Quality in Managed Long-Term Services and Supports Programs. Appendix H. Wisconsin's Family CARE


  Element     Description  
MLTSS Program Family Care
Lead Agency Wisconsin Department of Health Care Services, Division of Long Term Care
Medicaid Authority 1915(b)/(c)
Inception 1999
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)
  1. State Quality Oversight Infrastructure
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.

  1. State IT Infrastructure for Supporting Quality Oversight
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.
  1. MCO Quality Oversight Responsibilities
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:

  • Monitor and detect under utilization and over utilization of services (MCOs are required to run submit IBNR reports to the state that compare authorized to delivered services.
  • Assess the quality and appropriateness of care furnished to members.
  • Have appropriate health professionals reviewing the provision of health services.
  • Monitor the performance of subcontracted providers.
  • Assure that licensed/certified providers and non-licensed/non-certified providers continuously meet required licensure, certification, or other standards and expectations, including caregiver background checks, education or skills training, and reporting of CIs to the MCO.
  • Provide for systematic data collection of performance and results make changes as needed.

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:

  • Appropriate risk assessments are performed on a timely basis.
  • Members participate in the preparation of the care plan and are provided opportunities to review and accept it.
  • MCPs address all participants' assessed needs (including health and safety risk factors) and outcomes.
  • MCPs are updated and revised in accordance with the applicable standards for timeliness and when warranted by changes in the members' needs and outcomes.
  • Services are delivered in accordance with the type, scope, amount, and frequency specified in the MCP.
  • Members are afforded choice among covered services and providers.
  1. State Audits of MLTSS Program
The state Oversight Teams utilize several approaches to discover problems and monitor MCO improvement including review of:
  • Annual on-site Quality Review conducted by the EQRO.
  • IBNR reports that compare authorized to delivered services.
  • MCO or state level grievances and appeals.
  • Ombudsman program reports.
  • CI reports.

The Oversight Teams also are required to:

  • Follow-up on individual member concerns.
  • Consult with the MCO on requests for use of isolation, seclusion and restrictive measures.

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.

  1. Performance Measures and Quality-Related Reports
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.
  1. LTSS-Focused PIPs
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.

  1. Care Coordination
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:

  • 1:80 for nursed;
  • 1:40 for service coordinators.

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.


  • What is the core issue/concern/need?
  • How does the core issue relate to the member's long-term care outcome?
  • Does the core issue affect the member's health or safety?
  • Does the core issue affect the member's independence, ADLs, or IADLs?
  • What options address the core issue while supporting the long-term care outcome?


  • Member, guardian/legal representative and IDT staff identify and consider all potential options to address the core issue.
    • Assess the current interventions in place.
    • Review interventions from the past (e.g., what has worked previously?).
    • Explore the role of natural supports (family, friends, and volunteers).
    • Explore community resources that may be appropriate (supports and services that are not authorized or paid for by the MCO and are readily available to the general public).
    • Address the core issue as if the member were not in a managed/long-term care program (e.g., how would this issue be met if you were not in the program?).
    • Identify the member's ability and responsibility to address the core issue.
    • Explore loaner programs and rental vs. purchase options.
  • Review with the member which options are:
    • Most effective in supporting the member's long-term care outcome?
    • Most cost-effective in supporting the member's long-term care outcome?
  • What organizational policy or guidelines apply?
  • Negotiate with the member or guardian to reach a decision that best supports the member's long-term care outcome.
  • If a service is to be authorized, explore the option for the member to self-direct this part of the POC.
  1. 24-Hour Back-Up
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.
  1. CI Reporting and Investigation
The state defines a CI as a circumstance, event or condition resulting from action or inaction that is either:
  • Associated with suspected abuse, neglect, financial exploitation, other crime, a violation of member rights, or any unplanned, unapproved use of restrictive measures.
  • Resulted in serious harm to the health, safety or well-being of a member, substantial loss in the value of the personal or real property of a member.
  • Resulted in the unexpected death of a member.
  • Posed an immediate and serious risk to the health, safety, or well-being.

The MCO is required to have designated staff to conduct CI investigations to determine:

  • Whether the CI occurred and the facts of the CI.
  • The type and extent of harm experienced by the member.
  • Any actions that were taken to protect the member to halt or ameliorate the harm.
  • Whether reasonable actions by the provider or others with responsibility for the well-being of the member could have prevented the incident.
  • Whether any changes in the MCO's or provider's policies or practices might prevent occurrence of similar incidents in the future.

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.


  • CIs must be reported within 1 business day after the CI was discovered.
  • Within 3 calendar days of learning of the incident, the member or his/her guardian is notified of the CI (unless the guardian is a subject of the investigation).
  • A CI investigation is completed, by designated staff, within 30 days unless information or findings necessary for completion of the investigation cannot be obtained within that time for reasons outside of the MCO's control, in which case the investigation should be completed as promptly as possible.

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:

  • Category/date of CI.
  • Setting where the incident occurred.
  • Description of the harm experienced by the member.
  • Description of the immediate actions taken to protect the member and to halt or ameliorate the harm.
  • Description of the underlying circumstance(s) that caused or allowed the incident to occur.
  • Date MCO incident analysis was completed.
  • Brief description of any policies or standard practices that have been or will be changed or adopted to prevent similar incidents in the future.

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.

Additional Notes:

  • MCOs and its subcontracted providers are required to follow the state's written guidelines and procedures on the use of isolation, seclusion and restrictive measures in community settings, and follow the required process for approval of such measures.
  • Wisconsin has identified the following areas that that plan to work on to improve their CI system:
    • Coordinate CI system with other state programs (FFS);
    • Develop a system for state level aggregate data collection/analysis;
    • Develop a standard mortality review process.
  1. Mortality Review
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.
  1. EQRO Responsibilities
The state contracts with an EQRO to provide quality monitoring services--referred to as the AQR includes the following activities:
  • QCR;
  • CMR;
  • Validation of PIPs.

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:

  • MCO Annual Quality Report--results of all review findings.
  • Detailed report of all findings at a member level.

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:

  • Revision of a care plan.
  • Corrective action within a timeframe to be specified in the notice if the effect on the member is determined to be serious.
  • Additional review to determine the extent and causes of the noted problems.
  • Action to correct systemic problems that are found to be affecting additional members.

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.

  1. Ombudsman/ Function
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.

  1. Experience of Care/ Satisfaction Surveys
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.

  1. Membership Oversight
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.
  1. State Technical Assistance to MCOs
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.
  1. MCO Report Cards on LTSS
None specified.
  1. Financial Incentives, Penalties and Withholds
The state has established financial incentive payments for MFP enrollments, but do not have incentives for any quality-related activities or outcomes.
  1. Other Quality Management/ Improvement Activities
None specified.
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
CMS = Centers for Medicare and Medicaid Services
CNA = Comprehensive Needs Assessment
EQRO = external quality review organization
FFS = fee-for-service

FTE = full-time equivalent
HIPAA = Health Insurance Portability and Accountability Act
IADL = instrumental activity of daily living
IBNR = incurred but not reported
IDD = intellectual and developmental disabilities

IDT = Interdisciplinary Team
IT = information technology
LOC = level of care
LTSS = long-term services and supports
MCO = managed care organization

MCP = Member-Centered Plan
MCQS = Member Care Quality Specialist
MFP = Money-Follows-the-Person
MH = mental health
MLTSS = managed long-term services and supports

NCQA = National Committee on Quality Assurance
NF = nursing facility
PEONIS = Personal Experience Outcomes Integrated Interview and Evaluation System
PIP = performance improvement project
POC = plan of care

QCR = Quality Compliance Review
QI = quality improvement
QM = quality management
RAD = resource allocation decision
RN = registered nurse

SP = service plan

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