Quality Assurance: Its Everybodys Business

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Quality Assurance Its Everybodys Business

• Valerie J. BradleyHuman Services Research
  Institute
• October 23, 2003
• South Carolina Association on Mental Retardation
• Myrtle Beach, South Carolina

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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

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25 States have been sued for wait listing
individuals with developmental disabilities for
Medicaid long-term services
Gary Smith, HSRI, 2003
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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)

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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

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Changing Landscape
Between 1999 and 2002, states expanded waiver
programs by 110,000 individuals
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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

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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

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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
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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

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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-03-576 6/20/03 www.gao.gov)
  

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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)

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CMS Action Plan

• Strengthen Federal Oversight
• Training for central and regional office CMS
  staff
• CMS procedural guidance for reviews
• Resource and strategy reviewmore cost effective
  method to review and improve services
• Improve Federal Follow-up Capability
• Technical assistance projects (National
  Contractors for Quality)

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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

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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

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Types of Technical Assistance

• On-site and off-site individualized TA to state
  agencies administering HCB services
• Creating resources and productsfor all states
• State to state linkages sharingof resources
• Presenting at state and nationalconferences

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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

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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

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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

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HCBS Quality Framework
cms.hhs.gov/medicaid/waivers/frameworkmatrix.asp
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Participant Access

• Information and Referral
• Intake and Eligibility            
• User-friendly processes
• Eligibility determination
• Referral to community services
• Individualization of services
• Prompt initiation

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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

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Provider Capacity and Capabilities

• Availability of individual and agency providers
• Review of provider qualifications
• Monitoring of providerperformance

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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

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Participant rights and responsibilities

• Civic and human rights safeguards
• Decision making authority
• Provisions for alternate decision making
• Due process and grievance mechanisms

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Participant Outcome and Satisfaction

• Participant outcomes
• Participant satisfaction

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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

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Continuous Quality Improvement

• Close the loop
• Information from quality assurance
• drives decision making!
• 
  Therefore.

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Continuous Quality Improvement
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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

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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

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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

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A FEW EXAMPLESFROM A MORTALITY REPORT
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A FEW MORE EXAMPLESFROM 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 Alzheimers (7), Anoxia
(3),Epilepsy (2), and Parkinsons (1) 5 of
deaths were due to Renal Failure 4 of deaths
were due to Digestive System Diseases
Benchmarks Leading Causes of Death
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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

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Important Finding
Variables
STRONGEST PREDICTORS
1
3
AGE MOBILITY SUPERVISION
2
Strength (How much it Contributes to Mortality)
Significance (smaller than .05)
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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)
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Conclusions and Recommendations
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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
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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

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• 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

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• 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

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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

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Final Words

• Beware the Continuous Improvement of Things
  Not Worth Improving
• W. Edwards Deming

CAUTION