1. 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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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 – 6/20/03 –
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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. 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

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

24. 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

25. 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

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

27. 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

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

29. Continuous Quality Improvement
Human Services Research Institute

30. 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

31. 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

32. 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

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

34. 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

35. Human Services Research Institute

36. Human Services Research Institute

37. 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

38. 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

39. 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

40. Conclusions and Recommendations
Human Services Research Institute

41. 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

42. 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

43. 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

44. 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

45. 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

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