Pay for Performance for LTSS

November 4, 2013

Lisa Alecxih, Senior Vice President

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Overview

• Pay for Performance Framework for LTSS

• Requirements for Successful Pay for Performance System

• Questions to run on:– Does the framework seem consistent with elements that

would be important to incentivize?– What might need to change in your organization to succeed

under pay for performance?

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Pay for Performance Framework for LTSS

• Organization/Structure– Assessments, Records and Information Exchange– Workforce Development– Culture of Person Centered Thinking and Continuous Quality Improvement

• Process– Participant Safeguards– Participant Choice and Pursuit of Personal Goals (Person Centered Planning)– Participant Rights and Responsibilities– Relationships and Community– Continuous Quality Improvement for Service Delivery

• Outcomes– Clinical – Participant Experience– Workforce

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Organization

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Organization: Assessments, Records and Information Exchange

• Strength-based assessments

• Documentation shared electronically across LTSS, primary, acute, and behavioral health providers

• Person centered planning tools

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Organization: Workforce Development

• Staff qualifications (degrees and certifications)

• Staff capabilities and competencies

• Training related to:– Principles of “person-centered care” and direct care staff decision-making– Leadership tools and techniques, as well as improving communication

among staff and with other providers for supervisors and middle managers

– Relevant populations, disease processes, and palliative care, improving their understanding of participant/resident needs, and thus responsiveness

• Adjusting salaries to market standards, to improve staff satisfaction

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Organization: Culture of Person Centered Thinking and CQI

• Relationship-based organizational culture

• Empowering staff to communicate more effectively and to address concerns as they arise

• Evidence-based care decision support tools

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Process

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Process: Participant Safeguards

• Prevention and investigation of abuse, neglect and exploitation

• Tracking of major and unusual incidents

• Ensuring safety of housing and environment

• Regulation of behavior interventions

• Standards for medication management

• Provisions for personal safety and security

• Preparation for natural disasters and other public emergencies

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Process: Participant Choice and Pursuit of Personal Goals (Person Centered Planning)

• The consumer sets the agenda

• The consumer chooses the team

• The team works on the consumer’s agenda

• There are measurable accomplishments

• The team celebrates those accomplishments

• The plan is about the individual’s life

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Process: Participant Rights and Responsibilities

Ensure that participants:  

• Exercise civic and human rights

• Participate in decision making authority

• Have provisions for alternate decision making

• Have access to due process and grievance mechanisms

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Process: Relationships and Community

• Orienting all new staff, participants/residents, family members and volunteers to the relationship and community culture

• Governance that includes participants

• Leadership committed to relationships and community

• Managers modeling relationship skills

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Process: Continuous Quality Improvement for Service Delivery

• Ongoing service and support coordination

• Provision of needed services

• Ongoing monitoring

• Responsiveness to changing needs

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Outcomes

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• Hospitalization events, including exacerbations of:

– Chronic conditions (diabetes, asthma, COPD, and congestive heart failure)

– Acute illnesses (bacterial pneumonia, urinary tract infection, dehydration, infection due to device or implant)

• Pressure ulcers• Injurious falls

• Percent of residents who:

– Had bladder catheter inserted– Were physically restrained– Had moderate to severe pain– Had falls– Developed pressure sores– Had unexplained weight loss

Quality Indicators for HCBS Population Nursing Facility Pay for Performance

Outcomes: Clinical

Ellen Schultz, Sheryl M. Davies, Kathryn M. McDonald (2012). Development of Quality Indicators for Home and Community-Based Services Population: Technical Report for the Agency for Healthcare Research and Quality accessed at http://www.qualityindicators.ahrq.gov/Downloads/Resources/Publications/2012/HCBS%20QI%20Technical%20Report.pdf.

Werner and Tamrara Konetzka (2013). “The effect of pay-for-performance in nursing home: Evidence from Medicaid Programs,” Health Services Research 48 (4) accessed athttp://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12035/abstract .

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Outcomes: Participant Experience

• National Core Indicators Project developed by HSRI covers:– Individual Outcomes– Health, Welfare, and Rights– System Performance– Staff Stability– Family Indicators– http://www.nationalcoreindicators.org/

• CMS Participant Experience Survey developed by Truvent (at the time MedStat) covers:– Access to Care– Choice and Control– Respect/Dignity– Community Integration/Inclusion– http://www.hcbs.org/moreInfo.php/doc/652

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Outcomes: Workforce

• Staff stability measured through turnover and tenure

• Staff availability measured through vacancies

• Staff satisfaction

Specific measures for stability and availability defined in CMS sponsored report The Need for Monitoring the Long-Term Care Direct Service Workforce and Recommendations for Data Collection developed by the Direct Service Workforce Resource Center and posted at http://www.dswresourcecenter.org/tiki-index.php?page=Data+Collection

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Requirements for Successful Pay for Performance System

• Setting neutral to the extent possible

• Common understanding of the pay for performance framework and how the elements inter-relate among:– Payer (e.g., Medicaid staff)– Provider leadership and administration– Front-line staff

• Management Information Systems (MIS) and exchange protocols integrated into daily practice

• Continuous quality improvement– Metrics used to identify areas for improvement to pursue– Avoidance of punitive approach