Quality in Managed Long-Term Services and Supports Programs. II. Study Approach


The nature of our study is exploratory with the goal to understand how a handful of states have implemented Medicaid MLTSS quality oversight in their programs. This is not an evaluative study where we seek to assess or rank the states on the quality in their programs, or to assess their compliance with federal regulation or guidance. Rather, it is to learn how they have crafted their quality strategies, what constitutes its components, and how their approaches to quality may have changed over time and why. The most appropriate methodology for such a study is the case study approach.

During the spring and summer months of 2013, staff from Truven Health Analytics conducted site visits to MLTS programs in Michigan, Wisconsin and Texas. During the visits we carried out semi-structured in-depth interviews with state and MCO4 Quality Assurance/Quality Improvement (QA/QI) staff. In two states (Texas, Wisconsin) we were also able to have discussions with the External Quality Review Organization (EQRO).

In addition, in the spring of 2012 prior to the initiation of this project, the Truven Health team had the opportunity to visit two other MLTSS programs in Arizona and Tennessee. We leveraged much of the information garnered in those visits for this study, augmented with follow-up phone interviews and e-mail exchanges during the course of the current project. Individuals on our team also had previous exposure to three other MLTSS programs in Minnesota, North Carolina and Pennsylvania which we have also drawn upon for this study; likewise, we conducted phone interviews with staff in these states to supplement existing information.

The MLTSS programs highlighted in this brief range from the earliest adopters in the late 1990s to programs initiated in 2009 and 2010. As shown in Exhibit 1, the populations served in these programs run the gamut from the aged and disabled to those with intellectual and developmental disabilities (IDD), autism and severe mental illness and substance use disorders (SUDs), with some programs integrating both health care and long-term care.

To guide the discussions with informants, Truven Health developed a discussion guide to elicit information on various quality topics covered by the study, including the state's infrastructure supporting quality activities, monitoring mechanisms, member safeguards, and changes in the state's quality management strategies over time. The discussion guide was used for the site visits, as well as for follow-up communications with MLTSS programs previously visited. It guided discussion as well with state staff from whom we wanted to acquire additional detail on certain topics and/or to elicit information on recent changes in their quality systems.

EXHIBIT 1. Study States/Programs
  State   Program Authority   Initiated   Populations   HCBS     Institutional   Health
AZ Arizona Long-Term Care System (ALTCS) 1115 1988 Aged,
  Physically Disabled  
MI MI Medicaid Managed Specialty Support & Services Program   1915(b)/(c)   1998 IDD & MH X X  
MN Minnesota Senior Care Plus (MSC+) 1915(b)/(c) 2005 Aged X X X
Minnesota Senior Health Options (MSHO) 1915(a)/(c)
& Medicare
1997 Aged X X X
NC   North Carolina 1915(b)/(c) Medicaid Waiver for MH/DD/SA Services   1915(b)/(c) 2005 IDD, MH & SA X X  
PA Adult Community Autism Program (ACAP) 1915(a) 2009 Adults with Autism X X X
  (OT, PT, ST  
& DME only)
TN TennCare CHOICES in LTSS 1115 2010 Aged/Disabled X X X
TX Texas STAR+PLUS Program 1115 1998 Aged/Disabled X X X
WI Family Care 1915(b)/(c) 1999 IDD,
Aged &
Physically Disabled

We also relied on an environmental scan developed by Truven Health of the quality provisions found in MLTSS MCO contracts. This scan includes quality-related contract requirements for all eight MLTSS programs which we focus upon in this study.5

The body of this report attempts to summarize the multiple components of the quality management systems in the eight MLTSS programs. These components can be organized into three broad categories:

  • State infrastructure for monitoring quality;
  • Monitoring and improvement activities; and
  • Member safeguards.

At the end of the report, some additional quality-related topics that we pursued with our informants are presented.

The Appendices at the end of the report provides individual detailed summaries of the various components of the quality strategies in each of the eight MLTSS programs. The information residing there was gathered from our interviews, documents provided by the state, MCO or EQRO, as well as documents publicly available on state websites. We provide these more in-depth summaries of each state so that the reader has access to the rich detail about the structure of their quality management programs.

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