1. Independent Providers within a Quality Assurance & Improvement Framework Dilemmas, Future Directions, and Promising Practices Valerie Bradley & June Rowe Human Services Research Institute

2. Human Services Research Institute Who is an independent provider? Someone, in large part, employed and supervised directly by the individual and/or family Is not an employee of a private agency Is paid either directly by the state or, more likely, through a financial management service

3. Human Services Research Institute Brief historical perspective Community services have historically have been provided through private (mostly non-profit) agencies Provider agencies are held accountable for quality of staff and service quality QA/QI systems have largely focused on provider monitoring   Licensing   Certification   Accreditation

4. Human Services Research Institute Signs of Change   Family support movement set the tone by empowering families to hire their own staff through the use of family subsidies   Advent of personal care assistance and movement by physical disability community to control hiring and firing   Emergence of the self determination movement and the increasing “deconstruction” of the service system

5. Human Services Research Institute This is not new, rather it has deep historical roots self-determination independent living movement in-home supports for the elderly family support self-advocacy

6. Human Services Research Institute Self-directed supports and use of independent providers is growing and… …states are re-thinking their quality assurance and improvement approaches because… …changes in quality assurance and improvement strategies are directly influenced ! by changes in services and supports! Why are we discussing this now?

7. Human Services Research Institute So, why re-think quality now   Current QA/QI systems that are used to monitor “provider agencies” may not work well for individuals who are supported through independent providers   As states apply for “Independence Plus” waivers or build self-direction into their other waivers, they need to develop QA/QI strategies to ensure the health and welfare of waiver participants for these supports

8. Human Services Research Institute QA/QI systems for independent providers is a balancing act Choice Control Less intrusive monitoring HCBS assurances Safeguarding health and welfare

9. Human Services Research Institute QA/QI for independent providers – considerations Positives   Increased flexibility, choice and control   Close, caring reciprocal relationship between provider and individual/family   Individual/family directly monitor quality Vulnerabilities   Isolation of both the provider and individual   Maintaining the energy, competencies and ‘connectedness’ of the provider   Oversight for provider quality largely in the hands of the individual/family

10. Human Services Research Institute Re-thinking quality 1. 1. For independent providers quality starts in the beginning before monitoring… quality is preventive, upfront   Basic qualifications, skills and competencies for all providers Pre-screening Education/age requirements Threshold competencies

11. Human Services Research Institute   Person-centered planning Identifying the person’s needs for support, risks Individual and family competencies needed to effectively manage individual providers Person-specific competencies the providers need to support the individual Degree of monitoring in the planning process

12. Human Services Research Institute 2. 2. QA/QI safeguard strategies need to be more person-centered, individualized   Self-monitoring by educated individuals and families   Ongoing monitoring by the case manager/support coordinator is critical for early detection/prevention of problems

13. Human Services Research Institute Systemic QA/QI strategies to monitor the quality of independent providers Consumer affairs or ombudsman office   Trends in grievance reports or complaints (e.g., type, amount) Critical Incident Reporting Systems   Necessary, but challenging to rely on for these supports Published report cards on independent providers   As reported by individuals and families (UT) Person-centered review processes   Less prescriptive, more outcome-based (KA)

14. Human Services Research Institute Citizen/peer networking and quality councils   Joint problem solving, resource and information sharing Consumer/family surveys   National Core Indicators Consumer and Family Surveys (HSRI/NASDDDS)   Participant Experience Survey (Medstat Group)   “Ask Me” survey (MD)   Developmental Services Adult Consumer Outcomes survey (NH)

15. 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