Human Services Research Institute Quality Assurance: It’s Everybody’s Business Valerie J....

Human Services Research Institute

Quality Assurance: It’s Everybody’s Business

Valerie J. BradleyHuman Services Research Institute

October 23, 2003South Carolina Association on Mental RetardationMyrtle Beach, South Carolina


Changing Quality Landscape Exposure of fault-lines in the

system (e.g., GAO report, etc.) Self-determination/self directed

services Olmstead decision Recent CMS initiatives Direct support staff shortages Pressures to expand home and

community services


Developmental Disabilities Lawsuits

25 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services …

Gary Smith, HSRI, 2003


Decreasing/static funding – coming on top of an already strained provider network

Increasing federal expectations regarding quality management

Inefficient “business model” (e.g., clumsy rate structures, redundant, sometimes conflicting monitoring processes)

Changing landscape …


Growth in Waiver Services

1982…..a handful of waivers for a small number of people

2002…..90+ HCBS waiver programs for 380,000 people with developmental disabilities and growing

Rapid expansion of HCBS waiver program has had profound effects on the configuration of state service delivery systems


Changing LandscapePeople with Developmental Disabilities Receiving

HCBS or ICF/MR Services

0

100,000

200,000

300,000

400,000

500,000

90 92 94 96 98 00 02

ICF/MR HCBS

Between 1999 and 2002, states expanded waiver programs by 110,000 individuals


Implications Waiver program now serves more than three

times as many people as ICFs/MR State service systems are extremely reliant on

federal Medicaid dollars Services are being furnished at 10,000 sites by

agencies and individual providers No amount of on site monitoring or reviews can

provide an accurate picture of quality in increasingly complex systems


Signs of Change in Performance Management No longer just better than the institution Rooted in outcomes Emphasis on enhancement and

CQI Changing state role Changes in experiences and

expectations of families and people with developmental disabilities


More Signs of Change

Changes in accreditation approaches

Movement away from prescriptive standards to individualized risk management

Collaborative development of standards Consumer and family participation in

oversight (e.g., PA MN)

Satisfaction

CQI

Consensus


Federal Directions

Federal policy directions are having a profound affect on QA/QI

Revamped federal oversight framework Greatly heightened expectations for state

quality management systems, especially in HCBS


GAO Report on Federal Oversight of HCBS Waivers

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)


CMS Action Plan * Components of Quality: more

detailed expectationsGrants to States

Quality projects; Direct Service Worker force; Real Choices

Quality FrameworkIndependence Plus waiver

templatePromising practices

* Letter to Breaux and Grassley; also cms.hhs.gov/medicaid/waivers/quality.asp (Quality Workplan)


CMS Action Plan

Strengthen Federal OversightTraining for central and regional office

CMS staffCMS procedural guidance for reviewsResource and strategy review…more cost

effective method to review and improve services

Improve Federal Follow-up CapabilityTechnical assistance projects (National

Contractors for Quality)


CMS Action Plan

Obtain more Information about quality from states

Revamp waiver application States spell out quality management system

Annual State Quality Reports Improve content Electronic media: convert 372 report to

electronic Electronic database to track waivers

Quality Inventory


National Contractor Funded by CMS Started in 2001 with TA for Develop-

mental Disabilities Waiver Services Expanded in 2003 to provide TA for

Elderly/Disabled Waiver Services In-house expertise and over 50

experienced consultants


Types of Technical Assistance On-site and off-site individualized TA to state

agencies administering HCB services Creating resources and products

for all states State to state linkages & sharing

of resources Presenting at state and national

conferences


Major Tasks To assess identify trends in quality issues

flowing from Regional Office HCBS waiver reviews

To provide on-site and short-term technical assistance to the states to address specific quality and health/welfare concerns

To provide technical assistance to CMS Regional Offices re content of HCBS waiver reviews, applications, renewals or amendments


Major Tasks

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.

To provide national consultation and technical assistance regarding quality assurance and improvement in the implementation in HCBS waivers for people with developmental disabilities


National Technical Assistance Resources Resources available on HCBS.org:

CMS Waiver Review Trend Analysis Five State Monitoring Review Root Cause Analysis Quality Framework Future: Lessons learned, state examples, etc.

Toolkits (e.g., sampling etc.) Web-based conferences “Match making” between and among states Facilitated conference calls


HCBS Quality FrameworkHCBS Quality Frameworkcms.hhs.gov/medicaid/waivers/frameworkmatrix.asp


Participant Access

Information and Referral Intake and Eligibility

User-friendly processes Eligibility determination Referral to community services Individualization of services Prompt initiation


Participant-Centered Service Planning and Delivery Participant-Centered PlanningParticipant-Centered Planning

Adequate assessmentAdequate assessmentFree choice of providersFree choice of providersResponsive service planResponsive service planParticipant directed servicesParticipant directed services

Service DeliveryService DeliveryOngoing service and support coordinationOngoing service and support coordinationProvision of needed servicesProvision of needed services

Ongoing monitoringOngoing monitoring Responsiveness to changing needsResponsiveness to changing needs


Provider Capacity and Capabilities Availability of individual and agency providers Review of provider

qualifications Monitoring of provider

performance


Participant Safeguards

Risk and safety planningRisk and safety planning Critical incident managementCritical incident management Ensuring safety of housing andEnsuring safety of housing and environment environment Use of behavior interventionsUse of behavior interventions Medication managementMedication management Natural disasters and other publicNatural disasters and other public emergencies emergencies


Participant rights and responsibilities Civic and human rights

safeguards Decision making authority Provisions for alternate decision

making Due process and grievance

mechanisms


Participant Outcome and Satisfaction

Participant outcomes Participant satisfaction


System Performance

Conduct system performance appraisals Conduct quality improvement projects Ensure cultural competency Engage participants & stakeholders in

program design, quality assurance and improvement activities

Assure financial integrity


Continuous Quality Improvement

Close the loop

Information from quality assurance

drives decision making!

Therefore….


Continuous Quality Improvement

DiscoveryLicensingConsumer surveyIncident management

Design Features•Outcomes indicators•Provider enrollment •Rules, policies, Procedures

Quality ImprovementTrends AnalysisBenchmarkingStrategic Planning

RemediationReal time tracking of incidents and follow-upPlan of correctionProvider Qualification


Quality Framework …

Will drive revamped HCBS waiver application

AIM: shift federal oversight from periodic compliance reviews to assessing effectiveness and functionality of state quality management system

Concentration on data/reporting


Very high volume of activity to modify/strengthen

QA/I systems Plugging gaps/rethinking basic processes Focus: Participant outcomes (National Core Indicators) Focus: Securing systematic feedback from individuals and families Focus: risk assessment/planning

State Directions


More Directions

Focus: Incident management Focus: Functionality and effectiveness of

service planning processes and plan implementation

Focus: Rethinking QA/I in context of individual and family-directed services

Focus: Data systems in support of quality management


A FEW EXAMPLESFROM A MORTALITY REPORT

Mortality Rate by Where People LiveNo. Deaths per 1000 People

FY 2003

4.17.6

4.3

12.3

22.6

30.2

100.8

0

20

40

60

80

100

120

Home SL CTH CLA STS RC LTC

Residential Setting

No

. De

ath

s p

er

10

00

Pe

op

le

GENDER No. Deaths per 1000

FY 2003

11.5389.836

Men Women

Mortality Rate by Age Range Comparison of FY02 and FY03

0

20

40

60

80

100

120

140

160

180

200

No

. De

ath

s p

er

10

00

FY02 6.589 1.652 2.834 7.639 10.566 19.84139.807 47.511 92.486 200.00

FY03 6.395 1.211 5.100 5.981 7.394 18.63034.843 41.667 81.871 166.66

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

Only age range w ith an

increase in mortality rate

Mortality RateNo. Deaths per 1000

Comparison: FY01- FY02 - FY03

12.6512.06

10.79

FY01 FY02 FY03


22% of deaths were due to Heart Disease

22% of deaths were due to Cancer

19% of deaths were due to Pneumonia/Lung Diseases including 3% due to aspiration pneumonia

14% of deaths were due to Nervous System Diseases including Alzheimer’s (7%), Anoxia (3%),Epilepsy (2%), and Parkinson’s (1%)

5% of deaths were due to Renal Failure

4% of deaths were due to Digestive System Diseases

RANK Connecticut DMR

Calendar Year 2002

ConnecticutCalendar Year 1998

(most recent available)

U.S.

Calendar Year 2001

1 Heart DiseaseCancer

Heart Disease Heart Disease

2 Respiratory Disorders

Cancer Cancer

3 Nervous System Disorders

Respiratory Disorders Cerebrovascular Diseases (incl Stroke)

4 Renal Failure Accidents Chronic Respiratory Diseases

Benchmarks: Leading Causes of Death

FY03 Leading Causes of Death

A FEW MORE EXAMPLESFROM A MORTALITY REPORT


Mortality Rate by Level of Disabilityfor Persons Served by DMR

FY 2003

12.66

25.21

8.20 8.69 7.69

0

5

10

15

20

25

30

No MR orND

Mild Moderate Severe Profound

Level of Mental Retardation

No

. Dea

ths

per

100

0

Overall average rate = 10.80


Manner of Death No. Percent

Natural 132 97.8% Accident 1 0.7% Homocide 0 0% Suicide 0 0% Undertermined 2 1.5% Total 135 100.0%


0.014

0.018

0.022

0.0140.015

0

0

0

0

0

0

STS RC PRIV ICFCLA

PRIVCLA

PUB ICFCLA

PUBCLA

No

. P

eo

ple

Rate of Substantiated Abuse (No. Substantiated Incidents/No Served)

by Type of Residential SettingFY 2001

0.042

0.022

0.034 0.034

0.018

0

0

0

0

0

0

0

0

0

0

STS RC PRIV ICFCLA

PRIVCLA

PUB ICFCLA

PUBCLA

No

. P

eo

ple

Rate of Severe Injuries(No. Incidents of Severe Injury/No Served)


1.782

2.2081.963

3.381

4.078

0

1

1

2

2

3

3

4

4

5

STS RC PRIV ICFCLA

PRIVCLA

PUB ICFCLA

PUBCLA

No

. P

eo

ple

Rate of Unusual Incidents(No. Unusual Incidents/No Served)


3.934

17.285

1.888 2.498 2.571

0

2

4

6

8

10

12

14

16

18

20

STS RC PRIV ICFCLA

PRIVCLA

PUB ICFCLA

PUBCLA

No

. P

eo

ple

Rate of Restraint Utilization(No. Incidents of Restraint/No Served)


COMPARATIVE ANALYSES

• Useful as tool to help focus attention on differences

• Identify areas needing further review and analysis• Can target analysis

to region, type of provider or service

• Can combine with trends analyses to identify changes over time by region, provider or service

BASIC ANALYSIS OF SIMPLE DATA


Variable B S.E. Wald Sig Exp(B)AGE 0.054 0.002 542.587 0.000 1.056GENDER -0.048 0.08 0.365 0.546 0.953LEVEL OF MRMild MR -0.088 0.22 0.159 0.690 0.916Moderate MR -0.074 0.222 0.112 0.738 0.928Severe MR 0.138 0.226 0.373 0.541 1.148Profound MR 0.015 0.224 0.005 0.945 1.016SUPERVISIONMedium Spvsn 0.391 0.126 9.560 0.002 1.478High Spvsn 0.507 0.157 10.385 0.001 1.660VISIONImp/Corrected 0.069 0.094 0.537 0.464 1.072Imp/Not Corrected 0.175 0.139 1.587 0.208 1.191Imp/Blind 0.298 0.156 3.63 0.057 1.347MOBILITYUnsteady 0.63 0.12 27.402 0.000 1.877Assist Device 0.499 0.163 9.406 0.002 1.648Person Support 0.621 0.185 11.261 0.001 1.861WC/Indep 0.916 0.177 26.735 0.000 2.499WC/Depend 1.484 0.145 104.572 0.000 4.411Dependent 1.81 0.185 95.35 0.000 6.111

Constant -5.828 0.27 464.781 0.000 0.003

Variables

Significance(smaller than .05)

STRONGEST PREDICTORS

Strength(How much itContributes toMortality)

1

3

2

AGEMOBILITY

SUPERVISION

Important Finding:


Variable B S.E. Wald Sig Exp(B)AGE 0.054 0.002 542.587 0.000 1.056GENDER -0.048 0.08 0.365 0.546 0.953LEVEL OF MRMild MR -0.088 0.22 0.159 0.690 0.916Moderate MR -0.074 0.222 0.112 0.738 0.928Severe MR 0.138 0.226 0.373 0.541 1.148Profound MR 0.015 0.224 0.005 0.945 1.016SUPERVISIONMedium Spvsn 0.391 0.126 9.560 0.002 1.478High Spvsn 0.507 0.157 10.385 0.001 1.660VISIONImp/Corrected 0.069 0.094 0.537 0.464 1.072Imp/Not Corrected 0.175 0.139 1.587 0.208 1.191Imp/Blind 0.298 0.156 3.63 0.057 1.347MOBILITYUnsteady 0.63 0.12 27.402 0.000 1.877Assist Device 0.499 0.163 9.406 0.002 1.648Person Support 0.621 0.185 11.261 0.001 1.861WC/Indep 0.916 0.177 26.735 0.000 2.499WC/Depend 1.484 0.145 104.572 0.000 4.411Dependent 1.81 0.185 95.35 0.000 6.111

Constant -5.828 0.27 464.781 0.000 0.003

Variables in Logistic Equation

Mortality Prediction

Probability(How much more likely toDie than reference group)

1

3

2

People who are: MOBILITY DEPENDENT are 6X as likely to die as people who are mobility independent

EXAMPLE


Conclusions and Recommendations


We need to change our approach to Quality

“Our level of thinking has created problems that cannot be solved by the same level of thinking”

Albert Einstein


Important Next Steps Place individual outcomes at the

center of the system Enlist involvement of consumers

and families Identify key areas of performance

and develop indicators Create a quality management

entity Explore hotlines and

ombudspersons


Develop uniform reporting of critical health and safety events

Implement risk management and health assessments

Develop staff credentialing and expand training options

Reassess roles and responsibilities of case managers

Refine performance contracting Develop internal QA systems Integrate quality assurance responsibilities

across the system


Improve up-front quality expectations Increase transparency of QA systems and

develop a demand for information Explore quality assurance for individual

providers Expand understanding of participant

centered planning Develop a technical assistance capacity Build integrated data systems


Lessons for Providers Develop internal quality improvement plans

including trending and risk management 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 Recognize that quality assurance will become more

comprehensive and systematic


Final Words

“Beware the Continuous Improvement of Things Not Worth Improving”

W. Edwards Deming

Human Services Research Institute Quality Assurance: It’s Everybody’s Business Valerie J....

Documents

Transcript of Human Services Research Institute Quality Assurance: It’s Everybody’s Business Valerie J....