementation in San Diego County in Group 3, with SPA 1 beginning July 2019 and SPA 2 beginning January 2020. The data in the following exhibits are obtained from MCP Readiness Documents, MCP Enrollment Reports, MCP Quarterly HHP Reports, and Medi-Cal enrollment and claims data. Varied implementation timelines led to zero enrollment in tables. Similarly, enrollment lower than 11 is not reported. The analytic methods used to create the exhibits are found in Appendix A: HHP Data Sources and Analytic Methods. HHP Implementation and Infrastructure HHP Schedule Exhibit 273: United’s HHP Schedule by Group and County SPA 1 Implementation SPA 2 Implementation Group Counties Dates Dates Group 3 San Diego 7/1/2019 1/1/2020 Source: Health Homes Program Guide. UCLA Evaluation | Appendix E: UnitedHealthcare Community Plan of California, Inc. 281 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollment and Enrollment Patterns Growth in Enrollment Exhibit 274: Cumulative Total Enrollment in United, July 1, 2018 to September 30, 2019 Group 3 San Diego SPA 1 SPA 2 18-Jul 0 0 18-Aug 0 0 18-Sep 0 0 18-Oct 0 0 18-Nov 0 0 18-Dec 0 0 19-Jan 0 0 19-Feb 0 0 19-Mar 0 0 19-Apr 0 0 19-May 0 0 19-Jun 0 0 19-Jul 0 0 Group 3 SPA 1 Implementation 19-Aug -- 0 19-Sep -- 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 282 Appendix E: UnitedHealthcare Community Plan of California, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Size Compared to Eligible Beneficiary Population Exhibit 275: Proportion of HHP Total Eligible Beneficiaries from Targeted Engagement List (TEL) in United by Group and County, as of September 30, 2019 Group 3 San Diego Enrollment as of 11* September 2019 Potential Eligible 367 Beneficiaries on TEL % of TEL Enrolled 3.0% Source: Enrollment data from Managed Care Plan Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019 limited to available data for the period between July 1, 2018 and September 30, 2019. Estimate of eligible beneficiaries from May 2019 TEL. Notes: MCP is managed care plan. Those enrolled for less than 31 days were excluded from this analysis. *Total enrollment in counties with less than 11 enrollees in one or more SPA groups were calculated using 11 enrollees for those SPA groups. Enrollment Patterns Enrollment Continuity Exhibit 276: HHP Continuous Enrollment in United as of September 30, 2019 by Group and County Group 3 San Diego SPA 1 SPA 2 Total Enrollment <11 0 % of Enrollees -- 0.0% Continuously Enrolled Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: UnitedHealthcare Community Plan of California, Inc. 283 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Length Exhibit 277: HHP Length of Enrollment (in Months) for United Enrollees as of September 30, 2019 by Group and County Group 3 San Diego SPA 1 SPA 2 (n=<11) (n=0) Average 1 0 Source: Managed Care Plan (MCP) Enrollment Reports from August 2019 and Quarterly HHP Reports from Quarter 3 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 284 Appendix E: UnitedHealthcare Community Plan of California, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Enrollment Exclusions of Specific HHP Eligible Populations Exhibit 278: Number of HHP Eligible Beneficiaries Excluded in United by Reason for Exclusion as of September 30, 2019 Group 3 Reason for Exclusion San Diego Excluded because unsafe 0 behavior or environment Externally referred but -- excluded Excluded because not 0 eligible - well-managed Excluded because 0 duplicative program Excluded because declined 14 to participate Excluded because of -- unsuccessful engagement Excluded because not 0 enrolled in Medi-Cal at MCP Source: Managed Care Plan (MCP) Quarterly HHP Reports from September 1, 2018 to September 30, 2019. Notes: Those enrolled for less than 31 days were excluded from this analysis. UCLA Evaluation | Appendix E: UnitedHealthcare Community Plan of California, Inc. 285 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Demographics, Health Status, and Prior Healthcare Utilization HHP Enrollee Demographics Exhibit 279: United HHP Enrollee Demographics by SPA at the time of HHP Enrollment Group 3 San Diego SPA 1 SPA 2 Enrollment N <11 0 % 0-17 -- 0 Age (at time of % 18-64 -- 0 enrollment) % 65+ -- 0 Gender % male -- 0 % White -- 0 % Hispanic -- 0 Race/Ethnicity % African American -- 0 % other/unknown -- 0 Language % speak English -- 0 Medi-Cal full- scope during Average number the year prior of months to enrollment -- 0 Proportion ever Homelessness homeless during HHP enrollment -- 0 Source: Enrollment and homelessness data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Demographics at the time of HHP enrollment were obtained from Medi-Cal enrollment and claims data from July 1, 2016 to June 30, 2019. Homelessness data was limited to available data for the period between July 2019 and September 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. 286 Appendix E: UnitedHealthcare Community Plan of California, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Enrollee Health Status Exhibit 280: Top Ten Most Frequent Physical Health and Mental Health Conditions by SPA among United’s HHP Enrollees Group 3 San Diego SPA 1 SPA 2 Top Ten (n=<11) (n=0) Conditions Condition 1 (%) -- 0 Condition 2 (%) -- 0 Condition 3 (%) -- 0 Condition 4 (%) -- 0 Condition 5 (%) -- 0 Condition 6 (%) -- 0 Condition 7 (%) -- 0 Condition 8 (%) -- 0 Condition 9 (%) -- 0 Condition 10 (%) -- 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Chronic and other chronic health, mental health and potentially disabling condition categories were identified using the Chronic Condition Warehouse methodology using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. UCLA Evaluation | Appendix E: UnitedHealthcare Community Plan of California, Inc. 287 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Exhibit 281: Complexity of United’s HHP Enrollees’ Health Status by SPA, 24 Months Prior to HHP Enrollment Group 3 San Diego SPA 1 SPA 2 (n=<11) (n=0) Two specific conditions (Criteria 1) -- 0 Hypertension and another specific condition (Criteria 2) -- 0 Serious Mental Health Conditions (Criteria 3) -- 0 Asthma (Criteria 4) -- 0 Source: MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: Criteria 1 includes any two of the following conditions: chronic obstructive pulmonary disease, diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, chronic renal (kidney) disease, dementia, substance use disorders. Criteria 2 includes hypertension and one of the following: chronic obstructive pulmonary disease, diabetes, coronary artery disease, chronic or congestive heart failure. Criteria 3 includes one of the following: major depression disorders, bipolar disorder, psychotic disorders including schizophrenia. Criteria 4 includes asthma. HHP enrollees may meet multiple criteria. “--" indicates unreported data due to samples of less than 11 enrollees. 288 Appendix E: UnitedHealthcare Community Plan of California, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Health Care Utilization of HHP Enrollees Prior to Enrollment Exhibit 282: Average Health Care Utilization by SPA of United’s HHP Enrollees in the 24 Months Prior to HHP Enrollment Group 3 San Diego SPA 1 SPA 2 (n=<11) (n=0) Number of hospitalizations per enrollee -- 0 Number of emergency department visits per enrollee -- 0 Number of long-term skilled nursing facility stays per enrollee TBD 0 Number of short-term skilled nursing facility stays per enrollee TBD 0 Number of primary care services per enrollee -- 0 Number of specialty services per enrollee -- 0 Number of evaluation and management visits per enrollee -- 0 Source: Enrollment data come from MCP Enrollment Reports from August 2019 and Quarterly HHP Reports from September 2019. HHP enrollment was limited to available data for the period between July 1, 2018 and September 30, 2019. Utilization data was calculated using Medi-Cal claims data from July 1, 2016 to September 30, 2019. Notes: “--" indicates unreported data due to samples of less than 11 enrollees. Those enrolled for less than 31 days were excluded from this analysis. TBD indicates data that was unavailable at the time of this report. SPA 1 includes enrollees with chronic conditions and substance use disorders. SPA 2 includes enrollees with severe mental illness. Payments Associated with Health Care Utilization Prior to HHP Enrollment Data on payments for health care utilization of HHP enrollees prior to enrollment were not available at the time of this report. Future HHP reports will include this information. UCLA Evaluation | Appendix E: UnitedHealthcare Community Plan of California, Inc. 289 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Service Utilization among HHP Enrollees Overall HHP Service Delivery to HHP Enrollees Exhibit 283: Estimated Overall HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 (n=0) (n=0) Total number of units of service provided 0 0 Average number of units of service per enrollee 0 0 Median number of units of service per enrollee 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use was under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Modifiers U1-U7 accompanied both HCPCS code G0506 (July 2018 to September 2018) and HCPCS code G9008 (October 2018 to June 2019) to specify the service. Data are based on the number of months during HHP enrollment where HCPCS codes were present. 290 Appendix E: UnitedHealthcare Community Plan of California, Inc. | UCLA Evaluation UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program Types of HHP Services Delivered Exhibit 284: Estimated Average Number of HHP Services Provided to HHP Enrollees by SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 Service Type (n=0) (n=0) Engagement Services (U7) 0 0 Core HHP Services (U1, U2, U4 or U5) 0 0 Other Health Homes Services (U3 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Core HHP services include claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U1, U2, U4, or U5. HHP engagement service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U7. Other HHP service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U3 or U6. Data are based on the number of months during HHP enrollment where HCPCS codes were present. Appendix E: UnitedHealthcare Community Plan of California, Inc.| UCLA Evaluation 291 UCLA Center for Health Policy Research September 2020 Health Economics and Evaluation Research Program HHP Core Services by Modality and Staff Type Exhibit 285: Estimated Average Number of HHP Core Service Provided to HHP Enrollees by Modality and SPA, July 1, 2018 to June 30, 2019 Group 3 San Diego SPA 1 SPA 2 Modality (n=0) (n=0) In-Person (U1 or U4) 0 0 Phone/Telehealth (U2 or U5) 0 0 Staff Type Clinical Staff (U1, U2 or U3) 0 0 Non-Clinical Staff (U4, U5 or U6) 0 0 Source: Medi-Cal Claims data from July 1, 2018 to June 30, 2019. Notes: Only includes counties and SPAs with implementation timelines between July 1, 2018 and June 30, 2019. HCPCS is Healthcare Common Procedure Coding System, MCP is managed care plan, and UOS is unit of service. Service use is under-reported by MCPs in claims data. Each service (UOS) represented a 15-minute interaction between HHP staff and HHP enrollee. Multiple UOS’ were allowed within a single visit. Includes services provide by both clinical and non-clinical staff. HHP in-person service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 June 2019), and modifier U1 or U4. HHP telehealth service includes claims with HCPCS code G0506 (July 2018 to September 2018), HCPCS code G9008 (October 2018 to June 2019), and modifier U2 or U5. Data are based on the number of months during HHP enrollment where HCPCS codes were present. HHP Housing Services Exhibit 286: Housing Services among HHP Enrollees, July 1 to September 30, 2019 Group 3 San Diego SPA 1 SPA 2 (n=0) (n=0) Proportion of HHP Enrollees that were homeless or at risk for homelessness 0 0 Among those who were homeless or at risk for homelessness: Proportion of HHP enrollees that received housing services 0 0 Source: MCP Quarterly Reports from September 2019. Notes: MCP is managed care plan. 292 Appendix E: UnitedHealthcare Community Plan of California, Inc. | UCLA Evaluation The views expressed in this report are those of the authors and do not necessarily represent the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders. Copyright © 2020 by the Regents of the University of California. All Rights Reserved. The UCLA Center for Health Policy Research is affiliated with the UCLA Fielding School of Public Health and the UCLA School of Public Affairs. Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu www.healthpolicy.ucla.edu