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Care Coordination Organization Profile

Care Coordination Organization Profile

Understanding the Data

  • The Care Coordination Organization/Health Home Care Management Profile provides an overview of enrollment and care planning information for individuals with intellectual and/or developmental disabilities receiving OPWDD services.
  • Health Home Care Management, also known as Care Coordination, is provided by Care Coordination Organizations (CCOs). There are seven CCOs operating across New York State.
  • CCO Care Management is required for enrollment into OPWDD’s Home and Community Based Services (HCBS) Waiver.
  • The data displayed in this report represents statistics as of the end of calendar year 2023 with accompanying detail on data movements during January – December 2023.
  • The data is compiled from CCO roster data and self -reported information submitted to OPWDD through CCOs.
  • It is important to note that the COVID-19 health emergency had a significant impact on all CCOs’ operations. Although the Public Health Emergency (PHE) ended on 05/11/23, many flexibilities continued in effect after that date. Therefore, the data presented in this report may not be representative of timelines or demographical information during a typical year.

Care Management Enrollment

Figure 1:  People Receiving Care Management Services by Program Type (as of December 31, 2023)
A pie graph that shows HCBS Basic Plan enrollees: 3,697 (3%) and Health Home enrollees: 115,909 (97%)

Individuals have a choice of two service options, Health Home care management, which is the more comprehensive option, or HCBS Basic Plan Support, which is designed for individuals who do not need or want ongoing comprehensive care management.

The number of people receiving either Health Home or HCBS Basic Plan Support has remained constant at 97% and 3% respectively, since the implementation of CCOs.
 

Figure 2:  People Receiving Care Management Services by Program Type and Care Coordination Organization (as of December 31, 2023)
 Advance Care AllianceCare Design NYLife PlanPerson Centered ServicesPrime Care CoordinationSouthern Tier ConnectTri-County CareTotal
Health Home Services23,31427,26618,79617,0408,4821,29819,713115,909
HCBS Basic Plan Support Services1,223950446649132282693,697
Total24,53728,21619,24217,6898,6141,32619,982119,606

 

Figure 3: People Receiving Care Management Services by Care Coordination Organization (2023)
Southern tier connect: 1%, tri-county care: 17%, advanced care alliance: 20%, care design ny: 24%, LIFEPlan: 16%, person centered services: 15%, prime care coordination: 7%
Figure 4: People New to Receiving Care Management Services 
Bar graph of the numbers of people new to receiving care management services since 2018

A total of 37,687 people new to OPWDD Care Management services have enrolled since CCOs were implemented in 2018. Figure 4 breaks out this enrollment by years. On average only 1% of new enrollees select Basic HCBS Plan Support Services.

Figure 5: People New to Receiving Care Management Services by CCO
Care Coordination Organization2023Historical Data-2022Historical Data- July 2018-December 2021Total
Advance Care Alliance1,1987332,9994,930
Care Design NY1,2381,1775,3967,811
Life Plan9819613,1025,044
Person Centered Services7778232,219 3,819
Prime Care Coordination5395212,361 3,421
Southern Tier Connect7686343505
Tri-County Care2,4802,4247,25312,157
Total7,2896,72523,67337,687

CCO Disenrollment

Figure 6: Disenrollment Count and Percentages by Reason (2023)1
Bar graph that shows percentages of the reasons people disenrolled. Passed away: 23%, voluntary withdrawal from CCO: 22%, moved out of state: 20%, transferred to another CCO: 16%, not residing in a CCO eligible setting: 12%, enrolled in another comprehensive care management program not delivered through a CCO: 5%, requirements not met for level of care: 1%, ineligible for Medicaid: 1%

(1) Data Source = Roster, CCO 2 Forms Completed in CHOICES by CCOs. This data includes people who transferred from one CCO to another but who are still enrolled in a CCO. Additionally, the Reason for Disenrollment “Transferred to another CCO” also includes people who moved out of the CCO’s catchment area.

Figure 7:  Count of People Disenrolled from each CCO (2023)
Care Coordination OrganizationTotal Enrollments (as of December 31, 2023)Total Disenrolled January - December 2023Percentage of Disenrolled compared to Total Enrollments
Advance Care Alliance24,5379013.67% 
Care Design NY28,2161,1404.04% 
Life Plan19,2429665.02%
Person Centered Services17,6898354.72% 
Prime Care Coordination8,6145886.83% 
Southern Tier Connect1,326725.43% 
Tri-County Care19,9827173.59% 
Grand Total119,6065,2194.36% 

 

Figure 8: Disenrollment Count by Reason and CCO (2023)
Reason for DisenrollmentACACDNYLPPCSPCCSTCTCC
Voluntary Withdrawal from CCO17121822119417413232
Passed Away180344258229651576
Moved Out of State1901791431268612145
Transferred to Another CCO21951461437311322134
Not Residing in a CCO Eligible Setting12413612811345778
Enrolled in Another Comprehensive Care Management Program Not Delivered Through a CCO1793202537230
Requirements Not Met for Level of Care121944626018
Ineligible for Medicaid1259138-14
Grand Total9011,14096683558872717

2: The Reason f or Disenrollment “Transferred to another CCO” also includes people who moved out of the CCO’s catchment area.

CCO/Health Home Care Management Care Planning

Figure 9: Completion of Life Plans for New Enrollees (2023)
CCOs have 90 days from CCO enrollment to finalize an initial Life Plan for individuals new to CCO services. Figure 9 includes metrics based on enrollees new to care management who enrolled between November 2022 and October 2023, as these individuals would have a Life Plan due in the year 2023.
CCO Name% of Life Plans Completed for Individuals New to CCO Services- 90 Days% of Life Plans Completed for Individuals New to CCO Services- 120 Days
Advance Care Alliance78%95%
Care Design NY77%89%
Life Plan88%98%
Person Centered Services74%90%
Prime Care Coordination88%95%
Southern Tier Connect69%90%
Tri-County Care91%95%
Statewide Average85%94%

 

Figure 10: Completion of Annual Life Plans for All Enrollees (2023)
CCOs perform annual assessments to inform the review and revision of Health Home and Basic Plan Support Life Plans annually for all enrollees. Figure 10 depicts the percent of total enrollees’ annual Life Plans finalized within the annual required timeframe.
CCO NamePercent of Annual Life Plans Completed Within the Annual Timeframe
Advance Care Alliance98.16%
Care Design NY95.46%
Life Plan99.71%
Person Centered Services98.41%
Prime Care Coordination97.53%
Southern Tier Connect96.08%
Tri-County Care88.49%
Statewide  Average96.15%