Independence PlusSelfDirection: A Framework for Quality Assurance and Improvement Strategies

1
Independence Plus/Self-Direction A Framework
for Quality Assurance and Improvement Strategies 

• Ohio Association of County Boards of Mental
  Retardation/Developmental Disabilities
• November 2003
• June Rowe Human Services Research
  Institutejrowe_at_hsri.org

2
Brief historical perspective

• Community services have historically have been
  provided through private (mostly non-profit)
  agencies
• Provider agencies are held accountable for
  quality of staff and service quality
• QA/QI systems have largely focused on provider
  monitoring
• Licensing
• Certification
• Accreditation

3
Signs of Change

• Family support movement set the tone by
  empowering families to hire their own staff
  through the use of family subsidies
• Advent of personal care assistance and movement
  by physical disability community to control
  hiring and firing
• Emergence of the self determination movement and
  the increasing deconstruction of the service
  system

4
This is not new, rather it has deep historical
roots
self-determination independent living
movement in-home supports for the elderly
family support self-advocacy
5
State demonstration projects

• Robert Wood Johnson Foundation
  Self-Determination Initiative
• Began in 1997
• 19 states
• Impact assessment in 2001 by HSRI
• Cash and Counseling Medicaid Demonstrations
• 3 states
• Flexible monthly allowance
• Hire own choice of workers and purchase other
  goods and services
• Evaluated by Mathematica

6
Some of the lessons learned from the cash and
counseling evaluation

• Information about cash and counseling needs to be
  easy to understand and made available in
  different languages and media
• Outreach needs to be extended to family members
  since they often involved in making decisions
• Most consumers used the allowance to hire workers
  and nearly all workers were relatives or
  acquaintances of the consumer
• Consumers who did not have a relative or friend
  to hire often had difficulty recruiting a worker
• Most consumers will terminate employment of
  family members or friends whose work is
  unsatisfactory. Some need support to do so
• Consumer exploitation was extremely rare.
  Periodic telephone calls and visits were adequate
  to ensure that recipients were not exploited as
  their situations changed
• http//www.mathematica-mpr.com/PDFs/3state.pdf
• From Lessons Learned from the Implementation of
  Cash and Counseling in Arkansas, Florida, and New
  Jersey, Mathematica policy research, Inc. June
  2003

7
Independence Plus

• Basic goal of self-direction
• A waiver program that affords people needing
  long term services and supports with the option
  to control and direct HCB waiver funds (Medicaid)
  identified in an individual budget while living
  with their family or in their own homes.

8
This is accomplished by

• Recognizing the role of the individual/family in
  the planning and purchasing of services and
  supports by providing them with control over an
  agreed resource amount
• Increasing individual/family satisfaction through
  the promotion of personal control and choice
• Encouraging cost effective decision-making
• Promoting solutions to worker availability
• Delaying or avoiding institutional or other high
  cost out-of-home placements by strengthening
  supports to individuals or families

9

• Traditional waivers require states to safeguard
  the health and welfare of individuals (e.g.,
  provider standards, provider contract obligations
  and assurances, detailed policies and
  regulations, routine provider monitoring)
• Independence Plus still has the same
  requirements, but it is accomplished through the
  following essential elements

10

• Independence Plus has four basic component parts

• 2. An individual budget

1. A person centered plan
3. Supports that are self-directed
by the individual
4. Quality assurance and improvement
11
Quality assurance and improvement in Independence
Plus

• Back-up and/or emergency response systems for
  both the individual and the system as a whole
• System for reporting, reviewing and acting on
  critical incidents
• Monitoring expenditures of the individual budget
  
• Criminal background checks for workers, and

12

• A quality assurance and improvement program that
  articulates quality domains, dimensions,
  assurances and one which assures the health and
  welfare of participants in the waiver program
• Components
• Frequency of QA activities
• Domains measured
• How information collected (e.g., interviews)
• Persons conducting the reviews
• How families/consumers involved in quality
  assurance
• How the QA program is updated
• How problems are remediated
• Review and act on critical incidents
• Annual QA report

13

• And note that Independence Plus references the
  domains in the quality framework.

14

HCBS Quality Framework
15
Participant Access

• Information and Referral
• Intake and Eligibility            
• User-friendly processes
• Eligibility determination
• Referral to community services
• Individualization of services
• Prompt initiation

16
Participant-Centered Service Planning and Delivery

• Participant-Centered Planning
• Adequate assessment
• Free choice of providers
• Responsive service plan
• Participant direction
• Service Delivery
• Ongoing service and support coordination
• Provision of needed services
• Ongoing monitoring
• Responsiveness to changing needs

17
Provider Capacity and Capabilities

• Availability of individual and agency providers
• Review of provider qualifications
• Monitoring of providerperformance

18
Participant Safeguards

• Prevention and investigation of abuse,
  neglect and exploitation
• Tracking of major and unusual incidents
• Ensuring safety of housing and environment
• Regulation of behavior interventions
• Standards for medication management
• Provisions for personal safety and security
• Preparation for natural disasters and other
• public emergencies

19
Participant rights and responsibilities

• Ensure that participants  
• Exercise civic and human rights
• Participate in decision making authority
• Have provisions for alternate decision making
• Have access to due processand grievance
  mechanisms

20
Participant Outcome and Satisfaction

• Participant outcomes
• Participant satisfaction

21
System Performance

• Conduct system performance appraisals
• Support quality improvement
• Ensure cultural competency
• Support participant stakeholder involvement
• Maintain financial integrity

22
(No Transcript)
23
The growth of self direction and Independence
Plus by necessity cause us to re-think quality
assurance and improvement approaches because
changes in quality assurance and
improvement strategies are directly influenced
by changes in services and supports!
24
So, why re-think quality now

• Current QA/QI systems that are used to monitor
  provider agencies may not work well for
  individuals who are directing their own supports
  and are supported through independent providers
  
• As states apply for Independence Plus waivers
  or build self-direction into their other waivers,
  they need to develop QA/QI strategies to ensure
  the health and welfare of waiver participants for
  these supports

25
QA/QI systems for self-direction and independent
providers is a balancing act

Choice Control Less intrusive monitoring
HCBS and state assurances Safeguarding health
and welfare
26
Who is an independent provider?

• Someone, in large part, employed and supervised
  directly by the individual and/or family
• Is not an employee of a private agency
• Is paid either directly by the state or, more
  likely, through a financial management service

27
QA/QI for self-direction/independent providers
considerations

• Positives
• Increased flexibility, choice and control
• Close, caring reciprocal relationship between
  provider and individual/family
• Individual/family directly monitor quality
• Vulnerabilities
• Isolation of both the provider and individual
• Maintaining the energy, competencies and
  connectedness of the provider
• Oversight for provider quality largely in the
  hands of the individual/family

28
Core quality assurance and improvement attributes

• Placing individuals and families at the center of
  the QA/QI system
• Monitoring service quality without being
  intrusive
• Determining if independent providers have an
  understanding of their roles and responsibilities
• Determining if there is an adequate pool of
  independent providers who have both basic
  qualifications and competencies and specific
  skills to support individuals
• Determining if there are adequate safeguards for
  individuals who are directing their own services
  and being supported by independent providers

29

• Providing a means for individuals and families to
  freely express their concerns or dissatisfaction
  with their services and supports
• Determining if individuals are protected from
  harm when supported by independent providers
• Facilitating (and not impeding) timely service
  provision to individuals with chronic
  disabilities
• Obtaining participant feedback on the quality of
  services and supports provided by the independent
  provider
• Identifying trends and developing strategies for
  service improvement over time

30
Re-thinking quality Individual safeguards

• For self-direction and using independent
  providers quality starts in the beginning before
  monitoring quality is preventive, upfront
• 1. Basic qualifications, skills and
  competencies for all providers
• Pre-screening
• Education/age requirements
• Threshold competencies
• Methods for verification

31

• 2. Person-centered planning
• Identifying the persons needs for support, risks
  
• Individual and family competencies needed to
  effectively manage individual providers
• Person-specific competencies the providers need
  to support the individual
• Degree of monitoring in the planning process

32

• QA/QI safeguard strategies that are more
  person-centered, individualized
• Self-monitoring by educated individuals and
  families
• Ongoing monitoring by the case manager/support
  coordinator is critical for early
  detection/prevention of problems

33
4. The pivotal roles of the case manager or
support coordinator

• Makes sure the support plan includes
• Identification of risk factors
• Roles and responsibilities of the individual,
  family and other supports
• Skills and competencies of providers
• Monitoring of the support plan
• 5. Finally, the knowledge and competency of
• individuals and their families to direct
• their own supports is a key safeguard

34
Re-thinking quality systemic QA/QI strategies
for self-direction and independent providers

• Consumer affairs or ombudsman office
• Trends in grievance reports or complaints (e.g.,
  type, amount)
• Critical Incident Reporting Systems
• Necessary, but challenging to rely on for these
  supports
• Published report cards on independent providers
• As reported by individuals and families (UT)
• Person-centered review processes
• Less prescriptive, more outcome-based (KA)

35

• Citizen/peer networking and quality councils
• Joint problem solving, resource and information
  sharing
• Consumer/family surveys
• National Core Indicators Consumer and Family
  Surveys (HSRI/NASDDDS)
• Participant Experience Survey (Medstat Group)
• Ask Me survey (MD)
• Developmental Services Adult Consumer Outcomes
  survey (NH)

36

• An example from one state Arizona
• With much acknowledgement to Barbara Brent for
  the following slide presentation!

37

ArizonaDivision of Developmental Disabilities
Quality in Supporting People with Developmental
Disabilities and their Families at Home through
Independent Providers
38
Arizona

• Arizona has a population of over 5.4 million and
  covers 113,446 square miles.
• Diverse in people, geography, urban and rural
  communities.
• The Division supports approximately 23,000 people
  with developmental disabilities and their
  families.
• 13,000 waiver participants.
• 1115 Waiver. Division is program contractor for
  both acute and long term services.
• Most (87) individuals live in their family
  homes. This includes consumers that live on
  their own, with support.

39
Arizona

• The Division contracts with agency providers
  (Qualified Vendors). There are over 500 agency
  vendors.
• The Division also has agreements with over 3,000
  independent providers. In 2003, 3500 consumers
  received services through an independent
  provider.
• Individuals and their families are provided
  information about the type of services provided
  by both of these provider choices.
• Support Coordination is primarily provided
  through state employees. There are a few private
  agencies providing support coordination services.

40
The Arizona Provider Network

• Individuals with disabilities and their families
  may use independent providers for services such
  as
• Attendant care
• Habilitation (hourly support)
• Child and adult developmental homes
• Respite
• Day treatment/training
• Housekeeping

• If an individual and their family wish to use an
  independent provider, they may choose from the
  list of available providers or, if they know
  somebody they believe would be a good provider,
  that person may apply to become an independent
  provider.

41
Arizona Independent ProvidersSafeguards

• Support Coordinators
• Certification- background checks, fingerprinting,
  core training.
• Licensing and certification for developmental
  homes.
• Data base kept on all certified providers to know
  what certification is for, if it is current,if
  there are any actions, etc.
• Training and support at the district level.
• Satisfaction surveys.

42
Arizona Independent Provider Safeguards

• Family and Consumer Support Unit in Central
  Office.
• Training such as rights, behavioral
  supports,CPR/First Aid, training specific to the
  needs of the person.
• Individual support/service planning.
• Individual agreements with Division Business
  Operations.

• Risk assessments when the support team identifies
  this as a need (e.g. for persons with potential
  risks living in residential settings such as
  developmental homes or individually designed
  living arrangements).
• Community input from family leaders, advocacy
  groups and self advocates.
• Families are essential safeguards!

43
Arizona- What is Next

• Workgroup currently chartered to review
  monitoring for family members that are providers.
• Discussions at how to increase looking at quality
  up front.
• Continued support of bilingual providers.

44
Considerations for the future in quality
assurance and improvement for self-direction

• Integrating self-direction into the overall
  quality management strategy
• Developing specific outcomes and indicators to
  identify and address vulnerabilities and measure
  the quality of self-directed supports over time
• Not re-inventing the wheel but analyzing the
  effectiveness of the current QA processes to
  strengthen and add others

45
Consider the following

• Develop outcomes to measure the self-directed
  supports over time
• Crosswalk with the current QA processes to
  determine which have the potential to be
• Used consistently used throughout the system
• A reliable and valid measure
• A source of data collection
• Do not undermine the individuals control over
  his or her supports

46
Resources

• www.hsri.org
• www.cms.hhs.gov/newfreedom/528hill.pdf
• www.nasddds.org/publications
• www.outcomeanalysis.com
• www.mathematica-mpr.com/3rdLevel/cashcounselinghot
  .htm