Quality in Managed Long-Term Services and Supports Programs. Appendix E. Pennsylvania's Adult Community Autism Program


  Element     Description  
MLTSS Program Adult Community Autism Program (ACAP)
Lead Agency Pennsylvania Office of Developmental Programs, Bureau of Autism Services
Medicaid Authority 1915(a)
Inception 2009
Year LTSS Added 2009
Groups Enrolled Adults with autism.
# Enrolled 134 (September 1, 2013)--1 MCO for ACAP.
  1. State Quality Oversight Infrastructure
The state has a Program Director, a Clinical Director (also Directs other state programs), 2 ACAP Monitors and an Intake Enrollment Specialist. The ACAP team meets with the MCO on a monthly basis for full day meeting to keep communication open and to problem solve. Staff from the MCO includes the MCOs clinical directors, team leaders, and other approval staff as needed. The ACAP Monitors conducts a comprehensive on-site review of the ACAP on an annual basis to review overall quality in this program.
  1. State IT Infrastructure for Supporting Quality Oversight
The state has an IT system to collect assessment and SP information for ACAP participants. The MCO is required to purchase the software and required licenses to allow for electronic communication and transfer of this information to the state. The state also has an automated CI reporting system that MCOs use to report CIs and actions taken to respond to incidents. The state is able to use these systems analyze participant information to monitor the performance of the MCO.
  1. MCO Quality Oversight Responsibilities
The MCO is required to establish a Plan Advisory Committee to report to and advise the governing body on matters related to the complaint and grievance processes, QM, utilization review processes, and ethics. The Committee establishes, maintains, and provides support to a Complaint and Grievance Committee that is also accountable to the Governing Body. The Plan Advisory Committee reviews the MCO's procedures and makes recommendations for improvements. When the MCO or the state identifies deficiencies or areas for that need improving, the MCO and/or provider must take corrective action to ensure that the provider deficiencies are address and performance is improves.

The MCO is required to:

  • Establish ongoing mechanisms to monitor provider compliance with the state's standard for timely access to care and services as specified.
  • Monitor the performance of providers on an ongoing basis by conducting a formal review of each provider at least annually and if any deficiencies or areas of improvement are identified, take corrective action or require the provider to take corrective action.
  • Detect both under utilization and over utilization of services to assess the quality and appropriateness of care furnished to all participants.

The MCO is required to establish, maintain, and provide support to a Quality Management and Utilization Review Committee. The Committee provides guidance and assistance to support the MCO in carrying out the following responsibilities:

  • Developing mechanisms for collecting and evaluating information, identifying problems, formulating recommendations, disseminating information.
  • Implementing corrective actions, and evaluating the effectiveness of action taken.
  • Reviewing annually and making recommendations concerning the formulation, revision or implementation of the policies governing the scope of services offered, practice guidelines, medical supervision, ISPs, crisis intervention care, clinical records, personnel qualifications and program evaluation.
  • Providing technical advice regarding professional questions and individual service problems.
  • Participating in program evaluation including annual evaluation of the MCO's performance.
  • Assisting in maintaining liaison with professional groups and health providers in the community.
  • Participating in the development and ongoing review of written policies, procedures, and standards of patient care and QM.
  • Reviewing the adequacy and effectiveness of QM and utilization activities on a quarterly basis.
  • Developing mechanisms for evaluating responsiveness of the complaint and grievance processes and for collecting and analyzing information about voluntary disenrollment.

The MCO must also ensure that data received from providers is accurate and complete by verifying the accuracy and timeliness of reported data; screening the data for completeness, logic, and consistency; and collecting service information in standardized formats to the extent feasible and appropriate.

  1. State Audits of MLTSS Program
The state ACAP team meets with the MCO on a monthly basis for full day meeting to keep communication open and to problem solve. Topics for these meetings include concerns related to service utilization, employment, and problem solving related to specific participants. The state and MCO also discuss follow-up to monitoring, applicant referrals for enrollment, and assessment/SPs concerns. Staff from the MCO includes clinical directors, team leaders, and other staff as needed.

The state ACAP monitors conduct a comprehensive on site review of ACAP on an annual basis to review the MCO's performance, develop specific quality goals, and establish of performance measurement criteria. The MCO must submit reports required by the state 2 weeks before it meets with the state. The state ACAP Monitors also meet with families and participants (approximately 15% of the ACAP participants) and complete satisfaction questionnaires during their annual review process. During the annual review process, the state also looks at psychotropic medications (chemical restraint) (i.e., look at participants who have 4 or more psychotropic meds). (The MCO is required to ensure that this be reviewed by doctor/pharmacy.)

A findings report is sent to the MCO with a request for plans of correction if indicated. The state also discusses the results of their reviews during the monthly meetings held with the MCO. The state plays and active role in supporting the MCO to address gaps/issues identified.

  1. Performance Measures and Quality-Related Reports
The state has established the following performance measures:
  • Fewer episodes of:
    • Law enforcement involvement;
    • Psychiatric inpatient and ER hospitalizations;
    • MH crisis interventions;
    • Law enforcement involvement;
    • MH crisis interventions.
  • Increases in:
    • Annual dental exams;
    • In diabetes management;
    • Annual gynecological exams.
  • Percentages of:
    • Complaints received and resolved;
    • Grievances received and resolved.
  • Experience of care:
    • Increase in percentages of participants with jobs or volunteer opportunities;
    • Participant satisfactions and quality of life indicators.
  • The MCO is required to submit quarterly reports that include the following information:
    • Number of participant deaths;
    • Number of complaints received and resolved;
    • Number of grievances received and resolved;
    • Services furnished to participants.

The MCO is required to submit a quality report on an annual basis including standard measures, method of review, recommendations for improvement, and evaluation of corrective actions implemented.

  1. LTSS-Focused PIPs
The ACAP MCO is required to conduct 1 PIP. ACAP is part of a larger effort with the state Medicaid Agency to utilize an EQRO. The state has worked directly with the MCO and the EQRO to develop a PIP that is relevant to the ACAP population.

In addition, if deficiencies are identified by the MCO or the state, the MCO is required to develop a corrective action plan to improve performance.

  1. Care Coordination
The state conducts the initial eligibility assessment and forwards the information to the MCO. The state also asks families to complete a questionnaire regarding the applicant's contact with law enforcement, psychiatric hospitalization, and crisis intervention within past year.

The MCO is expected to meet with applicant to develop an initial support plan within 14 days of being notified by the state that an applicant is eligible for enrollment. The MCO also conducts a psychosocial assessment, a Scale of Independent Behavior Revised, and quality of life survey. The MCO also requests that participants who live with or very involved with family complete a parental stress scale. The results of all of the information is transmitted to the state's information system.

The participant's plan must be reviewed at least every 3 months, and after each episode that triggers implementation of the crisis intervention plan or the use of a restraint. Monitoring and annual reassessments must address the participant's progress toward more inclusive and less restrictive services than were provided the previous year. The MCO is required to complete an assessment annually designated by the state for each participant transmits the results of the assessments to the state in an electronic format.

The MCO is required to assign a team to each participant responsible for assessment, service planning, delivery of services, quality of services, and continuity of care. The team includes at a minimum:

  • Participant/guardian/family (consistent with the participant's or guardian's wishes);
  • Behavioral Health Specialist;
  • Supports Coordinator.

The MCO is required to ensure that every participant has an assigned PCP. The PCP may be a specialist, if the needs of a participant warrant.

The MCO is required to ensure that the authorized services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are furnished.

The MCO must establish practice guidelines to govern the authorization and delivery of services, which are based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field, consider the needs of the participants, are adopted in consultation with contracting health care professionals, and are reviewed and updated periodically as appropriate. Practice guidelines must be approved by the state before being implemented. Guidelines must be shared with all affected providers and, upon request, with participants and applicants.

The MCO must use a person-centered planning process in developing the Initial ISP and in developing, reviewing, and updating or revising the FBA-based ISP. The process must include:

  • Understanding the participant's present and future needs and desires.
  • Identifying the services and other supports the participant will need to meet his or her needs and desires.
  • Determining what steps need to be taken to meet the participant's needs and desires.

The MCO s required to develop a crisis intervention plan to plan for a crisis event to protect the partitioned from hurting himself/herself or others. The MCO will reassess the plan to avoid a crisis event in the future. A description of how the effectiveness of the plan and its implementation in supporting the participant will be monitored and evaluated on a regular basis and after each crisis event.

  1. 24-Hour Back-Up
The MCO is required to maintain an after-hours call-in system to provide access, 24 hours per day, 7 days per week for covered services when medically necessary.
  1. CI Reporting and Investigation
The MCO must ensure each provider responds, reports, and follows up on CIs as specified by the state. The state has a list of incidents that the MCO must use in their process. The MCO must use the state web-based program --called EIM. All incidents must be reported in the EIM within 24 hours of occurrence or awareness of incident. The MCO has to report preliminary information/demographics, information on what was done to ensure health and welfare during and after incident, and an incident description narrative. The state gets an alert that an incident was reported and reviews this information within 24 hours. The MCO has 30 days from completion of the initial section to then complete the report. The state reviews the completed report and then either closes the report or the state will ask for clarification on actions taken/information reported.

The MCO is expected to trend and analyze incident reports. The state monitors the MCOs performance as part of the annual review where participant records are reviewed (for example, did all incidents get reported?).

The MCO is required to develop Seclusion and Restraint policies and procedures and ensure that staff and providers receive training on these policies and the appropriate use of these restraints identified in the approved behavioral support plan. MCOs are required to file an incident report any time a Restraint is used.

  1. Mortality Review
The MCO is expected to review every death. The MCO is required to report all deaths to the state via the CI reporting systems described above. The MCO is also expected to review each death and reports the results of this review to the state.
  1. EQRO Responsibilities
ACAP is part of a larger effort with the state Medicaid Agency to utilize and EQRO. The EQRO reviews the MCO's activities and generates a compliance report and evaluation of the MCOs PIP.

The MCO is required to comply with requests from the state for submission of data required to complete an annual external independent review of the quality outcomes, timeline and access to authorized services. The MCO is also required to cooperate with the state/authorized representatives in the state's monitoring of MCO and provider compliance with the contract requirements and the provider's performance as it relates to participant outcomes and consistency of quality indicators.

  1. Ombudsman/ Function
The MCO has a complaint, grievance and state fair hearings procedures that is approved by the state. The MCO informs each participant verbally and via the Participant Handbook of the participant's right to file a complaint or grievance, the requirements and timeframes for filing a complaint or grievance, the availability of assistance in the filing process, the toll-free numbers that the participant can use to file a complaint or grievance, and the participant's right to request the state's Fair Hearing. The MCO must also inform the provider of the right of each participant to file a complaint or grievance. The MCO also has established a committee with representation from participants, family members, and MCO staff to discuss program issues.

In addition, the state encourages and receives direct inquiries from participants and family members and works directly with participants and the MCO to resolve any issues.

The state does not have independent ombudsman available to participants in ACAP.

  1. Experience of Care/ Satisfaction Surveys
The MCO is required to regularly evaluate participants' satisfaction with services using their satisfaction survey. Performance measures related to the survey focus on:
  • Increase in percentages of participants with jobs or volunteer opportunities.
  • Participant satisfactions and quality of life indicators.

The state is working with a consortium of autism experts to enhance this process.

Also, the MCO holds monthly meetings in various counties with family members and participants to gather feedback from participants.

The state ACAP Monitors also meet with families and participants (approximately 15% of the ACAP participants) and complete satisfaction questionnaires during their annual review process. A findings report is sent to the MCO with a request for plans of correction if indicated. The state also discusses the results of their reviews during the monthly meetings held with the MCO. The state plays and active role (via monthly meetings) in supporting the MCO to address gaps/issues identified. This is especially important when focusing on the challenges of supporting adults with autism.

  1. Membership Oversight
The MCO includes participants on their Quality Committee and Advisory Committee. The MCO host meetings with families of participants at least every other month to discuss the services and supports offered by the ACAP.

The state also hosts focus group meetings with participants to gather feedback and modify policies and procedures as needed.

A participant also sits on the state's Advisory Board and the 3 regional advisory boards established by the state. Participants are also invited to attend the state's annual Autism Training Conference where participants can share their experiences with the state, MCO and providers.

  1. State Technical Assistance to MCOs
The state maintains a close relationship with MCO. The state supports the MCO in all aspects of their QM systems including the use of state's information system for reporting incidents and documenting support plans.
  1. MCO Report Cards on LTSS
None specified.
  1. Financial Incentives, Penalties and Withholds
The state does not have financial incentives related to quality. The state does have the ability to withhold payment based on poor performance (for example, the MCO does not make required corrections or does not meet identified standards) but they have not needed to do this to date.
  1. Other Quality Management/ Improvement Activities
None specified.
ACAP = Pennsylvania Adult Community Autism Program
CI = critical incident
EIM = Enterprise Incident Management
EQRO = external quality review organization
ER = emergency room

ISP = Individualized Service Plan
IT = information technology
LTSS = long-term services and supports
MCO = managed care organization
MH = mental health

MLTSS = managed long-term services and supports
PCP = primary care provider
PIP = performance improvement project
QM = quality management
SP = service plan

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