CMS QUALITY FRAMEWORK: EXPECTATIONS FOR QUALITY IN HCBS WAIVER PROGRAMS

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CMS QUALITY FRAMEWORKEXPECTATIONS FOR QUALITY
IN HCBS WAIVER PROGRAMS

• Laura Nuss, CT DMR
• September 29, 2004
• Annual CCPA Conference

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CMS-National Picture

• Increase Quality Assurance and Improvement
  oversight of state Home and Community Based
  (HCBS) waivers
• CMS issues HCBS Waiver Protocols in 2001
  detailing quality assurance and improvement
  expectations for the states.
• In August 2002, CMS distributes the Quality
  Framework to provide a common frame of reference
  focusing attention on desired outcomes of quality
  management.
• July 2003, General Accounting Office (GAO)
  criticizes CMS for failure to aggressively
  monitor state oversight of HCBS waivers.
  Recommends CMS strengthen monitoring with more
  stringent requirements for states to report QA/QI
  activities.
• 2004, CMS issues new guidance to Regional Offices
  on conducting a review of a states HCBS waiver.
• 2004, officially adopts Quality Framework.
• 2004, develops new waiver application that
  includes Quality Framework expectations

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CMS-National Picture - continued

• New Freedom Initiative
• Makes it a priority of the federal government to
  promote community living for persons with
  disabilities of all ages
• Focus on the rights of all individuals with
  disabilities to learn and develop skills, engage
  in productive work, choose where they live and
  participate in community life
• Provides Real Choice Systems Change Grants aimed
  at building infrastructure that will result in
  effective andenduring improvements in community
  long-termsupport systems
• Initiates the Independence Plus waiver to
  offerimmediate opportunity to improve quality
  throughincreased choice and control on the part
  of peoplewith a disability or elderly.

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HCBS Waivers-What are they and why do we care?

• Optional Medicaid program that allows states to
  request a waiver from federal Medicaid
  regulations to provide community-based services
  and supports as an alternative to Medicaid State
  Plan services such as nursing homes and
  Intermediate Care Facilities (ICF)
• Provides Federal Financial Participation (FFP) by
  matching state funds expended for waiver services
  (50 77)
• Connecticut DMR has had a waiver since 1987, with
  an FFP rate of 50
• In 2002, 42 of all spending for MR services in
  CT was through the waiver (US Average 37, range
  10-80) State of the States in Developmental
  Disabilities, 2004, Braddock et. al.
• In 2003, DMR services returned 300 million in
  federal revenue
• Revenue helps the department work with the state
  to increase funds for those waiting for services
  and supports

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CT DMR HCBS Waivers

• Proposed second waiver requested for January 2005
  implementation
• Targeted towards increasing availability and
  variety of services and supports for people who
  live in their own or family home
• Shifts service delivery model to consumer choice
  and control even further
• Must include methods to address the Quality
  Framework

• Current waiver supports 6,000 plus individuals
• Expires October 2005
• CMS conducts a quality assurance review prior to
  allowing it to be renewed
• CTs review initiated June 2004
• Authorized services residential habilitation
  (CLA and CTH) day habilitation (DSO, SE)
  respite environmental modifications family
  training

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Quality Framework Expectations

• Design Designing quality assurance and
  improvement strategies into the HCBS program at
  the initiation of the program
• Discovery Engaging in a process of discovery
  tocollect data and direct participant
  experiences inorder to assess the ongoing
  implementation of theprogram, identifying both
  concerns as well as otheropportunities for
  improvement
• Remedy Taking actions to remedy specific
  problems or concerns that arise
• Continuous Improvement Utilizing data and
  quality information to engage in actions that
  assure continuous improvement in the HCBS
  program.

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Quality Framework uniform nationwide format
that makes states describe the key components of
the states QA/QI program in a consistent and
standard manner.
DOMAIN AREAS

• Participant access
• Participant-centered service planning and
  delivery
• Provider capacity and capabilities
• Participant safeguards

• Participant rights and responsibilities
• Participant outcomes and satisfaction
• System performance

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QUALITY FRAMEWORK AND DMR INITIATIVES

• Participant Access
• Information and Referral
• -Waiver info available
• Intake and Eligibility
• -user friendly
• -linked to community resources
• -choice between waiver and ICF/MR
• -services initiated promptly

• Waiver Fact Sheets
• Lower CM case loads
• Quarterly audits of records by CO Waiver Unit

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QUALITY FRAMEWORK DMR INITIATIVES

• Person-centered Planning
• Comprehensive assessment preferences, goals,
  health, needs, and other supports
• Participant decision-making-help to make informed
  choices
• Free choice of providers-info and support
• Comprehensive service plan-for all services to
  address all needs
• Self-direction- have authority and support to do
  so

• Revised Person-centered Plan
• Lower CM Caseloads
• Emphasis on CM representing all aspects of
  individuals life
• Portability
• Individual Budgeting
• New waiver service for broker supports
• Improve Self-advocacy training and support
• Standard review of quality of the plan by CM
  supervisors
• Quarterly audits of plan and choice by CO Waiver
  Unit

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QUALITY FRAMEWORK DMR INITIATIVES

• Service Delivery
• On-going service and support coordination- have
  continuous access to assistance to obtain and
  coordinate services and promptly address issues
• Service Provision- are furnished according to the
  IP
• Ongoing monitoring- regular, systemic and
  objective methods, including the persons
  feedback, use to monitor health, well being and
  achievement of personal goals
• Responsiveness to changing needs- changes
  promptly trigger consideration of modifications
  in the IP

• Lower CM case loads
• Design methods for CMs to consistently review IP
  and collect data permitting systemic analysis
• Implement consistent supervisory documentation to
  demonstrate effectiveness of oversight
• Quarterly audits by CO waiver unit
• Regional and State Quality Review visits include
  consumer interview

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Planning Cycle

• Develop Plan
• CM attends plan development meeting
• Ensures individual participates
• Ensures plan meets requirements
• Ensures documentation on form.

• Prepare to Develop Plan
• Asks preferences for planning
• Reviews record/current plan
• Ensures Health/Safety Screening complete
• Checks current assessments are available and
  complete
• Ensures team notified of meeting.

• Access to Supports
• Makes referrals
• Offers choice/selection
• Portability process
• Resource development.

• Monitor Supports and Review Plan
• CM visits in-home and day site
• Ensures plan implemented
• Ensures supports are in place and working
• Checks Health and Safety Screening
  recommendations and follow-up assessments are
  implemented
• Conducts probes
• Review plan and revise as needed.

• Initial Intake and Interview
• CM Assessment/Profile
• Gather background information
• Share information
• Share fact sheets
• Gather CAMRIS information
• H/S Screening
• Prepare for Individual Plan.

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Self-Directed Support

• The use of individual support agreements provides
  consumers and their families with greater choice
  and control over the services and supports they
  need and desire. The expansion of such
  self-directed support has, therefore, represented
  a major goal for DMR over the past five years.

As of the beginning of January 2004, over 800
individuals now have individual support
agreements, with almost 600 consumers and their
families exercising this choice for residential
support.
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CMS Grants to States

• Independence Plus for projects earmarked to
  build the necessary infrastructure required to
  submit an Independence Plus waiver
• Person-centered planning and service delivery
• Support Coordination/Brokerage
• Fiscal Intermediary Services
• Individual Budgeting Methodology.

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The Future of Individual Budgeting in Connecticut

• CMS Independence Grant
• Public process of establishing Level of Need and
  associated funding
• Use of key informant interviews analysis of
  individual characteristics, which drive support
  needs analysis of current funding levels
  associated with individual characteristics and
  PCP planning process samples to arrive at an
  individual budget methodology
• Use the methodology to support the application of
  an Independence HCBS Waiver and to revise the
  current comprehensive waiver

• Identify current individual funding amounts for
  all individuals currently supported so anyone can
  choose to self-direct existing resources
• Apply methodology to new individuals entering
  service for FY05
• Apply methodology to service system at large to
  plan a long-term equitable resource allocation
  process.

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Accessing Individual Supports

• Individuals can choose to convert existing
  funding within provider agency contracts and make
  it portable
• Individuals who are on the day and/or residential
  waiting list when entering service, may choose an
  individual support option
• To date in FY04, 86 people chose to exercise the
  option of portability
• Effective April 1, 2004, all people,regardless
  of setting, have portableresources.

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QUALITY FRAMEWORK DMR INITIATIVES

• Provider Capacity and Capabilities
• Networks and availability- enough providers to
  meet needs and provide choice
• Provider Qualifications- agency and individual
  providers possess required skills, etc.
• Provider Performance- all providers demonstrate
  ability to provide services in an effective and
  efficient manner per the plan

• Formal Provider Enrollment Initiative to create
  directories and expand options
• Expand training opportunities for staff hired
  directly
• Quality Service Review- process to review quality
  of all providers of service, regardless if
  licensed or not

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DMRS New Quality SystemWhy are we changing/what
are we doing?

• DMR participated in the National Quality
  Inventory Project funded by CMS to identify the
  state of the states in quality assurance and
  improvement programs for HCBS services
• To meet the requirements, must be able to
  demonstrate design, discovery, remediation and
  improvement functions are systematically in place
  and provide evidence
• DMR identified weaknesses in the following domain
  areas
• Participant access
• Participant-centered service planning and
  delivery
• Provider capacity and capabilities
• Participant safeguards
• Participant outcomes and satisfaction
• System performance.

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Quality Service Review

• Five years in the making with the participation
  of private provider representatives
• Built around answering if people are achieving
  positive, personal outcomes (17 of them in 6
  Focus Areas)
• Incorporates the National Core Indicators
  consumer interview as a valid measure for
  consumer satisfaction, and to compare ourselves
  to other states nationally
• Designed to collect performance and quality
  indicator data continuously during the normal
  course of business
• Becomes the process of quality assurance and
  improvement for providers of all types of
  services
• Should replace CLA licensing as we know it by
  incorporating CLA regulatory review into regional
  and system review activities.

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QUALITY FRAMEWORK DMR INITIATIVES

• Participant Safeguards
• Risk and Safety Planning- risk and safety is
  assessed and interventions identified to promote
  health, independence and safety
• Critical Incident Mgmt-
• Housing and Environment- safety and security is
  assessed and modifications offered if needed
• Behavior Interventions-used as last resort and
  with rigorous oversight
• Medication Management- managed effectively
• Natural and Public Emergencies- safeguards in
  place

• Expanded health and safety screening
• Include ISAs in Critical Incident Reporting
• Work with families and consumers to find ways to
  implement safeguards while respecting privacy in
  peoples own homes
• Develop new electronic incident reporting system
  to improve response and analysis

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QUALITY FRAMEWORK DMR INITIATIVES

• Rights and Responsibilities
• Civic and Human Rights- informed and supported to
  exercise
• Decision-making Authority- training and support
  provided to exercise authority
• Due Process- informed and supported to exercise
  Medicaid rights
• Grievances- informed and supported to file and
  seek resolution, and done so in a timely manner

• Emphasize support to make decisions in
  person-centered planning process
• Provide formal due process notice and information
  for DSS appeals
• Collect due process and grievance data to analyze
  trends, and monitor timely resolution
• Self-Advocacy Training Institute

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QUALITY FRAMEWORK DMR INITIATIVES

• Participant Outcomes and Satisfaction
• Satisfaction- individuals and family members
  express satisfaction with their supports
• Outcomes- services and supports lead to positive
  outcomes for each person

• Quality System Review designed around achievement
  of Personal Outcomes
• Incorporate National Core Indicators consumer
  interviews into QSR
• Expand use of NCI family surveys by Providers to
  increase consistent collection of information
  about satisfaction

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Purpose of the Core Indicators Project

• Develop, field-test, and disseminate a nationally
  recognized set of PERFORMANCE INDICATORS that can
  be used in any state to gauge the effectiveness
  of specialized, publicly-funded DD services and
  supports
• Establish corresponding NORMS AND STANDARDS as a
  basis for assessing and interpreting the
  indicators
• Design a CONSUMER SURVEY instrument and protocol
  for assessing system performance through the eyes
  of individuals who receive and rely on state DD
  agency funded services and supports
• Identify PRACTICAL APPROACHES for collecting,
  tracking and reporting the performance data in an
  economical and efficient manner.

The Core Indicators is entering its 6th year of
activity. Phase V reports on the results of
2002/03 (5th year).
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Current Participating States
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Why is Connecticut Participating?

• To ESTABLISH BENCHMARKS for the departments
  performance objectives
• To MEASURE THE EFFECTIVENESSof services and
  supports providedover time
• To inform the departments STRATEGIC PLANNING
  process
• To measure CONNECTICUTS PERFORMANCE nationally
  and against states with similar demographics
• To INFLUENCE THE PROCESS and assure it is
  consistent with Connecticuts values and service
  delivery system.

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QUALITY FRAMEWORK DMR INITIATIVES

• CMS Quality Grant Award
• Quality Councils and Quality Improvement
  Committees
• Advisory Committees
• Organizational Self-assessment for QI and
  Cultural Competency
• Include individuals and families in provider
  review teams
• DMR Cost standards

• System Performance
• System Performance Appraisal- state
  systematically engages in data collection and
  analysis of program performance and impact
• Quality Improvement there is a systemic approach
  to continuous improvement of quality
• Cultural Competency- effectively supports people
  of diverse cultural and ethnic backgrounds
• Participant and Stakeholder
• Involvement- have an active role in design,
  appraisal and QI activities
• Financial Integrity- is assured

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CMS Grants to States

• Quality Assurance and Improvement for projects
  earmarked to improve states QA/QI systems
  consistent with the Quality Framework, and to
  meet the CMS quality assurance requirements for
  self-directed services under the Independence
  Plus waiver

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CT Real Choice Grant

• Quality Assurance and Improvement
• Design a data management system to support QA/QI
  initiatives including the new Quality Service
  Review system, incident management system, and
  management of discovery, remediation and
  improvement activities
• Develop quality indicators for individuals who
  live in their own or family homes
• Develop self-advocacy knowledge of and
  participation in the quality system

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Role of Advisory Committees

• CMS Steering Committee
• Provide guidance to DMR on the role of
  individuals, families and the community at large
  in the new Quality Review system
• Participate in design methods to assess quality
  in individuals own or their familys home
• Participate fully in the design of the research
  required to establish Level of Need and
  Individual Budgeting methods, and participate in
  the oversight of the sub-contractors performance
• Provide guidance to DMR in the development of the
  Independence Plus Waiver
• Provide guidance to DMR in the implementation of
  a system of individualized funding
• Develop a plan to assure that the systems change
  funded by the grants are sustained beyond the
  term of the grants.

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Role of Advisory Committees

• Trades Meeting
• A monthly meeting is held with the three Trades
  Associations and representatives of the private
  sector.
• The agenda is developed in partnership
• Share information regarding policy, budget,
  department initiatives, review procedural
  changes that impact private sector
  operations- Address questions and respond to
  concernsProvider Council
• The Council has been in existence for four years
  with 18 designated members from the private and
  public sectors. Each Trade organization selects
  three standing members
• Issues are referred by the Trades meeting group.
  Issues are selected that
• Require more in-depth discussion for meaningful
  provider inputRequire a collaborative approach
  to develop policies or proceduresRequire
  analysis and feedback or recommendations to the
  Trades meeting.

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Role of Advisory Committees
Regional Advisory Committees

• Comprised of individuals, family members,
  community representatives, and advocacy
  organizations
• Provide advice and recommendations to the
  regional director regarding initiatives
• Independent review of quality data and make
  recommendations for improvement

State Quality Improvement Committee Review
state and system quality data and analysis,
recommend improvement initiatives, and monitor
compliance. Composition to include all
stakeholders. Begin 2005.
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What Does it Look Like to the Individual/Family?
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Our Goals and Vision

• Further self-determination allowing consumers and
  families to control their resources, design their
  own supports and choose those who serve them
• Enhance family and individual support
• Reduce our reliance on traditional services
• Reduce the size of our public operations using
  our staffs expertise to operate specialized
  supports
• Find ways to serve those who are un-served or
  underserved
• Fairly allocate and distribute the resources of
  the department to meet the needs of our consumers
• Ensure the health and safety of our consumers and
  safeguard against risk
• Develop consistent practice.

All to improve the QUALITY of our service
delivery system.
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The End