Maine
The grant’s primary purpose was to design a cohesive and coordinated quality management and improvement system across several waiver programs for older adults and adults with various disabilities. The grant had five major goals: (1) to create and formalize participant-centered interdepartmental infrastructures and develop a coordinated interdepartmental approach for quality management and improvement; (2) to engage participants in an active role in the planning, design, and evaluation of home and community-based services (HCBS); (3) to develop a coordinated incident management system for waiver programs; (4) to assess system performance on a regular and real-time basis; and (5) to develop a plan for sustainable interagency collaboration, participant involvement, and a coordinated quality improvement system.
The grant was awarded to the Department of Human Services, which was later merged with the Department of Behavioral and Developmental Services into the new Department of Health and Human Services (hereafter, the Department). An Office of Integrated Services and Quality Improvement (QI Office) was established as part of the merger.
The Department contracted with the Muskie School of Public Service to provide assistance throughout the grant on a wide range of activities, including managing the project; conducting participant surveys; writing reports; and assisting with the development of the common event form and instructions, the quality management plan, and the peer interviewing pilot.
Role of Key Partners -
An interagency work group was formed to coordinate grant activities across the three departments responsible for waiver programs (Human Services, Behavioral and Developmental Services, and Labor) and with the Medicaid agency. The purpose of the group was to share best practices and identify areas for collaborative quality improvement activities. As the grant activities progressed, subgroups were formed to work more intensely on specific topics (e.g., a common event reporting system, a peer interviewing project, and program-specific issues).
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The Quality Technical Assistance Group—comprising participants (older adults and individuals with physical or developmental disabilities), advocacy organizations, providers, and staff from the waiver programs and the Medicaid office—provided general oversight, advice, and input on grant activities.
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The Office of Integrated Services and Quality Improvement and the Office of Adults with Cognitive and Physical Disability Services (OACPDS) developed a peer-interviewing model for individuals with developmental disabilities. The QI Office created the standardized interview tool and protocols, and OACPDS provided expertise on community inclusion and linkages with providers and recipients of developmental services.
Major Accomplishments and Outcomes -
Grant staff modified the Participant Experience Survey (PES) to tailor it to Maine’s long-term services and supports system. Items related to the assessment and care planning process, worker availability, backup plans, and interest in self-direction were added. The survey was modified for use by participants in two waiver programs: the waiver for older adults and adults aged 18 to 64 with physical disabilities, and the waiver for adults aged 18 to 64 with physical disabilities who self-direct services. Both surveys included a number of common questions that allowed the State to compare participants’ experience in the two waiver programs.
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Grant staff also tested a variety of approaches to obtaining participant input, such as a web-based version of the modified PES for people who self-direct services.
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Grant staff prepared annual assessment and performance reports on the use and cost of services and the experience and satisfaction of participants across three waiver programs using quality indicators that were aligned with the CMS HCBS Quality Framework. The indicators were developed from a number of data sources, including participant surveys, mortality review data, and Medicaid/Medicare claims data. Many of the people served by HCBS waiver programs are dually eligible for Medicaid and Medicare. For this reason, it is necessary to link Medicaid and Medicare claims data at the individual level in order to obtain a complete picture of service utilization.
The linked Medicare and Medicaid data were available for the fiscal years 2000 and 2003. Based on the annual reports’ analyses and recommendations, the Department identified areas for enhanced quality assurance and quality improvement activities, such as additional training materials for participants who self-direct services. The Department developed a template to facilitate preparation of future reports.
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Grant partners developed a process by which people with disabilities partner with community members to interview individuals receiving developmental services about their quality of life. Three teams were recruited and trained, and the Co-Interviewing Model was piloted in August and September 2006 with three recipients of developmental services. All pilot participants were asked to provide feedback on the process; specifically, what worked and what could be improved.
Enduring Systems Change -
The Department of Health and Human Services created an integrated management team that promotes cross program communication, information sharing, issue identification, and opportunities for collaborative quality improvement. The integrated management team includes the office directors responsible for managing the HCBS waiver programs.
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Grant staff and partners conducted a comprehensive inventory and assessment of policies, procedures, operations, data sources, and information systems for the (1) Older Adults and Adults with Disabilities waiver program and (2) the Adults with Physical Disabilities Consumer Directed waiver program. They developed a common approach for mapping discovery methods with the CMS assurances and a database that enables a consistent approach for assessing strengths and gaps in discovery methods across waiver programs. The database can be used by other waiver programs (e.g., Adults with Mental Retardation/Developmental Disabilities) to create a similar inventory.
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Grant staff and partners developed cross-waiver health and welfare indicators, which can be measured using linked Medicaid and Medicare claims data. The indicators include avoidable hospitalizations, use of preventive health services, use of emergency rooms, use of medications, and use of multiple practitioners and pharmacists.
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Grant staff developed an event reporting system with the Office of Elder Services that includes a common reportable event form, and definitions and data elements ranging from death and serious injury to exploitation and medication errors. Event definitions and time frames are consistent across waiver programs, enabling improved reporting and monitoring.
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Based on the participant survey reports, the Department modified contracts with case management agencies. The modified contracts include more specific provisions related to health and welfare monitoring, development of backup plans, and linking participants with other community resources that support independence.
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Department staff involved with the grant developed an increased appreciation of the importance of including provisions that help to ensure quality during the design of programs and policies. This understanding was reflected in policies and programs developed during the grant period. For example, when developing the Family Provider Service Option, a self-direction option offered through one of the waiver programs, the State included program requirements related to training and background checks that help to ensure quality.
Key Challenges
The grant activities were undertaken during a time of major transition and competing priorities within the State. The merger of two major departments into the Department of Health and Human Services required the time and attention of many senior managers, and the quality management activities often had to compete with other leadership priorities. At the same time, the Department was implementing a major new management information system, which also consumed many hours of staff time. As a result, grant project meetings had to be planned carefully with well-constructed agendas.
Continuing Challenges
More resources and funding are needed to support quality management activities for HCBS waivers.
Lessons Learned and Recommendations
Quality management is resource intensive. To the extent possible, states should assign staff to this task as part of a dedicated and focused activity, and determine what quality activities already exist that might be duplicative or could inform current efforts.
Key Products
Educational Materials
Grant partners produced Maine’s Co-Interviewing Pilot Project Training Manual for peer interviewing of people with developmental disabilities.
Technical Materials
Grant staff and partners developed (1) a database for conducting an inventory of discovery methods cross-walked with the CMS waiver assurances, (2) a template for producing ongoing participant reports of quality indicators, and (3) a common event reporting form and definitions for use by all waiver programs.
Reports
The Muskie School of Public Service produced several reports, including the following:
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Individual and combined participant survey reports for each waiver program (Older Adults and Adults with Disabilities, Adults with Physical Disabilities who self-direct, and Adults with Mental Retardation/Autism).
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Maine’s Co-Interviewing Model and Pilot report, which outlines the key components of the model and presents feedback from the project pilot.
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Our Stories Booklet of Florence and Jackie, a qualitative approach to obtaining participant input that tells the stories of two HCBS participants.
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Lessons Learned and Plan for Sustainability describes the infrastructure for ongoing participant involvement in and quality management of home and community-based services.
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Quality Management Plan for Waiver Services for Elders and Adults with Disabilities, which is a summary of major quality management functions carried out at the departmental, program, and operating-agency levels.
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