Addressing Critical Incidents in the MLTSS Environment: Research Brief. Summary


In this Brief we have provided examples of the approaches that a handful of states take to address the occurrence of critical incidents among persons served through MLTSS programs. While not prescriptive about how Medicaid MLTSS programs must manage critical incidents, CMS provides guidance about essential aspects of a "well-conceived" critical incident system, including:

  • Identification, reporting and investigation of critical incidents.

  • Clarification of roles, responsibilities, expectations for the state, MCOs and providers.

  • State monitoring of MCO and provider compliance with critical incident protocols.

  • Tracking and trending of results for the purpose of system improvements.

  • Continuous process improvements.

CMS expects these aspects of member protections be incorporated into new MLTSS programs as well as integrated into existing programs as states "revise, renew or expand" their programs. CMS further states that, moving forward, they will use these criteria to review and approve programs using the 1115 or 1915(b) waivers for MLTSS.

As states review their system requirements for critical incident processes and related MCO contract requirements, multiple options are available for structuring the management of critical incidents. However, one thing is abundantly clear among the states cited in this Brief -- the MCO plays a pivotal role in reviewing, processing and investigating critical incidents. As such, it behooves states to carefully craft their expectations for the MCO's role and responsibilities for handling critical incidents, as well as the responsibilities of the provider network for collaborating with the MCO to manage incidents effectively. States on the cusp of implementing MLTSS should consider in the design of their program mechanisms for monitoring how MCOs and their provider network manage critical incidents, focusing on the outcome of protecting individual member well-being. Equally important in system design are mechanisms that require both the state and MCOs to examine critical incident data for the purpose of identifying trends that may be amenable to interventions -- perhaps system-wide, perhaps provider-based -- with the aim of fewer critical incidents or improved response to them when they occur.

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"CritIncidRB.pdf" (pdf, 79.42Kb)

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