Reforming and Improving Quality Through Managed Care

1. Reforming and Improving Quality Through Managed Care Megan O’Connor-Hebert, Deputy Commissioner Division of Quality Improvement New York State Office for People With Developmental Disabilities

2. OPWDD Overview • Serves 126,000 New Yorkers with intellectual and developmental disabilities • Close to 50% dually eligible for Medicaid/Medicare • 700+ nonprofit providers deliver services • State-operated services comprise 20% of all services provided (OPWDD has 22,000 employees) • > 70,000 individuals in 1915c HCBS waiver < 1,500 have individualized self-directed budgets > $70,000 HCBS expenditures per capita • 91% of Medicaid expenditures in NYS developmental disabilities system goes to support individuals receiving services in certified day and residential facilities

3. OPWDD Current System Reform Challenges Changing mindsets – moving from place-based to service-based; allowing more personal risk in risk-adverse environment Medicaid Redesign Team (MRT) and move to managed care Unsustainable fiscal platform, aging infrastructure, antiquated rate methodologies; 91% of funding tied to facility based residential and day services; administratively complex system with over 700 providers and over $13.5 million Medicaid transactions annually Demographics (multiple disabilities, autism, aging) Quality oversight concerns

4. Vision for New York’s Future Developmental Disabilities System and its Sustainability Minimize reliance on institutional care by enhancing specialized community-based services so that people in institutional settings can successfully transition to the community. Provide enhanced care coordination and person-centered planning Establish valid needs assessment and equitable resource allocation Create streamlined and flexible service delivery structures Modernize financial and administrative platform to be more person-centered and encourage efficiency and accountability Improve access and choice through “No Wrong Door” Provide enhanced supports for families enabling individuals to reside in less restrictive settings Measure quality outcomes at the system and individual level

5. The Shape of Public Systems is Changing… Increased reliance on data Moving from a “wholesale” to a “retail” system Centrality of service/care coordination More people with disabilities will be living with their families and in small supported settings Accountability and transparency are paramount CMS is a much bigger player

6. All States Must Assure that: Eligibility (Level of Care) is carried out in a valid, reliable, and equitable fashion Individual Plans include services and supports that align with individual goals, strengths and needs Provider qualifications are regularly checked and monitored Individual health and well being is maintained Financial accountability is maintained The Medicaid agency maintains administrative authority

7. HCBS Quality Framework

8. Emphasis on Quality Improvement CMS expects states to remediate individual situations but also to respond to trends in the data. In reviewing evidence, CMS looks to see if continuing compliance issues are identified through quality improvement initiatives. Must show how we review trends, develop and evaluate quality improvement strategies.

9. The Evolution of OPWDD’s Quality Oversight • 2009 HCBS Waiver Renewal – Metrics • DQI was a paper-based system with limited ability to store or aggregate data. • Vision – Move to individualized services • DQI’s review process built on review of certified sites’ ability to operate • NEEDED TO CHANGE!

10. Current Status Goal for People First Waiver: Quality outcome measures at the individual, provider, managed care, and systems levels and a continuous quality improvement approach throughout the system Moving system to InterRAI assessment suite of tools Continuing to work on activities outlined in the OPWDD comprehensive quality work plan submitted to CMS in January 2012 and restructuring OPWDD’s continuous quality improvement processes Culture change coordinator and performance measurement in commissioner’s office

11. OPWDD’s Quality Oversight Reforms Focus on Outcomes Health & Safety Oversight Accountability CQI Integrated Cohesive QI Strategy Transparency Use of Data/ Metrics Incentivizing

12. OPWDD Quality Improvement StrategyEngaging Entire OPWDD Enterprise in CQI

13. Developing & Tracking OPWDD System Metrics Short- and long-term Multiple purposes: process and performance management; accountability; relate to system goals and objectives; target areas for improvement; continuous quality improvement

14. Oversight of Health & SafetyINCIDENT MANAGEMENT (IRMA) • Strengthened IRMA and mandated reporting • Real Time monitoring of incidents (and soon investigations) • Standardized Incident management information including trend reporting features • IRMA can be used to analyze incidents by individual, provider, region or system-wide to determine where improvements are needed

15. Oversight of Health & Safety Restrictive Intervention Application (RIA) Eliminate unnecessary restraints/physical interventions Recently added mandatory electronic reporting of all physical interventions

16. Creation of a Statewide Mortality Review System • GOALS: • Eliminate preventabledeaths • Uniformity in review • Identify patterns and trends • Target preventive actions • Systems improvement “Elimination of preventable deaths for people with ID/DD through the uniform review of deaths to identify patterns, trends, and targeting preventive actions and systems improvements.”

17. UMASS/OPWDDPartnership Goals: Create an enhanced mortality review system that is consistent with current national practice. Analyze and review mortality information to take more focused corrective / preventive actions that can help reduce the risk and improve the quality of life for people receiving services.

18. Identify Outcomes of Services to Individuals Evolving system Historically – Compliance/QA focus Shifting from site-based “bricks & mortar” inspections to reviews focused on individuals and achievement of outcomes

19. OUTCOMES OF SERVICES/SUPPORTS-Key Principles- Accountability -Holding providers responsible including actively addressing poor performing agencies Transparency -We are posting information on the quality of agencies for individuals and families to use in decision making CQI -Working with agencies to ensure strong self assessment and QI systems. -Incentivizing excellent performance.

20. Early Alert (EA) AGENCIES: • EA list of agencies is posted on OPWDD’s website and updated regularly • Process and Criteria has been published • Management Plans required • Monitoring Schedules established GOALS: • Assist in guiding agencies back to quality and compliance • Ensure that governing board is aware of the concerns and involved in the corrective action plan • Includes a meeting of DQI staff, Agency executive staff and governing board • EA agencies cannot expand services

21. COMPASS OPWDD designation for premier or gold star agencies

22. WHAT IS COMPASS? ...an innovative organizational approach to individual empowerment, quality improvement, and program certification focusing the agency’s efforts toward quality through internal assessment rather than external review.

23. BENEFITS OF COMPASS To Individual Served: To Agency: Self initiated process Redefines regulatory oversight Empowers agency to self-monitor Mentorship opportunities OPWDD & peer recognition Involvement in OPWDD policy initiatives etc. • Increases the range of choices and opportunities • Involvement in agency decision-making • Encourages self determination • Empowerment to achieve valued outcomes in an agency that places them first

24. Provider Performance • Developed protocols with extensive involvement from stakeholder groups – Quality Indicators • Posted first protocol (Service Coordination/ Case Management) – April 2012 • Second protocol – Fire Safety and Environment • Draft report to be shared December 2012 • Involved IMS in developing a database to record findings based on outcomes for individuals.

25. Provider Performance Reports - “Report Cards” This version will have drop down menus under each category for performance in specific areas. Next Version of Performance Reporting:

26. PERFORMANCE DATA - USES • Quality of services & supports for an individual • Validate individual remediations • Individuals and families can review and use aggregated data as one tool in choosing a provider • Agency benchmarking • Analysis of system-wide patterns and trends – to inform our quality improvement strategy • Basis for systemic remediation: health & safety alerts, changes in public policies, etc.

27. Regulatory Reform Regulatory reform steering committee of stakeholders was formed (September 2012) The task of the Regulatory/Policy Reform Committee is to: • Obtain input from all stakeholders regarding needed changes to regulations, policy and guidance documents; • To identify barriers to OPWDD’s stated outcomes that currently exist within the OPWDD regulatory framework; • Make recommendations to OPWDD leadership to revise or eliminate OPWDD’s regulations, policies and guidance documents to remove the identified barriers and promote continuous quality improvement

28. Regulatory Reform Work Groups We organized 4 work groups based on priority areas of concern identified in stakeholder surveys conducted August 2012: Staffing/ workforce/ training Medication administration/ healthcare Habilitation Financial Recommendations due to Steering Committee December 2012

29. What’s Next? • Centralize review of Care at Home Waiver • Create care coordination protocol for CAH waiver that incorporates 1915c measures • Centralize review of Family Care Homes • Create outcome based review procedures • Develop a quality review procedure based on individual health, safety and achievement of outcomes to be piloted and revised during case studies and DISCO pilots

30. What it Looks LikeAccountability and Individual Choice

31. Accountability: Improving Quality These reforms will also: Measure meaningful indicators of quality: Individuals’ progress Support for DSPs Effective governance Quality improvement Individual/family satisfaction Create a quality rating scale that is available to the public. Use new technology to improve coordination of care, services, and personal outcomes.

32. The Process: A Five-Year Reform with ConstantEvaluation

33. CMS November 2012 The Center for Medicaid and CHIP Services (CMCS) is working to propel positive change forward Shared goal is comprehensive, integrated person-centered care and financing that supports better care, improved health, reduced costs Developing new paradigms of accountability: focus on quality, not transactions

34. CMS’s Proposed Quality Framework Move away from reimbursing for transactions, move towards reimbursing for quality Metrics are key—but it cannot simply center on the metrics—it is about whether there is a cohesive strategy Linkage of goals, interventions and metrics

35. Care Coordination Targeted Work GroupAugust – October 2012 Recommendations for Quality Outcome Measures Examples: # of people who identify as not wanting to be in a 24/7 setting that are being supported in less than a 24/7 setting. Care coordinators provide education on self direction to 100% of people served.

36. What’s Next? Create work groups of stakeholders to develop revised review protocols and outcome measures Create IT infrastructure to record data from reviews INFORMATION SHARING, COMMUNICATIONS, TRAINING

37. OPWDD Quality Framework for Managed Care • We have laid the foundation through recent QI reforms • Must incorporate quality outcome measures and all requirements • Balance meeting requirements of multiple waivers, MHL, federal MC regulations without administrative burden on OPWDD and DISCOs.

38. OPWDD Quality Framework for Managed Care(continued) Need cohesive strategy—must define DOH and OPWDD oversight roles to avoid duplication and confusion IT infrastructure is critical for increased expectation for data analysis in managed care world

39. 44 Holland Avenue Albany, NY 12229 518-474-3625 75 Morton Street New York, NY 10014 212-229-3350 703 East Maple Avenue Newark, NY 14513 315-331-8646 x3050 QUESTIONS COMMENTS www.opwdd.ny.gov