STRATEGY FOR ASSURING AND IMPROVING THE QUALITY OF
MI CHOICE WAIVER SERVICES AND SUPPORTS
FISCAL YEARS (FYs) 2012 and 2013
The following strategy is designed to assess and improve the quality of services and supports managed by twenty Organized Health Care Delivery Systems (OHCDS) (hereafter referred to as waiver agents) in the Home and Community Based Services Medicaid Waiver Program for the Elderly and Adults with Disabilities (hereafter referred to as MI Choice). The state agency responsible for establishing the components of the quality management plan (QMP) listed here is the Michigan Department of Community Health’s (MDCH), Medical Services Administration (MSA), which assigned this function to the Home and Community Based Services Section.
1. STRUCTURE AND PROCESS FOR DEVELOPING, REVIEWING AND REVISING MICHIGAN’S STRATEGY FOR QUALITY MANAGEMENT
The MI Choice program operates through an agreement with the Centers for Medicare and Medicaid Services (CMS). This agreement, or waiver application, delineates MDCH’s responsibilities for managing quality assurance and quality improvement in the waiver program. The Home and Community Based Services Section and the Long-Term Care Policy Section jointly developed the waiver agreement.
The MI Choice Quality Management Collaborative is an advisory group that contributes to development of the state’s QMP, provides input to development and implementation activities, and is involved in interpreting data from quality activities. The entire collaborative meets approximately four times per year with smaller committees meeting approximately 10-12 times per year. MI Choice participants chair the collaborative, and the membership includes program participants, caregivers and staff from waiver agencies. MDCH staff provides administrative support and serve as ad-hoc members.
The MDCH QMP encompasses the following elements.
a. Design: The Quality Management strategy includes processes and safeguards to:
· prevent problems with quality;
· ensure the delivery of high quality services and supports;
· implement performance measures to assure the quality of providers;
· assure participants’ health and safety;
· assure participant choice in care settings and providers; and
· ensure appropriate and accurate payments.
b. Discovery: MDCH uses several methods for gathering information to verify that the QMP is implemented and functioning as intended.
· Clinical Quality Assurance Reviews
· Administrative Quality Assurance Reviews
· Consumer surveys
· Critical Incident reporting
· Quality Indicators
· Various routine and ad hoc data analysis
c. Remediation: Using the results from the discovery methods, often with the involvement of the Quality Management Collaborative, MDCH and the waiver agents develop action plans to remediate problems and ensure continuous quality improvement.
d. Improvement: MDCH, the Quality Management Collaborative and waiver agents use data from participant assessment, satisfaction surveys, program outcomes and other information to identify methods to improve participants’ experiences in the program. Together, they develop and implement Quality Improvement interventions and assess the interventions for effectiveness.
2. HOME AND COMMUNITY-BASED SERVICES (HCBS) QUALITY FRAMEWORK
MDCH based the QMP on the CMS HCBS Quality Framework. The HCBS Quality Framework contains seven focus areas with desired outcomes for home and community- based services. MDCH incorporates each of these focus areas and added two additional focus areas:
a. Participant Access – Participants have ready access to home and community based care and supports in their community.
b. Participant-Centered Service Planning & Delivery – Services and supports are planned and effectively implemented in accordance with participant’s unique needs, expressed preferences and decisions concerning his/her life in the community. Participants will also have continuous access to assistance as needed to obtain and coordinate services and promptly address issues encountered in community living.
c. Provider Capacity and Capabilities –There are sufficient home and community based service providers and they possess and demonstrate the capability to effectively serve participants.
d. Participant Safeguards – Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices.
e. Participant Rights and Responsibilities – Participants receive support to exercise their rights and in accepting personal responsibilities.
f. Participant Outcomes and Satisfaction – Participants are satisfied with their services and achieve desired outcomes.
g. System Performance – The system supports participants effectively and efficiently and constantly strives to improve quality.
h. Administration – The MI Choice program is administered efficiently and effectively to maximize Medicaid buying power while giving precedence to the participant's best interests.
i. Services - Participants receive the MI Choice waiver services most appropriate for their needs.
3. QUALITY MANAGEMENT PLANS
a. MDCH QMP - Every two years, MDCH establishes a QMP that includes statewide goals and strategies. The MDCH QMP focuses on meeting CMS assurances and requirements for protecting the health and welfare of MI Choice participants, MDCH contract requirements, and targeted participant outcome improvement goals.
b. Waiver Agent QMPs - Each waiver agent establishes a QMP that addresses how the waiver agent intends to meet State and Federal assurances. Waiver agencies also update their QMPs based on agency results from quality reviews, participant outcomes, consumer survey results, complaint history, and other performance measures. MDCH approves the waiver agent’s QMPs and requires that waiver agents report on the progress of their QMPs on a yearly basis. Waiver agents are required to submit a new QMP at least every two years.
4. QUALITY ASSURANCE
The waiver agent QMP must include a systematic approach designed to continuously improve care and prevent or minimize problems prior to occurrence. Each waiver agent’s QMP must include the following assurances:
Level of Care
· An evaluation for nursing facility level of care (NFLOC) is provided to all applicants by the waiver agent for whom there is reasonable indication that services may be needed in the future.
· The levels of care of enrolled MI Choice participants are reevaluated by waiver agent at least annually to assure each participant continues to meet NFLOC criteria.
· The processes and instruments described in the approved waiver are applied appropriately by the waiver agent when making NFLOC determinations.
Plan of Care (POC)
· The POC addresses all of the participant’s assessed needs (including health and safety risk factors) and personal goals, either by the provision of waiver services or through other means.
· The waiver agent monitors the POC development in accordance with its policies and procedures.
· POCs are updated/revised by the waiver agent at least every 90 days or more frequently when warranted by changes in MI Choice participant’s needs.
· The waiver agent assures services are delivered in accordance with the POC, including the type, scope, amount, duration, and frequency specified in the POC.
· The waiver agent assures that it affords each participant with the opportunity to choose between MI Choice enrollment and institutional care and among waiver services and providers.
Qualified Providers
· The waiver agent verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to furnishing waiver services.
· The waiver agent monitors non-licensed/non-certified providers to assure adherence to MI Choice requirements.
· The waiver agent implements policies and procedures for verifying that providers furnish training in accordance with State requirements and the approved waiver.
Health and Welfare
· On a continual basis, the waiver agent identifies, addresses, and seeks to prevent the occurrence of abuse, neglect and exploitation.
Financial Accountability
· The waiver agent has processes in place to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.
Administrative Authority
· MDCH retains the administrative authority and responsibility for the operation of the MI Choice program by exercising oversight of the performance of waiver functions by waiver agents and other contracted entities.
5. MDCH QUALITY ASSURANCE REVIEWS
MDCH staff and contractors review program, clinical, and administrative activities annually to assure that waiver agents meet CMS and MDCH requirements, thereby assuring the health and welfare of MI Choice participants.
a. Clinical Quality Assurance Reviews (CQAR) - MDCH developed the annual CQAR process to meet CMS requirements for the review of POC authorizations and case record reviews. The CQAR team uses a sample size program from www.raosoft.com/samplesize.html using a 95% confidence level and +/- 5% margin of error to determine total number of records to review for each waiver agency each fiscal year. Records reviewed are a completely random sample of MI Choice participants. After completing the CQAR, MDCH conducts an exit interview with waiver program staff. In addition, for each waiver agent MDCH interviews at least 5 MI Choice participants in their homes. If MDCH finds significant issues, concerns, or questions in the first set of case records reviewed, it may opt to review additional records to verify initial findings.
The CQAR process covers nine focus areas consisting of 84 standards. Registered nurse (RN) reviewers examine participant enrollment, assessment data, NFLOC eligibility, the POC and care planning process, and reassessment data. The RN reviewers collect both qualitative and quantitative data, evaluate the waiver agent’s assessment and POC, and review the actions of supports coordinators to assure that the waiver agent protects the health and welfare of the participants to the greatest extent possible, all within a person-centered planning framework.
The RN reviewers compile data into reports and submit them to MDCH. The HCBS Section staff examines, summarizes, and forwards the reports to the waiver agent. The reports include any successes in practice and citations and/or recommendations for areas that the waiver needs to improve. The waiver agent has 30 days to respond to the citations with a corrective action plan. MDCH either accepts the corrective action plan, or suggests other actions to bring each waiver agent into full compliance with this portion of the review. The HCBS Section staff works with the waiver agent to assure the corrective action plan will produce quality improvements. MDCH monitors implementation of the corrective action plan throughout the year and again at the next year’s review.
b. Administrative Quality Assurance Reviews (AQAR) - HCBS Section staff conducts on site visits to verify administrative and program policy and procedural requirements on a biennial basis. The AQAR includes an examination of each waiver agent’s policy and procedure manuals, peer review reports, results from client satisfaction surveys, provider monitoring reports, provider contract templates, financial systems, claims accuracy, QMP, and required provider licenses to verify that the waiver agent meets all applicable requirements. HCBS Section staff also conducts home visits to assure participant satisfaction with services and assure that the POC meets all of the participant’s needs.
The AQAR process examines nine focus areas consisting of 194 standards. If the HCBS Section staff determine that the waiver agent does not meet a requirement, staff discusses the missing requirements with waiver agent staff prior to issuing the AQAR report. Following the review of the entire compliance document, the HCBS Staff prepare the AQAR report and send to the waiver agent.
As with the CQAR report, the AQAR report includes successes in practice and areas in need of improvement. The waiver agent then has 30 days to respond how they will address their areas in need of improvement in a corrective action plan. After receiving the waiver agent’s written response and engaging in any necessary clarifying discussion, HCBS Section staff notifies the waiver agent of its acceptance of the corrective action plan. The HCBS Section provides the waiver agent 30 additional days to correct any deficiencies noted in the final corrective action plan. HCBS Section staff continue to monitor the waiver agent’s progress toward meeting goals identified in the corrective action plan.
The MDCH Audit Office also conducts an audit on a sample of waiver agents every two to three years to validate that each waiver agent uses generally acceptable accounting procedures and meet financial assurances. The specific criteria used for each audit changes depending on identified or suspected problems or issues.
c. Consumer Surveys
Consumer Satisfaction and Quality of Life Surveys are used as tools to identify weaknesses and problems in the MI Choice program so that MDCH and waiver agents can make improvements in the quality of services and supports participants receive. MDCH has required each waiver agent to develop and conduct their own consumer surveys.
MDCH and the Quality Management Collaborative are in the process of developing a statewide consumer satisfaction survey for all waiver agencies to use. This will allow MDCH to compile statewide data and analyze to determine if quality improvement is needed regionally or statewide.
d. Critical Incidents Management
CMS requires a formal plan, developed and implemented by the state, to define, identify, investigate and resolve incidents, events, or occurrences that jeopardize the health and welfare of a participant. Currently, waiver agents submit critical incident reports twice a year to the HCBS Section. The report includes the findings, actions taken to protect the health and welfare of the participant, resolution, prevention strategies, and trends.
Note: Center for Information Management, Inc. is a custom IT solution company the waiver agents have contracted with to process data components such as participant assessment data, POC, etc. MDCH is currently working with this entity to develop a web based Critical Incidents reporting system which will enable real time reporting and review with follow-up resolutions. This system will be implemented during FY 2012.
6. QUALITY IMPROVEMENT GOALS
MDCH strives for continuous quality improvement in administering the MI Choice program. The quality improvement program is based on four key elements; design, discovery, remediation, and improvement. MDCH requires waiver agents to develop clear and quantifiable goals for improvement.
a. Nursing Facility Transition (NFT)
Goal: Each waiver agent must meet the NFT benchmarks provided to them by MDCH. Measurement: Number and percent of waiver agencies who meet their NFT benchmarks specified by MDCH.
b. Social Isolation
Goal: Decrease the percent of participants reporting social isolation with distress to a statewide average of 10%. Measurement: Number and percent of waiver agencies that have a percent of 10% or less of participants reporting social isolation with distress AND number and percent of waiver agencies that reduced their percentage of participants reporting social isolation from the previous year.
c. Consumer Surveys
Goal: MDCH will continue to work with the Quality Management Collaborative to complete development of a statewide consumer satisfaction and quality of life survey for MI Choice participants. MDCH will implement the consumer survey in FY 2013 and report results through standard periodic reports. Measurement: Number and percent of waiver agencies who implement the statewide survey within FY 2013.
d. Local Quality Collaboratives
Goal: Waiver agents will continue to develop their local quality collaborative groups and will report on quality assurance and quality improvement activities they conduct. The local groups will also have liaisons who report to the statewide Quality Management Collaborative to share regional information and best practices. Measurement: Number and percent of waiver agencies that have local quality collaboratives that meet at least quarterly.
e. Paperwork Reduction
Goal: Reduce the paperwork burden on the MI Choice Supports Coordinators, allowing for more meaningful and purposeful interactions between participants and supports coordinators, thus, improving participant outcomes. MDCH has initiated a project to collect, analyze, provide recommendations and implement a plan for a reduction in paperwork. Measurement: Number and percent of waiver agencies that implement plan to reduce paperwork.
