Human Services Research Institute Quality Assurance: It’s Everybody’s Business Valerie J....
-
Upload
gregory-woods -
Category
Documents
-
view
215 -
download
1
Transcript of 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
Human Services Research Institute
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
Human Services Research Institute
Developmental Disabilities Lawsuits
25 States have been sued for wait listing individuals with developmental disabilities for Medicaid long-term services …
Gary Smith, HSRI, 2003
Human Services Research Institute
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 …
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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)
Human Services Research Institute
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)
Human Services Research Institute
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)
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
HCBS Quality FrameworkHCBS Quality Frameworkcms.hhs.gov/medicaid/waivers/frameworkmatrix.asp
Human Services Research Institute
Participant Access
Information and Referral Intake and Eligibility
User-friendly processes Eligibility determination Referral to community services Individualization of services Prompt initiation
Human Services Research Institute
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
Human Services Research Institute
Provider Capacity and Capabilities Availability of individual and agency providers Review of provider
qualifications Monitoring of provider
performance
Human Services Research Institute
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
Human Services Research Institute
Participant rights and responsibilities Civic and human rights
safeguards Decision making authority Provisions for alternate decision
making Due process and grievance
mechanisms
Human Services Research Institute
Participant Outcome and Satisfaction
Participant outcomes Participant satisfaction
Human Services Research Institute
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
Human Services Research Institute
Continuous Quality Improvement
Close the loop
Information from quality assurance
drives decision making!
Therefore….
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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%
Human Services Research Institute
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)
by Type of Residential SettingFY 2001
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)
by Type of Residential SettingFY 2001
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)
by Type of Residential SettingFY 2001
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
Human Services Research Institute
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:
Human Services Research Institute
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
Human Services Research Institute
Conclusions and Recommendations
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
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
Human Services Research Institute
Final Words
“Beware the Continuous Improvement of Things Not Worth Improving”
W. Edwards Deming