NHTD Quality Management Program
Through a robust system of Discovery, information is gathered, when there are problems and analyzed to determine where the locus of the problem primarily lies, for example at provider or program level. Once appropriate action is taken to remedy the problem, the system of Discovery is used continuously to assure the proposed solution has been successful. Embracing the "participant-centered approach" to service provision, the Department of Health (DOH), Quality Management Specialists (QMS), Regional Resource Development Centers (RRDC), Regional Resource Development Specialists (RRDS), Nurse Evaluators (NE), Service Coordinators (SC) and other provider agencies work collaboratively with waiver participants with a focus on choice and satisfaction.
The NHTD QMP uses a five-level approach. Each level has a responsibility and an opportunity for identifying problems (Discovery), creating solutions at the provider level (Remediation) and assisting in changes in program policy (Improvement).
Level One is the waiver participant and natural (informal) supports. Waiver participants work with waiver providers to develop a Service Plan that reflects personal goals and strategies to assure successful outcomes.
The QMP assures waiver participants receive ongoing support and monitoring of their health and welfare throughout their participation in the waiver through:
- waiver participant education;
- Team Meetings;
- visits with the SCs;
- access to all waiver providers and the NHTD Complaint Line;
- annual Participant Satisfaction Surveys; and
- timely response to concerns or SRI.
Waiver participants play an active role in the Discovery process through communicating problems or issues to waiver providers. Working with the DOH, QMS, RRDC and waiver providers, waiver participants are part of the remediation process and provide input into solutions to assure successful outcomes.
Level Two is the SCs and other waiver service providers. Providers must employ self-monitoring strategies that assure the agency's policies and procedures regarding service provision to waiver participants meet the standards of the waiver (Discovery). When problems are identified, waiver providers must evaluate whether the difficulty is staff-specific and/or related to provider-specific or programmatic policies and procedures. If the provider's policies and procedures are the source of the problem, then the provider must assure changes in policies and procedures are made that continue to support the waiver participants and maintain compliance with the standards of the waiver.
Using the NHTD Program Manual as a guide, each provider will have the tools needed to understand and measure the quality of service provision. These tools include:
- policies regarding Service Plan (SP) development;
- changing procedures;
- Participant Satisfaction Surveys;
- Complaint procedures and SRI protocols;
- Serious Incident Review Committee (SIRC);
- Team Meetings; and
- outcomes of DOH surveys and Office of Medicaid Inspector General (OMIG) audits.
Level Three is the RRDC which employs the RRDS and NE. The RRDC has a lead role in the transition and diversion of waiver participants. It is responsible for:
- outreach, education and training;
- resource identification and referral, networking, assuring level of care, maintaining an aggregate budget and approving SPs;
- the RRDS acts as a gatekeeper and a point of contact for the NHTD waiver. He/she interviews all potential waiver providers;
- interviews all potential waiver participants;
- reviews every Application Packet and SP, and assures cost neutrality in the region; and
- the RRDS also compiles and reviews data collected from waiver providers and waiver participants in his/her region for quality assurance.
The NE must be a Registered Nurse certified to conduct PRI and SCREEN (refer to Appendix F) assessments to evaluate, as necessary, new waiver participants and participants returning to the community following a significant medical event that may have altered the individual's cognitive or physical abilities. The NE will evaluate
- SPs at the direction of the RRDS, as appropriate; and
- provide the results of his/her evaluation to the SC selected by the waiver participant, as well as to other appropriate parties at the direction of the RRDS.
The RRDC personnel maintain regular contact with the QMS and DOH Waiver Management staff (WMS) regarding quality management issues. Through these activities, the RRDC staff plays an essential role in the Discovery, Remediation and Improvement processes.
Level Four is the QMS, another key resource in the waiver. The QMS is responsible for
- overseeing the SRI process;
- providing technical assistance to the RRDS as requested;
- analyzing data obtained from RRDS reports, participant complaints and retrospective record reviews, monitoring for regional trends;
- working with the RRDS and waiver providers to remedy any issues discovered and makes recommendations to DOH WMS for systemic improvements;
- reviewing SPs over $300 per day to assure the health and welfare needs of the waiver participant are met in a cost effective manner; and
- assuring Participant Satisfaction Surveys are conducted through face-to-face visits with participants to assess satisfaction.
The QMS personnel maintain regular contact with the RRDC personnel and DOH WMS regarding quality management issues.
Level Five is the DOH WMS, who has the overall responsibility for the waiver. The DOH WMS consists of skilled professionals who have knowledge regarding diverting and transitioning individuals from nursing homes and maintaining them in the community. This team works collaboratively with the OMIG and other State agencies to share information useful to the waiver's success.
DOH WMS conduct ongoing reviews of Discovery information received through:
- Regional Forums;
- RRDS, QMS and waiver provider reports;
- fair Hearings;
- Complaint Line calls;
- quarterly meetings with QMS and RRDS;
- random retrospective record reviews;
- financial audits; and
Through the team's ongoing collaborative efforts, data is shared and analyzed for use in implementing remediation at the provider and/or regional level and developing strategies for implementation on a state or system-wide level. DOH WMS may initiate remediation actions including additional provider training, restriction of the provider opportunity level (vendor hold) for providing services to participants, or termination of a provider agreement. The staff maintains open communication through a variety of forums with all entities involved with the waiver, providing feedback and direction for change or improvement. DOH WMS meets at least quarterly with the RRDS and QMS to identify concerns and examine remedial actions.
DOH WMS continuously monitors the outcomes of these changes or improvements through ongoing Discovery measures to assure the standards of the waiver program are maintained through all levels of the QMP. That staff works with the RRDS and QMS to identify trends that need response by Remediation and/or Improvement activities to assure the underlying philosophy and assurances of this waiver are maintained. DOH WMS also monitors the QMS and RRDC by conducting on-site visits and annual evaluations to assure they are meeting contractual obligations.
Another forum important for data sharing is a Quality Advisory Board, designed to keep waiver participants, stakeholders, advocates and community representatives informed and involved in the process for change or improvement to the NHTD waiver program. This Board works with DOH WMS at least twice a year to review trends and provide feedback.
The QMP is an ongoing process whose strategies change over time in response to the changing needs of the NHTD waiver and New York State. The success of the QMP strategies are reviewed minimally at every quarterly RRDS and QMS meeting, with the submission of RRDS and QMS quarterly reports, annually and at other times at the discretion of DOH WMS. An annual summary and report is sent to CMS describing the ability of the waiver to meet the assurances described in the application.