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HCBS Quality Framework 

Development

Webinar 

June 28, 2017 2pm EST
Webinar Agenda 

I. Introduction 

II. Presentations:

I. National Quality Forum: Kim Ibarra, MSc, Senior 

Program Manager

II. The SCAN Foundation: Bruce Chernof, MD, FACP, 

President and Chief Executive Officer 

III.Question and Answer Session

IV.Closing

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Administration for Community Living 

Quality Webinar Series 

Addressing Performance Measure 

Gaps in Home and Community-Based 

Services to Support Community 

Living

Kim Ibarra

Senior Project Manager

June 28, 2017
Roadmap

5

Introduction: NQF and the HCBS 

Quality Project 

A Deeper Dive into the Committee’s 

Recommendations 

Prioritized Domains, Subdomains, 

and Example Recommendations

Conclusion: A Path Forward
Introduction to NQF and the HCBS Quality 

Project

6
7

What is the National Quality Forum?

NQF leads, prioritizes and collaboratesto drive measurable improvements in health 

and healthcare.

The National Quality Forum’s (NQF) mission is to lead national collaboration to 

improve health and healthcare quality through measurement.
A New Frontier for NQF...

8

Addressing Performance Measure Gaps 

in Home and Community-Based Services 

to Support Community Living
Project Purpose and Objectives

 Provide multi-stakeholder guidance on the highest priorities 

for measurement of home and 

community-based services that support high-quality 

community living 

 Create a conceptual framework for measurement, including 

an HCBS definition

 Perform a synthesis of evidence and environmental scan for 

measures and measure concepts

 Identify gaps in HCBS measures based on the framework and 

environmental scan

 Make recommendations for advancing 

HCBS quality measurement
 Joe Caldwell (Co-Chair), National 

Council on Aging 

 Stephen Kaye (Co-Chair), University 

of California San Francisco

 Robert Applebaum, Scripps 

Gerontology Center, Miami 

University 

 Kimberly Austin-Oser, Anthem, Inc. 

 Suzanne Crisp, Public Partnership 

Limited

 Jonathan Delman, University of 

Massachusetts Medical School

 Camille Dobson, National Association 

of States United for Aging and 

Disabilities

 Sara Galantowicz, Abt Associates Inc.

 Ari Houser, AARP Public Policy 

Institute

 Patti Killingsworth, Bureau of 

TennCare

Multistakeholder Committee

10

 Charlie Lakin, National Institute on 

Disability and Rehabilitation Research 

(former)

 Clare Luz, Michigan State University

 Sandra Markwood, National Association 

of Area Agencies on Aging 

 Barbara McCann, Interim Health Care

 Sarita Mohanty, Kaiser Permanente 

Nortern California

 Gerry Morrissey, The MENTOR Network 

 Ari Ne’eman, Autistic Self Advocacy 

Network

 Andrey Ostrovsky, Care at Hand (former)

 Mike Oxford, Topeka Independent Living 

Resource Center 

 Lorraine Phillips, University of Missouri

 Mary Smith, Illinois Division of Mental 

Health

 Anita Yuskauskas, Pennsylvania State 

University
Federal Advisory Group

version 3/24/16 11

 Sophia Chan, CMS 

 Eliza Bangit, ACL

 Ellen Blackwell, CMS

 Mike Smith, CMS

 Elizabeth Ricksecker, CMS 

 D.E.B. Potter, ASPE

 Lisa Patton, SAMHSA

NQF Staff

 Margaret Terry, Senior Director

 Rachel Roiland, Senior Project Manager

 Andrew Anderson, Senior Project Manager

 Desmirra Quinnonez, Project Analyst
Key Milestones

Committee Web 

Meeting 

Feb 2015

In-Person Meeting 

Apr 2015

Interim Report: 

Definition & 

Framework 

July 2015

Committee Web 

Meeting 

Aug 2015

Interim Report: 

Environmental Scan 

& Synthesis 

Dec 2015

Committee Web 

Meeting 

Jan 2016

In-Person Meeting 

March 2016

Interim Report: 

Priorities & 

Recommendations 

June 2016

Final Report 

Sept 2016
Quality in Home 

and CommunityBased Services to 

Support 

Community Living: 

Addressing Gaps in 

Performance 

Measurement 

13
What is ACL’s Interest in HCBS Quality?

14

 HCBS Definition

 Characteristics of High Quality HCBS

 Conceptual Framework

 Overview of the 11 HCBS Domains

 Identification of barriers to measuring HCBS quality

 Overview of Global Recommendations

Presentation by Eliza Navarro Bangit, JD, Director of the Office 

of Policy and Analysis and Development on May 10, 2017 
15

HCBS refers to an array of services and 

supports delivered in the home or other 

integrated community setting that promote 

the independence, health and well-being, selfdetermination, and community inclusion of a 

person of any age who has significant, longterm physical, cognitive, sensory, and/or 

behavioral health needs. 
Conceptual Framework 

16
A Deeper Dive into the Committee’s 

Recommendations

17
Committee Recommendations

18

Global Recommendations

 Address overall approaches to quality measurement 

in HCBS

Domain-Specific Recommendations

 Short-term: measures ready for implementation or 

expansion in the near future

 Intermediate: further development needed on 

existing measures

 Long-term: more research is needed, particularly 

around building an evidence base to support 

measure development
Global Recommendations 

19

 Support quality measurement across all domains and 

subdomains

 Build on existing quality measurement efforts

 Develop and implement a standardized approach to data 

collection, storage, analysis, and reporting

 Ensure emerging technology standards, development, and 

implementation are structured to facilitate measurement

 Triangulate HCBS quality measurement using an appropriate 

balance of measure types and units of analysis

 Develop a core set of standard measures for use across the 

HCBS system, along with a menu of supplemental measures 

that are tailorable to the population, setting, and program

 Convene a standing panel of HCBS experts to evaluate and 

approve candidate measures
Prioritized Domains, Sub-Domains, and 

Example Domain-Specific 

Recommendations

20
Service Delivery and Effectiveness

21

Definition: Level to which services are provided in a manner 

consistent with a person’s needs, goals, and preferences that 

help the person to achieve desired outcomes

Subdomains

 Delivery

 Person’s needs met and goals realized

Example Recommendations

Short-Term Expand implementation of process measure concepts 

related to the person’s needs met and goals realized 

subdomain.

Intermediate Support measure development for the delivery

subdomain, focus on identifying specific aspects of service 

delivery that are important to HCBS consumers

Invest in developing person-centered outcome measures
Person-Centered Planning and Coordination

22

Definition: An approach to assessment, planning, and 

coordination of services and supports that is focused on 

the individual’s goals, needs, preferences, and values.

Subdomains

 Assessment

 Person-centered planning

 Coordination

Example Recommendations

Short-Term Review existing measure concepts in the assessment 

subdomain to evaluate whether changes can be made to 

make them more generalizable.

Intermediate Promote a balanced approach to development and use of 

system and individual-level measures for each subdomain
Choice and Control 

23

Definition: Level to which individuals who use HCBS, on 

their own or with support, make life choices, choose their 

services and supports, and control how those services and 

supports are delivered.

Subdomains

 Personal choices and goals

 Choice of services and supports

 Personal freedoms and dignity of risk

 Self-direction 

Example Recommendations

Short-Term Assess the evidence for and scientific acceptability of 

measure concepts and instruments currently in use.

Intermediate Develop structure quality measures to assess program 

practices and designs that promote Choice and Control 
Community Inclusion 

24

Definition: Level to which people who use HCBS are 

integrated into their communities and are socially 

connected, in accordance with personal preferences.

Subdomains

 Social connectedness and relationships

 Meaningful activity

 Resources and settings to facilitate inclusion 

Recommendations

Short-Term Test the validity and reliability, and expand use of process 

and structure measure concepts related to the meaningful 

activity subdomain.

Intermediate Support efforts to further examine how to operationalize 

the construct of Community Inclusion and develop 

outcome quality measures for this domain.
Caregiver Support

25

Definition: Level of support available to and received by 

family caregivers or natural supports of individuals who 

use HCBS.

Subdomains

 Family caregiver/natural support well-being

 Training and skill-building

 Family caregiver/natural support involvement

 Access to resources 

Example Recommendations

Short-Term Ensure records/care plans identify family caregivers/ 

natural supports, with consumer consent as appropriate.

Long-Term Develop infrastructure to collect and manage data on 

family caregiver/natural support well-being, training, and 

involvement, and the availability and use of resources.
Workforce

26

Definition: Adequacy, availability, and appropriateness of 

the paid HCBS workforce.

Subdomains

 Person-centered approach to services

 Demonstrated competencies, when appropriate 

 Safety and respect for the worker

 Sufficient workforce numbers, dispersion, and availability

 Adequately compensated, with benefits

 Culturally competent 

 Workforce engagement and participation

Example Recommendations

Short-Term Identify or develop measures of worker retention and 

turnover, worker wages and benefits, worker satisfaction, 

worker training and skill competency.
Human and Legal Rights

27

Definition: Level to which the human and legal rights of 

individuals who use HCBS are promoted and protected.

Subdomains

 Freedom from abuse and neglect

 Optimizing the preservation of legal and human rights

 Informed decision-making

 Privacy 

 Supporting individuals in exercising their human and legal 

rights 

Example Recommendations

Short-Term Identify measures of human and legal rights currently in 

use in HCBS programs, assess their validity and reliability, 

and expand their use .
Equity

28

Definition: extent to which all dimensions of holistic health 

are assessed and supported.

Subdomains

 Individual health and functioning

 Health promotion and prevention

Example Recommendations

Short-Term Identify reliable and valid health and functional 

assessment tools commonly used in community settings 

from which standardized quality measures could be 

developed

Intermediate Identify and develop standardized quality measures 

derived from health and functional assessment tools 

routinely used in community settings
Holistic Health and Functioning

29

Definition: Extent to which all dimensions of holistic health 

are assessed and supported.

Subdomains

 Individual health and functioning

 Health promotion and prevention

Example Recommendations

Short-Term Identify reliable and valid health and functional 

assessment tools commonly used in community settings 

from which standardized quality measures could be 

developed

Intermediate Identify and develop standardized quality measures 

derived from health and functional assessment tools 

routinely used in community settings
System Performance and Accountability

30

Definition: Extent to which the system operates efficiently, 

ethically, transparently, and effectively in achieving desired 

outcomes.

Subdomains

 Financing and service delivery structures

 Evidence-based practice

 Data management and use 

Example Recommendations

Short-Term Expand the use of measures and measure concepts 

related to rebalancing, waiting lists, and unmet need.

Intermediate Develop a uniform measure of HCBS waiting lists.

Long-Term Evaluate promising practices in HCBS delivery through the 

lens of the Committee’s HCBS quality framework
Consumer Leadership in System 

Development 

31

Definition: Level to which individuals who use HCBS are 

well supported to actively participate in the design, 

implementation, and evaluation of the system at all levels. 

Subdomains

 System supports meaningful consumer involvement

 Evidence of meaningful consumer involvement

 Evidence of meaningful caregiver involvement 

Example Recommendations

Short-Term Allocate resources necessary for developing consumer 

leadership reporting

Intermediate Develop structure, process, and outcome measures to 

assess the subdomains of consumer leadership in system 

development
32

Conclusion: A Path Forward
A Path Forward for HCBS Quality 

Measurement

33

 Develop and test measures that capture the many facets 

of HCBS quality

 Implement NQF-endorsed measures

 Establish and/or strengthen infrastructure to support 

quality measurement

 Continue multistakeholder collaboration and efforts to 

improve the quality of HCBS and help consumers achieve 

their goals of living healthy, meaningful lives in their own 

communities

What Matters Most: Essential 

Attributes of a High-Quality System of 

Care for Adults with Complex Care 

Needs

Bruce A. Chernof, MD

President & CEO

Administration for Community Living 

Quality Webinar Series 

June 28, 2017
Working Group Members

G. Lawrence Atkins

Executive Director

Long Term Quality Alliance

Melanie Bella

Independent Consultant

Rich Bringewatt

Co-Founder and CEO

National Health Policy Group

Co-Founder and Chair

SNP Alliance

Helen Burstin

Chief Scientific Officer

National Quality Forum

Bruce Chernof

President and CEO

The SCAN Foundation

Jennifer Dexter

Assistant VP, Government Relations 

Easterseals

Lynn Friss Feinberg

Senior Strategic Policy Advisor

AARP Public Policy Institute

Jennifer Goldberg

Directing Attorney

Justice in Aging

Ann Hwang

Director

Community Catalyst, Center for 

Consumer Engagement in Health 

Innovation

Alice Lind

Manager

Grants and Program Development

Washington State Health Care Authority

Debra Lipson

Senior Fellow

Mathematica Policy Research

Margaret E. O’Kane

President

National Committee for Quality 

Assurance

Pam Parker

Medicare-Medicaid Integration 

Consultant

Minnesota Department of Human 

Services

Carol Regan

Senior Advisor

Community Catalyst, Center for 

Consumer Engagement in Health 

Innovation
Key Definitions

Essential Attribute 

A feature regarded as a characteristic or inherent part of 

care delivery by providers serving adults with complex 

care needs, which affects its success or failure.

Adults with complex care needs 

Individuals having two or more mental and/or physical 

chronic conditions, and additional functional limitations 

that collectively have an effect on health status and 

quality of life. 
Essential Attributes

Attribute 1:

Each individual’s range of 

needs and goals, both 

medical and non-medical, 

as well as for 

family/caregivers, are 

identified and re-

evaluated on an ongoing 

basis to drive care plans.

Attribute 4:

Individuals and their 

family/caregivers 

continually inform the way 

the delivery system is 

structured to ensure that it 

is addressing their needs 

and providing resources 

tailored to them.

Attribute 2:

Each individual’s needs are 

addressed in a 

compassionate, meaningful, 

and person-focused way 

and incorporated into a 

care plan that is tailored, 

safe, and timely.

Attribute 3:

Individuals have a cohesive, 

easily navigable delivery 

system so that they can get 

the services and information 

they want by themselves or 

with support when needed, 

and avoid the services they 

do not need or want.
Attribute 1:

Each individual’s range of 

needs and goals, both 

medical and non-medical, 

as well as for 

family/caregivers, are 

identified and re-evaluated 

on an ongoing basis to 

drive care plans.
Attribute 2:

Each individual’s needs are 

addressed in a 

compassionate, 

meaningful, and personfocused way and 

incorporated into a care 

plan that is tailored, safe, 

and timely.
Attribute 3:

Individuals have a 

cohesive, easily navigable 

delivery system so that 

they can get the services 

and information they want 

by themselves or with 

support when needed, and 

avoid the services they do 

not need or want.
Attribute 4:

Individuals and their 

family/caregivers 

continually inform the way 

the delivery system is 

structured to ensure that it 

is addressing their needs 

and providing resources 

tailored to them.
Essential Attributes At Work

National Quality Forum

• Essential Attributes of a High-Quality System of Care: 

How Communities Approach Quality Measurement

Nation Committee for Quality Assurance

• Person Driven Outcome Measures
Essential Attributes

Attribute 1:

Each individual’s range of 

needs and goals, both 

medical and non-medical, 

as well as for 

family/caregivers, are 

identified and re-

evaluated on an ongoing 

basis to drive care plans.

Attribute 4:

Individuals and their 

family/caregivers 

continually inform the way 

the delivery system is 

structured to ensure that it 

is addressing their needs 

and providing resources 

tailored to them.

Attribute 2:

Each individual’s needs are 

addressed in a 

compassionate, meaningful, 

and person-focused way 

and incorporated into a 

care plan that is tailored, 

safe, and timely.

Attribute 3:

Individuals have a cohesive, 

easily navigable delivery 

system so that they can get 

the services and information 

they want by themselves or 

with support when needed, 

and avoid the services they 

do not need or want.
Sign up for email alerts at 

www.TheSCANFoundation.org

Follow us on Twitter

 @TheSCANFndtn

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 The SCAN Foundation

Our Vision: 

A society where older adults 

can access health and 

supportive services of their 

choosing to meet their needs. 

Our Mission: 

To advance a coordinated and 

easily navigated system of highquality services for older adults 

that preserve dignity and 

independence. 
Q&A SESSION 

46
Next Webinar: August 16, 2pm EST 

Representatives from Human Services Resource Institute and the 

University of Minnesota Research Rehabilitation Training Center will 

discuss survey development and its importance in HCBS quality 

measurement. 

The materials from this webinar will be posted at the link below: 

https://www.acl.gov/programs/strengthening-aging-and-disabilitynetworks/improving-quality-services 

Please also visit this website for further information and resources on HCBS 

quality. 

Any questions or feedback may be e-mailed to HCBS-Quality@acl.hhs.gov. 

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