Department of Mental Retardation

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Department of Mental Retardation
Connecticut Fall Foliage
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Managing a Decentralized Service Network

• NASDDDS Annual Meeting
• Arlington, Virginia
• November 9 10, 2006

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Connecticut DMR Transition to a New Quality
System

• Presented by
• Mary McKay and Sheila Mulvey
• with assistance from Beth McArthur

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State of Connecticut
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State of Connecticut

• Connecticut
• 169 towns
• 3.5 million residents
• Town Government
• Local Education Associations
• Limited county focus
• State agencies with regional catchments

• Department of Mental Retardation
• Budget 860,000,000
• 15,000 consumers
• 4,000 additional B-3
• 150 private agencies
• Central Office and 3 Regions administer all
  funding and services
• State operates small percent of services

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NORTH REGION
North Canaan
Hartland
Somers
Colebrook
Suffield
Union
Enfield
Stafford
Thompson
Norfolk
Salisbury
Granby
Woodstock
Canaan
East Granby
Winchester
Windsor Locks
Barkhamsted
Ellington
East Windsor
Putnam
Ashford
Tolland
Simsbury
Willington
Windsor
Eastford
Goshen
Sharon
Canton
Pomfret
New Hartford
South Windsor
Vernon
Bloomfield
Cornwall
Torrington
Killingly
Mansfield
Hampton
Avon
Brooklyn
Hartford
Coventry
Manchester
Chaplin
West Hartford
East Hartford
Harwinton
Bolton
Litchfield
Warren
Burlington
Farmington
Andover
Kent
Wethersfield
Windham
Canterbury
Glastonbury
Plainfield
Columbia
Newington
Bristol
Morris
New Britain
Scotland
Thomaston
Sterling
Plainville
Hebron
Washington
Rocky Hill
WEST REGION
Plymouth
Lebanon
Bethlehem
Sprague
New Milford
Marlborough
Berlin
Watertown
Voluntown
Southington
Franklin
Cromwell
Lisbon
Wolcott
Portland
Griswold
East Hampton
Woodbury
Colchester
Waterbury
Roxbury
Norwich
Sherman
Bozrah
Middletown
Meriden
Middlebury
Bridgewater
Middlefield
Preston
Cheshire
Prospect
New Fairfield
Naugatuck
East Haddam
Salem
North Stonington
Southbury
Brookfield
Haddam
Montville
Wallingford
Durham
Beacon Falls
Ledyard
Hamden
Oxford
Bethany
Danbury
Chester
Newtown
Lyme
North Haven
Waterford
Seymour
Killingworth
Deep River
Stonington
Bethel
Woodbridge
North Branford
Essex
Ansonia
Groton
East Lyme
Monroe
Guilford
Old Lyme
Derby
New Haven
Old Saybrook
Clinton
Redding
New London
Ridgefield
Shelton
Madison
East Haven
West Haven
Orange
Branford
Westbrook
Easton
Trumbull
Milford
Weston
Stratford
Wilton
SOUTH REGION
Fairfield
Bridgeport
New Canaan
Westport
Norwalk
Stamford
Darien
Greenwich
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Connecticut DMR

• Governing Statutes
• Narrow definition of consumer eligibility (MR
  only)
• Other disability populations not served (Autism
  Pilot)
• Services to persons under care and custody of
  Commissioner or designee historically meant in
  facilities
• State dollars fund all services CMS federal
  match for waivers goes into CT General Treasury
  not directly to DMR or providers

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Connecticuts Medicaid Waivers for Home
Community Based Services

• Department of Social Services is CT Medicaid
  Single State Agency
• Elder Care Waiver
• Personal Care Assistance (PCA) Waiver
• Acquired Brain Injury (ABI) Waiver
• Katie Beckett Model Waiver
• Comprehensive Waiver (DMR)
• Individual and Family Supports Waiver (DMR)

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HCBS Waivers Administered by Connecticut DMR

• Comprehensive Waiver
• Since 1987, as an alternative to ICF/MR
  facilities
• Expired September 2005 new Comp Waiver 10/1/05
• Authorized services package gt52,000 includes
  residential and day habilitation respite family
  training environmental modifications
  transportation specialized medical equipment,
  etc.
• Option to self-direct
• 4,351enrollees 5,117 cap (at end of three years)
• FFP rate 50

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HCBS Waivers Administered by Connecticut DMR

• Individual Family Supports Waiver
• Applied under federal Independence Plus
  initiative
• CMS approval February 2005, reviewed September
  2006
• Authorized service package up to 52,000 includes
  individual support habilitation adult companion,
  respite, PERS transportation consultative
  services interpreter vocational services
  environmental modifications, etc.
• Option to self-direct
• 3,185 enrollees 3,693 cap (at end of three
  years)
• FFP Rate 50

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Traditional Quality Management

• Licensing / Certification Regulations
• Groups homes (Community Living Arrangements or
  CLAs)
• Community Training Homes (CTHs)
• ICF/MRs
• No formal quality assurance requirements
• Supported Living Services
• Employment and Day Programs
• Respite Care
• Self-Directed Supports

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Why Change our QM System?

• CMS Quality Framework states should rethink
  quality management in waiver services
• DMR interest in measuring the achievement of
  service outcomes, not just regulatory compliance
• Advent of self-determination and person-centered
  services with focus on consumer choice and
  control
• Waiver services happening in many places not just
  traditional programs (peoples homes, jobs, etc)
  but lack formal QM
• DMR shifting from master provider contract system
  to individual budgets and unit rate payments for
  qualified vendors of services

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HCBS Quality Framework
DMR evaluated our system against the new CMS
Quality Framework
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CMS Systems Change Grants2003 DMR received two
grants to fund the systems change

• QA/QI Grant
• 500,000 over 3 years
• Development of Self-Advocacy initiative
• Development of PP for safeguards in own or
  family homes
• Design QSR data application system

• Independence Plus Grant
• 175,000 over 3 years
• Development of CT Level of Need (LON) assessment
  tool
• Development of Individual Budget resource
  allocation methodology

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QSR Has Two Meanings

• Quality Service Review
• Measure Personal Outcomes and Support
  Expectations as a method to assess quality of a
  service provider
• Regional and State level tools to monitor, manage
  follow-up, and certify providers of service

• Quality System Review
• Use data collected via tools to evaluate system
• Have a system of design, discovery, remediation
  improvement for all DMR systems to assure
  access, good planning, safeguards, satisfaction
  provider quality, and fiscal integrity
• Include consumers and families in all areas

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HCBS Quality Framework and new Connecticut QSR

• DMR QSR Focus Areas
• Planning and Personal Achievement
• Relationships and Community Inclusion
• Choice and Control
• Rights, Respect and Dignity
• Safety
• Health and Wellness
• Satisfaction

• HCBS Quality Framework Outcome Areas
• Participant Access
• Participant-Centered Service Planning and
  Delivery
• Provider Capacity and Capabilities
• Participant Safeguards
• Participant Rights and Responsibilities
• Outcomes and Satisfaction
• System Performance

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Description of the QSR Tool

• Focus Areas with principle statements (7)
• Personal Outcome Measures (23)
• Support Expectations Measures (32)
• Quality Elements (268) assessed through
• Consumer Interview (74) National Core Indicator
  interview questions
• Support Staff Interview (51)
• Observation (22)
• Record Review (60)
• Safety / Environmental Review (52)
• Application Packet (9)
• Elements weighted to reflect importance in
  evaluating the achievement of the outcome
• Organized further by Service Type

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Description of the QSR System

• All quality review activities draw from the same
  universe of quality review indicators
• Case Managers review implementation of the
  Individual Plan and other experiences for each
  consumer yearly
• Case Manager Supervisors review a of plans for
  each Case Manager every quarter
• Regional Quality Monitors and State Quality
  Reviewers conduct reviews of day settings, CLAs
  and sample of Supported Living and self-directed
  supports each year
• All findings are entered into a data system and
  sorted to apply to the appropriate outcome or
  indicator for the service provider

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Personal Outcomes - examples

• Person directs the planning process
• Expresses preferences and personal goals for
  inclusion in the planning process
• Chooses services, providers and self-direction to
  extent desired
• Is developing personal competencies and achieving
  goals

• Has relationships of his/her choosing
• Participation and activities in the community of
  his/her choosing
• Feels valued and respected
• Understands and exercises rights
• Is satisfied with the course of his/her life,
  with providers, with services

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Support Expectations - examples

• The plan addresses needs and preferences
• Information is provided to make informed
  decisions
• The plan is implemented, and changed as needed
• Individual is supported to acquire and maintain
  relationships

• Concerns and grievances are sought and responded
  to
• Personal funds are protected
• Safety is assured through implementation of
  support needs
• Assistance is provided to assess satisfaction

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Quality Management Safeguards
When services are delivered in persons family or
own home

• Incident Reporting (if occurs when staff are
  present in family home)
• -Death resulting from severe injury
• -Use of most restrictive restraint
• -Hospital admission (other than planned
  admission)
• -Severe Injury
• -Vehicle accident involving moderate or severe
  injury
• -Missing person
• -Fire caused by the individual and emergency
  response required
• -Police arrest
• -Victim of assault or rape
• -Victim of theft or larceny
• Abuse and Neglect Reporting
• Abuse or neglect is reported according to
  current policy

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Quality Management Safeguards
When services are delivered in persons family or
own home

• Program Review Committee / Behavior Programs
• Regional PRC reviews and authorizes if paid
  staff develop or implement aversive behavior
  programs, including restraint.
• Human Rights Committee (HRC)
•   HRC reviews issues or programs that limit or
  restrict persons human rights
• DMR Registry
• Check DMR Registry (re termination for
  substantiated A/N before hiring and thereafter,
  periodically to ensure that current staff are not
  on the Registry)
• Criminal History Review and Verification
• Conduct criminal history background check for
  CT convictions
• Motor Vehicle License and Record Review
• Must be done if staff will be driving the
  individual
• Workers Compensation and Liability Insurance
• Required for employees who work more than 26
  hours per week
• Training Requirements
• As specified in HCBS Waiver provider
  qualifications and specifics pertaining to
  individual served

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System Review, Analysis Improvement
Revise Policy and Procedure
Provider Profile
Quality Improvement Councils
Plans of Correction or Improvement Target Staff
and Organization Development
State Level Quality Review of Public and Private
Provider Organizations of Individuals Across
All Settings
State
Supervisory Staff Review a of Case Manager and
Quality Monitor Activity to Assure Quality
Region
Safety and Support Outcomes Reviewed for a of
Individuals living in their own homes (SL or ISA)
by Quality Monitors.
Safety and Support Outcomes Reviewed for a of
Individuals in 100 of CLAs and Day Settings by
Quality Monitors.
Service and Support Outcomes Reviewed for 100 of
Individuals by Case Managers
INDIVIDUAL PLAN DEVELOPMENT, IMPLEMENTATION,
MODIFICATION
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Case Manager Role

• Contact with all consumers served
• Fundamental role is Individual Plan
• Quality reviews cover
• individual interview regarding satisfaction
• observation of waiver service delivery
• record review
• Safety / environmental check in some settings
• System also measures case management as a state
  service (DMR and Medicaid State Plan)

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Family and Consumer Roles

• Participation in QSR System Design
• Grant requirements for consumer and family input
  via focus groups, steering committees for design
  of quality system, applicability in family homes
• Input on Waiver and Self Direction Guides
• Regional family forums
• Consumers and families as trainers of staff
• Training materials developed by and for consumers
• Self-advocates families as NCI interviewers

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Family and Consumer Roles

• Regional Quality Councils
• To provide feedback on the departments quality
  system from the individual and family
  perspective.
• Advise the department on priority quality issues
  as determined by the Council.
• Review regional trends in identified priority
  areas.
• Recognize excellence of providers / best
  practices to promote improvement.
• Act as a resource to providers / refer providers
  to needed resources.
• Provide feedback on Provider Profile formats to
  make more usable for families and consumers.
• Identify service gap issues and make
  recommendations to stimulate new services /
  providers.
• Make improvement recommendations to Statewide
  Council / Committee.
• Participate in completing interviews with
  families and consumers.

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Family and Consumer Roles
West Region Quality Council The West Region of
CT DMR serves a 57 town area including and
surrounding the major cities of Stamford,
Danbury, Bridgeport, Norwalk, Torrington and
Waterbury. The Region serves a total of  7,133
individuals.  The Region's Quality Review and
Improvement Council is a function of the Regional
Advisory Council. Beside Advisory Council
members, membership is open to all interested
individuals and family members.  The Quality
Council set their focus on assisting individuals
and families in the transition to a waiver system
by connecting them to families and providers.    
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Family and Consumer Roles

• West Region Quality Council Accomplishments 05-06
• Recruited a core membership through the Region's
  Advisory Council, mailings and newsletters both
  local and state. 
• Reviewed the work of the Consumer-Resource
  Connections Group that provides support and
  technical assistance to identified individuals
  who can potentially share resources.
• Conducted a presentation by the CT Family Support
  Network by the Southwest and Northwest Regional
  Coordinators on their network of referrals and
  connecting to resources for individuals and
  families. 
• Participated in the annual Provider Fair that
  showcased private providers and the supports
  offered to individuals and families. 
• Developed questions to ask a provider before
  hiring by adding to and combining comprehensive
  suggestions and questions designed by
  self-advocates.
• Served as part of the interviewing committees in
  the hiring of the region's Abuse and Neglect
  Liaison and the Quality Coordinator. 

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Family and Consumer Roles

• West Region Quality Council
• Planning Development Stage
•  Develop a prototype for the Qualified Provider
  Database
• Geographical area, provider information and
  description of services        
• A DMR status profile of each provider        
• Web based and as link to other supports 
• Develop a flow chart / map for individuals and
  families to serve as a guide of what to do, what
  to expect and where to go for support
• Plan for participation in the completion of
  interviews with families and consumers  

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Role of the Provider

• Organizational Self-Assessment
• Continuous Improvement Plan
• Corrective response to elements identified
  through case management reviews, regional quality
  reviewers, and state level review
• Regions summarize data and outcomes to review
  provider performance twice annually
• Provider profile created for use by all

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Integrating Regional and State Quality Reviews
Quality System Review Data Indicators
Observation Record Review
Consumer Interview (
NCI) Support Staff Interview Safety
Checklist
22 items 60 items
74 items
51 items
up to 52
depends on setting
Regional Quality Review Visit
Case Management Review
Case Management Supervisor Review
Follow
-
up
- Consumer Interview
tracking of
- Observation Indicators
other QA
- Record Review
system
- Safety Checklist
activities
- Support Staff Interview
Interim Tracking System

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Other Quality System Components

• Development of a quality Individual Plan for each
  individual
• Case Manager and Supervisor oversight of the Plan
  
• PRC and HRC Committees
• Medication Administration Regulations
• Incident and Abuse / Neglect Reporting and
  Follow-up
• Mortality Reviews
• Regional Quality Visits
• Contract Administration and Monitoring
• Licensing
• NCI Surveys
• Complaints and PARS
• Financial Audits

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Data Base Features
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Data Base Features
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My QSR Dashboard View
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Internal Notification Inbox
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Locate Consumers Vendors
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Sample Review Screen
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Report Summary Page
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Follow Up Plan
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Where we are Today

• Systems change grant activities continue
• CT LON tool in operation
• QSR measures / tools finalized and some have been
  incorporated into business functions
• Computer application design / construction by
  vendor completed implementation Dec. 2006
• QSR system reviews piloted in DMR programs
• QSR system reviews in private agencies in 2007
• Web-based Incident Management system under
  development

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Contact informationMary.mckay_at_po.state.ct.usBe
th.mcarthur_at_po.state.ct.us
Department of Mental Retardation
Lighthouse Point Park, New Haven, Connecticut