Twenty-four hour back-up can refer to having an informal back-up plan in the event that a direct care worker does not show, as well as to the existence of a formal systems-level back-up when the informal back-up plan fails. This may include on-call care coordinators and/or providers.
Quality in Managed Long-Term Services and Supports Programs. B. Critical Incident Review and Investigation
In recent years, CMS has placed substantial emphasis on the importance of critical incident management processes in the 1915(c) HCBS waiver programs. With CMS' MLTSS guidance, this expectation now extends to MLTSS programs.
Care coordination is the back-bone of member safeguards. Care coordinators are the system's eyes and ears for ensuring the well-being of members. They help the individual devise a service/support plan that is intended to meet their unmet needs, minimize risk, maintain health/function, and provide quality of life.
Member safeguards are a critical component of the design of any MLTSS program, and serve to protect the health, safety and welfare of persons served, typically individuals with cognitive, emotional and/or physical vulnerabilities.
Two states were in the process of developing report cards at the time the study was being conducted. In Texas, the EQRO was assisting the state to finalize a legislatively-mandated MCO report card which will eventually be published on the state's website.
Quality in Managed Long-Term Services and Supports Programs. I. Quality-Related Financial Incentives, Penalties and Withholds
States have opportunity in designing their payment structures to reward MCOs for quality care/outcomes and to dis-incentivize them for performance below acceptable thresholds. In our interviews with states as well as in reviewing MCO contracts and other supporting information on state websites, we identified multiple examples of states using monet
Quality in Managed Long-Term Services and Supports Programs. H. Long-Term Services and Supports Performance Improvement Projects
All Medicaid managed care programs must have an ongoing series of PIPs focused on clinical and non-clinical areas. 20 In this inquiry, our interest was to discover the types of PIPs MLTSS programs conduct and if they have particular relevance to MLTSS services and/or populations--in essence whether the programs require their MCOs to engage in L
Quality in Managed Long-Term Services and Supports Programs. G. External Quality Review Organization Responsibilities
Our interest in the EQRO pertains to activities they perform above and beyond those required under the Medicaid managed care regulations (compliance review, validation of encounter data, performance measures and PIPs). In particular, we were focused on additional quality management activities for which states employ EQROs in their MLTSS programs.
"Stakeholder engagement", inclusive of program oversight, is considered a key element in CMS' guidance document. Moving forward, CMS expects states to involve stakeholders, including members, in program evaluation and monitoring. CMS also expects states to require MCOs to convene member advisory committees to provide feedback on MCO MLTSS operatio
CMS' recent MLTSS guidance calls for states and/or MCOs to measure members' experience of care and quality of life. All of the programs reviewed field either satisfaction or experience of care surveys, with most administering them on an annual basis. In some instances, the surveys are conducted by the state, whereas others are completed by the MCO
In 2008, the U.S. Government Accountability Office (GAO) recommended that CMS encourage states to conduct mortality reviews in 1915(c) HCBS waivers. 16 The mortality review process typically involves screening a death to ascertain whether it meets a pre-determined criteria for an in-depth review, investigation by a mortality review committee of
Verifying the delivery of home and community-based LTSS services is a critical component of managed care oversight due to the vulnerability of populations served. Late or missed visits, especially those that provide assistance in essential every day activities, place the member at potential risk of untoward outcomes.
All the MLTSS programs conduct routine audits of MCOs. What varies among them is the frequency and intensity of focus. Half of the programs conduct annual audits in-house (Pennsylvania, North Carolina, Texas, and Wisconsin), and two delegate this responsibility to the EQRO (Texas, Wisconsin).
Quality in Managed Long-Term Services and Supports Programs. IV. Monitoring and Improvement Activities
All of the programs we examined rely on a variety of mechanisms to assess quality of care and MCO compliance with contract requirements for delivering services and supports. In this section we focus on audits, MCO reporting, verification of service receipt, mortality reviews, member feedback, how members participate in quality oversight, the EQRO'
Quality in Managed Long-Term Services and Supports Programs. III. State Infrastructure for Quality Monitoring
CMS' recent guidance on the design of Medicaid MLTSS programs identifies the resources that a state must have for overseeing program quality. These include resources to:
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
A growing number of states have decided to expand their Medicaid managed care programs to encompass Long-Term Services and Supports (LTSS). From 2004 to 2012, the number of states with Medicaid managed LTSS (MLTSS) programs doubled from eight to 16, and ten more states are projected to implement MLTSS programs by 2014. 1 As states move their LT
As of 2012, 16 states had managed long-term services and supports (MLTSS) programs for Medicaid beneficiaries. This is an exploratory study of how eight of these states implemented Medicaid MLTSS quality oversight in their programs.
The following acronyms are mentioned in this report and/or appendices.
We are grateful to the states, managed care organizations and external quality review organizations who opened their doors to us and shared their particular methods, successes and challenges in managed long-term services and supports quality management. In particular, we acknowledge: