1. Human Services Research Institute Quality Assurance: It’s Everybody’s Business Valerie J. Bradley Human Services Research Institute October 23, 2003 South Carolina Association on Mental Retardation Myrtle Beach, South Carolina

2. Human Services Research Institute Changing Quality Landscape Exposure of fault-lines in the system (e.g., GAO report, etc.) Self-determination/self directed services Olmstead decision Recent CMS initiatives Direct support staff shortages Pressures to expand home and community services

3. Human Services Research Institute Developmental Disabilities Lawsuits 25 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services … Gary Smith, HSRI, 2003

4. Human Services Research Institute Decreasing/static funding – coming on top of an already strained provider network Increasing federal expectations regarding quality management Inefficient “business model” (e.g., clumsy rate structures, redundant, sometimes conflicting monitoring processes) Changing landscape …

5. Human Services Research Institute Growth in Waiver Services 1982…..a handful of waivers for a small number of people 2002…..90+ HCBS waiver programs for 380,000 people with developmental disabilities and growing Rapid expansion of HCBS waiver program has had profound effects on the configuration of state service delivery systems

6. Human Services Research Institute Changing Landscape Between 1999 and 2002, states expanded waiver programs by 110,000 individuals

7. Human Services Research Institute Implications Waiver program now serves more than three times as many people as ICFs/MR State service systems are extremely reliant on federal Medicaid dollars Services are being furnished at 10,000 sites by agencies and individual providers No amount of on site monitoring or reviews can provide an accurate picture of quality in increasingly complex systems

8. Human Services Research Institute Signs of Change in Performance Management No longer just better than the institution Rooted in outcomes Emphasis on enhancement and CQI Changing state role Changes in experiences and expectations of families and people with developmental disabilities

9. Human Services Research Institute More Signs of Change Changes in accreditation approaches Movement away from prescriptive standards to individualized risk management Collaborative development of standards Consumer and family participation in oversight (e.g., PA MN) Satisfaction CQI Consensus

10. Human Services Research Institute Federal Directions Federal policy directions are having a profound affect on QA/QI Revamped federal oversight framework Greatly heightened expectations for state quality management systems, especially in HCBS

11. Human Services Research Institute GAO Report on Federal Oversight of HCBS Waivers No detailed guidance to states on necessary components of a QA system States provide limited information about quality approaches in annual reports Quality issues have been identified in HCBS waivers CMS reviews are not timely (GAO Report: GAO-03-576 – 6/20/03 – www.gao.gov)www.gao.gov

12. Human Services Research Institute CMS Action Plan *  Components of Quality: more detailed expectations  Grants to States  Quality projects;  Direct Service Worker force;  Real Choices  Quality Framework  Independence Plus waiver template  Promising practices * Letter to Breaux and Grassley; also cms.hhs.gov/medicaid/waivers/quality.asp (Quality Workplan) cms.hhs.gov/medicaid/waivers/quality.asp

13. Human Services Research Institute CMS Action Plan  Strengthen Federal Oversight  Training for central and regional office CMS staff  CMS procedural guidance for reviews  Resource and strategy review…more cost effective method to review and improve services  Improve Federal Follow-up Capability  Technical assistance projects (National Contractors for Quality)

14. Human Services Research Institute CMS Action Plan  Obtain more Information about quality from states  Revamp waiver application  States spell out quality management system  Annual State Quality Reports  Improve content  Electronic media: convert 372 report to electronic  Electronic database to track waivers  Quality Inventory

15. Human Services Research Institute National Contractor Funded by CMS Started in 2001 with TA for Develop- mental Disabilities Waiver Services Expanded in 2003 to provide TA for Elderly/Disabled Waiver Services In-house expertise and over 50 experienced consultants

16. Human Services Research Institute Types of Technical Assistance On-site and off-site individualized TA to state agencies administering HCB services Creating resources and products for all states State to state linkages & sharing of resources Presenting at state and national conferences

17. Human Services Research Institute Major Tasks To assess identify trends in quality issues flowing from Regional Office HCBS waiver reviews To provide on-site and short-term technical assistance to the states to address specific quality and health/welfare concerns To provide technical assistance to CMS Regional Offices re content of HCBS waiver reviews, applications, renewals or amendments

18. Human Services Research Institute Major Tasks To respond to crisis situations at the request of CMS in order to provide Regional Offices and/or states with rapid access to potential remedies and resources. To provide national consultation and technical assistance regarding quality assurance and improvement in the implementation in HCBS waivers for people with developmental disabilities

19. Human Services Research Institute National Technical Assistance Resources Resources available on HCBS.org:  CMS Waiver Review Trend Analysis  Five State Monitoring Review  Root Cause Analysis  Quality Framework  Future: Lessons learned, state examples, etc. Toolkits (e.g., sampling etc.) Web-based conferences “Match making” between and among states Facilitated conference calls

20. Human Services Research Institute HCBS Quality Framework cms.hhs.gov/medicaid/waivers/frameworkmatrix.asp

21. Human Services Research Institute Participant Access Information and Referral Intake and Eligibility  User-friendly processes  Eligibility determination  Referral to community services  Individualization of services  Prompt initiation

22. Human Services Research Institute Participant-Centered Service Planning and Delivery  Participant-Centered Planning  Adequate assessment  Free choice of providers  Responsive service plan  Participant directed services  Service Delivery  Ongoing service and support coordination  Provision of needed services  Ongoing monitoring  Responsiveness to changing needs

23. Human Services Research Institute Provider Capacity and Capabilities Availability of individual and agency providers Review of provider qualifications Monitoring of provider performance

24. Human Services Research Institute Participant Safeguards  Risk and safety planning  Critical incident management  Ensuring safety of housing and environment  Use of behavior interventions  Medication management  Natural disasters and other public emergencies

25. Human Services Research Institute Participant rights and responsibilities Civic and human rights safeguards Decision making authority Provisions for alternate decision making Due process and grievance mechanisms

26. Human Services Research Institute Participant Outcome and Satisfaction Participant outcomes Participant satisfaction

27. Human Services Research Institute System Performance Conduct system performance appraisals Conduct quality improvement projects Ensure cultural competency Engage participants & stakeholders in program design, quality assurance and improvement activities Assure financial integrity

28. Human Services Research Institute Continuous Quality Improvement Close the loop  Information from quality assurance drives decision making! Therefore….

29. Human Services Research Institute Continuous Quality Improvement Design Features Outcomes indicators Provider enrollment Rules, policies, Procedures Quality Improvement  Trends Analysis  Benchmarking  Strategic Planning Remediation  Real time tracking of incidents and follow-up  Plan of correction  Provider Qualification

30. Human Services Research Institute Quality Framework … Will drive revamped HCBS waiver application AIM: shift federal oversight from periodic compliance reviews to assessing effectiveness and functionality of state quality management system Concentration on data/reporting

31. Human Services Research Institute  Very high volume of activity to modify/strengthen QA/I systems  Plugging gaps/rethinking basic processes  Focus: Participant outcomes (National Core Indicators)  Focus: Securing systematic feedback from individuals and families  Focus: risk assessment/planning State Directions

32. Human Services Research Institute More Directions  Focus: Incident management  Focus: Functionality and effectiveness of service planning processes and plan implementation  Focus: Rethinking QA/I in context of individual and family-directed services  Focus: Data systems in support of quality management

33. Human Services Research Institute A FEW EXAMPLES FROM A MORTALITY REPORT

34. Human Services Research Institute 22% of deaths were due to Heart Disease 22% of deaths were due to Cancer 19% of deaths were due to Pneumonia/Lung Diseases including 3% due to aspiration pneumonia 14% of deaths were due to Nervous System Diseases including Alzheimer’s (7%), Anoxia (3%),Epilepsy (2%), and Parkinson’s (1%) 5% of deaths were due to Renal Failure 4% of deaths were due to Digestive System Diseases RANKConnecticut DMR Calendar Year 2002 Connecticut Calendar Year 1998 (most recent available) U.S. Calendar Year 2001 1 Heart Disease Cancer Heart Disease 2 Respiratory Disorders Cancer 3 Nervous System Disorders Respiratory DisordersCerebrovascular Diseases (incl Stroke) 4 Renal FailureAccidentsChronic Respiratory Diseases Benchmarks: Leading Causes of Death FY03 Leading Causes of Death A FEW MORE EXAMPLES FROM A MORTALITY REPORT

35. Human Services Research Institute

37. COMPARATIVE ANALYSES Useful as tool to help focus attention on differences Identify areas needing further review and analysis Can target analysis to region, type of provider or service Can combine with trends analyses to identify changes over time by region, provider or service BASIC ANALYSIS OF SIMPLE DATA

38. Human Services Research Institute Variables Significance (smaller than.05) STRONGEST PREDICTORS Strength (How much it Contributes to Mortality) 1 3 2 AGE MOBILITY SUPERVISION Important Finding:

39. Human Services Research Institute Variables in Logistic Equation Mortality Prediction Probability (How much more likely to Die than reference group) 1 3 2 People who are: MOBILITY DEPENDENT are 6X as likely to die as people who are mobility independent EXAMPLE

40. Human Services Research Institute Conclusions and Recommendations

41. Human Services Research Institute We need to change our approach to Quality “Our level of thinking has created problems that cannot be solved by the same level of thinking” Albert Einstein

42. Human Services Research Institute Important Next Steps Place individual outcomes at the center of the system Enlist involvement of consumers and families Identify key areas of performance and develop indicators Create a quality management entity Explore hotlines and ombudspersons

43. Human Services Research Institute Develop uniform reporting of critical health and safety events Implement risk management and health assessments Develop staff credentialing and expand training options Reassess roles and responsibilities of case managers Refine performance contracting Develop internal QA systems Integrate quality assurance responsibilities across the system

44. Human Services Research Institute Improve up-front quality expectations Increase transparency of QA systems and develop a demand for information Explore quality assurance for individual providers Expand understanding of participant centered planning Develop a technical assistance capacity Build integrated data systems

45. Human Services Research Institute Lessons for Providers Develop internal quality improvement plans including trending and risk management Work with states to streamline QA/QE procedures Continue to work to upgrade the status of direct support professionals Enlist people with disabilities and families Continue to train staff in person-centered principles Recognize that quality assurance will become more comprehensive and systematic

46. Human Services Research Institute Final Words “ Beware the Continuous Improvement of Things Not Worth Improving ” W. Edwards Deming