odp’s waiver quality strategy: where does im4q fit in?€¦ · to meet these expectations, we...

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ODP’s Waiver Quality Strategy: Where does IM4Q fit in?

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Hello. My name is Dolores Frantz. I will be one of the presenters for this presentation on ODP’s Waiver Quality Strategy – Where Does IM4Q Fit In?

I am the Director of Quality Management for the Office of Developmental Programs. My role is to assist ODP staff and stakeholders to develop and implement quality assurance and quality improvement strategies that are based on ODP’s Mission, Vision, Values and Quality Framework. ODP works to apply quality management principles, practices and tools to all of its programs and operations, including waiver programs, public and private ICFs/ID, and base‐funded services. Our focus in this webcast will be the Quality Improvement Strategy, or QIS, found in the Consolidated and Person/Family Directed Support, or P/FDS, Waivers effective July 1, 2012.

The other presenter will be Diana Ramirez. Diana is ODP’s Quality Management Coordinator. Diana works along with me to support ODP staff and stakeholders to implement quality management across the Office. Diana participated in the development and writing of ODP’s Quality Improvement Strategy for the Consolidated and P/FDS Waivers, including performance measures, remediation and improvement strategies. She assists staff in the Bureau of Supports for People with Intellectual Disabilities to review and analyze waiver performance data during statewide and regional quality oversight group meetings.

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Certificates of Achievement will be available to Supports Coordinators and SC Supervisors after completing all course requirements.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test. Please view and then save or print your certificate in order to receive credit for this course.

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Let’s first review the objectives for this course.

After completing this presentation, you will be able to:

• Understand the Home and Community Based Services, or HCBS, Quality Framework

• Describe the Centers for Medicare and Medicaid Services, also known as CMS, Quality Improvement Strategy for the Consolidated and P/FDS Waivers

• Explain CMS Assurances and ODP’s performance measures in the areas of Service Plans and Health and Welfare, and

• Clarify how IM4Q data is used in conjunction with ODP’s waiver performance data to drive quality improvement

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Many of you are familiar with the Home and Community Based Services Quality Framework that is fostered by CMS and that ODP has adopted. Because the steps in this Framework are the foundation for the quality management we do in ODP and for our discussion today, I’d like to take a few minutes to review some of its very important aspects.

In response to the promptings of Congress, CMS developed a comprehensive definition of quality specific to Home and Community Based Services by engaging national associations, subject matter experts, and consumers in creating a Home and Community Based Services Quality Framework to serve as a guide for all stakeholders involved. The Framework was developed in partnership with the National Associations of State Directors of Developmental Disabilities Services, State Units on Aging, and State Medicaid Directors.

The Framework begins by showing with the arrows on the left that the manner in which a program is designed and implemented will determine the results, or outcomes, that are achieved for the individuals who are enrolled in it. ODP has taken great care to improve the descriptions in the Consolidated and P/FDS Waiver Renewal Applications of our program design in all program areas. Some of these areas include person‐centered service planning, provider qualifications, incident management and other strategies we use to monitor health and welfare.

The broad outcome areas affected by program design are then listed in the Framework as:• Participant Access• Participant‐Centered Service Planning and Delivery• Provider Capacity and Capabilities• Participant Safeguards• Participant Rights and Responsibilities• Participant Outcomes and Satisfaction• System Performance

The Quality Framework next depicts that each of these program areas is managed by using a specific quality management method. The steps in this method are Discovery, Remediation, and Improvement. Together with Design, this quality management method is called the DDRI Model.

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In the Waiver Applications, CMS specifies six program areas that must be described in great detail. States must also explain how they will collect and submit evidence, that is, “assure” that all these aspects of the program will be carried out as they are described.

The six areas are: • Level of Care Determinations, • Service Planning and Delivery, • Provider Qualification, • Health and Welfare, • Administrative Authority, and • Financial Accountability

Management of each of these areas is outlined in the Waiver Applications in Appendices dedicated to each one. CMS expects the State to use the DDRI Model when it develops its methods and establishes the degree of compliance that will be achieved for each of the waiver assurances and subassurances. Today we’re going to focus in on the functions of Service Planning and Delivery and Health and Welfare, but first let’s define the DDRI Model in more detail.

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A description of design for each of the assurances must include how the State has planned to ensure that each required function is carried out, how the State monitors performance of those involved in carrying out the function, and who is responsible for monitoring. For example, the State must describe in detail how ISPs will be developed, implemented, monitored and evaluated to ensure that positive outcomes are achieved.

The State must then describe the performance measures it will use to discover how well we’ve performed in carrying out the steps we described. We need to include how often we will collect and study the data and what our sources for performance data are, along with how we go about collecting and aggregating, reviewing and analyzing the information for each waiver assurance and subassurance area.

Remediation means that we must explain how we will take action whenever we come across individual situations in which the program design has not been carried out as expected. We must also describe how long it takes us to address any issues we find.

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CMS expects the State to monitor, generate and evaluate these results continuously—e.g., monthly, and quarterly—and to report performance data annually in the year‐end report we know as the CMS 372.

To meet these expectations, we reevaluated our current AE Oversight Monitoring process that was based on a two‐year cycle and redesigned it to capture and report data on performance on a one‐year cycle.

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The last step in the DDRI Model is improvement. In this step, the State must describe strategies it uses to bring data together and analyze it over time to recognize systemic issues that interfere with the achievement of 100% compliance and positive outcomes for individuals. The State must then outline changes we will make to improve the system into the future. The DDRI Model then begins all over again.

It is during this last step, improvement, where ODP will look at IM4Q data results in conjunction with all other performance data to determine whether positive outcomes have been achieved for individuals enrolled because of all our efforts. We encourage all our stakeholders, AEs and providers, including supports coordination organizations, to conduct the same review process locally as they identify goals and objectives for improvement initiatives and Quality Management, or QM, Plans.

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To summarize, key elements of our Quality Strategy include:

• Performance measures are required for all assurances and subassurances

• States should be able to:• Continually reach 100% compliance• Aggregate remediation data so that a determination of how quickly

issues are resolved can be made• Describe and document methods of remediation, and• Describe relevant quality improvement initiatives such as training,

policy change, introduction of new processes or process redesign

• States may use consumer surveys in conjunction with all other data.

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To emphasize, we must achieve 100% compliance. If our discovery data reflect less than 100% compliance, then we must initiate and complete remediation actions such that discovery evidence plus remediation evidence equals 100% compliance. If less than 100% compliance is achieved, the State must provide an explanation why to CMS.

Diana will next describe what is required of us in the area of Service Planning, what we measure and how we’ll look at IM4Q data to help us evaluate our performance.

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Hi, this is Diana Ramirez. The next section of this presentation concentrates on Service Plans.

The Service Plans Waiver Assurance requires that the State design and implement an effective system for ensuring that service plans of waiver participants meet their needs.

The Service Plans Waiver Assurance is divided into five subassurances that evaluate service plan development, implementation, and monitoring.

Subassurance A examines whether service plans address all assessed needs of waiver participants through waiver services and/or other means.

Subassurance B evaluates whether the State monitors to ensure service plans are developed according to the State’s methodologies contained in policies and procedures.

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Subassurance C addresses the expectation that service plans are updated at least annually and when warranted by changes in waiver participants’ needs.

Subassurance D assesses whether services are delivered as they have been incorporated into service plans, including in the type, scope, amount, duration and frequency specified.

Finally, Subassurance E examines whether choice between waiver services and institutional care is made available to potential waiver program enrollees, and whether choice between or among waiver services and providers is offered.

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Compliance in meeting Subassurance A expectations that all assessed needs are addressed and that individual outcomes relate to identified preferences—person‐centered planning—has been significant across AE Oversight Monitoring Cycles 1, 2, and 3. In Cycle 3 Year‐to‐Date, with 45 AEs evaluated, we are 95% compliant with addressing all assessed needs in the ISP and 98% compliant with ensuring that outcomes listed on the ISP relate to an identified preference.

In the Service Plans area, remember that we believe that the quality of the ISP is central to the outcomes the individual will achieve. In these measures, we are trying to ensure that all needs of the individual are noted and included in the plan.

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This past year, a new performance measure was added to the quality strategy for Service Plans in the waiver renewal applications to satisfy Subassurance A further. This measure tests whether a risk assessment is completed for each individual to identify health and welfare risk areas. Where health and welfare risk factors exist, we evaluate whether risk mitigation strategies have also been built into the ISP. As you can see, YTD we’ve found that a risk assessment was completed in 99% of 221 records and that risk factors were addressed with mitigation strategies in 95% of cases.

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The State is required to ensure that service plan development is carried out using the principles and processes defined in ODP’s policies and procedures.

The ISP Signature Form has been implemented to assist in improving compliance with documenting that individuals and required team members are in attendance at the Annual ISP meeting. This change has had a significant impact. We can demonstrate much more clearly that team members have attended ISP meetings. Where compliance was 87% in Cycle 2, in Cycle 3 YTD, it is 94%.

As mentioned previously, CMS expects that specific remediation actions will be identified for each performance area, and ODP has identified specific remediation actions for Service Plans. For example, if a risk assessment is not found in every ISP at the time of review, ODP will expect that a risk assessment is completed and documented. And if there are risks factors identified, ODP will also expect that risk mitigation strategies are incorporated in the individual’s ISP.

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If all services and supports are not included in each ISP reviewed, we will expect that the ISP is updated to include those services and supports.

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And if any services authorized are found to be inconsistent with the service definitions in the approved waiver, the affected ISP will need to be revised to correct those inconsistencies.

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Compliance with offering individuals choice between and among services and providers has improved dramatically through the introduction of the ISP Signature Form as the designated tool to be used to document these conversations.

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In addition to the measures assessing whether choice of services and choice of willing and qualified providers are offered, ODP has also added a measure to the next AE Oversight Monitoring Cycle, Cycle 4, to evaluate whether individuals are provided choice of participant‐directed services. The measure looks at number and percent of new waiver enrollees and waiver participants who are provided information on participant‐directed services.

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Different than in Cycle 2 AE Oversight Monitoring, in Cycle 3 ODP reviewers determined whether services and supports in the approved ISP were received using the documentation Supports Coordinators entered into the record when they visited and evaluated implementation of the individual’s ISP.

This measure is very important to consider when we evaluate IM4Q responses to the question of whether individuals feel they are receiving the services they need.

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On the previous slides, we’ve shown you some of the measures we will use over the life of the Consolidated and P/FDS Waivers that just went into effect July 1, 2012 to demonstrate our performance in the program area of Service Planning and Delivery. All throughout each year, we’ll be tracking these data and taking steps to correct any problems we find as they arise.

At the end of each fiscal year, we’ll bring together all of our data from the various data sources to try to understand whether we’ve achieved positive results for individuals enrolled in the Waivers. Some of the most important IM4Q data in this analysis is the measure that asks whether individuals feel they’ve received the services they need. As I mentioned previously, we try to ensure plans are developed that address all the individual’s assessed needs. We ask Supports Coordinators to evaluate through their monitoring visits whether the services included in the ISP are actually delivered. We can also look at data from PROMISe ™ to determine whether claims were submitted for payment for the services delivered to the individual.

We can then add IM4Q data into the mix to determine whether individuals believe they are receiving the services they need. We will trend these results over time as well. Each year we will look at where there are gaps in our performance, if any, and try to close those gaps through training or policy, for example. We will also look for ways to change our program design where we receive internal and/or external stakeholder input that suggests we can improve the way we carry out the person‐centered planning function.

For FY 06‐07 and FY 07‐08, we discovered through our IM4Q survey process that 78% and 79% of participants in the Consolidated Waiver reported they received the services and supports they need.

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On this slide, we can see that data collected during the IM4Q survey processes conducted during FY 08‐09, FY 09‐10, and FY 10‐11 show that a similar number of Consolidated Waiver participants, 76%, 76%, and 77% respectively, reported they always received the services they need. In addition, 16%, 18%, and 16% respectively, reported they sometimes received the services they need.

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Looked at in another way, we can show the number of participants in the Consolidated Waiver who responded they always and sometimes received the services they need.

ODP encourages our staff, AEs and providers, including supports coordination organizations, to engage in further discussion and analysis of these IM4Q data results together with consideration of the data that tell us how well we perform the processes of service planning and delivery. We encourage everyone to question why, if we can show that participants and team members are engaged in the ISP process, that assessed needs are addressed in ISPs, and that services in ISPs are delivered, more participants are not reporting they receive the services they need.

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Another layer of analysis that may assist in the discussion is reflected on this slide. For FY 10‐11, we’ve displayed the percentage of Consolidated Waiver participants who reported they received the services and supports they need by Region—Central, Northeast, Southeast, and West. Now we can see more clearly that 80% of waiver participants in Central Region, for example, reported they always receive the services they need and another 13% of waiver participants in Central Region reported they sometimes receive the services they need.

We encourage AEs to continue this analysis to determine performance by AE within regions, and encourage AEs and providers, including supports coordination organizations, to analyze performance at the provider level. Given this more and more specific analysis, staff throughout the system can begin to hypothesize reasons for why waiver participants reported as they have and address those issues as we look to the future. After any recommended changes are made, we can reassess our performance in this area during the next IM4Q survey cycle. This effort is consistent with the quality improvement model ODP has practiced for many years, the PDCA or plan, do, check, act model.

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Now Dolores will describe some of the performance measures we will use to ensure Health and Welfare processes are carried out for our waiver programs and some of the IM4Q data we will use to evaluate our overall performance in this assurance area.

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The Health and Welfare Assurance area has only one statement of assurance. This statement is central to our efforts to safeguard individuals. Despite the fact that there is only one statement, CMS has much broader expectations of States to ensure the health and welfare of individuals, including in the areas of health maintenance and resolution of complaints.

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ODP will continue to track and trend the # and % of critical incidents, confirmed, by type, in order to identify areas where we may need to make changes to improve across our system. Critical incidents are those incidents that require a certified investigation. This slide displays the number of confirmed incidents of abuse, neglect, and exploitation for participants in the Consolidated Waiver.

As you know, ODP uses the incident management process that brings ODP, AEs, SCOs, other qualified waiver providers of licensed and unlicensed services, individuals, Health Care Quality Units, or HCQUs, families and advocacy groups together to promote the safety, well‐being and rights of participants in ODP’s waiver programs. The Incident Management, or IM, Bulletin guides this work.

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This slide contains a display of additional categories of incidents of confirmed allegations of abuse, neglect, and exploitation, that is neglect, rights violations, and misuse of funds.

ODP employs a multiple level review that occurs during the initial reporting and investigation processes and there are required timeframes associated with this review. In the last year, ODP developed and incorporated into the waiver renewal applications additional performance measures to assist us in determining whether reporting and investigation processes and timelines are observed in the interest of safeguarding individuals.

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These additional performance measures include a series we will use to evaluate the steps in the processes of reviewing and taking action to respond to critical incidents.

These measures are:

• # and % of critical incidents in which prompt action (which is defined as demonstrated within 24 hours) is taken to protect the participant’s health, safety and rights

• # and % of AEs that review incidents within 24 hours of the report, and

• # and % of critical incidents finalized within the required timeframe, which is 30 days

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A series of measures that ODP will use to evaluate our performance in completing the steps required to investigate critical incidents was also developed.

These measures are:

• # and % of AEs that completed investigations in accordance with ODP standards

• # and % of confirmed critical incidents where corrective actions were carried out or planned by the appropriate entity within the required timeframe, and

• # and % of AEs that maintain documentation of incident management training

As mentioned previously in the discussion of the Service Plans waiver assurance, CMS expects that specific remediation actions will be identified for each performance area. ODP has identified specific remediation actions for each area within the Health and Welfare waiver assurance to comply with this requirement. For example, ODP and AEs review incidents within 24 hours. If ODP or the AE determines that documentation of prompt action that should have been taken to safeguard an individual is not present, the provider will be contacted to ensure that the appropriate follow‐up occurs and is documented. And if investigations are not completed in a manner consistent with ODP’s expectations, certified investigators may be required to undergo additional training and evaluation.

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ODP evaluates both the number of incidents of restraints and the unduplicated number of individuals affected. This slide displays the number of incidents of restraints for those individuals who have behavior support plans. ODP uses specific remediation strategies to reduce and/or eliminate restraints. These strategies include:

• Referral of individuals to local HCQUs for clinical reviews or to the regional Positive Practices Resource Team, also known as PPRT, for evaluation and further recommendations in conjunction with providers

• Identification of reasons for behaviors leading to restraint and selection of alternative approaches to address the individual’s need

• Training and technical assistance to providers

We also study the number of medication errors and continue to expect providers to complete a simplified root cause analysis including not only what happened but also the immediate remediation and steps for changes to prevent future errors.

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In the last year, ODP also developed and incorporated into the waiver renewal applications an additional performance measure that will help us ensure waiver participants receive information about reporting abuse, neglect, and exploitation. A procedure has been developed to support this initiative. Supports Coordinators will share information with waiver participants and document their efforts on the ISP Signature Form. A brochure has also been made available for each individual waiver participant to keep and important contact numbers are available on the brochure.

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On the previous slides, we’ve shown you some of the measures we will use over the life of the Consolidated and P/FDS Waivers that just went into effect July 1, 2012 to demonstrate our performance in the program area of ensuring Health and Safety. All throughout each year, we’ll be tracking these data and taking steps to correct any problems we find as they arise.

At the end of each fiscal year, we’ll bring together all of our data from the various data sources to try to understand whether we’ve achieved positive results for individuals enrolled in the Waivers. Some of the most important IM4Q data in this analysis are the measures that ask whether individuals feel safe in their homes, during day activity, and in their neighborhoods. As I mentioned previously, we try to ensure that individual incidents are addressed and investigated where necessary and that corrective actions are implemented timely. We monitor and evaluate restraint utilization and medication errors. During our record review process in AE Oversight Monitoring, we also check to be sure there are no unreported critical incidents. This past year, we’ve added training for individuals in how to prevent, detect, and report incidents of abuse, neglect, and exploitation. We ask Supports Coordinators to evaluate through their monitoring visits whether there are any risks to health and welfare that need to be addressed.

Our intention is to then add IM4Q data into the mix to determine whether individuals believe they are safe in their homes, during day activity, and in their neighborhoods. We will trend these results over time as well. Each year we will look at where there are gaps in our performance, if any, and try to close these gaps through training or policy, for example. We will also look for ways to change our program design where we receive internal and/or external stakeholder input that suggests we can improve the way we carry out the monitoring of health and welfare.

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To demonstrate how we might study whether waiver participants feel safe, we’ve displayed on this slide the IM4Q data results from the view of friends, families, and guardians for Consolidated Waiver participants feeling safe at their day activity during FY 08‐09, FY 09‐10, and FY 10‐11. We found that 74%, 78%, and 74% of respondents reported they felt waiver participants always felt safe at their day activity for each year respectively. An additional 14%, 12%, and 14% of respondents respectively, reported they felt waiver participants felt safe at their day activity most of the time.

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On this slide, we’ve depicted the number of respondents involved in answering this question.

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And on this slide, we’ve gone to the next layer of analysis by displaying the results for this question by Region. For example, we found that 68% of respondents reported that waiver participants in Western Region always felt safe during day activity, while another 19% of respondents in Western Region reported that waiver participants felt safe most of the time.

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Again, we encourage AEs to continue this analysis to determine performance by AE within regions, and encourage AEs and providers, including support coordination organizations, to analyze performance at the provider level. Given this more and more specific analysis, staff throughout the system can begin to hypothesize reasons for why friends, families, and guardians reported as they have and address those issues as we look to the future. After any recommended changes are made, we can reassess our performance in this area during the next IM4Q survey cycle. This effort is consistent with the quality improvement model ODP has practiced for many years, the PDCA or plan, do, check, act model.

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Please be reminded that Certificates of Achievement will be available to Administrative Entity and provider staff as well as Supports Coordinators and SC Supervisors after completing all course requirements.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and a post‐test and viewing then saving or printing your certificate. Please return to where you initiated this webcast to complete the course requirements and access the Certificate.

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Thank you for viewing this webcast.

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