QIS Indicators: HCBS Mental Health Waiver - Focused Discussion Forum

Helping Families. Supporting Communities. Empowering Individuals.

Illinois Department Healthcare & Family Services

Illinois Department of Human Services
Division of Mental Health

December 16, 2010

Agenda

  1. Purpose and Scope of Forum
  2. Update on HCBS Waiver Status
  3. Purpose of QIS
  4. Overview of QIS Requirements
  5. 6 Assurances
  6. Steps in the QIS Process
  7. Performance Indicator/Measure Example
  8. Review Illinois Draft QIS Indicators
  9. Q & A
  10. Next Steps

Purpose of QIS

  • The State and the state's providers are fulfilling obligations as set out for the HCBS program
  • Recipients of HCBS services are better off
  • The services and care provided are beneficial and aim to achieve good outcomes

QIS Requirements

  • CMS requires states with 1915C Waivers to report the results of their evaluation of compliance with assurances.
  • CMS oversight is based principally on the review of evidence that waiver assurances have been met. The State's role in producing reliable evidence of compliance is paramount in the review process.
  • The measures selected and the evaluation performed based on data collection must be rigorous.

QIS Assurances

  • Persons enrolled in the waiver have needs consistent with an institutional level of care (Level of Care)
  • Participants have a service plan that is appropriate to their need and that they receive the services/supports specified in the plan (Service Plan)
  • Waiver providers are qualified to deliver services/supports (Qualified Providers)
  • Participants' health and welfare are safeguarded and monitored (Health and Welfare)
  • Claims for waiver services are paid according to state payment methodologies (Financial Accountability)
  • The State Medicaid agency is involved in the oversight of the waiver and is ultimately responsible for all facets of the program (Administrative Authority)

Quality Improvement Strategy (QIS) Steps

  • Design: Performance Measures (PMs) and Data source(s)
  • Discover: Use results of your PMs to monitor and report on results
  • Remediate: Fix individual problems and reports on results
  • Improve: Carry out systemic actions to improve performance & pre/post analysis to see if actions worked

Steps in the QIS Process

  • State produces data on performance measures
  • CMS requests data/evidence report from State
  • CMS provides Findings report to State based on submitted evidence one year prior to Waiver renewal.
  • Findings report includes recommendations for needed changes in renewal application

Performance Indicator/Measure Example

Sub-assurance a.i.e: Participants are afforded choice: between waiver services and institutional care; and between/among waiver services and providers.

Performance Measure:

  • Indicator 1: Number and percent of waiver participants with a completed and signed freedom of choice form that states that choice was offered between institutional care and waiver services
  • Indicator 2: Number and percent of waiver participants with a completed and signed freedom of choice form that states that they were offered a choice of waiver service providers.

Performance Measure:

  • Numerator: # of participants with a freedom of choice form completed and signed stating that they were offered a choice between waiver services and institutional care
  • Denominator: Total number of enrolled waiver participants

Performance Measure:

  • Numerator: # of participants with a freedom of choice form completed and signed stating that they were offered a choice of provider
  • Denominator: total number of enrolled waiver participants

Data Source

Data Source

Responsible Party for data collection/generation

(check each that applies)

Frequency of data collection/generation:

(check each that applies)

Sampling Approach

(check each that applies)

  • Clinical/Medical Record
  • Waiver Enrollment
  • Form Data Residing in MIS
  • State Medicaid Agency
  • Operating Agency
  • Sub-State Entity
  • Other: Specify
  • Weekly
  • Monthly
  • Quarterly
  • Annually
  • Continuously and Ongoing
  • Other: Specify
  • 100% Review
  • Less than 100% Review
  • Representative Sample; Confidence Interval =95%
  • Stratified: Describe Groups
  • Other: Describe

Data Aggregation and Analysis

Responsible Party for data aggregation and analysis

(check each that applies)

Frequency of data aggregation and analysis:

(check each that applies)

  • State Medicaid Agency
  • Operating Agency
  • Sub-State Entity
  • Other: Specify
  • Weekly
  • Monthly
  • Quarterly
  • Annually
  • Continuously and Ongoing
  • Other: Specify

IL QIS Indicators: Level of Care

Sub-assurance #1: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future

Indicator: Number and percent of waiver applicants who had a level of care assessment that indicated a need for institutional level of care prior to enrollment in the waiver

Performance Measure:

  • Numerator: # of applicants with level of care assessments prior to enrollment into the waiver.
  • Denominator: total number of waiver applicants.

Sub-assurance #2: The LOC of enrolled participants is reevaluated at least annually or as specified in the approved waiver.

Indicator: Number and percent of waiver participants whose LOC is evaluated within 12 months of their last LOC assessment

Performance Measure:

  • Numerator: Number of participants whose LOC is reevaluated on or before the 12 month anniversary date.
  • Denominator: # of participants whose LOC is due to be reevaluated. (Note: the indicator will be calculated a minimum of 31 days after the LOC reassessment is due)

Sub-assurance #3: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant LOC

Indicator: Number and percent of LOC determinations made for waiver participants in which the LOC criteria were accurately applied

Performance Measure 1 (to detect false positives) :

  • Numerator: # of 'positive' LOC determinations (indicating a need for waiver services) on which the provider and the reviewer agreed
  • Denominator: # of 'positive' determinations made by waiver providers

Performance Measure 2 (to detect false negatives):

  • Numerator: # of 'negative' determinations (indicating no need for service) on which the provider and the reviewer agreed
  • Denominator: # of 'negative' determinations made by waiver providers

IL QIS Indicators: Service Plan

Sub-assurance #1: Service plans address all participants' assessed needs, including health & safety risk factors & personal goals either by waiver services or other means.

Indicator 1: Number and percent of participants who had service plans that addressed their assessed needs (including health care needs).

Performance Measure:

  • Numerator: #of participants with service plans that addressed their assessed needs
  • Denominator: Total number of participants' service plans reviewed

Indicator 2: Number and percent of service plans that address participants' goals as indicated in the assessment(s)

Performance Measure:

  • Numerator: # of service plans that address participants goals based on the assessments
  • Denominator: total number of participants service plans reviewed

Sub-assurance #2: The State monitors service plan development in accordance with its policies and procedures.

Indicator: Number and percent of service plans developed within timeframe as specified per waiver policies and procedures

Performance Measure:

  • Numerator: # of service plans completed within specified time frame per waiver policies and procedures
  • Denominator: total number of service plans reviewed

Sub-assurance #3: Service plans are updated/revised at least annually or when warranted by changes in the waiver participant's needs.

Indicator 1: Number and percent of service plans that were reviewed, and revised on or before waiver participants' annual review date

Performance Measure:

  • Numerator: # of service plans reviewed and revised annually
  • Denominator: total number of service plans reviewed

Indicator 2: Number and percent of service plans that were reviewed and revised due to changes in the waiver participant's needs.

Performance Measure:

  • Numerator: # of service plans that were revised as warranted by changes in the waiver participant's needs
  • Denominator: Total number of service plans that indicated a change in waiver participant's needs.

Sub-assurance #4: Services are delivered in accordance with the service plan, including in the type, scope, amount, duration, and frequency specified in the service plan.

Indicator: Number and percent of participants' records reviewed who received services in the type, amount, frequency and duration as specified in the service plan

Performance Measure:

  • Numerator: # of participants' records reviewed who received services specified in service plan (type, scope, amount, duration and frequency)
  • Denominator: total number of participants whose records were reviewed

Sub-assurance #5: Participants are afforded choice: between waiver services and institutional care; and between/among waiver services and providers.

Indicator 1: Number and percent of waiver participants with a completed and signed freedom of choice form that states that choice was offered between institutional care and waiver services

Performance Measure: Numerator: # of participants with a freedom of choice form completed and signed stating that they were offered a choice between waiver services and institutional care

Denominator: total number of records reviewed

Indicator 2: Number and percent of waiver participants with a completed and signed freedom of choice form that states that they were offered a choice of waiver service providers.

Performance Measure:

  • Numerator: # of participants with a freedom of choice form completed and signed stating that they were offered a choice of provider
  • Denominator: total number of records reviewed

Indicator 3: Number and percent of waiver participants with a completed and signed freedom of choice form that states that they were offered a choice of waiver services.

Performance Measure:

  • Numerator: # of participants with a freedom of choice form completed and signed stating that they were offered a choice of waiver services
  • Denominator: total number of records reviewed

IL QIS Indicators:Qualified Providers

Sub-assurance #1: The state verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other standards prior to their furnishing waiver services.

Indicator: Number and percent of waiver providers initially and continually meeting licensure/certification standards in accordance with State law prior to providing waiver services

Performance Measure:

  • Numerator: # of waiver providers meeting licensure/certification standards
  • Denominator: total number of waiver providers

Sub-assurance #2: The state monitors non-licensed/non-certified providers to assure adherence to waiver requirements.

Indicator: Number and percent of non-licensed/non-certified waiver providers meeting waiver requirements prior to service provision

Performance Measure:

  • Numerator: # of non-licensed/non-certified waiver service providers meeting waiver requirements for service provision prior to service provision
  • Denominator: total number of non-licensed/non-certified waiver service providers

Sub-assurance #3: The state implements its policies and procedures for verifying that provider training is conducted in accordance with state requirements and the approved waiver.

Indicator: Number and Percent of providers, meeting training requirements in accordance with state requirements

Performance Measure:

  • Numerator: # of waiver providers that meet training requirements in accordance with established state requirements.
  • Denominator: Total number of waiver providers

IL QIS Indicators: Health & Welfare

Sub-assurance #1: The State, on an on-going basis, identifies, addresses, and seeks to prevent occurrences of abuse, neglect & exploitation.

Indicator 1: Number and percent of participants' records reviewed that documents that participants (and/or legal guardians) received information/education about how to report abuse, neglect, exploitation and other critical incidents as specified in waiver policies and procedures.

Performance Measure:

  • Numerator: # of participants and/or legal guardian receiving information/education on how to report abuse, neglect, exploitation and other critical incidents as documented in the clinical record
  • Denominator: total number of participants' records reviewed

Indicator 2: Number and percent of complaints addressed within timeframe specified in waiver policies and procedures.

Performance Measure 1:

  • Numerator: # of complaints addressed within required timeframe as specified in waiver policies and procedures;
  • Denominator: total number of complaints reported

Indicator 3: Number and percent of records documenting that a reminder was provided to waiver participants to obtain an annual physical

Performance Measure:

  • Numerator: # of waiver participant's records reviewed documenting a reminder to participants to obtain an annual physical
  • Denominator: total number of waiver participant's records reviewed

Indicator 4: Number and percent of waiver survey respondents who report that they are treated with respect and dignity by waiver service providers.

Performance Measure:

  • Numerator: # of survey respondents reporting they are treated with respect and dignity by waiver service providers
  • Denominator: Total number of waiver survey respondents completing the survey.

IL QIS Indicators: Financial Accountability

Assurance: State Financial Oversight exists to assure that claims are coded and paid for in accordance with the reimbursement methodology specified in the approved waiver.

Indicator 1: Number and percentage of claims submitted that were submitted for individuals enrolled in the waiver on the date services were rendered.

Performance Measure:

  • Numerator: Number of waiver service claims that were submitted for individuals authorized to receive waiver services on dates that services were rendered.
  • Denominator: Total number of waiver service claims submitted for individuals receiving waiver services.

Indicator 2: Number and Percentage of waiver service claims submitted for FFP that were specified in participants' service plans.

Performance Measure:

  • Numerator: Number of waiver services claims submitted for FFP that were specified in participants service plan
  • Denominator: Total Number of service claims that were submitted for FFP for individuals receiving waiver services.

Q & A

  • Questions?
  • Comments and Suggestions

Continuous Review & Comment

For Announcements, calendars, drafts, frequently asked questions (FAQ), other information please see the DHS website Mental Health Medicaid Waiver 1915(c) (www.dhs.state.il.us/page.aspx?item=51565) page.

For comments, input, questions please email the dedicated email account at DHS.HCBSMHWAIVER@illinois.gov