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CAHPS® Home and Community-Based Services Survey and Related NQF-Endorsed Measures

HCBS Quality Webinar Series

Administration for Community Living

February 21, 2018

Jean Close, Deputy Director, DCST, DEHPG, CMS

Kerry Lida, DCST, DEHPG, CMS

Elizabeth Frentzel, American Institutes for Research, Survey Developer Team Susan Raetzman, Truven Health Analytics, Survey Developer Team

This document was made possible under Contract HHSM-500-2010-0025I-T006 from the Centers for Medicare & Medicaid Services.  The contents of this presentation are solely the responsibility of the author(s) and do not necessarily represent the official views of the Centers for Medicare & Medicaid Services or any of its affiliates.

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Testing Experience and Functional Tools (TEFT) Demonstration:  Quality Components

Functional Assessment Standardized Items (FASI)

Key features of the HCBS CAHPS Survey

National Quality Forum (NQF)–endorsed measures derived from the survey

Current state activities

Publicly available resources

Q&A

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Agenda

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TEFT Demonstration:  Quality Components

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Functional Assessment Standardized Items (FASI)

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Key Features of FASI

Person-centered measures of functional ability & need for assistance

Aligned with federally standardized items for measuring function in the Medicare program and adapted for the LTSS population

Standardized approach allows for:

Common approach and definitions

Following the individual over time and across settings/programs

Comparisons across state HCBS programs

Electronic exchange of HCBS data:

Among providers, case managers, and beneficiaries

Allows data to follow the individual

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Elements Included in FASI

Self care activities such as eating and dressing

Mobility activities such as bed mobility and transfers, ambulation, and wheelchair use

Instrumental Activities of Daily Living (IADL) activities such as meal preparation, finances, and housework

Supports and services needed to complete daily activities such as assistive devices and paid and unpaid assistance services

Process for participants to identify personal priorities

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FASI Timeline Under TEFT
| Time Frame | FASI Activity                                                                      |
|------------|------------------------------------------------------------------------------------|
| 2015-2016  | Alpha test and OMB clearance                                                       |
| 2017       | FASI assessor training                                                             |
|            | Round 1 data collection                                                            |
|            | Data analysis; review by Technical Expert Panel                                    |
|            | FASI set finalized for Round 2                                                     |
| 2018       | 6 Grantees demonstrate FASI use in their HCBS programs (March-May data collection) |
|            | Develop and test FASI-based performance measures with TEP input (June-August)      |
|            | Submit measures to NQF for endorsement (September)                                 |

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FASI Data Elements:  Alignment with CMS Data Standardization Initiatives 

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Key Features of the HCBS CAHPS Survey

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Cross-disability consumer experience survey for eliciting feedback from beneficiaries receiving Medicaid HCBS services and supports

Focus on participant experience, not satisfaction

Allows for comparisons across programs serving different target populations  

Individuals who are frail elderly 

Individuals with a physical disability

Individuals with an intellectual or developmental disability

Individuals with a brain injury

Individuals with serious mental illness

Other HCBS recipients

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Overview of the HCBS CAHPS Survey

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HCBS CAHPS Survey Development Process

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Unit of analysis = HCBS program or accountable entity

Accountable entity = operating entity responsible for managing and overseeing a specific HCBS program within a given state (e.g., managed care organization [MCO])

Focus of analysis can vary

Program

MCO

Case management agency

County

State

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Sample Design

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Common Services and Providers

Common services

Personal care and behavioral health care 

Transportation

Home care

Case management

Employment assistance

Common providers

Personal assistant and behavioral health staff

Medical transportation services

Case manager

Homemaker

Job coach

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HCBS CAHPS Survey Instruments

Core instrument

Supplemental Employment Module

English and Spanish versions of both

Phone or in-person

Standardized implementation instructions in guide (free from CMS)

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Domains Addressed by the HCBS CAHPS Survey

Key Survey Sections

Getting Needed Services

Communication with Providers

Case Managers

Choice of Services

Medical Transportation

Personal Safety

Community Inclusion and Empowerment

Employment (optional supplemental module)

Domains Addressed 

Community Participation

Choice and Decision Making

Relationships

Service Coordination

Work

Self-Direction

Access

Medications

Wellness

Rights and Respect

Safety

Everyday Living

Person-Centered Planning Process

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Cognitive Screening Questions

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Program- and Provider-Specific Terms

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Alternate Response

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Proxy Respondents

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State choice to conduct data collection inhouse or use a vendor

CMS does not approve vendors for the CAHPS® Home and Community-Based Services Survey 

NCQA Survey Vendor Certification for CAHPS is not required.  

Training ensures consistent data collection within states that use multiple entities and maximizes the quality of data collected

Recommended qualifications of data collection entities

Be familiar with the instrument structure, content, and intent

Be knowledgeable about the unique features of the instrument and implications for how it is administered

Have experience conducting surveys with HCBS populations or people with cognitive impairment

Have Computer-Assisted Personal Interview (CAPI) and Computer-Assisted Telephone Interview (CATI) capability

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Data Collection Entity Qualifications

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NQF-Endorsed Measures Derived from the HCBS CAHPS Survey

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Topics of 19 Measures Derived from the HCBS CAHPS Survey

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| Survey Item # | Composite Measure: Staff Listen and Communicate Well           |
|---------------|----------------------------------------------------------------|
| 28            | Staff treat you with courtesy and respect                      |
| 29            | Staff explanations are easy to understand                      |
| 30            | Staff treat you the way you want them to                       |
| 31            | Staff explain things in a way that is easy to understand       |
| 32            | Staff listen carefully to you                                  |
| 33            | Staff know what kind of help you need with everyday activities |
| 41            | Homemakers treat you with courtesy and respect                 |
| 42            | Homemaker explanations are easy to understand                  |
| 43            | Homemakers treat you the way you want them to                  |
| 44            | Homemakers listen carefully                                    |
| 45            | Homemakers know what kind of help you need                     |

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Composite: Staff Listen and Communicate Well

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| Survey Item # | Composite Measure: Planning Your Time and Activities |
|---------------|------------------------------------------------------|
| 75            | Can get together with nearby family                  |
| 77            | Can get together with nearby friends                 |
| 78            | Can do things in community                           |
| 79            | Needs more help to do things in community            |
| 80            | Takes part in deciding what to do with their time    |
| 81            | Takes part in deciding when they do things each day  |

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Composite: Planning Your Time and Activities

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Overall Top-Box Scores for Groups of Questions and Global Ratings

Scores include complete cases with proxies. Scores are reported as top-box scores.

Source: NQF Submission, July 2016

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Case Management Composite Scores, by HCBS Population

Key

^ = Above Average Scores

˅ = Below Average Scores

Scores include complete cases with proxies. Scores are reported as top-box scores.

Source: NQF Submission, July 2016

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Assess program performance

Point-in-time snapshot

Track changes over time

Document successes and identify areas for program improvement

Assess impact of program improvement initiatives

Provide information to stakeholders on program performance

Internal staff, providers, and managed care organizations, beneficiaries, legislators, and the general public

Measures align with some CMS quality requirements

Potential to compare results across states

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Using the Survey for Program Quality Management

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HCBS CAHPS Alignment with Existing Quality Measures

HCBS CAHPS measures are being integrated into the Core Set of Adult Healthcare Quality Measures for Medicaid

NQF MAP Workgroup recommendations to add HCBS CAHPS measures to measure sets for various programs

MAP Family of Measures for duals and the Starter Set (NQF Dual Eligible Beneficiaries Workgroup, August 2017) 

CI-LTSS Measure Set (NQF Medicaid Innovation Accelerator Project, September 2017)

Managed LTSS Association has integrated HCBS CAHPS measures into existing quality framework

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State Activities

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What Makes the HCBS CAHPS Survey Appealing

Person-centered

Cross-disability

Ability to compare programs

Increased accessibility via in person and phone modes, alternate response options, proxy respondents

Development aligned with CAHPS

Reflects what is important to beneficiaries

Rigorous methods, for example, psychometric testing

Trademark that providers recognize

Measures available (National Quality Forum-endorsed)

Flexibility to tailor the survey by adding questions

Publicly available from CMS

Free of charge to access

Resources for help in using survey

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| State         | Individuals Who Are Frail Elderly | Individuals With a Physical Disability | Individuals Who are Frail Elderly and/or With a Physical Disability | Individuals With an Intellectual or Developmental Disability | Individuals With a Brain Injury | Individuals With Serious Mental Illness |
|---------------|-----------------------------------|----------------------------------------|---------------------------------------------------------------------|--------------------------------------------------------------|---------------------------------|-----------------------------------------|
| Arizona       | .                                 | .                                      | X                                                                   | X                                                            | .                               | .                                       |
| Colorado      | X                                 | .                                      | X                                                                   | X                                                            | .                               | .                                       |
| Connecticut   | X                                 | X                                      | .                                                                   | .                                                            | X                               | X                                       |
| Georgia       | X                                 | X                                      | X                                                                   | .                                                            | X                               | .                                       |
| Kentucky      | .                                 | X                                      | X                                                                   | X                                                            | X                               | .                                       |
| Louisiana     | .                                 | .                                      | X                                                                   | X                                                            | .                               | .                                       |
| Maryland      | .                                 | .                                      | X                                                                   | .                                                            | X                               | .                                       |
| Minnesota     | X                                 | .                                      | .                                                                   | .                                                            | X                               | X                                       |
| New Hampshire | .                                 | .                                      | X                                                                   | X                                                            | X                               | X                                       |
| Tennessee     | .                                 | .                                      | X                                                                   | .                                                            | .                               | .                                       |

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Populations Participating in Overall TEFT Demonstration of HCBS CAHPS Survey by State

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CONNECTICUT WaiverS

11 Medicaid waivers

7 Operated directly by Medicaid agency

3 Operated by the DD agency

1 operated by Mental Health Agency

Two HCBS State Plan Options

1915i effective 2012

1915k effective 2015

Performance measures in Waivers varied 

Evidence collection for CMS always challenging

Goal is a consistent approach to reward quality and facilitate reporting

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CT Case Management Contract

Added performance bonus incentives to the contracts in 2013

Pool is divided by the number of performance standards

Performance Incentives based on 3 Composite scores

Case manager is helpful

Choosing the services that matter to you

Personal safety and respect

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HCBS CAHPS Survey Use

Fee for Service HCBS Waivers

2018 for all regions except Southwest

MCOs in Community HealthChoices 

2018: Southwest (Phase 1)

2019: Southeast (Phase 2) 

Annually starting 2020: Statewide

Include Supplemental Employment Module

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 >

www.dpw.state.pa.us 

 >

www.dhs.state.pa.us

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Publicly Available Resources

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CMS webpage on HCBS CAHPS Survey

Full URL: https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/cahps-hcbs-survey/index.html

TA guides forthcoming from CMS

Standardized instructions for implementing survey

Detailed instructions for analyzing data

HCBSCAHPS@us.ibm.com mailbox for questions	

NQF #2967 in the NQF Quality Positioning System

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Key HCBS CAHPS Survey Resources

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Questions?

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