Addressing Performance Gaps in
HCBS to Support Community Living
Tina Hilmas RN BSN
September 22, 2015
http://www.centerforpatientsafety.org/
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Center for Patient Safety
• Federally-designated Patient Safety Organization
• Not for Profit established in 2005
• Dedicated to promoting safe and quality healthcare through
the reduction of errors
• Our focus is on learning what errors occur, why they occur and
how to prevent patient harm. We emphasize the importance
of culture in promoting safe systems of care, culture that
supports individualized care, teamwork and communication.
• We work with licensed healthcare providers collaboratively to
learn how to reduce serious events and patient harm within
the federal confidentiality and privilege protections of the
federal Patient Safety and Quality Improvement Act of 2005
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Shameless Plug
• Did you know that when analyzing home care patient safety events
reported to the Center for Patient Safety that falls are the number
one cause of a safety event in home care?
• Beginning September 21, 2015 we start Falls Awareness Week
• September 23rd is Falls Prevention Awareness Days
• CPS is collaborating with Long Term Care to investigate falls with
injuries in long term care facilities
• Missouri is higher than the national average in regards to falls with
injuries
• Resources
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http://www.champ-program.org/page/99/falls-prevention-toolkit
http://stopfalls.org/news-events/fall-prevention-awareness-week/
http://www.patientsafety.va.gov/professionals/onthejob/falls.asp
http://www.cdc.gov/steadi/
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History/Need for Project
•
•
Up until early 1980’s CMS was biased toward institutionalized care
“Katie Beckett” Waiver (Tax Equity and Fiscal Responsibility Act - TEFRA)
– Katie was 3 year old in Iowa who developed viral encephalitis which paralyzed her
diaphragm which meant she required a vent for breathing and tube feedings as she
couldn’t swallow
– She gradually improved but would always have complex medical needs which lead to
extreme costs
– At the time (1981) the way the law regarding financial assistance was set up families had
1 of 2 options:
• put the child in an institution in order to qualify for Medicaid
• become impoverished
– Katie’s story got the attention of President Reagan and in 1981 the Katie Beckett Waiver
was created which allowed for Katie and children like her to qualify for Medicaid while
receiving care at home
– At same time many studies documented that at least 1/3 of Medicaid funded persons
living in nursing homes could reside at home if additional support services were
available.
•
Missouri was one of the first states to put this into effect in April 1982
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Fast Forward and Fast Facts
• Home and Community Based Services are increasingly coming under
federal scrutiny
• AHRQ (Agency for Healthcare Research and Quality) published
Comparative Effectiveness Review article in November 2012 comparing
HCBS to Institutional Care
– Brought out the following facts:
• Medicaid spending is rising faster for HCBS than for Nursing Homes
• National Spending on HCBS from 1995 to 2009 more than doubled
• Spending went from 19% in 1995 to 43% in 2009
– Results basically stated need for more research (see posters)
– However, one major highlight was that it noted that outcome measures were not
standardized across the settings
• 2012 Commission on Long Term Care noted annual costs for long term
care services were approximately $140 billion (34% of all Medicaid
funding)
• At that time close to half of the $140 billion was due to HCBS
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Fast Forward and Fast Facts
• CMS predicts that when today’s numbers are reconciled over half of
long term care expenditures will be comprised of HCBS
• Commission on Long Term Care recently met with Congress to
discuss need for improvement in Long Term Care across all settings
but with particular attention to the HCBS area
• Currently there are no national standardized quality measures for
the home and community based arena. (Those that are present are
not readily available nor are they uniform/standardized across
states)
• With over half of long term care expenditures being put towards
HCBS and with an average of 60% of Medicaid funding coming from
federal dollars the need has become apparent for standardization
and comprehensive quality performance measurements
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Overview
• November 2014 National Quality Forum (NQF)made a call for
nomination for a multi-stakeholder committee to provide input on
performance measurement gaps in home and community based
services.
• 2 year project under contract with the Department of Health and
Human Services
• States are continuing to shift resources from institutional care to
HCBS
• There is a need to ensure that a high quality HCBS system is in place
to support elderly and disabled
• NQF recognizes that HCBS are vital to promoting independence and
wellness for people with long-term care needs
– Focus on older adults and the disabled.
– Recognize that efforts to measure and improve quality in HCBS are limited
yet needed
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Project Goals
• Create a conceptual framework for measurement, including a
definition for HCBS
• A synthesis of evidence and environmental scan for measures
and measure concepts
• Identify gaps in HCBS quality measures based on the
developed framework
• Make recommendations for prioritization HCBS measure
development efforts
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Timeline of Project
Phase 1: Initial
evidence and
environmental
scanning of
defined
sources
Starts Dec. 2014
Operational
definition of
HCBS and
framework
domains and
subdomains
development
Phase 2:
Tailored
evidence and
measure
scanning
based on
domains/subdomains
Spring/Summer 2015
Fall2015/Winter 2016
Committee
analysis and
prioritization
of measure
gaps
Spring 2016
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Project Reports
REPORTS
DUE DATES
Draft Report: Operational Definition and Draft
Conceptual Framework for HCBS Performance
Measurement
July 15, 2015
Draft Report: Environmental Scan of Measures
and Synthesis of Evidence for HCBS
November 15, 2015
Draft Report: Recommendations on HCBS
Measure Concepts for Translation and
Advancing Measurement
July 15, 2016
Final Report: Recommendations on Addressing
Performance Measure Gaps in HCBS to Support
Community Living Quality
September 4, 2016
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Back to Basics
• AHRQ began developing measures for HCBS about 8 years ago
(http://www.ahrq.gov/professionals/systems/long-termcare/resources/hcbs/hcbsreport/index.html)
• While it is a few years old, it was very thorough and included
over 200 measures
• NQF is using this report as a foundation to identify measures
for HCBS
• CMS has sponsored the development of a taxonomy for HCBS
explaining types of and uses for HCBS which is to be
implemented into the new version of the Medicaid Statistical
Information System (MSIS)
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Emerging Activities based on Project
• Electronic service plans for long term supports and services (eLTSS)
• CMS’s TEFT (Testing Experience and Functional Tools) is working on
several tools:
– HCBS consumer experience of care survey
– Continuity Assessment Record and Evaluation (CARE) tool functional item
set
• Together these are setting the groundwork for an eLTSS health
record and interoperability standards to exchange records across
providers
• For this to happen though must start with a standard definition.
– Reviewed more than 200 information sources
– Identified 27 different existing definitions of HCBS and LTSS
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Operational Definition
The term “home and community-based
services” (HCBS) refers to an array of long-term
supports that promote the independence, wellbeing and choices of an individual of any age
who has physical, cognitive, and/or behavioral
health needs and that are delivered in the
home or other integrated community setting.
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Characteristics of High Quality HCBS
• These outline how services SHOULD be delivered
• Define the importance of ensuring the adequacy of the
workforce
• The importance of integrating healthcare and social services
• And lastly the importance of supporting the caregivers of
those who utilize HCBS
• These characteristics are also centered on fostering an HCBS
system that is:
– Ethical
– Accountable
– Centered on the achievement of an individual’s desired outcomes
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Characteristics
• Provides for a person-driven
system that optimizes individual
choice and control in the pursuit
of self-identified goals
(employment, enjoying life)
• Promotes social connectedness
by including people who use
HCBS in the community to the
same degree as people who do
not use HCBS
• Includes a flexible range of
services that are accessible,
appropriate, effective, sufficient,
dependable, and timely to
respond to individuals’ strengths,
needs and preferences
• Integrate health and social
services to promote well-being
• Protects the individual’s human
and legal rights, including privacy;
dignity; freedom from abuse,
neglect and exploitation; respect;
and independence
• Ensures each individual can
achieve the balance of personal
safety and dignity of risk that he
or she desires
• Utilizes and supports a workforce
that is trained, adquate, and
culturally competent
• Supports family caregivers
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Characteristics
• Engages individuals who use
HCBS in the design,
implementation and evaluation of
the system and its performance
• Reduces disparities by offering
equitable access to and delivery
of services
• Coordinates and integrates
resources to maximize
affordability and long-term
sustainability
• Supplies valid, meaningful,
integrated, aligned and accessible
data
• Fosters accountability through
measurement and reporting of
quality and outcomes
• Other discussions
– The degree to which traditional
health services (doctor
visit/hospital stays) should be
integrated.
• Coordination and integration are
important
• Avoid “over-medicalizing”
– Concept of Safety and how to
incorporate it in a manner that
empowers the client/participant
• Should be balanced with other goals
• Not over-emphasized to a point that
would diminish goals such as
mobility/socialization
• Should be individualized
– How best to support paid and
unpaid caregivers
– Definition of Culturally Competent
Services
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Domains and Sub-Domains
• The Domains listed in the following slide follow along with the
characteristics of a high quality HCBS company .
• The subdomains help to further define the Domains scope
and help to clarify idea for measurement.
• The Domains and Sub-Domains are still in the development
phase and while the Domains have basically been agreed
upon, further definition and clarification is what the
committee is working on at the current moment.
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Domains
Domains for Measurement Description of Domain
Workforce/Providers
The adequacy and appropriateness of the provider network and HCBS workforce
Consumer Voice
The level of involvement that individuals who use HCBS have in the design, implementation, and
evaluation of the HCBS system at all levels
Choice and Control
The level to which individuals who use HCBS are able to choose their services and control how those
services are delivered
Human and Legal Rights
The level to which the human and legal rights of individuals who use HCBS are promoted and
protected
System Performance
The level of accountability within the HCBS system and the extent to which it operates efficiently,
ethically and is able to achieve desired outcomes
Full Community Inclusion
The level to which HCBS integrates individuals into their communities and fosters social connectedness
Caregiver Support
The level of support (i.e. financial, emotional, technical) available for the paid and unpaid caregivers of
individuals who use HCBS
Effectiveness/Quality of Services
The level to which HCBS services are able to produce intended outcomes
Service Delivery
Aspects of services that enable a positive consumer experience (i.e. accessibility, respect,
dependability, well-coordinated)
Equity
The level to which HCBS is equitably delivered and made available to a broad array of individuals who
need long-term supports
Health and Well-Being
The level of integration between healthcare and other supportive services to promote holistic wellness
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Sub-Domains
Domains for Measurement
Subdomains Corresponding to Each Domain
Workforce/Providers
Sufficient numbers and appropriately dispersed; dependability; respect for
boundaries, privacy, consumer preferences and values, skilled, demonstrated
competencies when appropriate; culturally competent, sensitive, mindful;
adequately compensated (with benefits) safety of the worker; teamwork, good
communications and value-based leadership
Consumer Voice
Meaningful mechanism for input (i.e. design, implementation, evaluation);
consumer-driven system; breadth and depth of consumer participation; level of
commitment to consumer involvement; diversity of consumer and workforce
engagement
Choice and Control
Choice of program delivery models and provider(s), self-direction, particular
worker (s) and setting(s); personal freedoms and dignity of risk; achieving
individual goals and preferences (i.e. individuality, person-centered planning);
self-direction; shared accountability
Human and Legal Rights
Delivery system promotes dignity and respect; privacy; informed consent;
freedom from abuse and neglect; optimizing the preservation of legal and
human rights; sense of safety; system responsiveness
System Performance
Consumer engagement; participatory program design; reliability; publicly
available data; appropriate and fair resource allocation based on need; primarily
judged by the aggregate of individual outcomes; waiting lists; backlog; financing
and service delivery structures; availability of services; efficiency and evidence
based practices; data integrity
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Sub-Domains (con’t)
Domains for Measurement Subdomains Corresponding to Each Domain
Full Community Inclusion
Enjoyment or fun; Employment; education, or productivity; social connectedness and
relationships; social participation; resources to facilitate inclusion; choice of setting;
accessibly built environment
Caregiver Support
Training and skill-building; access to resources (respite, crisis support); caregiver
well-being (stress reduction, coping); caregiver and/or family assessment and
planning; compensation
Effectiveness/Quality of Services
Goals and needs realized; preferences met; health outcomes achieved; technical skills
assessed and monitored; technical services delivered; team performance; rebalancing
Service Delivery
Accessibility (geographic, economic, physical); appropriate (services aligned with
needs and preferences); sufficiency (scope of services, capacity to meet existing and
future demands); dependable (coverage, timeliness, workforce continuity, knowledge
of needs and preference, competency) timely initiation of services; coordination of
care (assessment, development of plan, information exchange between all member
of the care team, implementation of the plan and evaluation)
Equity
Reduction in health and service disparities; transparency of resource allocation,
access or waiting list; safe accessible and affordable housing; availability, timeliness,
consistency across jurisdictions
Health and Well-Being
Physical , emotional and cognitive functioning; social well-being, spirituality; safety
and risk as defined by consumer; freedom from abuse, neglect and exploitation;
health status and wellness (prevention, management of multiple chronic conditions);
behavioral health
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Visual Conceptual Framework
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Next Phase
• Identify existing measures applicable to HCBS, with an
emphasis on those that map to the conceptual framework’s
domains and subdomains
• Identify examples of HCBS quality measures to guide
Committee discussion of implementation barriers and
mitigation strategies (a selection of measures that can lend
themselves to examination as ‘test cases’)
• Identify measure concepts and ideas that should be further
developed into future performance measures that will best
support community living quality
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Odds and Ends
• Stated that while surveys from individuals regarding
experience with care (i.e. HHCAHPS) alone do not constitute a
performance measure, could utilize aggregated data from
these types of tools
• It has not been stated or proposed at the current time that
reimbursement be tied in with quality
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Questions
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Resources
• National Quality Forum: Measuring HCBS Quality
– http://www.qualityforum.org/Measuring_HCBS_Quality.aspx
• AARP Public Policy Institute: State Studies Find Home and
Community Based Services to Be Cost-Effective
– http://www.aarp.org/content/dam/aarp/research/public_policy_institute
/ltc/2013/state-studies-find-hcbs-cost-effective-spotlight-AARP-ppi-ltc.pdf
• HCBS Quality Measures Summit
– http://www.medicaid.gov/medicaid-chip-program-information/bytopics/quality-of-care/downloads/quality-summit-2014.pdf
• AHRQ: Environmental Scan of Measures for Medicaid Title XIX
Home and Community-Based Services
– http://www.ahrq.gov/professionals/systems/long-termcare/resources/hcbs/hcbsreport/index.html
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