As a process measure, it is not designed to address the outcome of care planning—whether the services authorized by MLTSS plans and specified in the care plan meet members’ goals. One way to evaluate this outcome is through person-reported outcome measures reported through a survey or another method that asks individuals about their perspective on their care.

In these circumstances, MLTSS plan records should clearly document that no caregiver was involved to satisfy the measure criteria. For example, there are situations in which it may not be appropriate to engage the caregiver, including cases in which the member refused to involve the caregiver, or the invited caregiver declined to participate. Reasons for lack of caregiver involvement are not required; documentation that a caregiver was not involved suffices.

There must be documentation that at least three attempts were made to reach the member, and they could not be reached. The rate of exclusion due to inability to reach a member should also be reported along with the measure performance rate.

To meet the LTSS Comprehensive Care Plan and Update measure numerator, the care plan must be signed by the member, unless the care plan is under appeal in the specified timeframe, and there is documentation that the care plan was in appeal. There is an exclusion for members who refuse to take part in care planning. This exclusion is reported with the measure rate, so the overall measure rate can be interpreted correctly.

There must be documentation of the refusal, which would result in exclusion from the measure. The rate of exclusion due to a member refusing to participate should be reported along with the measure performance rate.

Use the most recently updated care plan.