# Presentation: 340309

## Federal Quality Assurance and Improvement Initiatives

- Mary Jean Duckett
- Centers for Medicare and Medicaid Services
- May 8, 2002

**Notes:**
Federal Quality Assurance and Improvement Initiatives, a presentation by Mary Jean Duckett of the Centers for Medicare and Medicaid Services. Presented at the AHRQ-NGA meeting, State Long Term Care Systems: Reducing Cost, Quality and Access, held in Indianapolis, IN May 6-8, 2002.

## Shifting Federal focus - Current

- Prospective assurances of quality in waiver applications followed by retrospective review, 3-5 years later
- Quality assurance expectations to meet regulatory compliance and/or problem identification, most often with respect to health and welfare

- Duckett

**Notes:**
Federal activity related to quality represents a change in focus for CMS. Historically, the Federal focus lay on getting assurances from States followed by a retrospective review of waiver programs. We used to ask the State to provide assurances, then look to see if the State was meeting those assurances.  This changed in the past year. 

## Shifting Federal focus - future

- CMS recognizes that it has a role that goes beyond simply giving permission to states to develop institutional alternatives and to monitor compliance with regulatory requirements
- It requires that it assess more closely the systems of quality assurance and improvement in place and that it provide direct assistance to its state partners concurrently

- Duckett

**Notes:**
I want to recognize that CMS’ role is changing from permission giving to developing and monitoring compliance. This new role requires that CMS assess quality assurance more closely and provide assistance to States. We are taking a systems focus now, and looking at quality improvement as well as quality assurance. We recognize the Federal role in quality improvement of service-based programs.

## CMSO Quality Initiatives

- Establishing a Framework for Quality Improvement within HCBS
- Developing Quality Improvement Tools for States
- Developing Quality Improvement Tools for CMS
- Engaging in Quality Assessment and Performance Improvement
- Providing Technical Assistance and Resources

- Duckett

**Notes:**
CMS is now developing Quality Improvement tools for States and Federal government, engaging in quality assessment and providing technical resources.

## CMSO

- Duckett

**Notes:**
CMS’ structure is such that services are not housed in any one place. There are many groups within CMS, and groups have Quality Initiatives as part of their responsibilities.

## Framework for Quality

- National Inventory of Quality Improvement Strategies (DEHPG)
- Establish a framework/description of relevant quality domains that will facilitate a common dialog
- Identify relevant strategies which states might use to monitor and improve quality within those domains
- Conduct research to establish the current “state of the art” for state QA/QI systems for information sharing and planning purposes

- Duckett

**Notes:**
The National Inventory of Quality Improvement Strategies is in Thomas Hamilton’s group. The goal is to establish a framework or description of quality domains to facilitate dialog. These are the areas you need to address when discussing quality. You need to identify strategies to improve quality in those domains, and produce research to establish current state of the art for State QI frameworks.  You need to do all this to establish a framework for a common dialog.  We anticipate publishing a technical manual by the end of  this year.

## Tools for States

- Consumer Experience Survey/Users Guide (FSQG)
- Voluntary Tool for States
- 2 Modules:  Elderly/Non-elderly disabled and MR/DD

- Duckett

**Notes:**
We are also producing a consumer experience survey developed by the financial systems and quality group. This is a voluntary tool States can use to get feedback from consumers about HCBS programs.  There are two modules - elderly beneficiaries and MR/DD.  These are the largest populations served under HCBS waiver systems. 

## Tools for States

- Reliability and Validity of Consumer Experience Survey (FSQG)
- Current status: Conducting field tests in 3 States
- Expected Completion Date: October 2002

- Duckett

**Notes:**
We are field-testing modules in three States, and expect to complete the field tests and have a product by October of 2002.

## Tools for States

- Self Directed Measures (DEHPG)
- Development of performance indicators aimed at family and self-directed service systems, i.e., system  performance indicators
- Serve as a guide to states as they develop their family and self-directed waivers
- States could use it to assess the quality and comprehensiveness of their family and self-directed programs

- Duckett

**Notes:**
The third tool is self-directed measures.  Performance indicators are directed at family and community and are self-directed services and they are systems performance indicators. They can serve as a guide for States as they develop -directed programs and key into issues they need to think about. States can use them to assess the quality of programs. They can be used for development stage and as an ongoing tool to evaluate program. A product is due perhaps in the next fiscal year. 

## Tools for CMS

- Collection and Analysis of State Data for Long-Term Care/ State Planning Data for Systems Change (DEHPG)
- Develop a HCBS waiver database
- Identify LTC data available and needed for planning
- Design Data Reports and analytical tools
- Develop data collection and transfer processes and procedures

- Duckett

**Notes:**
The fourth tool is the collection and analysis of State planning data for Long Term Care.  States need data to go to their legislators and propose change, as does the Federal government. We will develop an HCBS waiver database.  Our data was formerly limited to the number of programs and the populations served and what services are provided. The new system will have more specific data on content, what are the average per capita cost, how many services are provided, who are the eligibility groups, are special income level groups covered, what was the actual experience (number served and actual average per capita cost).  We will also try to expand waiver data to include other long term care data to look and community and institutional services. The longer term goal is to include non-Medicaid data so we can predict effects on other parts of long term care system. We are planning for electronic submissions of annual cost reports and reviews to speed the process and make submission easier for States.

## Quality Assessment and Improvement

- HCBS Waiver Quality Review Protocol
- Guide for Conducting Quality Reviews (FSQG)
- Guide for States/Regional Offices (RO) to use as they conduct Quality Reviews
- Focus on adequacy and appropriateness
- Estimated Completion Date:  October 2002

- Duckett

**Notes:**
Last year, we issued the HCBS waiver protocol that regional offices use to review State waiver programs. We are now developing a guide that builds on the protocol to guide the program reviews. It will focus on advocacy and appropriateness of reviews.

## National Contractor for HCBS Quality (DEHPG)

- Resource to CMS Regional Offices (RO) and States
- Follow up to RO visits utilizing the protocol where significant opportunities for improvement are identified
- Urgent or Emergent follow-up in special circumstances
- State requests for consultation, triaged through RO/CO

- Duckett

**Notes:**
The national contractor for HCBS quality is a resource to regional offices and States. It follow up on the protocol to identify areas for review improvement. We are also developing an urgent follow up and triage protocol to prioritize what States will work with the contractor first due to limited resources. 

## National Contractor for HCBS Quality (DEHPG)

- Contractors to assist in Root Cause Analysis and identification of quality improvement strategies
- NOT look-behind review
- NOT additional monitoring or review
- Repository of CMS Quality related tools, Technical Assistance and Training
- 2002 focus for MR/DD

- Duckett

**Notes:**
The contractor assists with root cause analysis to determine the cause of problems and strategies to improve performance.  This is NOT a look-behind or another review of waiver program or determining whether the regional did its job. It is a tool for States at their request for additional technical assistance. Information developed through the contractor will become a repository of CMS information for training. The contractor works with States and produces products to assist other States.  Montana is working with the contractor and regional office. We may also work with Georgia, Tennessee and Iowa.  Our focus now is on MR/DD programs.

## Technical Assistance and Resources

- Promising Practices (DEHPG)
- 3 year ongoing project to identify and describe promising practices within state programs intended to assist persons with disabilities of all ages to live and fully participate in communities of their choice
- Highlighted will be both broad systems reform efforts (e.g., Michigan’s 1915b/c combo for specialty services) as well as specific tools utilized by states (e.g., Wyoming’s method for individual budgets)
- Ongoing posting to CMS web site.

- Duckett

**Notes:**
CMS will provide technical assistance and resources.  Promising Practices was a three year project to identify and describe promising programs. CMS recognizes that every State has programs with effective practices that could be useful to other States.  There is no best program. Each has best practices.  CMS will highlight broad system reforms as well as specific tools/aspects of programs.  Promising practices will be posted on the CMS website.

## Technical Assistance and Resources

- Promising Practices
- http:www.hcfa.gov/medicaid
- Look for “promising practices in home and community-based services”

- Duckett

**Notes:**
You can find information on promising practices on the HCFA website/CMS website as well as other helpful information.  The old address - www.hcfa.gov has been replaced with www.cms.gov.

## TA (cont.)

- Data Readiness Project (FSQG)
- Compile info on selected QI activities that are data driven
- Prepare technical assistance briefs to states
- Estimated completion date:  late spring
- Provide technical assistance to selected states
- Estimated completion date:  October 2002

- Duckett

**Notes:**
Another technical assistance project by Rachel Block’s group is a data readiness project to compile information on quality improvement activities that are data driven. What activities have States tried that have worked? We will prepare technical assistance briefs based on the information.  We anticipate completing it by Fall 2002.

## TA (cont.)

- Conference on Quality Measurement and Improvement
- May 2-3, 2002, Nashville, TN
- Feature national/state experts and best practices in quality measurement/improvement
- Will include practices identified through the “Data Readiness” project

- Duckett

**Notes:**
Information on data readiness was shared at the Quality Assurance held in Nashville in April. We will also produce technical assistance documents based on the Nashville conference to share information with States that were unable to attend.

## Other Initiatives of Note

- Study of the impact of Medicaid home and community based service programs on quality of life, quality of care, utilization and cost (OSP - Lewin)
- Elderly/Disabled and Persons with MR/DD
- Resource Network - www.hcbs.org

- Duckett

**Notes:**
We are also working on a study of the impact of Medicaid HCBS on quality of life, quality of care . This study is being conducted through a contract with Lewin and focuses on the two largest populations served – elderly and disabled and MR/DD.  Information is available on the resource network web site - www.hcbs.org.

## Other Initiatives of Note

- Development and Validation of Performance Measure Set for for the Evaluation of Medicaid Services Rendered to People with DD (SCG)
- Indicators for ICF/MR settings
- Compliance/Feedback/Benchmarking

- Duckett

**Notes:**
The Survey and Certification Group is development and validating performance measures for ICF/MR settings. The measures can be used by States to ensure compliance, obtain feedback, and to set benchmarks.

## Summary

- Coordinated, quality effort that utilizes prospective assurances and retrospective reviews, but will include concurrent quality improvements to further enable the full inclusion and participation of persons with disabilities in communities of their choice.

- Duckett

**Notes:**
We feel that we need to increase the tools available in the Toolbox. Our only previous tools were to terminate programs or non-renew waivers but we also want to have new tools that improve programs.