Part 2: Demonstration Design
9 and 10. Quality Assurance and Improvement
The template used for the MFP quality management strategy will follow the same format that DADS will use for its overarching Quality Management Plan. Minor changes, however, are necessary as DADS will undertake some additional quality assurance and improvement activities associated with the MFP grant by tracking pre- and post-transition health and well-being, as well as program satisfaction information.
Pre-transition health information will be obtained from the most recent assessment conducted during the individual’s residency in the nursing facility or ICF/MR. Information concerning satisfaction of services and supports will be determined from the results of one of the annual experience surveys conducted by DADS.
During the post-transition period, Texas will use quality assurance activities to monitor changes in the individual’s health condition so that the plan of care may be amended or other actions taken as necessary. Additionally, information about the individual’s satisfaction of services will be collected and compared to pre-transition survey results.
A relocation specialist will make frequent visits with the individual to ensure the transition is progressing smoothly and that services in the plan of care are adequately addressing the needs of the individual. If not, the case manager will be contacted for appropriate revisions to the plan of care or other actions will be taken as necessary.
Current Quality Initiatives
Texas has developed many elements of an effective quality assurance and improvement system. One of the “Guiding Principles” for DADS is “Customer Focus – individual needs, preferences and rights of the persons served are primary to the design, development and implementation of all programs and service delivery systems”.
Various organizational areas within DADS provide procedures, processes, and policies to ensure health and welfare of all individuals. The Access and Intake area’s primary function is to ensure that DADS services at the local level are accessed through an easily coordinated and efficient system. Provider Services administers contracts with hundreds of community and in-home service providers. The division ensures that consumers have a full array of services delivered by qualified providers and conducts contract monitoring in cooperation with other DADS divisions. Regulatory Services is responsible for Licensing and Credentialing Operations, Survey Operations, and Enforcement Operations. All of the functional areas of DADS provide critical components to a comprehensive quality management strategy.
DADS also uses other tools to ensure quality services. This includes review and appropriate action on critical incident reports, reports of suspected abuse, neglect or exploitation, maintenance of DADS Employee Misconduct Registry and pre-employment criminal background checks. The discovery process will also include case/chart reviews of active participants to help ensure services are being provided at an appropriate level and meet the needs of the individual.
The Department of Family and Protective Services (DFPS) may take actions against staff who provide direct services that fail to protect a consumer from Abuse and Neglect, including referral to local law enforcement, or the appropriate licensing board.
Texas is using quality inventory tools for all community-based waiver and ICF/MR services. DADS joined the National Core Indicators Project and contracted with an external entity to conduct both face-to-face and mail experience surveys of our program participants on an annual basis. (DADS uses a consumer survey developed by the Human Services Research Institute and the Participant Experience Survey developed by MEDSTAT for CMS.) Texas is one of the few states in the country that undertakes a survey of this size and scope. The purpose of the project is to obtain information from the participant’s perspective about their experiences receiving DADS services. The first phase was conducted in 2005 and provided an initial baseline of data that DADS will build upon. Future surveys will provide additional data that will enable DADS’ staff to analyze and trend over time to identify areas for improvement and to measure if improvement strategies are effective.
Texas used funds from its 2003 QA/QI Real Choice Systems Change grant to design a Quality Assurance and Improvement Data Mart that will produce standardized reports, as well as provide capability for ad hoc reporting of provider performance and consumer outcomes data.
As required by federal law, HHSC contracts with an External Quality Review Organization (EQRO) to independently review quality, timeliness, and access in managed care programs such as STAR+PLUS. The Texas EQRO accomplishes this responsibility through the following activities: validation of Managed Care Organization (MCO) performance improvement efforts; calculation of MCO performance on quality measures contained in the HHSC contract; validation of MCO encounter data; measurement of consumer satisfaction via standardized surveys such as the Consumer Assessment of Health Plan Services (CAHPS); and execution of focused quality studies.
HHSC is responsible for monitoring the Family-Based Alternatives and STAR+PLUS contracts. This will include monitoring for performance measures and conducting an annual on-site audit. Additionally, the contractor is required to submit detailed monthly monitoring reports and to meet with the HHSC contract manager on a regular basis to review the progress of the initiative and specific contract measures. External funds have been secured for a third party evaluation of the contractor’s efforts in each of the next three years. The STAR+PLUS MCO contracts include performance measures and targets for quality improvement. These include state-developed and selected national Healthplan Employer Data and Information Set measures.
The DSHS Quality Management Unit uses performance-based risk assessment to identify contractors/MHAs at high risk for contractual non-compliance and delivery of poor quality services. DSHS implements appropriate interventions to increase compliance and service quality. The unit responds to complaints, advocates for consumer's rights and provides data analysis and information to management and external stakeholders. Contracted DSHS MHAs and substance abuse providers create and conduct their own quality management processes. To support contractor efforts in this endeavor, DSHS publishes contractor review tools for use in day-to-day provider oversight processes.
Proposed Quality Management Strategy
During the Pre-implementation Phase of the MFP grant, Texas will develop, in cooperation with the stakeholder task force, a detailed Quality Management Strategy that is derived from CMS’ Quality Framework. The primary objective of the quality management strategy will be to administer and measure a quality system that: 1) ensures that the State meets each of the framework’s required assurances; 2) identifies and acts on opportunities for program and service improvements; and 3) reflects the values and principles across all MFP activities. The MFP quality management strategy will be based on discovery, remediation, improvement, evidence-based best practices, and education. In order to monitor consumer outcomes, Texas will develop a matrix for the MFP quality management strategy that specifically identifies: each discovery process, all responsible entities, the frequency of various processes, data and type of information used, and any reports generated. This matrix will be similar to one developed for each of DADS home and community-based programs and will contain variables related to the MFP Initiative. The MFP matrix will clearly address each of the mandatory CMS assurances (Level of Care Determinations and Re-evaluations, Service Plan, Qualified Providers, Health and Welfare, Administrative Authority, and Financial Accountability). Additionally, it will be designed to measure Participant Access, Participant-Centered Service Planning and Delivery, Provider Capacity and Capability, Participant Safeguards, Rights and Responsibilities, System Performance, and Participant Outcomes and Satisfaction.
An example of the MFP matrix for quality assurance in the MFP Initiative is attached at Appendix I.
Some of the discovery methods currently used, and those that will be included in the MFP quality management strategy, include collection of program data contained in various databases maintained by the collaborating agencies.
The National Core Indicators (NCI) and the Participant Experience Survey tools are used to calculate quality indicators. The results will provide an important discovery method for areas of improvement as identified by the participants receiving services. DADS Quality Assurance and Innovation unit intends to include all MFP grant participants in future experience surveys.
The DADS Data Mart that will compile data currently collected in multiple automated systems and will produce standardized reports and provide ad hoc reporting for the MFP grant. The areas covered by the reports will include participant demographics, services utilization, enrollments, levels of care, plans of care, consumer-directed options, critical incidents, abuse, neglect, and exploitation, provider compliance and oversight, transfers, discharges, complaints, and recoupments. The system will have the capability to provide management reports at the participant level.
Each year, staff will compile information regarding the MFP grant initiative. The annual report of the MFP quality management strategy will include key information relevant to each assurance and focus area and include information about transitions from institutions, as well as participant satisfaction. The report will provide internal and external stakeholders with information on quality indicators, including status of MFP grant outcomes, including program remediation and improvement activities. DADS Quality Assurance and Improvement unit will routinely update the MFP quality management strategy based on feedback from stakeholders.
As part of the proposed quality management strategy, DSHS and HHSC will continue to provide their current quality assurance activities described above and data from all three agencies will be coordinated.
Texas Department of Aging and Disability Services – Reference Guide 2005
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April 24, 2009