The Role of ILCs in Managed LTSS Quality
- Slides: 39
The Role of ILCs in Managed LTSS & Quality & Outcomes in LTSS Steve Kaye Community Living Policy Center University of California San Francisco CFILC Statewide February 11, 2014
Community Living Policy Center • New policy-focused research center at UCSF – Successor to the PAS Center – Funded by • National Institute on Disability & Rehabilitation Research • Administration for Community Living, HHS – Collaboration with • • University of Illinois at Chicago Paraprofessional Healthcare Institute DREDF Topeka Independent Living Resource Center National Council on Aging Henry Claypool Sibling Leadership Network
Community Living Policy Center • Goals: – Identify & study promising practices in LTSS – Promote quality & outcome measures & data systems – Create plan for future LTSS research – Support the U. S. Dept. of HHS Community Living Council & new “Community Living Strategic Plan”
The Role of ILCs in Managed LTSS
How this project came about SPIL called for study of IHSS DOR contracted with UCSF People said: Focus instead on managed LTSS Changed scope of work One focus: How do ILCs gear up for transition to managed care? • Participated in CFILC committee • Found out what others are doing/proposing in other states & nationally • • •
Potential role of ILCs in managed LTSS • MCOs know a lot about acute care but not LTSS • They are medical model organizations unfamiliar with the social model – Don’t understand the importance of LTSS in supporting independent living – Don’t value community participation as a goal – Don’t understand or value consumer direction • They may not have adequate experience with PWDs • ILCs are uniquely positioned to help solve these problems and ensure that consumers get adequate, appropriate, high quality services
ILCs have diverse, sometimes conflicting goals • On the one hand… – Serve consumers as best we can – Maintain adherence to independent living philosophy – Freely advocate for systems change • On the other hand… – Need to diversify funding stream – Keep up with changing healthcare/LTSS landscape – Seize opportunity to improve LTSS system
Four suggested goals 1. Infuse an independent living perspective into the medical-model world of the MCO 2. Foster a consumer-directed, independent provider model of LTSS 3. Ensure that consumers receive appropriate & adequate acute care & LTSS, including nonmedical services 4. Promote accountability for LTSS quality & outcomes related to independent living
Suggested activities • Partnership: a contractual relationship with an MCO to provide a service to them or their members. • Program: service provision by the ILC that is external to the MCOs, funded by a government agency or a foundation. • Advocacy: an area of focus for systems change advocates, consumer-advocates, or other ILC staff working to change attitudes or practices.
Goal 1: Infuse an independent living perspective into the medical-model world of the MCO • Partnership: Provide training to MCO staff and providers on the independent living philosophy. • Partnership: Position ILC staff or consumer advocates to work within the MCO and serve as experts in independent living and LTSS. • Advocacy: Recruit knowledgeable consumer-advocates or ILC staff to serve on boards and committees within the MCOs, or external committees established by oversight bodies.
Goal 2: Foster a consumer-directed, independent provider model of LTSS • Partnership: ILCs could contract with their counties to help connect consumers with available workers • Partnership: Provide training for workers, as appropriate, in independent living and the skills needed to support consumers. • Partnership: Provide training to consumers in how to hire, manage, and fire workers, deal with paperwork, etc. • Advocacy: ILCs could work to make MCOs aware of the advantages of consumer-directed services.
Goal 3: Ensure that consumers receive appropriate & adequate acute care & LTSS, incl. non-medical • Partnership: Contract with MCOs to provide customer service or troubleshooting for their members needing LTSS. • Advocacy/Program: An external ombuds program to advocate for consumers in their dealings with MCOs. • Program/Partnership: Create a peer mentorship program for plan members with disabilities. • Program: Provide consumer education or options counseling about plan choices, services & programs, etc.
Goal 3: Ensure that consumers receive appropriate & adequate acute care & LTSS (cont. ) • Partnership: Provide, or participate in providing, care coordination services for members receiving LTSS, based in an independent living framework. • Partnership: Contract with the MCOs to provide training for MCO staff and providers in cultural competence, disability awareness & accommodations. • Partnership: Provide accessibility assessments of programs & facilities, and consultation on how to improve accessibility.
Goal 3: Ensure that consumers receive appropriate & adequate acute care & LTSS (cont. ) • Partnership: Contract with MCOs to transition people out of nursing homes and other institutions. • Partnership: MCOs may welcome assistance from ILCs in helping members avoid institutionalization and remain in the community. • Partnership/Program: ILCs could provide training to family members in how to support their family member in living independently and avoiding institutionalization.
Goal 4: Promote accountability for LTSS quality & outcomes related to independent living • Statewide Advocacy: With senior organizations, advocate that the state require MCOs to monitor quality & outcomes and report to public. • County Advocacy: With senior organizations, advocate for MCOs to monitor quality & outcomes and report to public. • Advocacy: Using quality & outcomes data, consumer complaints, & other information, periodically assess the performance of the MCOs.
Quality & Outcomes in LTSS Why? What? How?
Why measure quality/outcomes in managed LTSS • Danger of managed LTSS turning system into a black box • Enables state oversight of plans’ commitments to consumer-focused, quality services • Outcome data can encourage plans to focus on meeting consumer needs • Advocates can track outcomes, compare across plans, make both plans & state accountable • Outcome data can help consumers choose plan (or FFS) • Comparative effectiveness of programs and settings – Shift resources to programs and settings with better outcomes.
CLPC framework for quality & outcomes in LTSS program characteristics LTSS Resources The LTSS Consumer LTSS system responsiveness
LTSS program characteristics LTSS Resources The LTSS Consumer Paid & unpaid providers LTSS received Supportive environment Met/unmet need Outcomes LTSS system responsiveness
LTSS program characteristics • Scope. Eligibility criteria, extent and nature of benefits, cost containment strategies. • Financing. Spending by setting; global/flexible budgeting; financial robustness & sustainability. • Equity. Fairness across populations and geographic areas; uniform, unbiased assessment. • Organization. Consolidated system versus fragmented patchwork of separate programs. • Navigability. Assistance gaining access to & navigating programs, facilitated or streamlined application process. timely eligibility decisions.
LTSS system responsiveness • Accountability/transparency. Data systems & measures of quality/outcomes, public reporting, oversight & contract enforcement. • Consumer empowerment. Ombuds programs, complaint resolution & reporting, grievance & appeals, stakeholder role in development & oversight. • Quality improvement processes. System adjusts to feedback from data, stakeholders, etc. • Policy environment. Policy/program malleability.
LTSS Resources Paid & unpaid providers Supportive environment • Caregiver/family support. Support for & status of families and family/friend caregivers, compensation of family members, and impact of caregiving on families. • Workforce development. Job characteristics such as wages and benefits, training/certification, injury rates, and satisfaction. • Worker availability & quality. Worker shortages, workforce turnover/retention, skill levels that match consumer needs.
LTSS Resources • Accessibility/accommodations. Home & community accessibility features; accommodating physical & social environment. Paid & unpaid providers • Technology. Availability & use of AT to support community living. Supportive environment • Personal resources. Financial resources, social support. • Settings. Extent to which the setting is integrated, offers consumer control, and promotes participation & engagement.
• Satisfaction with quality & sufficiency. The LTSS Consumer LTSS received Met/unmet need Outcomes • Appropriateness. Personcenteredness; consumer choice, direction, & control; support in making decisions about services; reliability; respect & dignity. • Coordination. Care coordination & integration of acute care & LTSS. • Utilization. Healthcare & LTSS utilization, barriers to utilization, and maintenance of or transition to community living.
• Amount The LTSS Consumer LTSS received Met/unmet need Outcomes – Level of need – Amount of paid & unpaid LTSS received – Extent to which services received enable person to participate • Adequacy – Extent to which paid & unpaid LTSS meet the person’s needs – Consequences of unmet need
The LTSS Consumer LTSS received Met/unmet need Outcomes • Health and function. Incl. mental health & secondary conditions, and ability to maintain functioning. • Safety. Sense of security, freedom from abuse & victimization, injury prevention. • Well-being. Includes life satisfaction, happiness, sense of autonomy, & other consumerassessed quality of life measures. • Participation. Social/economic participation, relationships, social inclusion, and community engagement & integration.
How to obtain data • Program records and administrators • Advocates & other stakeholders • Consumer records – Administrative records – Medical or claims records (encounter data) • Analyses of national or state survey data • Surveys – LTSS recipients – Families & family caregivers
What can advocates do? • Inspect existing outcome surveys – Ask state for any surveys used to measure LTSS outcomes in HCBS Waiver programs – Review surveys for appropriateness to desired measurement goals – Identify gaps and provide suggestions to fill them • Advocate for stakeholder input on measures – State could establish forums for consumer/advocate input • Advocate for required quality measures from MCOs – Through contract language, state- and MCO-level policies • Recommend specific quality measures to MCOs
Identifying and Selecting Long-Term Services and Supports Outcome Measures A Guide for Advocates January 2013 [Available at: http: //dredf. org/2013 -documents/Guide-LTSSOutcome-Measures. pdf] Prepared by the Disability Rights Education and Defense Fund (DREDF) in collaboration with the National Senior Citizens Law Center. Funded by the National Institute on Disability and Rehabilitation Research (Grant #H 133 B 080002)
Quality & Outcomes in LTSS Example: Proposed Evaluation of the DOR Transition Fund
Evaluating the DOR transition fund • ILCs can apply to DOR for funds to help transition people out of institutions • ILCs report back on what they spent the money on, but aren’t required to track consumer or report outcomes • Project focused on addressing these questions – Did the person remain in the community? – Did they do well after they transitioned? – Are they better off after transitioning than before?
How to measure the outcomes of interest Is there an existing survey we can use? Short answer: No Are there existing measures we can use? Yes, many surveys ask relevant questions And: There is a conceptual framework for LTSS outcomes that closely matches the IL perspective • Inspected 24 surveys and identified 150 survey questions relevant to 12 outcome domains • • •
Personal Experience Outcomes Integrated Interview and Evaluation System (PEONIES) • A set of quality of life domains developed for Wisconsin’s HCBS programs • IL focus that resonates with transition team priority areas • Not a measurement tool, but a list of important areas for measurement • 12 domains in three areas: – Choice in living arrangement, services, daily life – Health, safety, abuse/neglect – Personal experience: extent of relationships, importance of activities, community involvement, stability, respect/fairness, privacy
Recommendations to DOR • Administer survey before transition • Wait a fixed period of time for each consumer – 6 months, 9 months, 1 year? • Locate consumer and report on residential situation • Administer nearly identical survey • Report pre- and post survey data to DOR • Possibly also gather hours/utilization data
Survey development • Spoke with transition teams to discuss what outcome domains were important to consumers who transitioned • Areas corresponded to several PEONIES domains • Asked transition teams to review existing questions corresponding to PEONIES domains • Each team selected or adapted several questions • Triangulated based on responses & survey design principles • Asked teams to review draft survey and revised it based on feedback
The survey (post-transition version) To start, I have some questions about your living arrangement: – Do you like where you live? – In general, do you feel safe in your home? Next, I’d like to talk about how you spend your time. Would you say the following statements are true, mostly true, or false? – – – I have freedom and control over what I do and how I spend my time. I can get out of my home whenever I choose. I am satisfied with how much contact I have with friends and family. I am satisfied with my level of social and community activity. I am satisfied with the way I am spending my life these days. I feel that I am a part of my community.
The survey (post-transition version) Now I have some questions about the people who are paid to help you in your home or elsewhere: – Did you help choose the people who are paid to help you? – Do the people paid to help you listen to what you ask them to do? – Do the people paid to help you always do what they are paid to do? – Do the people who are paid to help you respect your privacy? Here are some questions about your quality of life: – How often do you feel lonely? Would you say very often, sometimes, rarely, or never? – How would you rate your quality of life? Would you say excellent, very good, fair, or poor? • One final question: What would you say has been the biggest change in your life since you left the facility?
Evaluating the transition fund • Consumers transitioned & expenditure • ILC ranking of number transitioned • Proportion of consumers still living in the community at follow-up, and other settings • Distribution of survey responses on all measures • Comparison of pre and post survey responses • Optionally, estimate of cost savings based on post-transition service usage
Conclusions • Many potential roles for ILCs as consumers transition into managed, integrated care: partnerships with MCOs, programs funded in other ways, systems change advocacy • Measuring quality & outcomes in LTSS is a particularly pressing issue: system, resources, and consumer-level measures • Consumer-focused outcome measures are of particular interest to the IL community • Measurement tools can be constructed using existing tools as a starting point
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