1. Human Services Research Institute Overview of Quality Assurance and Enhancement A Framework for Best Practice Val Bradley Human Services Research Institute

2. Human Services Research Institute Changing Quality Landscape Exposure of fault-lines in the system (e.g., CMS and the press) Exposure of fault-lines in the system (e.g., CMS and the press) Emergence of self-determination Emergence of self-determination Olmstead decision and proposed closures Olmstead decision and proposed closures Struggles with MIS applications Struggles with MIS applications Direct support staff shortages Direct support staff shortages Expansion of supports to individuals on the waiting list Expansion of supports to individuals on the waiting list

3. Human Services Research Institute 23 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services … Gary Smith, HSRI, 2003

4. Human Services Research Institute Decreasing/static funding – coming on top of already strained providers Decreasing/static funding – coming on top of already strained providers Increasing federal expectations Increasing federal expectations Inefficient “business model” (e.g., clumsy rate structures, etc.) Inefficient “business model” (e.g., clumsy rate structures, etc.)

5. Human Services Research Institute Signs of Change in Performance Management No longer just better than the institution No longer just better than the institution Rooted in outcomes Rooted in outcomes Emphasis on enhancement and CQI Emphasis on enhancement and CQI Changing role of the state Changing role of the state Changes in experiences of families and people with mental retardation Changes in experiences of families and people with mental retardation Changes in accreditation approaches Changes in accreditation approaches Inclusion

6. Human Services Research Institute More Signs of Change Movement away from prescriptive standards to individualized risk management Movement away from prescriptive standards to individualized risk management Collaborative development of standards Collaborative development of standards Inclusion of consumer and family participation in oversight Inclusion of consumer and family participation in oversight Satisfaction CQI Consensus

7. Human Services Research Institute CMS Quality Initiative

8. Human Services Research Institute Purpose of National Technical Assistance To provide training and technical assistance to CMS Central and Regional Offices and states in quality assurance and improvement in HCBS waiver services for individuals with developmental disabilities. To provide training and technical assistance to CMS Central and Regional Offices and states in quality assurance and improvement in HCBS waiver services for individuals with developmental disabilities.

9. Human Services Research Institute Major Tasks To assess identify trends in quality issues flowing from Regional Office HCBS waiver reviews 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 and welfare concerns To provide on-site and short-term technical assistance to the states to address specific quality and health and welfare concerns To provide technical assistance to Regional Offices regarding the content of HCBS waiver reviews, applications, renewals or amendments To provide technical assistance to Regional Offices regarding the content of HCBS waiver reviews, applications, renewals or amendments

10. 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 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 To provide national consultation and technical assistance regarding quality assurance and improvement in the implementation in HCBS waivers for people with developmental disabilities

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12. National Technical Assistance Resources available on HCBS.org: Resources available on HCBS.org: –5 State Monitoring Review –Root Cause Analysis –Suggested Criteria –Quality Framework –Future: Lessons learned, state examples, etc. Toolkits (e.g., state licensing and monitoring) Toolkits (e.g., state licensing and monitoring) Web-based conferences Web-based conferences “Match making” between and among states “Match making” between and among states Facilitated conference calls Facilitated conference calls

13. Human Services Research Institute Status of State Requests Active (8) Active/Short Term (5) Initial Exploration (4) Referred (8) Completed (0)

14. Human Services Research Institute Regional Office Trainings November – Case management (Hill and Mitchell) November – Case management (Hill and Mitchell) December – Behavior management policies (Hitzing and Mullen) December – Behavior management policies (Hitzing and Mullen) March – Health and Medication – (White- Scott March – Health and Medication – (White- Scott Videos will eventually be available on line Videos will eventually be available on line

15. Human Services Research Institute Other CMS Initiatives Participant Experience Survey Participant Experience Survey Systems Change Grants Systems Change Grants Development of Protocol guidelines Development of Protocol guidelines Identification of best practice Identification of best practice Systems Change grants Systems Change grants Independence Plus template Independence Plus template Support for individuals moving out of institutions Support for individuals moving out of institutions TA for elderly and disabled waiver services TA for elderly and disabled waiver services

16. Emergence of Performance Indicators First appeared in behavioral and acute care First appeared in behavioral and acute care Provide some “cues” for managing these complex systems Provide some “cues” for managing these complex systems Highlight impact of cost containment Highlight impact of cost containment Illuminate what’s working Illuminate what’s working Provide early warning signs Provide early warning signs

17. Human Services Research Institute Characteristics of Performance Indicators Reflect major organizational or system goals. Reflect major organizational or system goals. Address issues that can be influenced by the organization or system Address issues that can be influenced by the organization or system Have face validity Have face validity Point a direction Point a direction Reflect rates or major events Reflect rates or major events Related to associated standards Related to associated standards

18. Human Services Research Institute Participating NCI States

19. Human Services Research Institute HCBS Quality Framework rights and responsibilities Domains Participant access Provider capacity and capabilities Participant safeguards Participant outcomes and satisfaction System performance Participant- centered service planning and delivery Participant rights and responsibilities Quality

20. Human Services Research Institute Participant Access Information and Referral Information and Referral Intake and Eligibility Intake and Eligibility –User-friendly processes –Eligibility determination –Referral to community services –Individualization of services –Prompt initiation

21. Human Services Research Institute Participant-Centered Service Planning and Delivery Participant-Centered Planning Participant-Centered Planning –Adequate assessment –Free choice of providers –Responsive service plan –Participant direction Service Delivery Service Delivery –Ongoing service and support coordination –Provision of needed services –Ongoing monitoring –Responsiveness to changing needs

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

23. Human Services Research Institute Participant Safeguards Participant Safeguards Prevention and investigation of abuse, neglect and exploitation Prevention and investigation of abuse, neglect and exploitation Tracking of major and unusual incidents Tracking of major and unusual incidents Ensuring safety of housing and environment Ensuring safety of housing and environment Regulation of behavior interventions Regulation of behavior interventions Standards for medication management Standards for medication management Provisions for personal safety and security Provisions for personal safety and security Preparation for natural disasters and other public emergencies Preparation for natural disasters and other public emergencies

24. Human Services Research Institute Participant rights and responsibilities Participant rights and responsibilities Ensure that participants: Ensure that participants: Exercise civic and human rights Exercise civic and human rights Participate in decision making authority Participate in decision making authority Have provisions for alternate decision making Have provisions for alternate decision making Have access to due process and grievance mechanisms Have access to due process and grievance mechanisms

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

26. Human Services Research Institute System Performance Conduct system performance appraisals Conduct system performance appraisals Support quality improvement Support quality improvement Ensure cultural competency Ensure cultural competency Support participant & stakeholder involvement Support participant & stakeholder involvement Maintain financial integrity Maintain financial integrity

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28. Review of Outcome- Focused Monitoring Mechanisms

29. Human Services Research Institute Immediate Challenges Quality assurance for individual providers Quality assurance for individual providers Sustainability of person-centered QA Sustainability of person-centered QA Effectiveness and efficiency of current processes Effectiveness and efficiency of current processes Integration of information Integration of information Development of internal QA systems Development of internal QA systems

30. Human Services Research Institute Integration of quality assurance responsibilities across the system Integration of quality assurance responsibilities across the system Involvement of families and people with disabilities Involvement of families and people with disabilities Improvement in up-front quality expectations upfront (e.g., Pennsylvania). Improvement in up-front quality expectations upfront (e.g., Pennsylvania). Transparency of QA systems and development of a demand for information Transparency of QA systems and development of a demand for information

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

32. Human Services Research Institute Continuous Quality Improvement Outcomes indicators Plan of correction Provider Qualification Real time tracking of incidents and follow-up Analysis of specific trends Benchmarking Strategic Planning Trends Analysis

33. Human Services Research Institute Conclusions and Recommendations

34. Human Services Research Institute Important Next Steps Place individual outcomes at the center of the system Place individual outcomes at the center of the system Enlist assistance of consumers and families Enlist assistance of consumers and families Identify key areas of performance Identify key areas of performance Create a quality management entity Create a quality management entity Make results available and accessible Make results available and accessible

35. Human Services Research Institute Develop uniform reporting of critical health and safety events Develop uniform reporting of critical health and safety events Develop staff credentialing and expand training options Develop staff credentialing and expand training options Reassess roles and responsibilities of case managers Reassess roles and responsibilities of case managers Refine performance contracting Refine performance contracting Develop quality management entity Develop quality management entity

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37. Expand understanding of participant centered planning Expand understanding of participant centered planning Develop a technical assistance capacity Develop a technical assistance capacity Implement risk management and health assessments Implement risk management and health assessments Build integrated data systems Build integrated data systems Develop hotlines and ombudspersons Develop hotlines and ombudspersons

38. Human Services Research Institute Lessons for Providers Develop internal quality improvement plans Develop internal quality improvement plans Work with states to streamline QA/QE procedures Work with states to streamline QA/QE procedures Continue to work to upgrade the status of direct support professionals Continue to work to upgrade the status of direct support professionals Enlist people with disabilities and families Enlist people with disabilities and families Continue to train staff in person-centered principles Continue to train staff in person-centered principles Assume that quality assurance will become more comprehensive and systematic Assume that quality assurance will become more comprehensive and systematic

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