Independent Providers within a Quality Assurance

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Independent Providers within a Quality Assurance
Improvement Framework

• Dilemmas, Future Directions, and Promising
  PracticesValerie Bradley June Rowe Human
  Services Research Institute

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Who is an independent provider?

• Someone, in large part, employed and supervised
  directly by the individual and/or family
• Is not an employee of a private agency
• Is paid either directly by the state or, more
  likely, through a financial management service

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Brief historical perspective

• Community services have historically have been
  provided through private (mostly non-profit)
  agencies
• Provider agencies are held accountable for
  quality of staff and service quality
• QA/QI systems have largely focused on provider
  monitoring
• Licensing
• Certification
• Accreditation

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Signs of Change

• Family support movement set the tone by
  empowering families to hire their own staff
  through the use of family subsidies
• Advent of personal care assistance and movement
  by physical disability community to control
  hiring and firing
• Emergence of the self determination movement and
  the increasing deconstruction of the service
  system

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This is not new, rather it has deep historical
roots
self-determination independent living
movement in-home supports for the elderly
family support self-advocacy
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Why are we discussing this now?

• Self-directed supports and use of independent
  providers is growing and
• states are re-thinking their quality assurance
  and improvement approaches because
• changes in quality assurance and
• improvement strategies are directly
  influenced
• by changes in services and supports!

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So, why re-think quality now

• Current QA/QI systems that are used to monitor
  provider agencies may not work well for
  individuals who are supported through independent
  providers
• As states apply for Independence Plus waivers
  or build self-direction into their other waivers,
  they need to develop QA/QI strategies to ensure
  the health and welfare of waiver participants for
  these supports

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QA/QI systems for independent providers is a
balancing act

Choice Control Less intrusive monitoring
HCBS assurances Safeguarding health and welfare
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QA/QI for independent providers considerations

• Positives
• Increased flexibility, choice and control
• Close, caring reciprocal relationship between
  provider and individual/family
• Individual/family directly monitor quality
• Vulnerabilities
• Isolation of both the provider and individual
• Maintaining the energy, competencies and
  connectedness of the provider
• Oversight for provider quality largely in the
  hands of the individual/family

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Re-thinking quality

• For independent providers quality
• starts in the beginning before monitoring
  quality is preventive, upfront
• Basic qualifications, skills and competencies
  for all providers
• Pre-screening
• Education/age requirements
• Threshold competencies

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• Person-centered planning
• Identifying the persons needs for support, risks
  
• Individual and family competencies needed to
  effectively manage individual providers
• Person-specific competencies the providers need
  to support the individual
• Degree of monitoring in the planning process

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• QA/QI safeguard strategies need to be more
  person-centered, individualized
• Self-monitoring by educated individuals and
  families
• Ongoing monitoring by the case manager/support
  coordinator is critical for early
  detection/prevention of problems

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Systemic QA/QI strategies to monitor the quality
of independent providers

• Consumer affairs or ombudsman office
• Trends in grievance reports or complaints (e.g.,
  type, amount)
• Critical Incident Reporting Systems
• Necessary, but challenging to rely on for these
  supports
• Published report cards on independent providers
• As reported by individuals and families (UT)
• Person-centered review processes
• Less prescriptive, more outcome-based (KA)

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• Citizen/peer networking and quality councils
• Joint problem solving, resource and information
  sharing
• Consumer/family surveys
• National Core Indicators Consumer and Family
  Surveys (HSRI/NASDDDS)
• Participant Experience Survey (Medstat Group)
• Ask Me survey (MD)
• Developmental Services Adult Consumer Outcomes
  survey (NH)

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HCBS Quality Framework