Practical Approaches to Designing and Conducting Surveys for Quality Management Teresa Richard Texas Department of Aging and Disability Services 2006

DADS Texas Department of Aging and Disability Services (DADS) Texas Department of Mental Health and Mental Retardation Texas Department of Human Services Texas Department on Aging

Grant Award Grant Award - $500,000 Awarded by Centers for Medicare and Medicaid Services (CMS) September 30, 2003 – September 29, 2006 Texas one of 19 states

Task Force Quality Assurance and Quality Improvement (QA/QI) Task Force Convened in December 2003 Help DADS to develop and implement the goals of the grant Members include self-advocates, family members of people with disabilities, representatives of advocacy groups, providers, and community MHMR centers

QA/QI Task Force Members

Goal 1 Research and develop a methodology or tool that accurately reflects waiver participants’ experiences, and measures participants’ achievement of their goals and aspirations

Goal 1 Activities Task Force members reviewed eight survey tools The National Core Indicators (NCI) tool was chosen Task Force members developed six additional questions relating to self-determination

DADS Long Term Care Programs Operating agency for Long Term Care programs for older Texans and people with disabilities Leveraged existing funds used for Nursing Facility Long Term Care Quality Reviews Amended Rider language to include long term care programs in addition to nursing facilities

Conducting the Surveys for 2005 Amended existing contract with vendor Interviewers were Registered Nurses Future survey projects will use competitive bidding process and expand recruitment to LVNs and Social Workers

Interviews Face-to-face interviews with people 18 years of age and older who receive DADS’ Medicaid waiver and Intermediate Care Facilities for Persons with Mental Retardation (ICF/MR) Program Services Children/Family Mail Surveys for families of children under 18 years of age who receive services in DADS programs

Survey Tools National Core Indicators Consumer Survey Developed by the Human Services Research Institute Used for face-to-face interviews Four domains: consumer outcomes; system performance; health, welfare, and rights; self- determination

Survey Tools National Core Indicators Children Family Survey Used for mail surveys English and Spanish versions Used Dillman’s method for mail surveys

Survey Tools Participant Experience Survey (Elderly/Disabled) Developed by MEDSTAT Group, Inc. for the Centers for Medicare and Medicaid Services Used in face-to-face interviews Five domains: access to care; choice and control; respect/dignity; community integration/inclusion; and self-determination

Survey Tool Questions Task Force members developed six additional questions relating to self-determination Received permission and assistance from the developers of the tools to pilot questions HSRI to consider adding questions to survey for all states

Waivers NCI Consumer Survey Home and Community-Based Services Texas Home Living Deaf Blind – Multiple Disabilities Community Living Assistance and Support Services Intermediate Care Facilities for Persons with Mental Retardation Consolidated Waiver Program

Waivers PES Survey Community Based Alternatives Consolidated Waiver Program NCI Children Family Survey All children under 18 in four of the waiver programs

Sampling Methodology Face-to-Face Proportional sampling strategy used based on the number of people receiving services in each county by program Sample sizes valid at the 95% confidence level with a confidence interval of 5

Sampling Methodology Face-to-Face Sampling Methodology 254 counties in Texas 54,000 people receiving services (2005) 1,980 face-to-face interviews completed Sample size was determined by dividing the number of people in the county by the total number of people in the program multiplied by sample size needed for each program

Sampling Methodology Mail Surveys Mailed a survey to all families of children in the Medically Dependent Children Program (up to 21 years of age) Mailed surveys to families of children under age 18 and who live at home with their family in other waiver programs 2,060 surveys mailed 800 returned (39%)

Sampling Methodology Mail Surveys Employed method known as the Total Design Method (TDM) developed by Don A. Dillman Used a three-phased mail out approach Introduction letter Cover letter, survey, addressed/stamped return envelope Reminder letter Used green paper for visual appeal

Interviewer Recruiting/Training Vendor recruited RNs statewide through screening and interviews Interviewers attended full day of training in Austin, Texas Training was conducted by Sarah Taub from Human Services Research Institute Sara Galantowicz from MEDSTAT Group, Inc.

Training Training (con’t) DADS staff included training on process for reporting suspected instances of abuse, neglect, and exploitation Task Force members attended training and provided insight on self-determination questions Mock interviews conducted with self- advocates Provided Disability Etiquette training Videotaped for subsequent trainings

Results Included demographics about participants Indicators calculated for each program Quality indicators calculated based on the responses to the survey questions Published reports for both face-to-face and mail surveys Summary reports available on the DADS website (

Results Results reviewed by Task Force members and DADS internal workgroup Both groups identified top areas for improvement and developed strategies and recommendations Personal Choice and Life Decisions Self Advocacy

Next Steps Received approval from the Commissioner of DADS to move forward with recommendations and strategies Continue annual face-to-face and mail surveys to identify trends over time Expand number of programs surveyed Work with other internal and external entities to provide data analysis

Next Steps Data Mart Design and development of a Data Mart that will compile information regarding program provider performance and participant outcomes in DADS’ programs Will use survey data in tandem with Data Mart reports as tools to promote quality management