Pay for Performance for LTSS

1. Pay for Performance for LTSS November 4, 2013 Lisa Alecxih, Senior Vice President

2. Overview • Pay for Performance Framework for LTSS • Requirements for Successful Pay for Performance System • Questions to run on: • Does the framework seem consistent with elements that would be important to incentivize? • What might need to change in your organization to succeed under pay for performance?

3. Pay for Performance Framework for LTSS • Organization/Structure • Assessments, Records and Information Exchange • Workforce Development • Culture of Person Centered Thinking and Continuous Quality Improvement • Process • Participant Safeguards • Participant Choice and Pursuit of Personal Goals (Person Centered Planning) • Participant Rights and Responsibilities • Relationships and Community • Continuous Quality Improvement for Service Delivery • Outcomes • Clinical • Participant Experience • Workforce

4. Organization

5. Organization: Assessments, Records and Information Exchange • Strength-based assessments • Documentation shared electronically across LTSS, primary, acute, and behavioral health providers • Person centered planning tools

6. Organization: Workforce Development • Staff qualifications (degrees and certifications) • Staff capabilities and competencies • Training related to: • Principles of “person-centered care” and direct care staff decision-making • Leadership tools and techniques, as well as improving communication among staff and with other providers for supervisors and middle managers • Relevant populations, disease processes, and palliative care, improving their understanding of participant/resident needs, and thus responsiveness • Adjusting salaries to market standards, to improve staff satisfaction

7. Organization: Culture of Person Centered Thinking and CQI • Relationship-based organizational culture • Empowering staff to communicate more effectively and to address concerns as they arise • Evidence-based care decision support tools

8. Process

9. Process: 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

10. Process: Participant Choice and Pursuit of Personal Goals (Person Centered Planning) • The consumer sets the agenda • The consumer chooses the team • The team works on the consumer’s agenda • There are measurable accomplishments • The team celebrates those accomplishments • The plan is about the individual’s life

11. Process: 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 process and grievance mechanisms

12. Process: Relationships and Community • Orienting all new staff, participants/residents, family members and volunteers to the relationship and community culture • Governance that includes participants • Leadership committed to relationships and community • Managers modeling relationship skills

13. Process: Continuous Quality Improvement for Service Delivery • Ongoing service and support coordination • Provision of needed services • Ongoing monitoring • Responsiveness to changing needs

14. Outcomes

15. Outcomes: Clinical Quality Indicators for HCBS Population Nursing Facility Pay for Performance • Hospitalization events, including exacerbations of: • Chronic conditions (diabetes, asthma, COPD, and congestive heart failure) • Acute illnesses (bacterial pneumonia, urinary tract infection, dehydration, infection due to device or implant) • Pressure ulcers • Injurious falls • Percent of residents who: • Had bladder catheter inserted • Were physically restrained • Had moderate to severe pain • Had falls • Developed pressure sores • Had unexplained weight loss Ellen Schultz, Sheryl M. Davies, Kathryn M. McDonald (2012). Development of Quality Indicators for Home and Community-Based Services Population: Technical Report for the Agency for Healthcare Research and Quality accessed at http://www.qualityindicators.ahrq.gov/Downloads/Resources/Publications/2012/HCBS%20QI%20Technical%20Report.pdf. Werner and TamraraKonetzka (2013). “The effect of pay-for-performance in nursing home: Evidence from Medicaid Programs,” Health Services Research 48 (4) accessed at http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12035/abstract .

16. Outcomes: Participant Experience • National Core Indicators Project developed by HSRI covers: • Individual Outcomes • Health, Welfare, and Rights • System Performance • Staff Stability • Family Indicators • http://www.nationalcoreindicators.org/ • CMS Participant Experience Survey developed by Truvent (at the time MedStat) covers: • Access to Care • Choice and Control • Respect/Dignity • Community Integration/Inclusion • http://www.hcbs.org/moreInfo.php/doc/652

17. Outcomes: Workforce • Staff stability measured through turnover and tenure • Staff availability measured through vacancies • Staff satisfaction Specific measures for stability and availability defined in CMS sponsored report The Need for Monitoring the Long-Term Care Direct Service Workforce and Recommendations for Data Collection developed by the Direct Service Workforce Resource Center and posted at http://www.dswresourcecenter.org/tiki-index.php?page=Data+Collection

18. Requirements for Successful Pay for Performance System • Setting neutral to the extent possible • Common understanding of the pay for performance framework and how the elements inter-relate among: • Payer (e.g., Medicaid staff) • Provider leadership and administration • Front-line staff • Management Information Systems (MIS) and exchange protocols integrated into daily practice • Continuous quality improvement • Metrics used to identify areas for improvement to pursue • Avoidance of punitive approach