Overview of Quality Assurance and Enhancement A Framework

Overview of Quality Assurance and Enhancement A Framework for Best Practice Val Bradley Human Services Research Institute

Changing Quality Landscape n n n Exposure of fault-lines in the system (e. g. , CMS and the press) Emergence of self-determination Olmstead decision and proposed closures Struggles with MIS applications Direct support staff shortages Expansion of supports to individuals on the waiting list Human Services Research Institute

23 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services … Gary Smith, HSRI, 2003 Human Services Research Institute

n Decreasing/static funding – coming on top of already strained providers n Increasing federal expectations n Inefficient “business model” (e. g. , clumsy rate structures, etc. ) Human Services Research Institute

Signs of Change in Performance Management n n n No longer just better than the institution Rooted in outcomes Emphasis on enhancement and CQI Changing role of the state Changes in experiences of families and people with mental retardation Changes in accreditation approaches Human Services Research Institute Inclusion

More Signs of Change n n n Movement away from prescriptive standards to individualized risk management Collaborative development of standards Inclusion of consumer and family participation in oversight Human Services Research Institute on i t c a f Satis Consensus CQI

CMS Quality Initiative Human Services Research Institute

Purpose of National Technical Assistance n To provide training and technical assistance to CMS Central and Regional Offices and states in quality assurance and improvement in HCBS waiver services for individuals with developmental disabilities. Human Services Research Institute

Major Tasks To assess identify trends in quality issues flowing from Regional Office HCBS waiver reviews n To provide on-site and short-term technical assistance to the states to address specific quality and health and welfare concerns n To provide technical assistance to Regional Offices regarding the content of HCBS waiver reviews, applications, renewals or amendments n Human Services Research Institute

Major Tasks n 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. n To provide national consultation and technical assistance regarding quality assurance and improvement in the implementation in HCBS waivers for people with developmental disabilities Human Services Research Institute

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National Technical Assistance n n n Resources available on HCBS. org: – 5 State Monitoring Review – Root Cause Analysis – Suggested Criteria – Quality Framework – Future: Lessons learned, state examples, etc. Toolkits (e. g. , state licensing and monitoring) Web-based conferences “Match making” between and among states Facilitated conference calls Human Services Research Institute

Status of State Requests Active (8) Active/Short Term (5) Initial Exploration (4) Referred (8) Completed (0) Human Services Research Institute

Regional Office Trainings n November – Case management (Hill and Mitchell) n December – Behavior management policies (Hitzing and Mullen) n March – Health and Medication – (White. Scott n Videos will eventually be available on line Human Services Research Institute

Other CMS Initiatives n n n n Participant Experience Survey Systems Change Grants Development of Protocol guidelines Identification of best practice Systems Change grants Independence Plus template Support for individuals moving out of institutions TA for elderly and disabled waiver services Human Services Research Institute

Emergence of Performance Indicators n n n First appeared in behavioral and acute care Provide some “cues” for managing these complex systems Highlight impact of cost containment Illuminate what’s working Provide early warning signs

Characteristics of Performance Indicators Reflect major organizational or system goals. n Address issues that can be influenced by the organization or system n Have face validity n Point a direction n Reflect rates or major events n Related to associated standards n Human Services Research Institute

Participating NCI States WA VT ME MT MA WY SD RI PA IA NE UT IL IN WV DE KY NC AZ Orange County CT OK SC AL HI Human Services Research Institute

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 Human Services Research Institute Domains

Participant Access Information and Referral n Intake and Eligibility n – User-friendly processes – Eligibility determination – Referral to community services – Individualization of services – Prompt initiation Human Services Research Institute

Participant-Centered Service Planning and Delivery n Participant-Centered Planning – – n Adequate assessment Free choice of providers Responsive service plan Participant direction Service Delivery – – Ongoing service and support coordination Provision of needed services Ongoing monitoring Responsiveness to changing needs Human Services Research Institute

Provider Capacity and Capabilities n Availability of individual and agency providers n Review of provider qualifications n Monitoring of provider performance Human Services Research Institute

Participant Safeguards n n n n Prevention and investigation of abuse, neglect and exploitation Tracking of major and unusual incidents Ensuring safety of housing and environment Regulation of behavior interventions Standards for medication management Provisions for personal safety and security Preparation for natural disasters and other public emergencies Human Services Research Institute

Participant rights and responsibilities Ensure that participants: n Exercise civic and human rights n Participate in decision making authority n Have provisions for alternate decision making n Have access to due process and grievance mechanisms Human Services Research Institute

Participant Outcome and Satisfaction n Participant satisfaction n Participant outcomes Human Services Research Institute

System Performance n Conduct system performance appraisals n Support quality improvement n Ensure cultural competency n Support participant & stakeholder involvement n Maintain financial integrity Human Services Research Institute

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Review of Outcome. Focused Monitoring Mechanisms Human Services Research Institute

Immediate Challenges n Quality assurance for individual providers n Sustainability of person-centered QA n Effectiveness and efficiency of current processes n Integration of information n Development of internal QA systems Human Services Research Institute

n Integration of quality assurance responsibilities across the system n Involvement of families and people with disabilities n Improvement in up-front quality expectations upfront (e. g. , Pennsylvania). n Transparency of QA systems and development of a demand for information Human Services Research Institute

Continuous Quality Improvement Close the loop v. Information from quality assurance drives decision making! Therefore…. Human Services Research Institute

Continuous Quality Improvement Outcomes indicators Benchmarking Strategic Planning QA Processes Licensing Consumer survey Incident management Trends Analysis Human Services Research Institute Plan of correction Provider Qualification Analysis of specific trends Real time tracking of incidents and follow-up

Conclusions and Recommendations Human Services Research Institute

Important Next Steps Place individual outcomes at the center of the system n Enlist assistance of consumers and families n Identify key areas of performance n Create a quality management entity n Make results available and accessible n Human Services Research Institute

Develop uniform reporting of critical health and safety events n Develop staff credentialing and expand training options n Reassess roles and responsibilities of case managers n Refine performance contracting n Develop quality management entity n Human Services Research Institute

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n Expand understanding of participant centered planning n Develop a technical assistance capacity n Implement risk management and health assessments n Build integrated data systems n Develop hotlines and ombudspersons Human Services Research Institute

Lessons for Providers n n n Develop internal quality improvement plans 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 Assume that quality assurance will become more comprehensive and systematic Human Services Research Institute

Final Words “Beware the Continuous Improvement of Things Not Worth Improving” W. Edwards Deming Human Services Research Institute