Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Establishing a Quality Assurance System That Effectively Balances Risk and Autonomy


Community living presents a different set of risks from those associated with living in an institution. Transition programs need to have a quality assurance (QA) system that monitors and helps ensure service quality and client safety, particularly in the immediate period after transition and for the first few months. At the same time, however, such a QA system must respect individuals’ autonomy by acknowledging their choice to assume risk. The balance is delicate and can be hard to achieve. Programs that use a participant direction model allow individuals to assume more responsibility and accountability than those that use an agency-directed model. (See Chapter 7 for a full discussion of participant direction service delivery models).

The assurances CMS requires from states for approval of HCBS waiver services include “necessary safeguards” to safeguard the “health and welfare” of persons receiving services in the community. Since HCBS waiver programs serve a diverse array of target populations, no one-size-fits-all application of these QA requirements can be prescribed. (See the Appendix for an overview of CMS requirements for quality management and improvement systems.)

Diversion Strategies: State Examples

Several states have recognized the need to prevent both unnecessary nursing facility admissions and unnecessarily long stays that result in a loss of housing.

Rhode Island developed a protocol for the State’s long-term care nurses--who conduct level-of-care determinations and Level I Preadmission Screening and Resident Review (PASRR)38--to identify and refer individuals who do not appear to be at risk for a long stay when admitted. Based on the success of this protocol, in 2005 the State enacted a statute requiring that registered nurses (RNs) reevaluate all new nursing facility admissions 45 days after admission. The RNs who perform level-of-care and PASRR determinations flag individuals who appear to require only a short stay, and a computer-generated letter to this effect is sent to the resident and the nursing facility. A computer-generated reminder is sent to the RNs 45 days after admission, instructing them to evaluate the most recent MDS assessment to determine whether a continued stay is required.39

Rhode Island also enacted a statute in 2004 requiring the Department of Human Services (DHS) to inform nursing facility residents about home and community services that may enable them to live in a less restrictive community setting or their own home. The law requires DHS to mail a brochure describing the range of available services to all nursing facility residents whom the state long-term care nurses have identified as likely candidates for discharge within several months of admission.40

Nebraska operates a nursing facility preadmission program--Senior Care Options (SCO)--to ensure that Medicaid applicants in need of nursing facility care receive information on alternative choices appropriate to their level of care. SCO staff, located throughout the State, are trained to use the Blaylock Risk Assessment Scoring System (BRASS) screening tool, an instrument that identifies patients at risk for prolonged hospital stays at admission and in need of discharge planning services; BRASS can also be used to identify individuals at risk for long nursing home stays.

As a result of positive experience with the tool, the State changed its preadmission screening procedures. Every AAA now employs the BRASS tool for preadmission screening to identify individuals who should be reassessed in 3 to 6 months. For these individuals, Medicaid provides only a short-term authorization to enter a nursing home so that they will have to be reassessed to remain there. This change has led to active discharge planning to return new admissions to the community, and has resulted in shorter nursing home stays.41

Nebraska also allows service coordinators to authorize waiver services for individuals who will likely be eligible for Medicaid coverage. Based on basic financial information provided by the applicant, the service coordinator consults with a Medicaid eligibility worker who can judge whether it appears that the applicant will be eligible for Medicaid. If, ultimately, the applicant is not eligible, the State uses funds from the Social Services Block Grant to pay for services, which has occurred only twice over a 2-year period.42

New Jersey’s preadmission screening process for all nursing home admissions designates Medicaid beneficiaries as “Track One” or “Track Two” depending on whether they are likely to remain in the facility for a long or short period of time. All short-term residents receive a letter indicating that they are certified for 6 or fewer months and are contacted by Community Choice counselors who work with them to develop a relocation plan.43

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