1. Human Services Research Institute Overview of Quality Assurance and Enhancement A Framework for Future Directions, Trends and Promising Practices June Rowe and Sarah Taub Human Services Research Institute

2. Human Services Research Institute Changing Quality Landscape Exposure of fault-lines in the system (e.g., GAO report, etc.) Exposure of fault-lines in the system (e.g., GAO report, etc.) Emergence of self-determination Emergence of self-determination Olmstead decision and proposed closures Olmstead decision and proposed closures Struggles with MIS applications Struggles with MIS applications Direct support staff shortages Direct support staff shortages Expansion of supports to individuals on the waiting list Expansion of supports to individuals on the waiting list

3. Human Services Research Institute 23 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 Decreasing/static funding – coming on top of an already strained provider network Increasing federal expectations regarding a quality framework Increasing federal expectations regarding a quality framework Inefficient “business model” (e.g., clumsy rate structures, redundant, sometimes conflicting monitoring processes) Inefficient “business model” (e.g., clumsy rate structures, redundant, sometimes conflicting monitoring processes)

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

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

7. Human Services Research Institute CMS is also opening up the discussion about quality….. The Quality Framework

8. Human Services Research Institute HCBS Quality Framework rights and responsibilities Domains Participant access Provider capacity and capabilities Participant safeguards Participant outcomes and satisfaction System performance Participant- centered service planning and delivery Participant rights and responsibilities Quality

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

10. Human Services Research Institute Participant-Centered Service Planning and Delivery  Participant-Centered Planning Adequate assessmentAdequate assessment Free choice of providersFree choice of providers Responsive service planResponsive service plan Participant directionParticipant direction  Service Delivery Ongoing service and support coordinationOngoing service and support coordination Provision of needed servicesProvision of needed services  Ongoing monitoring  Responsiveness to changing needs

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

12. Human Services Research Institute Participant Safeguards  Prevention and investigation of abuse, neglect and exploitation  Tracking of major and unusual incidents  Ensuring safety of housing and environment  Regulation of behavior interventions  Standards for medication management  Provisions for personal safety and security  Preparation for natural disasters and other public emergencies public emergencies

13. Human Services Research Institute Participant rights and responsibilities Ensure that participants: Ensure that participants: Exercise civic and human rights Exercise civic and human rights Participate in decision making authority Participate in decision making authority Have provisions for alternate decision making Have provisions for alternate decision making Have access to due process and grievance mechanisms Have access to due process and grievance mechanisms

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

15. Human Services Research Institute System Performance Conduct system performance appraisals Conduct system performance appraisals Support quality improvement Support quality improvement Ensure cultural competency Ensure cultural competency Support participant & stakeholder involvement Support participant & stakeholder involvement Maintain financial integrity Maintain financial integrity

16. Human Services Research Institute

18. Continuous Quality Improvement Close the loop  Information from quality assurance drives decision making! drives decision making! Therefore…. Therefore….

19. 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  Analysis of specific trends  Plan of correction  Provider Qualification

20. Human Services Research Institute What does this means for how states are thinking about quality? Example 1: 5 state licensing study

21. Human Services Research Institute  Respect and dignity  Rights and responsibilities  Personal safety and risk  Abuse neglect (critical incidents)  Environment  Individual’s funds  Health and Medication  Community inclusion and integration  Independence and Autonomy  Choice and decision-making Person-Centered Outcomes

22. Human Services Research Institute Strong relationship of person-centered outcomes to service planning Individual involvement in planning Individual involvement in planning Identifying people’s preferences, choices (e.g., services, housemates, work) and personal goals Identifying people’s preferences, choices (e.g., services, housemates, work) and personal goals Assessing/evaluating people’s needs for support Assessing/evaluating people’s needs for support Developing strategies for implementing goals Developing strategies for implementing goals Monitoring people’s progress Monitoring people’s progress

23. Human Services Research Institute Survey Methodology Person centered survey process have the following in common: Person centered survey process have the following in common: A representative sample of individuals served by the agency A representative sample of individuals served by the agency Surveys are completed through: Surveys are completed through: Documentation Review Documentation Review Interviews with individuals, staff, family, case managers Interviews with individuals, staff, family, case managers All surveys include observation of individuals in the location where they receive services All surveys include observation of individuals in the location where they receive services Surveys also include a review of agency documentation Surveys also include a review of agency documentation related to organizational strength and stability: related to organizational strength and stability: Staff orientation/training Staff orientation/training Incidents/Investigation reports Incidents/Investigation reports Internal QA Plans Internal QA Plans

24. Human Services Research Institute Safeguarding Outcomes & Requirements Most uniformly prescriptive set of requirements and outcomes: Rights Rights Informing individuals and family members about individual rights and responsibilities Informing individuals and family members about individual rights and responsibilities Abuse, neglect and exploitation Abuse, neglect and exploitation Reporting allegations of abuse Reporting allegations of abuse Investigate allegations, take action if the investigations are substantiated Investigate allegations, take action if the investigations are substantiated Protect individuals from harm Protect individuals from harm Restrictive procedures Restrictive procedures Psychotropic medications, behavior support plans, and restraints Psychotropic medications, behavior support plans, and restraints Require Require –Assessments –Behavior support plans –Data collection and monitoring –External review –Prohibitions or limitations on some restrictions Staff competency Staff competency

25. Human Services Research Institute Medications: prescriptive requirements for management and administration of medications Medications: prescriptive requirements for management and administration of medications Health: More prescriptive requirements for medications than health, although monitoring of health is growing: Health: More prescriptive requirements for medications than health, although monitoring of health is growing: Routine examinations Routine examinations Identification of health care needs Identification of health care needs Access to health care services Access to health care services special diets nutritional meals special diets nutritional meals Environmental Environmental Greatest requirements: larger residential living situations and/or residences that provided 24-hour staffing and site-based day supports Greatest requirements: larger residential living situations and/or residences that provided 24-hour staffing and site-based day supports Less prescriptive for more independent living situations, people lived in their own apartments and/or received less than 24-hour supports Less prescriptive for more independent living situations, people lived in their own apartments and/or received less than 24-hour supports Accessibility required when needed Accessibility required when needed

26. Human Services Research Institute More emphasis on staffing and staff competency Less emphasis on staff educational level and degrees Less emphasis on staff educational level and degrees Staff ratios less prescriptive; tied into individual needs Staff ratios less prescriptive; tied into individual needs Staff knowledge and competency seen as an essential safeguard! Staff knowledge and competency seen as an essential safeguard! Some training required before staff can work alone with individuals Some training required before staff can work alone with individuals Emergency procedures (e.g., evacuation) Emergency procedures (e.g., evacuation) Abuse/neglect reporting, Abuse/neglect reporting, Knowledge support strategies for the individual Knowledge support strategies for the individual Administration of medications (if the state has a delegated staff giving medications) Administration of medications (if the state has a delegated staff giving medications) Human rights Human rights Incident reporting Incident reporting First aid and CPR First aid and CPR Medication administration certification in many states Medication administration certification in many states

27. Human Services Research Institute Example 2: Monitoring Individual Providers

28. Human Services Research Institute QA/QI for Individual Providers Why now? Why now? –Increased self-direction –Services more individualized Vulnerabilities Vulnerabilities –Isolation of both the provider and individual –Who is responsible for the skills and competencies of the provider? –Oversight for provider quality left largely in the hands of the individual/family

29. Human Services Research Institute Challenges to Our Notions of Quality Preventive, upfront Preventive, upfront person-centered QA is key person-centered QA is key – –Basic qualifications, skills and competencies – –Identifying the person’s needs for support, risks, and degree of monitoring in the planning process – –Individual and family competencies to effectively manage individual providers

30. Human Services Research Institute Individual Providers = More Person-Centered QA Self-monitoring by educated individuals and families Ongoing monitoring by the case manager/support coordinator is critical for early detection/prevention of problems

31. Human Services Research Institute Monitoring the Quality of Individual Providers Consumer affairs or ombudsman office Consumer affairs or ombudsman office Published report cards on independent providers Published report cards on independent providers Person-centered review processes Person-centered review processes Citizen/peer networking and quality councils Citizen/peer networking and quality councils Consumer/family surveys Consumer/family surveys

32. Human Services Research Institute Given the changing landscape what are our immediate challenges and potential solutions for sustainability?

33. Human Services Research Institute Improving the Sustainability of Person-Centered Monitoring Improve the effectiveness and efficiency of current processes Improve the effectiveness and efficiency of current processes Integrate information (FL, PA) Integrate information (FL, PA) Develop internal QA systems Develop internal QA systems Integrate quality assurance responsibilities across the system (MA) Integrate quality assurance responsibilities across the system (MA)

34. Human Services Research Institute Improve Sustainability Involve families and people with disabilities (PA) Involve families and people with disabilities (PA) Improve up-front quality expectations upfront (PA) Improve up-front quality expectations upfront (PA) Increase transparency of QA systems and development of a demand for information (CT) Increase transparency of QA systems and development of a demand for information (CT) Explore quality assurance for individual providers (UT, OR, NH) Explore quality assurance for individual providers (UT, OR, NH)

35. Human Services Research Institute Conclusions and Recommendations

36. Human Services Research Institute Important Next Steps Place individual outcomes at the center of the system Place individual outcomes at the center of the system Enlist assistance of consumers and families Enlist assistance of consumers and families Identify key areas of performance Identify key areas of performance Create a quality management entity Create a quality management entity Make results available and accessible Make results available and accessible

37. Human Services Research Institute Develop uniform reporting of critical health and safety events Develop uniform reporting of critical health and safety events Develop staff credentialing and expand training options Develop staff credentialing and expand training options Reassess roles and responsibilities of case managers Reassess roles and responsibilities of case managers Refine performance contracting Refine performance contracting

38. Human Services Research Institute Expand understanding of participant centered planning Expand understanding of participant centered planning Develop a technical assistance capacity Develop a technical assistance capacity Implement risk management and health assessments (OR, MA, CA) Implement risk management and health assessments (OR, MA, CA) Build integrated data systems (CA, FL, PA) Build integrated data systems (CA, FL, PA) Develop hotlines and ombudspersons Develop hotlines and ombudspersons

39. Human Services Research Institute

41. Lessons for Providers Develop internal quality improvement plans Develop internal quality improvement plans Work with states to streamline QA/QE procedures Work with states to streamline QA/QE procedures Continue to work to upgrade the status of direct support professionals Continue to work to upgrade the status of direct support professionals Enlist people with disabilities and families Enlist people with disabilities and families Continue to train staff in person-centered principles Continue to train staff in person-centered principles Assume that quality assurance will become more comprehensive and systematic Assume that quality assurance will become more comprehensive and systematic

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