Welcome to the webinar, “What is ACL's Interest in HCBS Quality.” 

Please remember to mute your phones for the duration of the webinar. The 

link to for closed captioning is in the chat. >> I want to turn it over 

to Meredith Raymond. 

Good Afternoon! Thank you for joining us for the kickoff of our Home and 

Community-Based quality webinar series, What is ACL’s Interest in HCBS 

Quality? This series will consist of informational webinars occurring on 

a bi-monthly basis to build awareness of ACL’s commitment to and 

development of HCBS quality measures--- and to provide a platform among 

internal and external stakeholders to share developments and collaborate 

on efforts concerning HCBS quality. To begin, today’s webinar will 

provide a broad overview of ACL’s HCBS quality initiatives: Due to a very 

full agenda, we will keep introductions short: Edwin Walker, Deputy 

Assistant Secretary for Aging will provide welcoming remarks, Susan 

Jenkins, Director, Office of Performance and Evaluation will discuss an 

overview of quality measurement, Eliza Bangit, Director of the Office of 

Policy Analysis and Development will discuss our work with the National 

Quality Forum, Shawn Terrell will discuss our contract work with the 

National Core Indicators and survey development, Amanda Reichard will 

present an overview of the Rehabilitation Research Training Center at 

University of MN and their studies on measure development, If time 

allows, we will have a Q&A period to answer the pre-selected question, 

How do you measure quality?” Now, I’d like to Introduce Edwin Walker, our 

Deputy Assistant Secretary for Aging to provide welcoming remarks.

Thank you very much. I would like to welcome everyone to the webinar. 

Here at the Administration for Community Living we are working with our 

partners and other federal agencies, states, consumers and advocates, 

providers, and stakeholders to create a sustainable LTSS system where 

older adults and people with disabilities have choice, control, and 

access to a full array of quality services that assure optimal outcomes 

including independence, good health, and quality of life. Advancing the 

identification, development, and implementation of measures of quality 

community living options that can be used by public and private entities 

is central to ACL’s vision: All people, regardless of age and disability, 

live with dignity, make their own choices, and participate fully in 

society. The concept of measurement forces us to ask ourselves – what is 

the basis for our claims and how are we fulfilling our mission through 

this work. The development and implementation of national standards for 

high quality long-term services and supports, and the systems that 

provide them, is needed to help track and measure the reach and 

effectiveness of national, state and community programs. ACL is working 

to support the development of standards and measures directly related to 

the well-being of older adults, persons with disabilities and their 

families, as well as the availability of and access to services and 

supports for all individuals. These standards are being developed and 

implemented through ongoing program performance, program evaluation, and 

other continual quality improvement strategies. HCBS are at the nexus of 

community living. More than 12 million Americans need long-term services 

and supports, a number that is expected to increase to 27 million by 

2050. There have been efforts on the Federal level to examine performance 

measurement and quality improvement for home and community-based services 
(HCBS). In 2005, the Agency for Health Research and Quality (AHRQ) 

contracted with Truven Health Analytics to conduct an environmental scan 

of HCBS quality measures for the Medicaid program. In 2014, the CMS 

Testing Experience and Functional Tools (TEFT) planning grants led to the 

development of an HCBS consumer experience-of-care survey used to 

construct performance measures related to beneficiaries’ experience with 

Medicaid services, and an electronic long term services and supports 

service plan standard (eLTSS) that can enable electronic exchange of 

information relevant to the care of persons receiving HCBS. 

There have also been efforts on the state level. There is growing use of 

surveys to assess HCBS quality, including the National Core Indicators 

(NCI), Money Follows the Person Quality of Life Survey, and Health 

Outcomes Survey used in the Program of All-Inclusive Care for the Elderly 

(PACE). Despite these efforts, the development, availability, and 

implementation of HCBS measures remain limited. Currently, there are 

many measures endorsed by the National Quality Forum (NQF), but very few 

are considered home and community based services-related. As we move 

towards value-based purchasing and increasingly integrate home and 

community based services with medical services, it becomes more critical 

to capture the experience of people who use HCBS and to work towards 

assuring that HCBS are of highest quality. ACL strongly supports any 

progress toward nationally validated outcome measures for long-term

services and supports and has invested in a number of initiatives, which 

you will hear more about today and in future webinars that are working 

toward this goal:

The National Quality Forum group on measuring HCBS quality completed a 

two-year effort to develop a conceptual framework for measurement, review 

existing literature for measurement guidance, identify gaps in measures, 

and made recommendations on HCBS measurement last fall. We also have 

supported the development and implementation of the National Core 

Indicators for Aging and Disability. These two related instruments 

continue to inform the field on state system performance. NIDILRR is 

funding a Rehabilitation Research and Training Center on Home and 

Community-Based Services Outcomes. The result will be a set of 

recommended measures and procedures to ensure that they support qualityof-life outcomes for people with disabilities and older adults.

The purpose of this informational webinar series is to increase awareness 

of ACL’s commitment to and development of HCBS measures and provide a 

platform among internal and external stakeholders to share developments 

and collaboration efforts in the HCBS quality field. 

The first three webinars in the series will focus on ACL initiatives; 

however we welcome your suggestions for topics of future webinars. 

We need you to help us continue this work and look to you for input, 

assistance and collaboration on all things HCBS quality!

Thank you and back to you Meredith. >> 

 

Thank you Edwin. Now I would like to introduce Susan Jenkins to provide 

an overview of quality measurements. 

Thank you Meredith. Thank you good afternoon everyone my name is Susan 

Jenkins and I have been working on gathering information about how our 

programs operate and whether they are providing quality services to 

individuals and communities for almost 25 years. I’ve seen firsthand 
how programs use data to make decisions, to find out what initiatives to 

pursue and what policies to implement, how much better they do when they 

have that data and then programs that don't. I’m happy to share some of 

what I learned with you today. >> Why is quality measurement important? 

Program evaluation is a systematic method for collecting, analyzing and

using information to answer questions about projects policies and 

programs. Particularly about the effectiveness and efficiency of those

policies programs and projects. It’s important to remember that when we

think about measuring how our programs and policies are performing, we 

have to look at quality and quality measurements. Quality measurement is 

a type of evaluation. Institute of measurement defines healthcare 

quality in a degree to which health outcomes are consistent with current

professional knowledge. With regard to home and community-based services

and ACL's mission to maximize the independence, well-being and health of 

people with disabilities, older adults and their families to include 

supportive services and the degree to which those services provide the 

well-being of those we serve. When thinking about quality we commonly 

think about six dimensions. The first is effectiveness. That is related 

to providing services that achieve the desired outcome which in this case 

is helping people live independently with maximal health and well-being. 

Another is efficiency. Are we doing the most that we can with the 

resources that we have? We also have to be concerned with equity which 

is related to providing services of equal quality to those who may differ 

in the personal characteristics. We also look at [ Indiscernible ] 

which relates to meeting consumers’ needs [ Indiscernible ] safety 

which is related to the actual potential bodily harm and finally 

timeliness which relates to obtaining the needed services and having 

access to the needed services as quickly as possible. And ACL examines

these [ Indiscernible ] particular focus on what we call a three-legged 

stool approach which tells us make sure that we provide the best 

services possible and do not pool to from one direction at the expense 

of other program. These three legs that we used to balance our measure 

to assure the overall -- we ask ourselves, are we serving the right 

people? Those who are most needy and can most benefit from our services? 

Another is efficiency. Are we providing the services at a reasonable 

unit cost and the other is quality. Are the services [ Indiscernible ] 

quality. To bring these ideas to life, imagine a meals program that is 

designed to help people stay in the community and live independently. We 

could appear to be successful if we serve people at low risk for being 

institutionalized because few of those people would ultimately enter a 

care facility but because they are at low risk for [ Indiscernible ] it 

is unlikely that our meals are actually making a difference. In that 

case we are not really meeting our purpose of helping people at risk for 

entering a facility to remain independent in the community. We could 

also be very efficient and serve a lot of people if we serve very poor

quality meals again not meeting our mission of the program because meals

may not be nutritious or people may not eat them. Many look at quality 

of the meal thing -- nutritional quality. It is only by balancing these

three things that we can truly make the mission of helping people live

independently. 

I want to offer a little bit of history. And make the point that the 

move to quality is not new even though if it has not always been talked 

about using the terms we talked about. Enacted in 1993 GPRA are a 
modernization act was designed to improve [ Indiscernible ] the GPRA 

modernization act of 2010 aims to ensure -- established important --

requirements that move for a more useful -- the modernization act also 

served as a foundation for helping agencies to focus on their eyes 

priority and create a culture where data and empirical data played a 

more important role in [ Indiscernible ] in other words using data and 

service quality to make programmatic policy decisions that improve the 

program and the services that we offer. 

In 2013 the memorandum shown on this slide offered -- continually 

improve program performance by applying listing evidence about what works 

generating new knowledge and using experimentation and innovation to test 

new approaches to program delivery. In HCBS, this means finding out which 

policies programs and -- communities do to make their own choices and to 

participate fully in society. >> In the recent 2018 budget blueprint the

current Administration also discusses the evidence a measurement of 

program quality. They talk about using real hard data to identify 

poorly performing programs and organizations which we would say are of 

a lower quality in identifying those that have high quality and making 

decisions us extensively based on [ Indiscernible ]. 

The question becomes what we measure and there are many reasons some of 

which were stated in the previous slide but also if we do not examine our 

programs objectively we cannot really know if they are improving people's 

lives either directly through services or indirectly through improved 

efficiency. Measurement is important to improve lower preforming 

programs and help us give -- to help them choose what services and 

approaches are best for them. And ensure that we are getting our money's 

worth, and making sure we’re getting the level of quality we expect. It 

is important to remember though that the measurement of quality is an 

improvement tool not in and in itself. We should use quality -- as a way

to serve in the people in the community and the best most effective way 

possible. 

What to measure. We cannot measure everything and even though I am an

evaluator and a focus on program manner, I do realize that we should not

have measurement overcome the value of the program so there is a saying 

that we used sometimes in the evaluation field that if you can define it 

we can measure it. We need to remember that just because we can measure 

something or it's easier to measure something that does not mean that we 

should. Measurement should complement the program and gather the most 

important information needed for decision-making and service improvement. 

If we try to think about what we would measure we would think about some 

common areas for measurement. There are several services that make most 

sense to measure because these are things that we can have control over

as we try to improve our programs or maintain a quality these include 

quality of how care is structured. For example is it whole it listed 

multidisciplinary, how the process of -- community living outcome 

and what are the consumer outcomes in terms of health well-being and 

independence. We can also look at the level of resources using to

compare the resources per positive outcome. For example we may want to

measure the cost per day of remaining in the community, the cost per 
person who reports living in the setting that they want to live in, or 

the cost per satisfactory [ Indiscernible ] developed. 

We think about what to measure, we think about how to create those 

measures. The basis of evaluation and performance measurement is 

comparing actual performance of your program service or policy to 

intended objectives peers sometimes those objectives are clearly defined 

but many times they are not, and many times they are not measurable it 

is written. Once we have an idea of the service structure called the

processes and cost as well as expected outcome for systems and consumers

we can start to develop specific measures. The measures that explicitly 

define what will be collected. And ACL -- follows the SMART --

performance of quality. So there are the five areas and by specific we 

mean description of the objective is well written in any way anyone can 

define it -- two different programs to different providers have to be 

reporting comparable severable data. They have to understand the 

objective in the same way. That ensures that an object is specific to 

make sure it is described and that it is observable so specific meaning

all those things. By measurable we mean the extent to which something 

can be evaluated -- quality measurement would be accuracy, format how 

well it fits within standard guidelines of service. Achievable, with the 

question can the program policy program or service make the [ 

Indiscernible ] different. We -- must contribute to our purpose and time 

oriented means we define -- so we have a goal for when we expect to have 

met the objective or milestone toward that objective. 

Another way to think about specific is by looking at the numerator and 

denominator and defining them very clearly as shown on this slide. What 

I mean is we define a numerator which might be who or what system 

component showed the desired -- in this example the number of person 

centered plan of care which would be divided by the denominator which 

should be the number of individuals enrolled in a program. In the 

denominator we do not include people are service components that were 

not exposed to are eligible for the service spirit you want to look at 

the people who could have made the change that we are looking for 

divided by all of -- we want to look at the people who made the change 

the desired change that were looking for divided by all of the people 

that had the opportunity to make that change. 

On the next slide, there is a funny way to highlight the importance of

knowing our denominator we have to know the context in which we are

operating to understand the quality of our program. In this case the 

little cat got three stars out of three stars and that's a much more 

positive outcome than what it really turns out to be which is three 

stars out of 1 million. So we take it back to an example on the 

previous page of we learned 10,000 consumers now have person centered 

plans. That’s great. It's great if we know that there were 10,500 people 

eligible to develop such plan. That'll be a rate of 95%. That would 

suggest that we have a quality program or approach for developing [ 

Indiscernible ] it is not so great a system included 50,000 consumers 

of which 10,000 which is only 20%. Thank you for all of your 

attention as I discussed quality measurements and thank you Meredith. 
Thank you, Susan. Now would like Eliza Bangit will discuss ACL’s work 

with the National Quality Forum. 

I will provide an overview today of the work of the National Quality 

Forum, or NQF on quality home and community-based to support community 

living. I am only providing a brief overview today so I invite all of 

you to tune in again on June 28 at the same time 2 PM. Our colleagues at

the national quality forum will present a more in-depth. Moving on. 

Next slide please. 

 Section1890 of the Social Security Act requires the Secretary of 

Health and Human Services to provide a consensus-based entity. Under this 

authority the Secretary of HHS designated the national quality forum as 

the CBE. In 2012 HHS awarded a contract to NQF to synthesize evidence and 

convene key stakeholders to make recommendations to HHS on a national 

strategy and priorities for health care performance measurement in all 

settings. 

 Under that contract NQF was also tasked with convening a multistate 

holder committee to produce recommendations to HHS for performance 

measurement in home and community-based services that support community 

living policy. 

This was a two-year project that involved the development of standard 

a HCBS definition, the creation of a conceptual framework for a HCBS 

measurements including domains and subdomains of development and 

characteristics of high quality HCBS which you will see later on in my 

slides. It also required NQF to produce an environmental scan of 

existing HCBS measures and instruments which then created an opportunity 

or platform for identifying gaps in a HCBS measurement as well as 

promising measures. The project also produced recommendations from the 

committee for prioritization in HCBS measurement. 

How was this project done? One of the first things that NQF did was

form a multi-stakeholder committee of national experts on HCBS quality. 

Something unique to this project was the active participation of the 

federal advisory group from HHS to help advise NQF throughout the 

project. 

When the committee was formed, NQF held committee in-person and Web 

meetings which were open to the public; it facilitated workgroup calls, 

and conducted online surveys to solicit the Committee’s input. Four

reports were published under this project, three were interim reports and 

one final report, which was released last year in September. NQF took 

public comments on all this. 

In the final report you will find the committee's definition of home and

community-based services. The term home and community-based services 

refers to an array of services and supports delivered in the home or 

other integrated community settings that promote the independence, health 

and well-being, self-determination, and community inclusion of a person 

of any age who has significant long-term physical, cognitive, sensory 

and/or behavioral health needs. You will find this definition on page 9 

of the final report. Stemming from the process of creating an 

operational definition of HCBS, the committee identified specific 

characteristics of a high-quality HCBS system. The committee felt that 
this was necessary because the operational definition as you just saw 

previously is more functional than aspirational. The committee wanted to 

also communicate its vision for what HCBS should be. Through extensive 

discussion the committee established that high-quality HCBS should be 

delivered in a way that provides for a person driven system that 

optimizes individual choice and control, promotes social connectedness 

and inclusion , includes flexible range of services that are provided in 

a setting of the individuals choosing, integrates health care and 

social services to promote well-being, promotes privacy, dignity, 

respect and independence , freedom from abuse, neglect, exploitation, 

coercion and extract restraint and other human and legal rights. It 

also ensures balance of personal safety and dignity of risk and supplies 

and supports an appropriately skilled workforce that is stable and 

adequate to meet demand. >> It also supports family caregivers. It 

engages individuals who use HCBS in the design, implementation and 

evaluation of the system. It reduces disparities by offering services

that are provided in a culturally sensitive and linguistically 

appropriate manner, coordinates and integrates resources to best meet the 

needs of the person. 

It delivers accessible, affordable and cost-effective services. It 

supplies data to all stakeholders and finally fosters accountability 

through measurement and reporting of quality of care and outcomes. 

One of the things the committee develops was an illustration as you see 

here of the conceptual framework to show how performance measurement

should work and HCBS. Each circle in the framework represents a level at 

which measurement can be applied. At the consumer level, the level of 

the person receiving HCBS. There is the provider level which is at the

level of service provision, and also at the system level. Measurement at 

each of these levels of analysis serves different purposes and responds 

to different information needs. You will see a list in the circle at the 

center of the diagram there are 11 domains and measurement that the

committee compiled. This illustrates overlapping levels because 

measurement can be applied at multiple levels within many domains. The 

continuous arrows surrounding the four circles indicate the transfer of 

information that is necessary to operate a dynamic, learning system and

the feedback loops between measurements and improvement efforts. >> As 

I mentioned in the previous slide the committee developed and defined 11 

domains and 40 subdomains for quality measurement in HCBS. The goals of 

constructing the domains and subdomains are to stimulate evidence-based

research in support of quality measure development, to guide quality 

improvement efforts, and highlight the important areas for measure

development. >> 

 Through its deliberations the committee identified gaps in 

measurement within all of the domains and subdomains and discussed the 

barriers and challenges in measuring quality. These barriers and

challenges include the lack of standardized measures across the country, 

the lack of or limited access to timely data on HCBS programs, the 

variability across the numerous federal state local and privately funded 

programs with respect to reporting requirement and the added 

administrative burden of data collection management, reporting, and 

incorporation into quality improvement activities. Again if you would 

like to learn more about the committee work on this please look for the 
final report that is on the national quality forum's website. Finally 

the committee also developed global recommendations that apply broadly to 

HCBS quality measurement. Its recommendations are: support quality 

measurement across all domains and subdomains. Build upon existing 

quality measurement efforts, develop and implement a standardized 

approach to data collection, storage, analysis and reporting, ensure that 

emerging technology standards, development and implementation are

structured to facilitate quality measure minute. Triangulate assessment 

of a HCBS quality using an appropriate balance of measure types and 

units of analysis and develop a core set that of standard measures for 

use across the HCBS system along with a menu of measures that can be 

tailored to the population, setting, and program, finally the committee 

recommended that we convene a standing panel of HCBS experts to continue 

to evaluate and approve candidate measures. 

Here's the slide with links to the reports and other materials produced

by the National Quality Forum under this project. This concludes my 

portion of the presentation. Thank you Meredith and turning it back to 

you. 

Thank you. We will now hear from Shawn Terrell who manages our contract 

work with National Core Indicators and survey development. This is Sean 

Terrell and you can advance the next slide. We have the contract with an 

organization, the Human Services Resource Institute to collaborate and we 

will go into a little bit to develop HCBS quality measurements from 

national core indicators for intellectual development disabilities, aging

and physical disabilities. This is really our first attempt to try to 

build off of the work done and start to build a set of measures that are-

- endorsed by NQF for use in variety of programs frankly and that -- the 

robust measures for NQF endorsement -- designed around paper performance 

kind of models. For that reason [ Indiscernible ] rigorous and wholly 

developed and pretty much on a sellable -- these are two sets of survey 

instruments that have their own history. For the National Core 

Indicators, they focus on adults with intellectual development 

disabilities who receive at least one service in addition to case 

management from state IDD systems. Most of the people are in some sort 

of home community -- this is in development and has been operational for 

a number of years started in 1997. There are three surveys in the 

suite of surveys that are offered . One is the adult consumer survey 

another is for family members and others staff stability. It's now 

operational in 46 states plus the District of Columbia. It is funded by 

state membership fees and ACL has supported expansion [ Indiscernible ] 

for a number of years. 

NCI for aging and disability is for older adults and adults with 

physical disabilities and this is a much broader array of service 

programs cost skilled nursing facilities, Medicaid waivers, Medicaid 

state plan, state-funded programs, older Americans act programs [ 

Indiscernible ] PACE the program for [ Indiscernible ] for the elderly 

and programs of Medicaid Medicare combined programs and manage long-term 

service support. It is a full gamut of people. For that reason it is a 

little more complex -- they started this in 2012. They have one survey 

which is an adult in person only. On their website -- the management 

website there is a three state report published. They are getting ready 
to publish a larger survey -- six states that should be out pretty 

soon. We're looking at about 20 states for 2017 and 2018 survey. It is 

growing rapidly. The states are interested in the surveys. Again 46 

states and this is growing at a high rate. >> Here's the coverage for 

these two. The green is participating in both NCI in NCI-AD and the sort 

of blue is participating in NCI only. And light blue not participating 

in either. 

 You see the map turning green over the next couple of years. 

 Here's the indicators. There’s a great deal of overlap with two sets 

of instruments. In NCI-AD was derived out of -- community participated 

in a think those of the self-determination, IDD versus [ Indiscernible ] 

aging disability . Self-determination was the old -- mostly people think

of self-direction and there are a few extra additional indicators in 

aging disability around every day living in affordability and future 

planning and control. In general they are quite consistent with each 

other. 

We have a contract with human services Institute with National

Association for State Directors, a developmental disabilities services in 

the national association first staging -- collaboration in these projects 

their goal is a number of things we are doing in this contract. First,

refine and expand the use of NCI and NCI AD. Anytime we see results we 

want to know are these results valid and reliable. If I see a graph 

cannot rely on those results to be telling the truth meaning that the 

data is actually good and accurate and developed according to standards 

for these kind of surveys. Can I review the literature on that ? 

Cannot go somewhere and find the report itself that shows that the 

surveys were developed [ Indiscernible ] data are accurate? Again on 

standard protocol if you will. What we are asking to do is do what is 

necessary to do the [ Indiscernible ] testing of reliability -- states 

sample around 400 people in their respective tools. Interview protocols. 

Making sure that people doing these in person interviews are trained 

and are delivering the interview as intended and that they are 

implemented in consistency across all states and publish all of them. In 

peer-reviewed journal so everyone can see them and see that reading is 

done very well. This one area -- last area -- because we have a lot of 

questions that relate to persons -- person centered planning 

 -- person centered planning are the key to underlie the --

premised on each person having control [ silence ] 

>> I think we are having technical difficulty. Amanda you could go

ahead and speak regarding rehabilitation research training center at the 

University of Minnesota we would appreciate it. 

Sure. If you will advance the slides. >> Hello I am Amanda Reichard 

with the National Institute on Disability Independent Living and

Rehabilitation Research known as NIDILRR -- ACL. I’m going to talk about 

one project that has been mentioned a couple of times today the research 

and training center on outcomes measurement for home and communitybased services. In 2015 NIDILRR held a grant competition for research 

in rehabilitation and training center on the quality of HCBS and I 

shortened that to our RTC because it's easier to say than rehabilitation 

and research training center. The University of Minnesota was awarded 
the grant for $875,000 per year for five years and is a mentioned this 

is [ Indiscernible ] the University of Minnesota staff are using this 

grant to develop HCBS qualities and measures and these measures will be 

applicable across a wide range of disability subgroups in the aging 

populations that receive HCBS. The grant team at Minnesota includes

partners in organizations that have relevant expertise that is specific 

to these disability sub groups in aging population that are covered by 

the measures. 

 These partners include several universities, the National Council on 

Aging and relevant policy and research organizations. >> The work of 

the University of Minnesota is in response to the NIDILRR and ACL --

ACL priorities are one identifier develop measures and test the 

reliability and validity in usability of those measures in assessing the 

person centered outcomes of individuals with disabilities who receive a 

HCBS. Another priority is to work closely with NIDILRR ACL in the 

National Quality Forum project on HCBS quality. Develop procedures and

mechanisms for applying HCBS outcome measures in policy and service 

delivery settings to in an effort to maximize the quality and 

appropriateness of HCBS from the end-user perspective. 

 Collaborate with stakeholder groups in developing evaluating or 

implementing strategies that increase the utilization of these new HCBS 

outcome measures. And finally serve as a national resource center 

related to person center measurement for HCBS outcomes. >> As a starting

point the University of Minnesota founded their work on the NQF framework 

that allows the described earlier. These 11 domains and framework focus

on consumer leadership in system development, system performance and 

accountability, equity, service delivery and effectiveness, person 

centered service planning and coordination, caregiver support, 

workforce, holistic health and functioning, community inclusion, human 

and legal rights, and choice and control. 

The grant at the University of Minnesota includes six main studies. The 

first study uses a participants or a planning and decision-making 

process for people with disabilities their family members and providers 

and program administrators and this is across five disability groups 

including people with IDD or intellectual and developmental disability, 

physical disabilities, traumatic brain injury, mental illness in aging 

population. The second study involves a gap analysis between what is 

included in the HCBS domains and subdomains and existing measures. In 

this study will attempt to identify measurement gaps through an analysis 

of what is currently available -- what instruments are currently 

available to focus on outcomes of HCBS and the NQF outcome -- ACL in -

- one into is almost complete. Study three will identify -- will

include identifying high-quality fidelity implementation pride is add 

code measurement program study for will refine and develop the HCBS 

measures. These will be -- this refinement will be based on the results 

from studies one through three to fill in those gaps and measurements 

that were identified. 

Study five will reliability validity and sensitivity to the measures 

that were changed by using a large-scale of testing of the most critical 

measurement [ Indiscernible ]. Finally, study six will involve 

identifying and testing risk adjusters to validity of the measurement 

instrument. 
Similar to allies that, this is another project that will be presenting 

in a future webinar so we hope you will be able to tune in for much 

greater detail for these projects in the result of their findings later 

this year. 

Thank you Meredith. 

Thank you. We have Sean back on and he would like to say a couple more 

statements. 

Thanks. So to finish up and I apologize I was cut off. 

 They are going to revise and develop some questions about [ 

Indiscernible ] planning insert into the existing surveys or they 

might create a new survey depending on how many questions we feel we 

need to have and we are currently working to some focus groups [ 

Indiscernible ] and others to help develop those questions. There's 

one more. This fits in with what Amanda is talking about. The work here 

that we want to have measures that are endorsed by NQF to put home 

community-based service measurements into the same arena as those that 

are more medically oriented. There are over 600 measures that are 

endorsed by NQF around the medical field and they get regularly 

inserted into a variety of [ Indiscernible ] programs for instance, 

managed care programs, programs that integrate medical and long-term 

service support. Those are out there they are used and they have a track 

record. In fact the challenge now is aligning those because they are 600 

and some are similar in their doing a lot of work on that. On the other 

hand on HCBS you don't have many measures and yet we are running into a 

situation where we have home community-based services and a full array 

of medical dedicated services for instance offered by the same plan but 

the only thing that has the value-based purchasing measures are the 

medical side. We want to have a HCBS measures to be as prominent as

those other measures are for the purposes of HCBS so we don't lose 

people so we don't lose the concept and more integrated world that we 

are entering into. That's the purpose. Want to get tread -- 20 

measures minimally out of the NCI and NCI a decent and we think [

Indiscernible ] place to start because the states Aarti have the 

infrastructure. There are 246 states that have state commitments and 

ongoing work to administer the surveys and so the measures -- the 

numerator and denominator is an easier fit as they are Aarti doing --

asking these questions. We think this is a good place to start for us. 

In coordination with everyone else what they are doing particularly the

work that Amanda it was just talking about in Minnesota so we do not have 

the overlap in these competing measures of the same thing that we see 

now in the medical field. The last thing that they continue to do is 

technical assistance on how to do all this work and how to do the surveys

etc. That's it for me. Thank you for coming back to this slide. I think 

it was relatively important. One more thing. This is a precursor so 

once the [ Indiscernible ] will be doing their own webinar in the not 

so distant future with more detailed look at what they are doing 

stating for that. 

Thank you to all of our speakers. We greatly value your work at ACL. We 

will move into the Q&A portion of our webinar. Because the time 
limitations the opportunity to submit questions was provided to those who 

registered previously. The question, “How do you measure quality was 

selected from the submissions. Ultimately the goal for measuring 

quality is to help guide decision-making and drive improvement over time. 

Unless we measure, it is difficult to know exactly what we need to 

improve and whether we have in fact achieved improvement. 

In order to begin to measure quality we need to know what data we should 

be measuring and we need to ensure that that data is reliable. This is a 

fundamental component that supports and advances quality driven efforts. 

We can measure quality in different ways. At HHS there are many efforts 

that support quality measurement including what you heard today of the 

three initiatives that ACL is spearheading. The Substance Abuse and 

Mental Health Services Administration (or SAMHSA) has a Behavioral Health 

Quality Framework and had identified several NQF endorsed measures under 

three of the goals: Person Centered Care, Healthy Living for Communities, 

and Reduce Costs of Behavioral Healthcare. The Centers for Medicare and 

Medicaid Services (or CMS) requires NQF endorsed measures in many of its 

funding authorities including managed care waivers, 1115 Demonstrations, 

and Dual Eligible programs. For HCBS Waiver programs, States are expected 

to develop a quality improvement plan and measure six assurances, which 

are administrative oversight, level of care, qualified providers, service 

plan, health and welfare, and financial accountability. Lastly, the 

Testing Experience and Functional Tools (TEFT) program recently received 

endorsement for 19 HCBS measures related to experience of care in HCBS 

programs. We hope this webinar was helpful and informative. Thank you for 

participating. The slides will be e-mailed to all who RSVP’d. The slides 

and transcript will also be posted to ACL.gov. As Edwin mentioned, we 

need you to help us continue this work and look to you for input, 

assistance and collaboration on all things HCBS quality! Our next webinar 

will be on June 28 and will expand on Eliza’s overview of quality 

framework development. Representatives from the National Quality Forum 

and the SCAN Foundation will discuss the progress made in quality 

framework development. An announcement will be sent out in early June 

with registration instructions. Thank you!

Thank you this concludes today's conference. You may disconnect at 

this time. >> [ event concluded ]