1. Evolution of Federal Quality Assurance and Improvement Principles for HCBS Waivers: Movement to More Specific Expectations Valerie J. Bradley, President Human Services Research Institute Missouri DD Stakeholders Meeting November 23, 2010

2. What Will We Cover? Background GAO and wake up call for CMS Quality Framework and the emergence a 3 dimensional performance structure “Operationalizing” the 6 waiver assurances Evidence and quality improvement How to be prepared for what comes next

3. Why Should We Care About Quality? We have created a movement and made promises to people with disabilities and their families Ideology alone does not create a stable and reliable system of supports The greater the investment the greater the expectations Unless we build quality in at the beginning, it is very hard to retrofit a program later

4. Waivers – Dominant Funding Source Waiver programs for people with DD account for about 75% of all waiver spending In 2008, there were about 525,000 waiver recipients with DD – a 740% increase from 1992 Total cost in ‘08 was 22.3 billion – about $42,500 per recipient Five times as many people receive waiver services than are served in ICFs/MR

5. CMS Gets a Wake-Up Call

6. GAO Report on Federal Oversight of HCBS Waivers -- 2003 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)www.gao.gov

7. HCBS Quality Framework

8. Major Change in Oversight  Shifted review process away from “snap shot in time”  Formalized ongoing dialogue between CMS and State  Based on state monitoring its own processes and procedures  Focused on state producing evidentiary based reports to demonstrate that assurances are met  CMS reviews reports based on assessment of how effectively state monitored its own performance and addressed issues identified

9. Assurances vs. Framework Level of Care Plan of Care Qualified Providers Health and Safety Financial Accountability Administrative Authority

10. Recent Changes

11. Development of 3.5 Performance measures required for all assurances and sub-assurance Each performance measure needs a metric, have face validity and focus on the right unit of analysis Remediation has to be described for each assurance Appendix H is now where you put information about how you improve quality

12. Requirements for More Focused Evidence Reports Should be continually reaching 100% compliance Should be able to aggregate remediation so that you can determine how quickly issues are resolved Should be able to describe methods of remediation Should be able to describe relevant quality improvement initiatives (training, policy change, etc.) Can use consumer surveys – but not as the sole source of evidence

13. “ What is it Lassie, Is Timmy in trouble?”

14. Sample Evidence Format* *Beth Jackson, 2010

15. Technical Assistance Continued funding of National Quality Enterprise Development of NQE website – Sign up for TA – Identify resources – Download presentations Bi-monthly public Quality calls

16. Increased Emphasis on Sampling 95% confidence/5% margin of error Has to be by waiver Sample size can vary depending on the magnitude of non-compliance – the higher the compliance level, the lower the sample size Sample calculators available on line: www.raosoft.com www.raosoft.com

17. Concentration on Health and Welfare Focus on restraints and restrictive practices Stress on incident management Economic downturn gives even more impetus to monitoring Concerns with medication management

18. Other Issues to Keep on Your Radar Interest in uniform practices across sub-state entities (e.g., counties) Focus on equitable allocation of waiver slots the state Importance of unified and standardized contracting procedures Performance measures for any delegated functions including fiscal intermediaries Necessity of educating and collaborating with your state Medicaid agency

19. What Can You Expect in the Next Few Years?

20. Changes on the Horizon Refinements and enhancements of waiver application that should result in more clarity regarding expectations Expanded use of web-based data submissions Increased clarity regarding assurances and measures

21. What Do You Need to Do? Make sure that you have performance measures for all assurances Don’t reinvent what you’ve already got Develop a good working relationship with your state Medicaid agency; re-inspect your MOU Make sure you can track remediation Introduce yourself to CPS, ADS – you will need their data Don’t over promise If you don’t have the evidence, develop an action plan

22. I Know It Won’t Be Easy – States are Already Having to do More with Less...

23. ... But you need to find a way to incorporate these requirements into your own QA process and tailor them to your needs. This is not the be all and end all of quality measurement and improvement but for the foreseeable future, this is the price of admission

24. What did she say? THE END