|MLTSS Program||Family Care|
|Lead Agency||Wisconsin Department of Health Care Services, Division of Long Term Care|
|Year LTSS Added||1999|
|Groups Enrolled||IDD, Aged and Physically Disabled|
|# Enrolled||33,141--IDD, Aged and Physically Disabled
9 MCOs (57 of 72 counties)
||The state has 9 MCO Oversight Teams composed of a CC and 1 or more MCQSs, and fiscal oversight staff. CCs oversee compliance and adherence to the MCO contracts and MCQS work on specific member issues. Three managers (2 regional managers and a manager of development and integration) supervise the 9 Oversight Teams.
In addition to this team structure, the state has a MH Specialist, an RN Consultant, and an Employment Initiatives team who are available to support the Oversight Teams with specific member quality concerns or policy issues. They also provide support directly to the MCOs, when appropriate. This support includes training, capacity development, and integration of best practice related to MCO contractual requirements.
NOTE: The state currently has currently 9 Oversight teams with of 1.5-3 FTEs per team. Resources may shift from team to team depending on MCO performance.
||The MCO oversight teams use oversight database (SharePoint) to document issues and to track the resolution or remediation of these issues. In addition, they require each MCO to maintain an information system to collect, analyze, integrate, and reports data to support the objectives of the QM program. The MCOs' system provides information on grievances, appeals, and performance measures.|
||MCO's have a governing board accountable for the MCO's QM program, a manager responsible for implementation of the QM plan with authority to deploy the resources as needed, and a QM committee. The QM committee includes both administrative and clinical personnel to facilitate communication and coordination between other functional areas of the organization that affect the quality of service delivery and clinical care.
The MCO's is required to have a QM program that include processes to:
MCOs are required to create a means for MCO staff and providers (including attendants, informal caregivers, and health care providers) to participate in the QM program. If the MCO identifies deficiencies or areas for improvement, the MCO and the provider are required to take corrective action.
MCO are required to conduct ongoing reviews that collects evidence to demonstrate that:
||The state Oversight Teams utilize several approaches to discover problems and monitor MCO improvement including review of:
The Oversight Teams also are required to:
The Oversight Teams are the state's primary resource for directing remediation and addressing individual member problems. The Teams regularly interact (monthly meetings and/or calls) with MCO staff and may identify concerns through this contact or direct observation. The MCO staff remediates individual member concerns and report the outcome to the Oversight Team. The Teams documents identified issues and concerns and the resolution or remediation of these issues in an oversight database (SharePoint) maintained by the state.
Oversight teams use quality data to discover and remediate problems or issues, and look for trends or concerns happening at the MCO level. Every 2 months, all of the Oversight Teams meet and address issues occurring in various MCOs and regions to learn, share, and look at trends that may require additional quality or policy oversight and development. For example, the teams may review CIs reports to look for both statewide as well and MCO specific trends.
The state focuses on "was the process followed" when evaluating the performance of the MCO. They use a no wrong door approach--quality can come from a number of places including MCO self-report.
Sometimes the state gets calls from MCO providers but encourage providers to work with their MCO to resolve any issues. However, sometimes the state will meets with groups or providers that cross of multiple MCOs to discuss system-wide issues.
The teams regularly interact with MCO staff (monthly meetings and/or calls) and may identify concerns through this contact or direct observation. The MCO staff remediates individual member concerns and report the outcome to the Oversight Team. The teams documents identified issues and concerns and the resolution or remediation of these issues in an oversight database (SharePoint) maintained by the state.
||The state has established a number of PMs in the 1915(c) waver to meet the waiver assurances. In addition, the MCO is required to specify 1 or more quality indicators specified for each PIP.|
||MCOs are required to work with the state and EQRO to complete PIPs using a performance improvement model or method based on the state's defined process. While the PIP is in the planning stage, the MCO submits the study questions and the project aims or goals to be reviewed by the state or the EQRO. PIPs must be approved by the state.
Each PIP must clearly define a focus area that relates to the demographic characteristics and to the prevalence and potential consequences of the desirable or undesirable conditions among the MCO's membership. The planned improvements should affect either a significant portion of the members or a clearly specified sub-portion.
MCO's PIPs address a broad spectrum of key aspects for member care and services in both clinical and non-clinical focus areas. MCO's are not specifically required to conduct an LTSS-focused PIP, however, the focus area is selected on the based on members' needs, care, and services, or on the basis of member input.
Each year, the MCO are required to make active progress on at least 1 PIP relevant to long-term care, and for those MCOs that include primary and acute care in the benefit package, 1 additional PIP relevant tor primary and acute care. The MCO may satisfy this requirement by actively participating in a collaborative PIP in conjunction with 1 or more MCOs. Each PIP must be completed in a reasonable time period so as to generally allow information on the success of the PIP in aggregate to produce new information on quality of care every year. The state may require specific topics for PIPs and specify performance measures.
MCOs are required to submit interim reports and document ongoing progress, and are required to report annually to the state on the status and results of each PIP.
||The ADRC does the initial LOC determination and then the MCO care coordinator (part of the IDT) conducts the CNA to develop the SP. The assessment includes a risk assessment conducted by the IDT to identify and mitigate risks. Members review and sign off on any risk identified during the assessment and service planning process.
MCOs are required to conduct a face-to-face visit with a member during each quarter of the calendar year. After the first 6 months of enrollment, if MCO staff has established a relationship with the member staff can waive the minimum standard but a member must receive at least 1 face-to-face visit each year.
Some MCOs have designated staff to work directly with to hospitals and NFs. This has helped to facilitate transitions back to a community setting. MCOs determine their caseload ratios. However, MCOs are required to submit a 3 year business plan that is approved by the state and the state will ask for rationale if the MCO's ratios vary significantly from the following state established norms:
All MCO care coordinators must use the principals established in the state's RAD method to try to balance need with cost-effective service planning in the Family Care Program. Cost-effective means, "effectively supporting a desired outcome at a reasonable cost and effort." The RAD includes the following basic questions to consider and guidelines to follow.
||The MCO is responsible for providing members with needed services 24/7 including immediate access to urgent and emergency services to protect health and safety, access to services in the benefit package and linkages to protective services.|
||The state defines a CI as a circumstance, event or condition resulting from action or inaction that is either:
The MCO is required to have designated staff to conduct CI investigations to determine:
MCO are required to adopt and carry out policies governing the processes used for identification, review and analysis of each CI to ensure that CIs are reported to designated MCO staff by providers or by other MCO staff. If there is a potential violation of criminal law, MCOs are required to report this to local law enforcement authorities. CIs meeting protective service criteria are reported in accordance with the applicable statute to the appropriate authority. MCOs are also responsible for training MCO staff and providers regarding these polices.
MCOs are required to have an ongoing program of collecting information about CIs, monitoring for patterns or trends, and using that information in the QM program. MCOs are required to submit a quarterly CI report to the state regarding member specific incidents (use a unique, traceable, HIPAA compliant identifier). The report includes:
Whenever egregious incidents occur, MCOs are expected to promptly report the incident to their respective Oversight Team. Minimally, the report must include the known facts of the incident and that member health and safety has been assured. The MCO is expected to conduct a full incident investigation and report back to the Oversight Team, as needed, and include all information in the quarterly report.
The MCO's assigned MCQS reviews the MCOs reports using a standard Internal Review Tool. The state provides feedback to the MCO within 30 days of the receipt of the MCO's quarterly report. The feedback includes any concerns about the MCO's response to a CI. The state's CC may also discuss issue with the MCO's Quality Manager and provides guidance, recommendations, and negotiation of improvement/corrective action as needed.
||MCOs are required to have a process to conduct mortality reviews. They must also report "unexpected deaths" on their quarterly report. However, the state does not conduct a state level review of mortality across the program.|
||The state contracts with an EQRO to provide quality monitoring services--referred to as the AQR includes the following activities:
The EQRO also validates the MCO's performance measure data.
The MCO must assist the EQRO in identifying and collecting information required carrying out on-site or off-site reviews and interviews with MCO staff, providers, and members.
Every 3 years, the EQRO conducts a full review using the CMS protocol for QCR. In the second and third review years, the EQRO reviews the MCOs to reassess any unmet standards. The EQRO follows protocols to develop review standards and assessment tools and assesses standards with a "Met", "Partially Met" and "Unmet" ranking.
The EQRO conducts annual CMRs of all MCOs. The EQRO reviews SPs and other documentation to assess whether MCOs comply with waiver and contractual requirements. The EQRO uses the NCQA sampling guidance of 1.5% of an MCO's membership or 30 records, whichever is greater. For this review, the EQRO assesses records using a "Met" or "Not Met" ranking. Each MCO also has an internal care plan review process that includes additional reviews of SPs and follow-up on findings.
The EQRO produces 2 reports after the AQR is completed:
Once the state Oversight Team receives the EQRO report, they develop corrective action plans as needed with the MCO. The MCO is required to cooperate in further investigation or remediation, which may include:
Progress on corrective action plans is monitored monthly at meetings of the MCO and the Oversight Team.
In addition to the individual MCO Annual Quality Reports, the EQRO prepares an overall program summary report annually.
||MCOs must have a Member Rights Specialist to help them through the appeals process.
Members also have access to 1 of the state's Ombudsman programs. The state has 2 distinct state Ombudsman programs--1 for members 60 and older (covers more than the Family Care Program) and 1 for members 18-59 (just for Family Care).
Ombudsmen also work with members to help to resolve an issue before it gets to the appeals process and to help members understand the appeals process.
MCOs provide information about member rights specialist and outside ombudsmen programs via the member handbook and brochures fork the Ombudsman Programs.
The Ombudsman Programs submit monthly reports to the state related to their activity associated with each of the MCOs in the state.
||The state has conducted a survey called PEONIS. State staff (or designees) conducted face-to-face interviews with 500 members. They are planning on making improvements to the tool and process in the future to improve the questions and the analysis to support QIs in the Family Care Program.
In addition, MCOs are required to conduct member satisfaction surveys. The state provides the MCOs with core questions but does not set out standard requirements related to the administration of the tool. Some MCOs send out questionnaires annually, other conduct phone interviews, and others send out the questionnaire and then conduct a follow-up interview. The state is looking to develop a uniform process across all MCOs.
At the state level, state staff has done some regional listening session and have created state advisory committees to gather participant feedback.
||The state has created state advisory committee to gather participant feedback related to quality. In addition, MCO governing boards include members of the Family Care Program.|
||The MCO Oversight Teams (CC and MCQSs) provide technical assistance and support to the MCOs as needed. In addition, the state is also committed to providing basic training to MCOs regarding the requirements of the Family Care Program and other program specific area as needed.|
||The state has established financial incentive payments for MFP enrollments, but do not have incentives for any quality-related activities or outcomes.|
|ADL = activity of daily living
ADRC = Aging and Disability Resource Center
AQR = Annual Quality Review
CC = Contract Coordinator
CI = critical incident
CMR = Care Management Review
FTE = full-time equivalent
IDT = Interdisciplinary Team
MCP = Member-Centered Plan
NCQA = National Committee on Quality Assurance
QCR = Quality Compliance Review
SP = service plan