Wisconsin Collaborative – Bringing Quality Improvement to Assisted Living Communities Heather Bruemmer, Executive Director/State Ombudsman, Wisconsin Board on Aging & Long Term Care Kevin Coughlin, Policy Initiative Advisor-Executive, Wisconsin Department of Health Services (DHS)

Covered Topics Overview of the Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL) Critical Role of the State Ombudsman Program Current Projects and Next Steps WCCEAL Potential as a National Model Demonstration of the WCCEAL QI (Quality Improvement) Website

History and Critical Events WCCEAL Fact Sheet https://www.dhs.wisconsin.gov/publications/p01584a.pdf

Media Attention USA Today investigation series, 2004 Washington Post Series, 2004 CBS News, “Assisted Living Erratic Regulations,” 2006 New York Times, “Assisted Living Care: ‘Uneven and Often Problematic,’” 2008 Miami Herald, “Neglected to Death” series, 2011 Frontline, “Life and Death in Assisted Living,” 2013

Federal Government Attention Assisted living (AL) workgroup: 2001-2003 Government Accounting Office (GAO) reports

Federal Government Attention (cont’d) U.S. Senate Special Committee on Aging - hearings Ensuring Quality and Oversight in Assisted Living, 2011 Roundtable: Assisted Living at the Dawn of America's “Age Wave”: What Have States Achieved and How Is the Federal Role Evolving?, 2011 Continuing Care Retirement Communities (CCRCs): Secure Retirement or Risky Investment?, 2010 Assisted Living: Examining the Assisted Living Working Group Final Report, 2003

Collaboration Key First Step

Critical Role of the State Ombudsman Program A Voice for Residential Long Term Care Consumers: http://longtermcare.wi.gov/docview.asp?docid=21554&locid=123 Making the Right Choice: Choosing a Residential Facility http://longtermcare.wi.gov/docview.asp?docid=19904&locid=123

Critical Role of the State Ombudsman Program (cont’d) Involvement of the Ombudsman Program from the very beginning of the collaborative was crucial Voice for the consumers living in assisted living facilities Support from the Department of Health Services and the provider associations was valuable as we became a key partner for WCCEAL

Critical Role of the State Ombudsman Program (cont’d) State Ombudsman involvement enabled discussion on Resident Rights and Resident Satisfaction in the assisted living facilities in Wisconsin Regional Ombudsmen educated providers about the WCCEAL collaboration throughout the state when doing Ombudsman work at the facilities

Internal Quality Improvement Essential to maintain quality Structure, process and outcome measures used to evaluate quality

WCCEAL Membership criteria The assisted living community is a member of a major association in good standing (Wisconsin Assisted Living Association [WALA], LeadingAge, Wisconsin Center for Assisted Living [WiCAL]). The community is licensed as an assisted living community. The community has implemented a provider association and department-approved quality improvement program. Adhere to membership rules. The provider has made a self-attestation that they are in substantial compliance with all regulations.

WCCEAL Provider association sponsored Department approved Comprehensive quality assurance and quality improvement (QA and QI) Includes nine guiding values (handout) https://www.dhs.wisconsin.gov/publications/p01584.pdf

One of the Major Guiding Values Continuous Quality Improvement Quality benchmarks Data collection Performance analysis Continuous efforts

Grant to Build the IT Infrastructure UW Institute for Clinical and Translational Research, $200,000 grant July 2011-June 2013

What Should We Collect?

QA and QI Facility information Resident information Quality measures: QI structure and process Resident satisfaction QI clinical outcomes

WCCEAL individual assisted living communities: Firewall WCCEAL individual assisted living communities: * Satisfaction results * Indicators *Other reported information Department of Health Services, Division of Quality Assurance, Division of Long Term Care, advocates, and public

What Information Will the AL Community Be Able to Access? Resident satisfaction: Community-specific data including comments Aggregate data from the relevant association to measure performance Aggregate WCCEAL data to measure performance Quality improvement variables: Community-specific data Peer group data to measure performance

What Data Do the Associations Have Access To? Resident satisfaction: Data from AL communities within each respective association, including individual resident comments Aggregate data from each respective association Aggregate WCCEAL data Quality improvement variables: Data from AL communities within each respective association Data from peer groups

What Data Does DHS Have Access To? Reports on satisfaction and quality indicators for: Overall WCCEAL Overall by association Overall by peer grouping (i.e., by client group, by size, or by other demographics) Note: DHS does not have access to an individual AL community’s data. Note: Ombudsman Program does not have access to an individual AL community’s data.

DHS Expectations When Issues Are Identified with an AL Community AL community will put mechanisms in place to improve identified quality issues. AL community’s association will provide assistance and support for improvement efforts. Center for Health Systems Research and Analysis (CHSRA) will help associations identify issues from the reports and possible strategies to improve. The AL community’s association will hold the community responsible for implementing its QA/QI program.

How the Department Will Use the Report Data Ongoing evaluation of the WCCEAL association's QA and QI approvals Deploying resources to improve the AL community and support WCCEAL participants Justifying less oversight of WCCEAL qualifying participants to legislators, advocates, funding agencies, and the public Branding WCCEAL as a marker of quality for possible use in value-based purchasing, insurance discounts, and other comparable circumstances

Innovations in American Government Award Program. WCCEAL received the 2014 designation as a Bright Idea.

2016 AHFSA Promising Practice Award Association for Health Facility Survey Agencies (AHFSA) Category – Quality Improvement, Regulatory Process http://www.ahfsa.org/annual-conference/promising-practices

Part of a Larger Community WCCEAL collaborative Access to resources and opportunities

Consumer Demand Consumers are more savvy today. Consumers demand quality. Consumers seek resources and answers to important questions about long term care.

Advocates Assisted living growth is everywhere in this country, get involved and ask questions about the quality of life and care in your home states. Utilize consumer voice as a resource and our WCCEAL Program.

Competition Raise the bar on quality. Positioned to compete better in the marketplace.

Regulations Proactive approach to regulatory compliance Sustained regulatory compliance Regulatory relief: If qualified, then less frequent surveys

Insurance Companies Decrease risk Increase ability to obtain and retain liability insurance Discounts and reduced premiums

CMS Guidelines to the States for Home and Community-Based (HCBS) waivers Greater emphasis on quality Sections 1915 (c), (i) and (k) of the Act all require states to demonstrate at the time of approval that they have a quality improvement strategy that includes performance and outcome measures for the Medicaid Home and Community Based Services (HCBS) waivers.

CMS Guidelines to the States for HCBS waivers (cont’d) In Wisconsin, 51 percent of Family Care service expenditure was for AL (Residential Care Apartment Complexes (RCAC), Community-Based Residential Facilities (CBRF), and adult family homes (AFH)). Thirty-nine percent of enrollees had some service cost during the year for AL.

National Quality Forum Measuring HCBS Quality http://www.qualityforum.org/Measuring_HCBS_Quality.aspx This project developed a conceptual framework and performs an environmental scan to address performance measurement gaps in home and community-based services to enhance the quality of community living. Create a conceptual framework for measurement, including a definition for HCBS. Perform a synthesis of evidence and environmental scan for measures and measure concepts. Identify gaps in HCBS measures based on the framework. Make recommendations for HCBS measure development efforts.

Government Oversight and Support for Quality Program Enforcement QA & QI Nursing Home Assisted Living Federal Regulations ✔ State Regulations Quality Improvement Organization (QIO) Advancing Excellence Nursing Home Quality Initiative AHRQ Nursing Home Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare Quality Improvement Community (QIES) Nursing Home Compare – 5 Star Minimum Data Set Quality Assurance Performance Improvement (QAPI) Online Survey , Certification and Reporting (OSCAR) Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL)

Wisconsin Partnership Program (WPP) Grant WCCEAL awarded five-year $1,000,000 grant to expand current WCCEAL efforts and to establish a comprehensive and robust quality infrastructure for Wisconsin assisted living centers (ALCs). This project has five specific aims: Expand the reach of WCCEAL by working with our support community partners to implement specific strategies to expand active participation by Wisconsin ALCs. Improve the WCCEAL data infrastructure to enable ALC to make data driven quality improvement decisions.

WPP Grant (cont’d) Evaluate and assess how to integrate WCCEAL participation into the Division of Long Term Care Family Care Quality Strategy. Establish quality improvement collaboratives and informational resources to support ALCs in targeting and improving their individual quality performance. Assess the impact of WCCEAL participation on changes in quality indicators and in regulatory enforcement outcomes.

WCCEAL Demographics As of 12/31/2015

Current Projects Implement five aims of the WPP grant Fall prevention grant Music & Memory plus iPad grant Secretary Rhoades Music & Memory grant Early adopter study Continued talks with AMDA (The Society for Post-Acute and Long-Term Care Medicine)

Next Steps: WCCEAL Expand the model: Add more outcomes Additional learning modalities Potential expansions to other states Collaboration with national organizations (Assisted Living Federation of America (ALFA), National Center for Assisted Living (NCAL), LeadingAge, Consumer Voice, National Ombudsman Resource Center, Administration for Community Living)

AL Quality Collaborative Model Information Dissemination Quality Improvement Supports Quality Improvement Measures and Reports Assisted Living Community Certification

AL Quality Collaborative Model with External Partners Information Dissemination Quality Improvement Supports Quality Improvement Measures and Reports Assisted Living Community Certification Assisted Living Communities Regulatory Entities Managed Care Organizations Provider Associations Public Funding Agencies Advocates Researchers

WCCEAL Demo - Visitor Login Process https://wcceal.chsra.wisc.edu/ Username:  wccealvisitor New password is: armadillo123

Questions and Answers Contact information Heather Bruemmer, Executive Director/State Ombudsman Wisconsin Board on Aging and Long Term Care Heather.Bruemmer@wisconsin.gov 1-800-815-0015 Kevin Coughlin, Executive Policy Initiative Advisor Department of Health Services Kevin.Coughlin@dhswisconsin.gov 608-266-6989