Quality Service Reviews Overview The Arc of Virginia 2013 State Convention Charline Davidson Department of Behavioral He

1. Quality Service Reviews Overview The Arc of Virginia 2013 State Convention Charline Davidson Department of Behavioral Health and Developmental Services August 9, 2013

2. DOJ Settlement Agreement Requirements for Quality Service Reviews (QSRs) Section V.1 “Quality Service Reviews” • The Commonwealth shall use Quality Service Reviews to evaluate the quality of services at the individual, provider, and system-wide level and the extent to which services are provided in the most integrated setting appropriate to the individuals’ needs and choice QSRs shall evaluate whether: • Individuals’ needs are being identified and met through person-centered planning; • Services are being provided in the most integrated setting appropriate to the individuals’ needs and consistent with their informed choice; and • Individuals are having opportunities for integration in living arrangements, work and other day activities; access to community services and activities; and opportunities for relationships with non-paid individuals Information from QSRs is intended to be used to improve practice and the quality of services on the provider, CSB, and system-wide levels

3. Quality Service Review Surveys QSRs shall collect information annually through: • Face-to-face interviews of a statistically significant random sample of individuals receiving services under the Agreement, to include: • Individuals receiving ID/DS and DD waiver services and supports • Individuals receiving services in community ICFs/ID • Individuals receiving services in state training centers • Individuals with ID/DD diagnoses in nursing facilities • Face-to-face surveys of all individuals who have been discharged from a state training center on or after October 13, 2011 • Surveys of family members • Surveys of providers/professionals

4. National Core Indicator (NCI) Survey Instruments • Will use the National Core Indicators (NCI) survey instruments to meet QSR requirements - http://nationalcoreindicators.org/indicators/ • NCI indicator domains align with information required for QSR surveys: • Individual Outcomes: • Work(finding and maintaining community integrated employment) • Community inclusion (participating in everyday community activities) • Choice and decision-making (making choices about their lives and are actively engaged in service planning) • Self-determination (having the authority and support to direct and manage their own services) • Relationships (having friends and relationships) • Satisfaction (receiving adequate and satisfactory supports)

5. NCI Surveys’ Domains - continued • Family Outcomes: • Information and planning (having information and support necessary to plan for their services and supports) • Choice and control (determining services and supports they receive and individuals/agencies providing them) • Access and support delivery (getting the services and supports they need) • Community connections (using integrated community services and participating in everyday community activities) • Family involvement (maintaining connections with family members not living at home) • Satisfaction (receiving adequate and satisfactory supports) • Family outcomes (having individual and family supports make a positive difference in the lives of families)

6. NCI Surveys’ Domains - continued • Health, Welfare, and Rights: • Safety (being safe from abuse, neglect, and injury) • Health(securing needed health services) • Medications (having medications effectively and appropriately managed) • Wellness (being supported to maintain healthy habits) • Restraints (system is making limited use of restraints/other restrictive practices) • Respect/rights (receiving the same respects/protections as others) • Direct Care Staff Stability and Competence • Turnover(low enough to maintain support continuity and resource efficiency) • Competence (staff are competent to provide services and supports) • System Performance: • Service coordination (accessible, responsive, and support participation) • Access(services are readily available to those who need and qualify for them)

7. Why Use NCI Surveys for QSRs? • The NCI Project is a collaborative effort between the National Association of State Directors of Developmental Disabilities Services (NASDDDS) and the Human Services Research Institute (HSRI) • Gathers a standard set of performance and outcome measures states can use to track performance over time, compare results across states, and establish benchmarks • National goal is to have all state participate in NCI • Virginia has experience implementing the NCI adult survey in selected regions to individuals receiving ID waiver services and the child family survey • NCI participation provides Virginia access to NASDDS/HSRI staff support and resources, including interviewer training and ODESA database

8. Project 15 QSR Team Charge and Membership • Project team is advising DBHDS on survey instrument content, survey administration, and use of survey results to improve practice and service quality • Team members include: • CSB staff representing the VACSB ID Council and Data Management Committee • Private provider • The Arc of Virginia • Department of Medical Assistance Services • Partnership for People with Disabilities • DBHDS executive leadership and Developmental Services, Licensing, Human Rights, and Case Management staff • The team has been meeting once or twice a month since its inception in December 2012

9. Project 15 QSR Team Accomplishments • The focus of DBHDS and QSR Team’s work has been on: • Adding a small number of questions to the NCI adult and family surveys • Developing two provider surveys for alternate year administration • Defining QSR first year implementation requirements • Communicating with and seeking input from stakeholders: • TACIDD • CSB ID directors and service coordinators • Developmental services providers • DBHDS has contracted with the Partnership for People with Disabilities at VCU to conduct individual, family, and provider surveys

10. Individual Survey • NCI Individual Survey • Statewide random sample of 800 surveys • Sample will be proportional to individuals that reside in each region • DBHDS is working with the Partnership to develop a target number of surveys for each region • Surveys will be conducted by the Partnership between November 2013 to May 2014

11. Family Surveys • NCI Family Surveys • Three mailed NCI family surveys – • Adult Family Survey (family members of people living in the family’s home who are 18 and older), • Family/Guardian Survey (family members of people living in residential settings who are 18 and older), and • Child Family Survey (families with a child living at home) • Surveys will be mailed and results compiled by the Partnership in the Spring 2014

12. Provider Surveys • NCI Provider Survey • Goal is to make the provider survey a useful tool for identifying issues and opportunities to improve practice and service quality from a provider perspective • QSR Team is recommending two surveys: • Service Access Survey – First Year • Staff Turnover Survey – Residential and Day Services Direct Support Staff and Case Managers/Support Coordinators – Second Year • Web-based surveys will be conducted by the Partnership in the Spring 2014

13. Case Management Overview The Arc of Virginia 2013 State Convention Dee Keenan, LCSW Department of Behavioral Health and Developmental Services August 9, 2013

14. DOJ Settlement Agreement Case Management Requirements For the purposes of this agreement, case management shall mean: • Assembling professionals and nonprofessionals who provide individualized supports, as well as the individual being served and other persons important to the individual being served, who, through their combined expertise and involvement, develop Individual Support Plans ("ISP") that are individualized, person-centered, and meet the individual's needs;

15. DOJ Settlement Agreement Case Management Requirements 2. Assisting the individual to gain access to needed medical, social, education, transportation, housing, nutritional, therapeutic, behavioral, psychiatric, nursing, personal care, respite, and other services identified in the ISP;

16. DOJ Settlement Agreement Case Management Requirements 3. Monitoring the ISP to make timely additional referrals, service changes, and amendments to the plans as needed.

17. DOJ Settlement Agreement Case Management Requirements The DOJ Settlement Agreement views the case manager or service coordinator as the hub of the service delivery system and the person responsible for ensuring the principles and practices of a person centered integrated system are implemented.

18. Overview of Measures Enhanced Case Management: …the individual’s case manager shall meet with the individual face-to-face at least every 30 days, and at least one such visit every two months must be in the individual’s place of residence (V.F.3)

19. Enhanced Case Management Target Population Criteria …for any individual who: • Receive services from providers having conditional or provisional licenses; • Have more intensive behavioral or medical needs as defined by the Support Intensity Scale (“SIS”) category representing the highest level of risk to individuals; • Have an interruption of service greater than 30 days;

20. Enhanced Case Management Target Population Criteria d. Encounter the crisis system for a serious crisis or for multiple less serious crises within a three-month period; e. Have transitioned from a Training Center within the previous 12 months; or f. Reside in a congregate settings of 5 or more individuals.

21. “The Commonwealth shall establish a mechanism to monitor compliance with performance standards” (III.C.5.d.)

22. Project Team 9 –Case Management • Initially met in 2012 • Developed Phase I measures • Developed mechanism for collecting measures • Developed Operational Guidelines and FAQs

23. Phase I Measures In March 2013, CSBs began collecting type, frequency and duration of ID Case Management Services • Some boards provided enhanced case management to all of the individuals who had Medicaid • Other boards provided enhanced case management to only those individuals who met at least one of the 6 DOJ criteria for the “target population”

24. Phase I Measures 050 100

25. What’s Next – Phase II Phase II …key indicators from the case manager’s face to face visits with the individual, and the case manager’s observations and assessments, shall be reported to the Commonwealth for its review and assessment of data (V.F.5.)

26. Phase II - continued “Reported key indicators shall capture information regarding both positive and negative outcomes for both health and safety and community integration….”

27. Phase II - continued Project Team 9 was reconvened in March 2013 Team Membership includes • CSB staff representing the VACSB ID Council and Data Management Committees • Private Provider • Department of Medicaid Services • DD Case Managers • Vocal Virginia • DBHDS executive leadership and Developmental Services, Licensing and Community Contracting

28. Proposal for DOJ Quality Measures – Case Management Five new data elements will be established in CCS 3 to collect this information starting March 6, 2014. Each data element would use a three-point scale to respond to the measure for the domain: ○ the measure was met, ○ the measure was partially met, or ○ the measure was not met.

29. Proposal for DOJ Quality Measures – Case Management

30. Licensing Overview The Arc of Virginia 2013 State Convention Les Saltzberg, Ph.D. Department of Behavioral Health and Developmental Services August 9, 2013

31. Overall Providers • 814 Provider Organizations • 1948 Services • 6507 Locations • 315 New Applications in Process • 31 Licensure Specialists

32. ID Providers (as of April 2013) • 586 Provider Organizations • 951 Services • 4780 Locations • 132 New Applications in Process (104 group homes)

33. This Includes: • 1100 Group Homes • 42 Intermediate Care Facilities/Institutions for Intellectually Disabled • 1085 Sponsored Residential Providers

34. Licensing High Risk Factors More frequent visits for the following providers: Providers who have a conditional license; Providers who serve individuals with intensive medical and behavioral needs as defined by the SIS category representing the highest level of risk to individuals; Providers who serve individuals who have an interruption of service greater that 30 days;

35. Licensing High Risk Factors d) Providers who serve individuals who encounter the crisis system for a serious crisis or for multiple less serious crises within a three-month period; e) Providers who serve individuals who have transitioned from a Training Center within the previous 12 months; f) Providers who serve individuals in congregate setting of 5 or more individuals

36. Enhanced Licensing Visit Protocol Visit Schedule A. Unexpected Deaths and Serious Injuries/Incidents resulting in significant injuries/risks – Investigations started within two weeks of notification. B. Significant Health and Safety CAP’s resulting from several sources (deaths, serious injuries, case management concerns CRC and CIM concerns, complaints, unannounced visits) – Individualized schedule but no less than monthly until issues are resolved.

37. Enhanced Licensing Visit Protocol C. Training Center Discharges – 45 days after admission. Further visits depending on status. D. Provisional License – Individual based on issues but no less than monthly while on Provisional license E. Conditional License – After initial admission visit and within thirty days. F. ICF/ID and All ID Group Homes – Every six months; Once a year for triennial

38. Enhanced Licensing Visit Protocol G. Sponsored Residential • Agency – Every six months • All new homes before opening • 25%of homes each year with a minimum based on size • Once a year for triennial H. Case Management – Every six months with greater sample of cases. Once a year for triennial providers with greater sample of cases I. ID Day Support – Every six months, once a year for triennial.

39. Licensing Program Overview “The licensure process will assess the adequacy of the individualized supports and services…” in the following domains: • safety and freedom from harm • physical, mental and behavioral health and well being • choice and self determination • community inclusion • stability • avoiding crisis • access to services • provider capacity

40. Questions?