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 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 Human Services Research Institute

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

Human Services Research Institute Changing landscape … 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) 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 Human Services Research Institute

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

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 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 Human Services Research Institute

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 Consensus CQI Human Services Research Institute

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 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) Detailed guidance…………new waiver template requirements More information from states……Revise the 372 report to require more reporting CMS reviews must be done and must be on time. Since resources are limited, we have to find a new and better way to conduct reviews. Human Services Research Institute

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) Sept 30 release of Real Choices Grants. 32 applications focused on Quality: a significant number will be funded. T.A. contractor to support them The Quality Framework is accepted and is being used by states and the training contractors. We are working on a new waiver template that incorporates the elements of self-direction. Human Services Research Institute

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) This two day training of Co and RO staff is part of the action plan. You will all be developing procedural guidance together. Human Services Research Institute

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 The new waiver template will incorporate self- direction and more specific requirements for improving quality The 372 report is under revision……Mark Davis has consulted with some of you Electronic data base…….it will be necessary for CMS CO to track waivers, reviews, amendments etc. Quality Inventory……I will explain more about this later Human Services Research Institute

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 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 Human Services Research Institute

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 Human Services Research Institute

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 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 Human Services Research Institute

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

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 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 Human Services Research Institute

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

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

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 Human Services Research Institute

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

Continuous Quality Improvement Human Services Research Institute

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 Human Services Research Institute

Human Services Research Institute State Directions 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 Human Services Research Institute

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 Human Services Research Institute

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

FY03 Leading Causes of Death Benchmarks: Leading Causes of Death A FEW MORE EXAMPLES FROM A MORTALITY REPORT FY03 Leading Causes of Death 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 Benchmarks: Leading Causes of Death RANK Connecticut DMR Calendar Year 2002 Connecticut Calendar Year 1998 (most recent available) U.S. Calendar Year 2001 1 Heart Disease Cancer 2 Respiratory Disorders 3 Nervous System Disorders Cerebrovascular Diseases (incl Stroke) 4 Renal Failure Accidents Chronic Respiratory Diseases Human Services Research Institute

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Human Services Research Institute COMPARATIVE ANALYSES BASIC ANALYSIS OF SIMPLE DATA 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 Human Services Research Institute

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

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

Conclusions and Recommendations 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 Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

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 Human Services Research Institute

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