1. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ VD-HCBS Training Series VD-HCBS Quality Assurance Monitoring February 2, 2012 Kevin Foley, U.S. Administration for Community Living Lori Gerhard, U.S. Administration for Community Living Suzanne Crisp, National Resource Center for Participant-Directed Services

2. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Learning Objectives At the end of this session, participants should: 1.Be able to describe the components of a VD-HCBS Quality Assurance Program. 2.Understand the meaning of the term “CQI (Continuous Quality Improvement)” and creation of an environment that enables CQI to occur. 3.Understand the value of monthly quality assurance reviews and reports. 4.Understand how to link CQI results with National information to continue to inform VD-HCBS program development. 5.Be able to develop and implement a Quality Assurance Program for the local VD-HCBS Program.

3. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Agenda Definition of key terms Policy guidance and procedures Decision points Lessons learned and recommendations Next steps and timelines Questions and answers

4. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Definition of Key Terms Continuous Quality Improvement – a system that seeks to improve the provision of services with an emphasis on future results. CQI uses a set of statistical tools to understand subsystems and uncover problems, but its emphasis is on maintaining quality in the future, not just controlling a process. Once a process that needs improvement is identified, a team of knowledgeable individuals is gathered to research and document each step of that process. Once specific expectations and the means to measure them have been established, implementation aims at preventing future failures and involves the setting of goals, education, and the measurement of results. If necessary, the plan may be revised on the basis of the results, so that the improvement is ongoing. Quality Assurance- refers to the planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled. It is the systematic measurement, comparison with a standard, monitoring of processes and an associated feedback loop that confers error prevention. Quality Assurance Tools – Tools used to monitor an organizations performance. Examples include: Consumer Satisfaction, Process Mapping, A/R Report, Cash Flow Report, Performance Metrics (days cash on hand & days cash outstanding)

5. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Definition of Key Terms Quarterly Reconciliation – The process that occurs in comparing undesignated funds and the allocation to Emergency back-up and Savings plan versus Total Budgeted Amount. Cash Flow Management Report – Monthly report that includes cash received and cash paid out for loans and owner investments and purchase of fixed assets. The cash flow report is like the “checkbook” for the organization. The report records every cash entry into the business and cash payment out of the business on a monthly basis. Cash Cycle– The period of time from paying out cash to generate sales (paying employees, purchasing inventory) and the time until receipt of cash from those sales. For VD-HCBS the cash cycle begins with the referral from the VAMC and ends when the payment for the monthly services is received at the SUA/AAA. The cash cycle for VD-HCBS ranges from 5 days (for assessments) to 45-90 days for monthly payments.

6. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Definition of Key Terms Days Cash on Hand – A performance metric used to project the number of days operating expenses that a not-for-profit could pay with its current cash available. Formula is (Total cash on Hand divided by Daily Operating Cost = Days Cash on Hand) Operating Cost formula is (Non-Profit’s Total Operating Expenses divided by 365 = Daily Operating Cost) Days Cash Outstanding — A performance metric used to estimate the collection period. Formula is (Total Receivable/Total Revenue from Sales for Period) x Days in Period = Total Days Cash Outstanding. Risk Mitigation: A plan developed by the Veteran with support of the counselor addresses ways to reduce the possibility of negative outcomes associated with risk

7. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Business Acumen Business Plan Operating Budget Operating Statement & Census Report Accounts Receivable Accounts Payable Cash Flow Management Annual Program Performance

8. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Reports Reimbursement Authorization of Plan AAA bills 1 time full assessment fee Authorization of Plan AAA bills 1 time full assessment fee Authorization of Plan AAA bills 1 time full assessment fee Authorization of Plan AAA bills 1 time full assessment fee 8 A/R= (Accounts Receivable) Money coming in Referral Intake Assessment Candidate Not Appropriate for PD Bill 1 time half assessment fee Candidate Not Appropriate for PD Bill 1 time half assessment fee Candidate Appropriate for PD Candidate Appropriate for PD Authorization of Budget Amount 6 Develop Veteran Monthly Budget 5 Develop Plan Plan Distribution Employer Paperwork Hiring Assistance 11 Employee Paperwork Establish Employment Initiate Services 14 Programmatic Quality Assurance Monitoring Reports Planned Savings Fund Rainy Day Fund Timesheets and Invoices 13 Payments 16 Reassessment Reimbursement Quarterly Reconciliation Financial Quality Assurance Monitoring 4a 11 8 3 2 1 7 12 910 15 2017 1819 24 232221 4b VD-HCBS Model Work Flow A/P= (Accounts Payable) Money going out Initiate Services 14

9. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ 22 20 19 2321 Reports Reimbursement Programmatic Quality Assurance Monitoring Reports Reimbursement Quarterly Reconciliation Financial Quality Assurance Monitoring 1920 212223 VD-HCBS Model Work Flow

10. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Quarterly Reconciliation

11. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Quality Assurance Determine if services meet or exceed veteran expectations Identify steps to define and attain program goals Ensure excellence is inherent in every component of the process Determine if processes to provide services are efficient Uses measurable strategies to prove level of quality

12. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Quality Improvement Identify areas to enhance or change for the better Continually assess processes and activity Present as a permanent process

13. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ What is Quality? Satisfied Preferences and desires are acknowledged as key Rights are honoredPersonal goals are met Services and supports are accessible and available Outcomes are positive Veteran

14. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Quotes from Individuals Quality is: “I understand the program and can work through the system” “I am happy with my services” “I know who to call if I have a problem” “I am able to live in harmony with my own values” “I know how much my budget is and what I can do with it” “I know who is coming, when they are coming and what they will do when they get here”

15. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ What is Quality? Program operates as intended Managed effectively Financially responsible Delivered with person centeredness Monitored Routinely Continues to improve System

16. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Quotes from Organizations Quality is: “Are we doing what we said we’d do?” “Are persons being served timely and adequately?” “ Do we know if something goes wrong?” “Are we providing beneficial and accessible supports?” “Are budgets being used wisely?” “Can we prove we operate with high quality services?”

17. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Approach is Quite Simple What do you want to happen? How do you know it is happening? What do you do when it doesn’t happen? How do you improve? Veteran System

18. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Common Elements Veterans play a significant role to define, report, and evaluate quality Quality is essential to program integrity Critical first step is designing quality into a program Second critical step is to know how the program is working Third step is to correct problems There is always room for improvement

19. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Processes to Ensure Quality Skills of veteran are determined – Additional supports needed? – Representative needed? Veteran is informed – Rights, risks and responsibilities – Program permissibles Accurate assessment of need is conducted – Assessment is standardized but personalized

20. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ More Processes Service plan matches need with preferences – Veteran-directed process – Emergency plan created – Risks assessed and mitigated – Monitoring plan created Feedback is obtained – Veterans surveys – Others opinions

21. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ A Closer Look Participant surveys Risk assessment and mitigation Fraud and Abuse

22. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Participant Survey Collects information about program in a systematic way Obtains insight into Veteran’s opinion about specific topics Measures and compares improvement or decline over time Assists to detect problems or weaknesses Uses information to improve the program

23. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Risk Assessment and Mitigation Process Focused on the Veteran Creates a process to deal with risks in a standardized way - consistent & equitable Allows us to balance autonomy & self-expression with safety Assesses exposure to potentially harmful situations Develops a plan to prevent or reduce such exposure and to address it quickly if it occurs Reduces liability

24. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Identifying, Preventing and Managing Fraud and Abuse Clearly identify Veteran roles and responsibilities Provide information and training Ensure effective supports are available Conduct monitoring activities Establish effective communication paths

25. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Business Plan Operating Statement A/R Report Cash Flow Management Report Cash Cycle Performance Metrics Days Cash on Hand Days Cash Outstanding Annual Program Performance Some Tools for Continuous Quality Improvement (CQI)

26. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Operating Statement Content Current Month & YTD information: Actual Census compared to Projections Actual Revenue compared to Projections Actual Expenses compared to Projections Margin/Loss compared to Planned Margin/loss Purpose/Use Tracking actual performance to budget/projected performance Inform Continuous Quality Improvement (CQI) Manage operations (reducing or increasing activity) Monitor organization’s progress in achieving goals. Assure financial health of organization

27. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Cash Flow Management Cash Flow Management Report Sources of Cash – Cash on Hand – Bank Accounts – Lines of Credit Current & Future Obligations/Liabilities Days Cash on Hand (performance metric) Content Purpose/Use Compares available cash to current and future obligations Assures the organization has available cash to satisfy obligations Day to Day Management of Organization – Informs management regarding need and/or use of lines of credit – Identifies cash flow issues

28. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Cash Flow Management Report 2012DECJANFEB Cash out Inventory Expenditures $ - Operating Expenses --- Advertising --- Insurance225 Office Expense150 Office Supplies100 Payroll Expenses Salaries and Wages2000 Payroll Taxes300 Benefits1000 Rent4200 Loan Principal Payments (2.97%)148.5144.1139.8 Interest Payments (1%)50 VDHCBS Veteran Expenditures (Total VDHCBS)11003000 8725 Administrative Fee (FMS)100200 400 Total Cash Out9373.511369.117289.8 Monthly Cash Flow (Cash In-Cash Out)6,7022,118621 Ending Cash Balance16,70218,82019,441 Cash Flow Report Example 2012DECJANFEB Cash In Cash Sales$ - Collections from Accounts Receivables - Consumer Directed Programs VDHCBS 13253237.56811 Medicare Medicare Reimbursement650072507000 Private Pay Private Pay Income325030004100 Equity Received--- Loans Received5000-- Other Cash in (receipts from other assets)--- Other Cash in (Interest, royalties)--- Total Cash In16,07513487.517911 Beginning Cash Balance10,00016,70218,820 Total Cash Available (Ttl Cash In + Bgn Bal) 26,07530,18936,731

29. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Days Cash on Hand Calculating Day’s Cash on Hand 1.Identify organization’s Total Cash on Hand Organization’s annual operating expenses 2.Calculate organization’s daily operating cost : Organization’s Annual Operating Expenses/365 = Organization’s Daily Operating Cost 3.Calculate days cash on hand : Total Cash on Hand/Daily Operating Cost = Days Cash on Hand Definition A performance metric used to project the number of days operating expenses that a not-for- profit could pay with its current cash available.

30. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Accounts Receivable System Key Components Invoicing/Billing Cash Receipts Accounts Receivable Report Days Cash Outstanding ( performance metric ) Purpose/Use Generate bills to consumers and/or third party payers Assure timely receipt of payment for services rendered Monitor and manage payment collection process

31. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Sample Accounts Receivable Report Month Ending Feb 29, 2012 Example 1 CustomerPayer30 days (Feb- 29) 60 days (Jan)90 days (Dec)120 + days (Nov +) Totals Bolt, BPP$525 $2,100 Doe, JPP$525$0 $525 PP Total$1,050$525 $2625 Veteran 1VA$3,025 $0-- Veteran 2VA$0 --- Veteran 3VA$2,325$1,425--- Veteran 4VA$4,025$800--- Veteran 5VA$2,313---- VA Total$11,688$5,250$0-$16,938 Medicare Total$7,000$1,000$1,250$225$9475 Total Cash Outstanding$19,738$6,775$1,775$750$29,038 Total Revenue from Sales$19,738 20,00019,800$79,276

32. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Cash Cycle—45 days Using assumption Veteran referred first day of month and receipt of payment 14 days after bill sent to VAMC Veteran Referred to AAA/SAA Day 1 Assessment Completed Day 3 Bill VA for Assessment Day 4 Payment received for Assessment Day 28 Veteran received services for the part of month Day 30 (last day of month) Bill submitted to VAMC for approved spending plan and VD-HCBS Administrative Fee Day 31 (first day of next month) Payment received from VAMC for first month services Day 45

33. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Days Cash Outstanding Calculating Day’s Cash Outstanding 1.Determine period of time measuring 2.Identify organization’s Total Receivable for period Total Revenue from sales for period Days in the Period 3.Calculate days cash outstanding : Total Receivable/Total Revenue from Sales) x Days in Period = Total Days Cash Outstanding. Definition A performance metric used to estimate the collection period. Formula is (Total Receivable/Total Revenue from Sales for Period) x Days in Period = Total Days Cash Outstanding.

34. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Annual Program Performance Goal Achievement (financial & program) Quality Assurance – Price charged/Operating costs of delivery – Staff efficiency rating – Length of Stay info of individuals – Market penetration/reach Informs Organization’s Business Plan for future years. (goals/performance metrics) Program sustainability and impact on larger systems