CMS HCBS Quality Initiative Nancy Thaler CMS/DEHPG Quality Team May 5, 2004

Why would you care?

Reality Waiting List “Friends”

Singing from the same page Increases the likelihood of success

Context for the Focus on Quality Growth & Expansion of HCBS waiver programs Growth in funding  $1.6B federal funds in 1991  $20.7B federal funds in 2004…..130% increase  Growth in people served  800,000 people  No. of 65+ will double between from 35 M to 70M Services are dispersed  Hundreds of thousands of locations across the community Self Direction presents challenges for assuring quality

Context for the Focus on Quality  GAO Report….August, 2003 Review of Federal Oversight of HCBS Waiver Programs Findings: 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

Context …..CMS Action Plan * Context …..CMS Action Plan *  Components of Quality: more detailed criteria for states  Grants to States  Quality projects;  Direct Service Worker;  Real Choices  Quality Framework  Independence Plus waiver template  Promising practices * Letter to Senators Grassley & Breaux

CMS Quality Initiatives  Quality Framework The foundation for Quality  Quality Inventory Report Learning what states need  Helping the states National Quality Contract …technical assistance Quality Tools Promising Practices Real Choice Grants ….$165M  Structural changes New Application & reporting requirements Changing federal over sight practices

What is Quality?

Quality Framework Focus Areas Participant Access Information and referral; intake and eligibility determination; referral; choice Participant Service Planning Assessment; service plan, implementation & monitoring; respond to changing needs; choice; participant direction Provider Capacity Licensure and certification; training; provider monitoring Participant Safeguards Incident management; risk assessment; behavior management ; med administration; natural disasters Rights and Responsibilities Due process; grievance procedures Outcomes and Satisfaction System Performance Quality Improvement program; financial management

Quality Framework Processes  Design…  Design… build quality in up front  Discovery…  Discovery… look for problems & opportunities for improvement  Remediation…  Remediation… fix problems  Improvement…  Improvement… make improvements

Total Quality Improvement Cycle Plan Do Check Act Design Discovery Remediation Improvement

Quality Inventory  Oct 02 – Jan -3  MR/DD and Aging/Disabled Waivers 246 waivers 750,000 people Response rate – 87%  Objective: to inventory state practices and identify T.A. needs

Access Most states report multiple strategies to ensure access & are making efforts to streamline. Person-centered practices 1/2 of states’ MR/DD waivers and 1/3 of E/D waivers report using self-directed services. What states call self-direction varies greatly. Provider Capacity Most states establish qualifications for providers and conduct a review of services delivery. Safeguards Most states have an Incident reporting and investigation system, do criminal record checks: ED waivers have abuse registries. Rights and responsibilities Almost all states have grievance mechanisms. Most provide individuals with alternate avenues (ombudsman) to register Outcomes/satisfactions 90% of states collect information about individual/family satisfaction 50% + collect information about outcomes System Performance States recognize the importance of measuring performance

Quality Inventory: MR/DD Findings Most programs are run by program agencies/not Medicaid agencies 87% MR/DD 70% A/D Local non-state entities have a role in 44% waiver 87% MR/DD have major initiatives to strengthen HCBS quality Gauging participant satisfaction was common practice; measuring participant outcomes was not 61% MR/DD monitor health status Most states have grievance/complaint systems Few states have Info. Tech capable of supporting QM

Quality Inventory: MR/DD Challenges Developing data based performance benchmarks Compiling information on the use of behavioral interventions Conducting mortality reviews Conducting medication reviews/reporting med errors Lowering case management ratios Strategies to promote access to health care Developing technology systems to support QM

National Contractor for HCBS Quality Resource to CMS Regional Offices (RO) and States Urgent or Emergent follow-up in special circumstances State requests for consultation Contractors to assist in Root Cause Analysis and identification of quality improvement strategies

Quality Tools Participant Experience Survey (PES)  Voluntary Tool for States  2 Modules: Elderly/Non-elderly disabled and MR/DD  Field-tested on more than 700 waiver participants  Electronic version available HCBS Quality Work Book  Step-by-step guidance on how to conduct quality improvement activities in HCBS, within the context of the Framework  Discusses how to use data for QI

Promising Practices: Identify and describe promising practices within states  Highlight both broad systems reform efforts  (e.g., Michigan’s 1915b/c combo for specialty services) and specific tools utilized by states  (e.g., Wyoming’s method for individual budgets)  Data Readiness Project  Compile info on selected QI activities that are data driven  Technical assistance briefs to states

CMS: Changing approach to Quality Past…. an inspection model that is based on personal observation and case reviews once during the life of a waiver Future…. a QM data driven model with continuous over-sight  Quality elements are designed into the program  Each state has a quality strategy to continually evaluate it’s own performance, to correct deficiencies and make system improvements….which will tell us if assurances are met outcomes are achieved people are satisfied  CMS reviews the effectiveness of the state’s Quality Management Strategy

Waiver Life Cycle…as it has been Waiver Life Cycle…as it has been CMS review State Waiver App State Waiver Renewal App CMS review CMS visit Findings and Recommendations CMS Report

Building Quality into the into the Waiver Life Cycle Waiver Life Cycle Yr S Yr S Yr S Yr S CMS visit CMS visit CMS review State Waiver App Q M State Waiver Renewal App QM Findings and Recommendations CMS Report CMS review

The Waiver Application: States Design Quality in Upfront !  A. Participant Access  The process and time frames to evaluate/re-evaluate the level of care for applicants  B. Participant-centered service planning and delivery Assess participants’ needs (personal goals, health and safety) Plan of Care: approving and updating/revising them Participant involvement in POC development Person responsible for monitoring the POC Providing participants with information about services and choice

The Waiver Application  C. Provider capacity and capabilities Service definitions Service limitations…. e.g. dollar limit; unit limit Provider requirements: licensure/certification and training Agency responsible to verify and actions taken when providers do not meet requirements  D. Participant Safeguards/Protecting Health and Welfare Managing instances of abuse, neglect, and exploitation (including the use of chemical, physical and manual restraint) Criminal background checks The state’s oversight of administration of medications Emergency back up Assure the safety of in the case of natural disasters

The Waiver Application  E. Participant Rights The state’s process for informing participants and assisting them in exercising their Medicaid due process rights The state’s recipient grievance/complaint system  F. Participant Satisfaction and Outcomes The state’s method or plan to solicit feedback on satisfaction with services from consumers and families The state’s method or plans for measuring participant outcomes

The Waiver Application  G. Systems Performance  State’s Quality Management Strategy  Structure of the QM program  Roles of Medicaid, operating and local agencies  Involvement of participants, families and other stakeholders  Contracts with independent review entities  Methods of Discovery; sources of data and Indicators  Process for priority determining improvement  Reporting to the public  The process for evaluating and updating the QM strategy  Financial Management System  The state’s system for reimbursing claims Single audit  Funding flow / four funding questions

The State Annual 373 Report: States report on quality yearly! Level of Care Determination  An evaluation for level of care is provided to all applicants  Enrolled participants are reevaluated at least annually  The process and instruments described in the approved wavier are applied  The state monitors level of care decisions and takes action Plan of Care  POCs address all participant’s assessed needs (including health and safety risk factors) and personal goals  POCs are updated/revised when warranted  Services are delivered in accordance with the POC  The state monitors POC development

The Annual Repot Choice  Participants are afforded choice  between waiver services and institutional care  between/among waivers services and providers Qualified Providers  The state verifies that providers meet required licensing and/or certification standards  The state monitors non-licensed/non-certified providers  The state identifies and rectifies situations where providers do not meet requirements  The state implements its policies and procedures for verifying that training is provided

The Annual Repot Health and Welfare  The state, on an ongoing basis, identifies and addresses and seeks to prevent instances of abuse, neglect, exploitation Administrative Authority  The Medicaid agency or operating agency conducts routine, ongoing oversight of the waiver program Financial Accountability  State financial oversight exists to assure that claims are coded and paid in accordance with the reimbursement methodology specified in the approved waiver.

. When Will the Change Happen? Interim Procedural Guidance….January 2004 Interim Procedural Guidance….January 2004 New CMS oversight procedures Request that a state provide evidence (not policies and procedures) that there are practices in place to monitor its own performance A review of the evidence provided by the state Follow up on an as needed basis A report based on the evidence

To find out more about CMS Quality InitiativesTo find out more about CMS Quality Initiatives Action Plan to Senators Grassley and Breaux Quality Framework Quality Inventory Report The Work Book Report to Sen. Grassley and Breaux Promising Practices Real Choice Grantees NT