CMSCMSHCBS Quality InitiativeHCBS Quality Initiative

Nancy ThalerCMS/DEHPGQuality TeamMay 5, 2004

Why would you care?

Reality

Waiting List

“Friends”

Singing from the same page

Increases the likelihood of success

Context for the Focus on QualityContext for the Focus on Quality

Growth & Expansion of HCBS waiver programs• Growth in funding

$1.6B federal funds in 1991 $20.7B federal funds in 2004…..130% increase

Growth in people served 800,000 people No. of 65+ will double between 2000 - 2030 from 35 M to

70M

• Services are dispersed Hundreds of thousands of locations across the community

Self Direction presents challenges for assuring quality

Context for the Focus on QualityContext for the Focus on Quality GAO Report….August, 2003

Review of Federal Oversight of HCBSWaiver Programs

Findings:

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

Context …..Context ….. CMS Action Plan *CMS Action Plan *

Components of Quality: more detailed criteria for states

Grants to States Quality projects; Direct Service Worker; Real Choices

Quality Framework Independence Plus waiver templatePromising practices

* Letter to Senators Grassley & Breaux

CMS Quality InitiativesCMS Quality Initiatives Quality Framework

The foundation for Quality Quality Inventory Report

Learning what states need Helping the states

National Quality Contract …technical assistance

Quality Tools Promising Practices Real Choice Grants ….$165M

Structural changes New Application & reporting requirements Changing federal over sight practices

What is Quality?What is Quality?

Quality Framework Focus AreasQuality Framework Focus Areas Participant Access

Information and referral; intake and eligibility determination; referral; choice

Participant Service PlanningAssessment; service plan, implementation & monitoring; respond to

changing needs; choice; participant direction Provider Capacity

Licensure and certification; training; provider monitoring Participant Safeguards

Incident management; risk assessment; behavior management; med administration; natural disasters Rights and Responsibilities

Due process; grievance procedures Outcomes and Satisfaction System Performance

Quality Improvement program; financial management

Quality Framework ProcessesQuality Framework Processes

Design… Design… build quality in up front

Discovery… Discovery… look for problems & opportunities

for improvement

Remediation… Remediation… fix problems

Improvement… Improvement… make improvements

Total Quality Improvement Cycle

Plan

Do

Check

Act

Design

Discovery

RemediationImprovement

Quality Inventory

Oct 02 – Jan -3

MR/DD and Aging/Disabled Waivers 246 waivers 750,000 people Response rate – 87%

Objective: to inventory state practices and identify T.A. needs

Access Most states report multiple strategies to ensure access & are making efforts to streamline.

Person-centered practices 1/2 of states’ MR/DD waivers and 1/3 of E/D waivers report using self-directed services. What states call self-direction varies greatly.

Provider Capacity Most states establish qualifications for providers and conduct a review of services delivery.

Safeguards Most states have an Incident reporting and investigation system, do criminal record checks: ED waivers have abuse registries.

Rights and responsibilities Almost all states have grievance mechanisms.

Most provide individuals with alternate avenues (ombudsman) to register

Outcomes/satisfactions 90% of states collect information about individual/family satisfaction

50% + collect information about outcomes

System Performance States recognize the importance of measuring performance

Quality Inventory: MR/DD Findings Most programs are run by program agencies/not Medicaid agencies

87% MR/DD 70% A/D

Local non-state entities have a role in 44% waiver

87% MR/DD have major initiatives to strengthen HCBS quality

Gauging participant satisfaction was common practice; measuring participant outcomes was not

61% MR/DD monitor health status

Most states have grievance/complaint systems

Few states have Info. Tech capable of supporting QM

Quality Inventory: MR/DD Challenges Developing data based performance benchmarks

Compiling information on the use of behavioral interventions

Conducting mortality reviews

Conducting medication reviews/reporting med errors

Lowering case management ratios

Strategies to promote access to health care

Developing technology systems to support QM

National Contractor for HCBS Quality

Resource to CMS Regional Offices (RO) and States

Urgent or Emergent follow-up in special circumstances

State requests for consultation

Contractors to assist in Root Cause Analysis and identification of quality improvement strategies

Quality Tools Participant Experience Survey (PES)

Voluntary Tool for States 2 Modules: Elderly/Non-elderly disabled and MR/DD Field-tested on more than 700 waiver participants Electronic version available

HCBS Quality Work Book Step-by-step guidance on how to conduct quality improvement

activities in HCBS, within the context of the Framework Discusses how to use data for QI

Promising Practices: Identify and describe promising practices within states

Highlight both broad systems reform efforts (e.g., Michigan’s 1915b/c combo for specialty services)

and specific tools utilized by states (e.g., Wyoming’s method for individual budgets)

Data Readiness Project Compile info on selected QI activities that are data driven Technical assistance briefs to states

CMS: Changing approach to Quality

Past….an inspection model that is based on personal observation and case reviews once during the life of a waiver

Future…. a QM data driven model with continuous over-sight

Quality elements are designed into the program

Each state has a quality strategy to continually evaluate it’s own performance, to correct deficiencies and make system improvements….which will tell us if

• assurances are met• outcomes are achieved• people are satisfied

CMS reviews the effectiveness of the state’s Quality Management Strategy

Waiver Life Cycle…as it has beenWaiver Life Cycle…as it has been

CMSreview

State WaiverApp

State Waiver RenewalApp

CMSreview

CMSvisit

Findings andRecommendations

CMS Report

Building Quality Building Quality into the into the Waiver Life CycleWaiver Life Cycle

Yr. 1373 S

Yr. 3373 S

Yr. 2373 S

Yr. 4373 S

CMS CMS CMS CMS

CMSvisit

CMSvisit

CMSreview

State WaiverApp

Q M

State Waiver Renewal

App QM

Findings andRecommendations

CMS Report

CMSreview

The Waiver Application: States Design Quality in Upfront ! A. Participant Access

The process and time frames to evaluate/re-evaluate the level of care for applicants

B. Participant-centered service planning and delivery Assess participants’ needs (personal goals, health and safety) Plan of Care: approving and updating/revising them Participant involvement in POC development Person responsible for monitoring the POC Providing participants with information about services and choice

The Waiver Application C. Provider capacity and capabilities

Service definitions Service limitations…. e.g. dollar limit; unit limit Provider requirements: licensure/certification and training Agency responsible to verify and actions taken when providers do

not meet requirements

D. Participant Safeguards/Protecting Health and Welfare

Managing instances of abuse, neglect, and exploitation (including the use of chemical, physical and manual restraint)

Criminal background checks The state’s oversight of administration of medications Emergency back up Assure the safety of in the case of natural disasters

The Waiver Application

E. Participant Rights The state’s process for informing participants and assisting them in

exercising their Medicaid due process rights The state’s recipient grievance/complaint system

F. Participant Satisfaction and Outcomes The state’s method or plan to solicit feedback on satisfaction with services

from consumers and families The state’s method or plans for measuring participant outcomes

The Waiver Application G. Systems Performance

State’s Quality Management Strategy Structure of the QM program

Roles of Medicaid, operating and local agencies Involvement of participants, families and other stakeholders Contracts with independent review entities

Methods of Discovery; sources of data and Indicators Process for priority determining improvement Reporting to the public The process for evaluating and updating the QM strategy

Financial Management System The state’s system for reimbursing claims Single audit Funding flow / four funding questions

The State Annual 373 Report: States report on quality yearly! Level of Care Determination

An evaluation for level of care is provided to all applicants Enrolled participants are reevaluated at least annually The process and instruments described in the approved wavier are

applied The state monitors level of care decisions and takes action

Plan of Care POCs address all participant’s assessed needs (including health and safety

risk factors) and personal goals POCs are updated/revised when warranted Services are delivered in accordance with the POC The state monitors POC development

The Annual Repot Choice

Participants are afforded choice between waiver services and institutional care between/among waivers services and providers

Qualified Providers The state verifies that providers meet required licensing and/or certification

standards The state monitors non-licensed/non-certified providers The state identifies and rectifies situations where providers do not meet

requirements The state implements its policies and procedures for verifying that training is

provided

The Annual Repot

Health and Welfare The state, on an ongoing basis, identifies and addresses and seeks to prevent

instances of abuse, neglect, exploitation

Administrative Authority The Medicaid agency or operating agency conducts routine, ongoing

oversight of the waiver program

Financial Accountability State financial oversight exists to assure that claims are coded and paid in

accordance with the reimbursement methodology specified in the approved waiver.

.When Will the Change Happen? When Will the Change Happen?

Interim Procedural Guidance….January 2004 Interim Procedural Guidance….January 2004 New CMS oversight proceduresNew CMS oversight procedures

• Request that a state provide evidence (not policies and procedures) that there are practices in place to monitor its own performance• A review of the evidence provided by the state• Follow up on an as needed basis• A report based on the evidence

•To find out more about CMS Quality To find out more about CMS Quality Initiatives Initiatives

www.cms.hhs.gov/quality/www.cms.hhs.gov/quality/ www.hcbs.org

Action Plan to Senators Grassley and BreauxQuality FrameworkQuality Inventory ReportThe Work Book Report to Sen. Grassley and BreauxPromising Practices

Real Choice Grantees

NThaler49@aol.comNThaler@cms.hhs.gov