Transcript Evolution of Federal Quality Assurance and Improvement

Evolution of Federal Quality Assurance
and Improvement Principles for HCBS
Waivers: Movement to More Specific
Expectations
Valerie J. Bradley, President
Human Services Research Institute
Missouri DD Stakeholders Meeting
November 23, 2010
What Will We Cover?
• Background
• GAO and wake up call for CMS
• Quality Framework and the emergence a 3
dimensional performance structure
• “Operationalizing” the 6 waiver assurances
• Evidence and quality improvement
• How to be prepared for what comes next
Why Should We Care About
Quality?
• We have created a movement and made promises to
people with disabilities and their families
• Ideology alone does not create a stable and
reliable system of supports
• The greater the investment the greater the
expectations
• Unless we build quality in at the beginning, it is very
hard to retrofit a program later
Waivers – Dominant Funding
Source
• Waiver programs for people with
DD account for about 75% of all
waiver spending
• In 2008, there were about 525,000
waiver recipients with DD – a 740%
increase from 1992
• Total cost in ‘08 was 22.3 billion
– about $42,500 per recipient
• Five times as many people receive waiver
services than are served in ICFs/MR
CMS Gets a Wake-Up Call
GAO Report on Federal Oversight of
HCBS Waivers -- 2003
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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)
HCBS Quality Framework
Major Change in Oversight
 Shifted review process away from
“snap shot in time”
 Formalized ongoing dialogue between
CMS and State
 Based on state monitoring its own processes and
procedures
 Focused on state producing evidentiary based reports
to demonstrate that assurances are met
 CMS reviews reports based on assessment of how
effectively state monitored its own performance and
addressed issues identified
Assurances vs. Framework
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Level of Care
Plan of Care
Qualified Providers
Health and Safety
Financial Accountability
Administrative Authority
Recent Changes
Development of 3.5
• Performance measures required for all
assurances and sub-assurance
• Each performance measure needs a metric, have
face validity and focus on the right unit of
analysis
• Remediation has to be described for each
assurance
• Appendix H is now where you put information
about how you improve quality
Requirements for More Focused
Evidence Reports
• Should be continually reaching 100% compliance
• Should be able to aggregate remediation so that you
can determine how quickly issues are resolved
• Should be able to describe methods of remediation
• Should be able to describe relevant quality
improvement initiatives (training, policy change, etc.)
• Can use consumer surveys – but not as the sole
source of evidence
“What
is it Lassie, Is Timmy in trouble?”
Sample
Evidence
Format*
*Beth Jackson,
2010
Technical Assistance
• Continued funding of National Quality
Enterprise
• Development of NQE website
– Sign up for TA
– Identify resources
– Download presentations
• Bi-monthly public Quality calls
Increased Emphasis on
Sampling
• 95% confidence/5% margin of error
• Has to be by waiver
• Sample size can vary depending on the
magnitude of non-compliance – the higher the
compliance level, the lower the sample size
• Sample calculators available on line:
www.raosoft.com
Concentration on Health and
Welfare
• Focus on restraints and restrictive practices
• Stress on incident management
• Economic downturn gives even more impetus
to monitoring
• Concerns with medication
management
Other Issues to Keep
on Your Radar
• Interest in uniform practices across
sub-state entities (e.g., counties)
• Focus on equitable allocation of waiver slots the state
• Importance of unified and standardized contracting
procedures
• Performance measures for any delegated functions
including fiscal intermediaries
• Necessity of educating and collaborating with your
state Medicaid agency
What Can You Expect in the
Next Few Years?
Changes on the Horizon
• Refinements and enhancements of waiver
application that should result in more clarity
regarding expectations
• Expanded use of web-based data
submissions
• Increased clarity regarding
assurances and measures
What Do You Need to Do?
• Make sure that you have performance measures for all
assurances
• Don’t reinvent what you’ve already got
• Develop a good working relationship with your state
Medicaid agency; re-inspect your MOU
• Make sure you can track remediation
• Introduce yourself to CPS, ADS – you will need their
data
• Don’t over promise
• If you don’t have the evidence, develop an action plan
I Know It Won’t Be Easy – States are Already
Having to do More with Less . . .
. . . But you need to find a way to incorporate
these requirements into your own QA process
and tailor them to your needs. This is not the
be all and end all of quality measurement and
improvement but for the foreseeable future,
this is the price of admission
THE END
What did she
say?