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TennCare HCBS Waiver Monitoring: Tools, Data, and Overview

This overview provides information on the monitoring process for the TennCare HCBS waivers, including the tools used, data analysis, and performance levels. It also discusses the criteria for 3 and 4-star status for providers.

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TennCare HCBS Waiver Monitoring: Tools, Data, and Overview

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  1. Waiver Monitoring Overview • DIDD implements HCBS Waivers under the administrative oversight of TennCare: • Self-Determination Waiver • CAC (Comprehensive Aggregate Cap) Waiver • Statewide Waiver • Monitoring for each waiver consists of QA utilizing two review tools: • Qualified Provider • Individual Review (state-wide sample selected at the beginning of each waiver-year) • All findings / issues are expected to be remediated with provider and systemic trends identified and addressed. • Findings / issues are reviewed and discussed by Regional and Statewide Quality Management Committees and with TennCare.

  2. Quality Assurance Tools & Data • FY ‘04 thru ’06 QA Tools: • included CMS Quality Framework and expectations • editing of QA Outcomes & Indicators • scoring and performance level revision • 06/07 to present: minimal changes to the Quality Assurance tools allows for: • comparison of data across extended period of time • QA Data Provides an overview of system performance • data utilized by DIDD (central / regional) • Quality Management Committees • TennCare • Data facilitates change and decision making • data is used in assessing progress and to identify areas of needed improvement • Special Reporting • review of Domains, Outcomes and Indicators • review of provider performance • comparison of performance across years

  3. Quality Assurance System Overview • Quality Assurance Survey Process: • Consultative Reviews • Annual Review except for some clinical providers and those providers achieving 3 or 4 Star status • Sample Selection • Notification / document request • On-site review • Conciliation process • Report of findings • Reporting through Regional and Statewide Quality Management Committees • Quality Improvement Planning

  4. Quality Assurance System Overview • Quality Assurance Tools: • Organizational: • Day-Residential / Personal Assistance / Clinical • Independent Support Coordination (organizational practices & review of data from waiver Individual Record Reviews) • Individual: • Day-Residential • Personal Assistance • Behavioral • Nursing • Therapy • Performance Levels: • Exceptional Performance • Proficient • Fair • Significant Concerns • Serious Deficiencies

  5. Quality Assurance System Overview • Quality Assurance Tool Structure: • Domains 1. Access and Eligibility 2. Individual Planning and Implementation 3. Safety and Security 4. Rights, Respect and Dignity 5. Health 6. Choice and Decision Making 7. Relationships and Community Membership 8. Opportunities for Work 9. Provider Capabilities and Qualifications 10. Administrative Authority and Financial Accountability • Outcomes • Indicators • Guidance and Provider Manual References

  6. Quality Assurance System Overview • Quality Assurance Scoring & Domain Applicability: • Domains Applicable by Provider Type: • Day-Residential: 2, 3, 4, 5, 6, 7, 8, 9, 10 • Personal Assistance: 2, 3, 4, 5, 6, 9, 10 • Support Coordination: 1, 2, 3, 9, 10 • Behavioral: 2, 3, 4, 6, 9, 10 • Nursing: 2, 3, 4, 5, 6, 9, 10 • Therapy: 2, 3, 4, 6, 9, 10 • On the web: • QA and Waiver Review Tools • Report Card Listing • Star Listing • Resource / Reference Documents

  7. Star Providers • 3 & 4-Star Status: • 4 Star: 96% or above (Exceptional) compliance on QA surveys for 2 years; • 3 Star: 85% or above (Proficient) compliance on QA surveys for 2 years; • Must achieve Substantial Compliance in Domain 3 • ISC agencies must achieve Substantial Compliance in Domain 2 • No Domain below Partial Compliance • Other criteria as applicable • Approval by the Regional Quality Management Committee, followed by submission to State-wide Quality Management Committee for final approval. • 3 & 4 Star providers skip a QA survey • 2-Star Status: • Recognition of performance • Criteria as applicable • Annual survey as scheduled • All 2, 3 & 4 Star criteria and awards are posted on the DIDD internet at: http://www.tn.gov/didd/article/star-agency-recognition

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