Transcript The Quality Puzzle - Human Services Research Institute

Independent Providers within
a Quality Assurance &
Improvement Framework
Dilemmas, Future Directions, and Promising
Practices
Valerie Bradley & June Rowe
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
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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
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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
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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
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Why are we discussing this now?
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!
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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
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QA/QI systems for independent
providers is a balancing act
HCBS assurances
Safeguarding
health and welfare
Choice
Control
Less intrusive monitoring
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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
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Re-thinking quality
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
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 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
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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
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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)
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
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)
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HCBS Quality Framework
Participant
access
Participant
outcomes
and
satisfaction
System
performance
Participant
rights
and
safeguards
responsibilities
Provider
capacity and
capabilities
Quality
Participant
rights and
responsibilities
Participantcentered
service planning
and delivery
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Domains