Section I, Part B – Demonstration Implementation Policies and Procedures
8. Quality
Provide a description of the State’s quality management system (QMS) for demonstration participants during the demonstration year and a description of what system they will be transitioned to after the 12-month demonstration period. Regardless of the financing and/or service delivery structure proposed under the demonstration, states must demonstrate how services during the 12-month transition period will:
- Be utilized to inform the CMS evaluation of the state’s MFP demonstration; and
- Meet or exceed the guidance for a QMS set forth under Appendix H of the 1915(c) HCBS waiver program.
Description of Texas’ Quality Management System
- Texas will provide a MFP-specific Quality Management Strategy for Medicaid 1915(c) waivers that do not currently utilize the new Appendix H, version 3.4 requirements. The quality management strategies have been developed to meet the MFP Operational Review Criteria, Quality Section I.B.8 Addendum, furnished by CMS.
- Texas currently utilizes Appendix H, version 3.4, for the following Texas 1915(c) Medicaid waivers:
- Community Based Alternatives (CBA), waiver number TX-2066
- Integrated Care Management (ICM), waiver number TX-19
- Medically Dependent Children’s Program (MDCP), waiver number TX-0181
- Texas Home Living (TxHmL), waiver number TX-0403
- Deaf-Blind with Multiple Disabilities (DBMD), waiver number TX-0281, has been submitted to CMS.
- A MFP specific Quality Management Strategy is attached at Appendices J, K, L, and M for the following Texas 1915(c) Medicaid waivers:
- Community Living and Assistance Support Services (CLASS), waiver number TX-0221.
- Consolidated Waiver Program (CWP), waiver number TX-0373.
- STAR+Plus, waiver number TX-0325.90
- Home and Community-Based Services (HCS), waiver number TX-0110.
As required by the Operational Protocol and Appendix H of the 1915(c) Home and Community Based Services (HCBS) waiver application, the required assurances will focus on the following issues:
- Level of care determinations
- Services plan description
- Identification of qualified HCBS providers for those participants being transitioned
- Health and Welfare
- Administrative authority
- Financial accountability
Quality Management staff from HHSC, DADS and DSHS will also coordinate oversight of incidents and service delivery issues/risks to determine how to improve services to participants. Consistent with HHSC and DADS practice, DSHS will conduct desk reviews of individual participant records maintained by a behavioral health provider as warranted by findings from an administrative data review. The Local Mental Health Authority will also provide ongoing oversight through its quality management program.
The quality management strategy specifically identifies:
- Each discovery process
- All responsible entities
- The frequency of various processes
- Data and type of information used
- Generated reports
In addition, the quality management strategy will measure the following:
- Participant access
- Participant-centered service planning and delivery
- Provider capacity and capability
- Participant safeguards
- Rights and responsibilities
- System performance
- Participant outcomes
MCOs (MCOs) maintain a quality improvement program that includes the following elements:
- Measure long-term service and support (LTSS) provider performance.
- Identify opportunities for improving performance
- Develop and implement action steps to improve performance
- Measure whether the targeted improvements have been achieved.
- Inform long-term service and support providers about the quality assurance program and related activities.
- Conduct utilization review activities on a sample of individuals receiving long-term services and supports.
HHSC contracts with an External Quality Review Organization (EQRO) to assist in improving the services delivered by MCOs through the following activities:
- Measuring and monitoring quality of care for Medicaid.
- Measuring and monitoring consumer and provider satisfaction.
- Monitoring the accessibility of care for eligible recipients.
- Monitoring Medicaid Star+PLUS participating managed care organizations' (MCOs) quality assurance and performance improvement plans and projects.
- Measuring financial performance and cost-effectiveness of the Medicaid MCOs.
- Conducting focused studies and special ad hoc analyses.
- Maintaining a data analysis platform and system to enable all functions.
- Performing MCO data validation, certification, and support activities for HHSC rate setting purposes.
- An individual’s initial POC is developed after a complete assessment has been conducted to assess the individual’s health needs. The type and amount of each service component is supported by:
- Documentation that other sources for the service component are unavailable and the service component does not replace existing supports;
- Assessments of the individual that identify specific service components necessary for the individual to live in the community, to ensure the individual’s health and welfare in the community, and to prevent the need for institutional services; and
- Documentation of the deliberations and conclusions of the service planning team that the services components are necessary for the individual to live in the community, to ensure the individual’s health and welfare in the community, and are appropriate to ensure the individual’s health and welfare in the community, and to prevent the need for institutional services. (40 Texas Administrative Code 97.157)
- All providers are required to develop and maintain a Quality Assessment and Performance Improvement Program (QAPI) that is implemented by a QAPI committee. Some of the elements of a QAPI Program must include an analysis of a representative sample of services furnished to clients contained in both active and closed records; review of negative client outcomes, effectiveness and safety of all services provided, the promptness of service delivery, and the appropriateness of the agency’s responses to client complaints and incidents; a determination that services have been performed as outlined in the POC, etc. (40 TAC 97.287).
Complaint and Incident Reporting Management
Please see Appendix N for complaint and incident management procedures.
Current Data Systems
Texas has mechanisms in place to monitor service utilization, enrollment data, billed services, planned services, and promptness of service initiation. These mechanisms include the Client Assessment, Review, and Evaluation (CARE) Form System (CFS), the Service Authorization System (SAS), the Quality Assurance and Improvement (QAI) Data Mart, and the EQRO's data system.
Client Assessment, Review, and Evaluation Form System
The Client Assessment, Review, and Evaluation (CARE) Form System (CFS) is used by the Home and Community Support Services Agency (HCSSA) to submit CARE forms to the Texas Medicaid and Healthcare Partnership (TMHP, the state’s MMIS contractor) for the determination of medical necessity (MN) and the Texas Index for Level of Effort (TILE – provider reimbursement calculation) scores. DADS staff may generate reports on MN and TILE scores in CFS.
SAS
SAS is used by DADS staff to authorize services and collect, process, and report participant authorization data. SAS maintains participant information, provider information, billing and payment information, and participant satisfaction interviews. Codes defining specific programs, services, and TILE scores drive the functionality of the system. A wide variety of reports can be generated from the data.
Medicaid Eligibility Service Authorization Verification Reports
HHSC’s MCOs and their long-term services and supports providers have access to the Medicaid Eligibility Service Authorization Verification (MESAV) report to request information about participants they are authorized to serve. This information can include Medicaid eligibility, medical necessity, co-payment, level of service, and service authorization.
Quality Assurance and Improvement Data Mart
The QAI unit of the Center for Policy and Innovation (CPI) of DADS will also use the QAI Data Mart designed as a result of funds received from the 2003 Quality Assurance/Quality Improvement (QA/QI) Real Choice Systems Change grant. The QAI Data Mart produces standardized reports and has the capacity to generage ad hoc reporting of provider performance and consumer outcome data. The QAI Data Mart provides an automated system to trend and analyze individual assessment data (e.g., Mental Retardation/Related Conditions [MRRC] and Minimum Data Set [MDS]) measures, performance indicators, and plan of care data in order to monitor trends.
EQRO Data System
HHSC employs the services of an EQRO to conduct some of its quality improvement activities. The EQRO has its own data system to identify and analyze the following types of events: Medicaid fee-for-service claims, all current and historical Medicaid encounter data submitted from the MCOs, Medicaid enrollment data, and Medicaid Behavioral Health Data from the Department of State Health Services (DSHS).
Plans for Future Enhancement of Mechanisms for Meeting Assurances
Texas is committed to continuous quality enhancement for 1915(c) waiver programs. As each 1915(c) waiver is renewed, a quality management strategy will be identified through the Appendix H portion of the Application for a 1915(c) HCBS waiver template.
Quality Review through Annual Surveys
Texas is using quality inventory tools for all community-based 1915(c) waiver and ICF/MR services. DADS joined the National Core Indicators Project and has contracted with an external entity to conduct both face-to-face and mail experience surveys of program participants on an annual basis. The project uses the National Core Indicators tool developed by the Human Services Research Institute (HSRI), as well as the Participant Experience Survey (PES) tool developed by MEDSTAT for the Centers for Medicare and Medicaid Services (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 his or her 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 complete trend analysis to identify areas for improvement, and to measure if improvement strategies are effective. The results provide an important discovery method for areas of improvement as identified by the participants receiving services.
The DADS QAI unit anticipates conducting pre-transition surveys of MFP participants and incorporating the MFP Demonstration participants in future annual experience surveys. Individuals receiving services under the Star+PLUS 1915(c) waiver will be included in the survey activities.
Please follow the guidelines set forth below for completion of this section of the OP:
- If the State plans to integrate the MFP demonstration into a new or existing 1915(c) waiver or HCBS SPA, the State must provide written assurance that the MFP demonstration program will incorporate, at a minimum, the same level of quality assurance and improvement activities articulated in Appendix H of the existing 1915(c) HCBS waiver application during the transition and during the 12 month demonstration period in the community.
The state need not provide documentation of the quality management system already in place that will be utilized for the demonstration. But, rather provide assurances in the OP that:
- This system will be employed under the demonstration; and
- The items in section (C) below are addressed.
In addition, the state should provide a brief narrative regarding how the existing waiver QMS already or will be modified to ensure adequate oversight/monitoring of those demonstration participants that are recently transitioned.
MFP Assurances
a. Texas can assure that the MFP Demonstration will meet the existing level of quality assurance and improvement activities of the current 1915(c) waivers. Texas’ MFP Demonstration will utilize existing 1915(c) waiver services as currently approved by CMS.
ai. Texas can assure that the same level of quality assurance and improvement activities as articulated in Appendix H will occur for the existing 1915(c) waivers during the transition and during the 12 month demonstration period.
aii. With respect to items in section (c), below, Texas is not offering any supplemental demonstration services. Texas can assure that the quality assurance process of its current 1915(c) CMS approved waivers have adequate remediation and improvement processes.
The Quality Section of this Operational Protocol (Section 8) describes how Texas’ existing waiver quality management strategies will ensure adequate oversight and monitoring of demonstration participants.
If the State plans to utilize existing 1915(b), State Plan Amendment (SPA) or an 1115 waiver to serve individuals during and after the MFP transition year, the State must provide a written assurance that the MFP demonstration program will incorporate the same level of quality assurance and improvement activities required under the 1915(c) waiver program during the individual’s transition and for the first year the individual is in the community. The state must provide a written narrative in this section of the OP regarding how the proposed service delivery structure (1915(b), SPA, or 1115) will address the items in section (c) below.
1915(b), State Plan Amendments, or 1115 Waivers.
Texas will not use a Medicaid 1115 waiver for purposes of this MFP Demonstration. The only 1915(b) waiver to be used is for managed care (Star+PLUS) in order to waive freedom of choice and limit the number of MCOs.
There is sufficient capacity in Texas’ Medicaid 1915(c) waivers for MFP participants. The Texas Legislature (2005) codified the MFP policies and created a separate line item for NF residents who want to relocate. This appropriation does not take away from other community slots appropriated by the Legislature.
For individuals with intellectual and developmental disabilities, there are specifically funded Home and Community-based Services (HCS) slots for individuals wanting to leave large (14+ bed) ICFs/MR and state supported living centers, and well as a priority set from slots abandoned by current users of HCS slots (referred to as “attrition slots”) due to death, leaving state, etc.
- The Quality Management System under the MFP demonstration must address the waiver assurances articulated in Appendix H of the 1915(c) HCBS waiver application and include:
- Level of care determinations;
- Service plan description;
- Identification of qualified HCBS providers for those participants being transitioned;
- Health and welfare;
- Administrative authority; and
- Financial accountability.
Texas’ 1915(c) waivers meet all of CMS assurances. This information was provided in the description earlier in this section of the Operational Protocol.
- If the State provides supplemental demonstration services (SDS), the State must provide:
- A description of the quality assurance process for monitoring and evaluating the adequacy of SDS service(s) to manage the barrier it was selected to address; and,
- A description of the remediation and improvement process.
Texas is not proposing to offer supplemental demonstration services during the MFP Demonstration. However, Texas will be providing Demonstration Services.
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Updated:
December 14, 2010
