Enhance Quality Outcomes

Initiative 8.06. - PACE Licensure

Within the PACE program, the Department will develop quality standards by establishing a PACE licensure type to ensure appropriate oversight and compliance. The Department will establish a PACE audit structure including fee cost, resource needs, timeline, survey elements, corrective action plan templates, reporting requirements, valid sample size, appeal process, performance measures, and interview questions. The Department will also develop a system to record and capture incident reviews, complaints, survey results, and reports. This will require the Department to submit amendments to the State Plan and Program Agreements with each PACE Organization.

Initiative 8.04. -  Pay-for-Performance for PACE

The Department will identify key performance measures to incorporate into a pay-for-performance methodology within the PACE capitation payments. The percentage for each performance measure will be identified and the monitoring processes and reporting requirements will be outlined. The appeals process and contractual language will also be developed.

Initiative 8.08. - CMS Quality Metrics

The Department will routinely stratify CMS quality metrics by disability and SMI status. To accomplish this, the Department will invest in data repositories that enable more robust insights into gaps in care as well as the providers and services with positive outcomes, supports, and programs for individuals receiving HCBS. The Department will share this data with the RAEs and CMAs to help them connect members with the highest-performing providers. This information may also be leveraged by the above-described eConsult system. The Department will use the funding for systems investments to create clear data linkages necessary for dashboards to be operational.

Initiative 8.11. - Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Benefits Training

(previously named Quality Measures and Benefits Training)

To ensure the best use of services potentially available to the HCBS population, the Department will develop training on quality performance measures with a focus on EPSDT benefit metrics. The team will use an analysis of EPSDT exceptions to illuminate current gaps in the HCBS program. The analysis will be used to create training materials that will include specific learning objectives on how and when to use EPSDT exceptions and how and when to use HCBS services. To the extent this analysis exposes policy gaps, this information would be used to inform policy and program adjustments. These trainings will also be used to assist the state to meet the federal requirement of an intersection of EPSDT and waiver services as outlined in the CMS Part V Manual.

To complete this project, the Department will provide a standard, adult learning training on EPSDT benefit and performance metrics. The final product will be posted on Department websites and updated regularly as a sustainability mechanism. The training is expected to be 4-6 separate training modules. 

Initiative 8.02. - Provider Oversight

The Department operates ten waivers to provide HCBS to our members. To do this, the Department contracts with the Colorado Department of Public Health and Environment (CDPHE) to certify providers, demonstrating they meet state and federal requirements regarding the safety and well-being of consumers. The certification process involves an initial survey when the provider enrolls in Medicaid and unannounced re-certification surveys periodically thereafter, in most cases every three years. Through onsite visits, surveyors capture comprehensive information on policies and procedures, consumer experience and satisfaction with services, staff perspectives on care quality, alignment between care plans and service delivery, and, in the case of residential settings, facility safety and cleanliness.

The Department has identified challenges with the certification processes, including lack of standardization across provider types and an increasingly complex process and workload. In addition, The Department does not have the tools necessary to analyze information on certification outcomes and hold providers to higher standards of quality of care.

The Department will finalize and implement work started in 2016 to address these challenges and to streamline the CDPHE oversight and application process. Specifically, the following work will be accomplished:

• Confirm prior decision points made on where the process could be simplified, or unnecessary steps could be eliminated entirely with the goal of reducing the time it takes a provider to become enrolled
• Implement a 3-tier system for all waiver services based on risk for fraud and abuse  
• Facilitate and support break-out cross-Department groups in making necessary changes
• Provide support to streamline and align the certification processes across survey types
• Make recommendations to improve data collection and sharing, so data is actionable 
• Create an action plan and timeline to implement recommendations from 2016 such as:
• Allow deeming based on accreditation, 
• Streamline and align current survey certification processes, 
• Emphasize Quality Management Programs, 
• Enhance remediation strategies, and
• Create a comprehensive picture of provider quality.
• Create recommendations to integrate the surveying and provider enrollment processes more fully across CDPHE, HCPF, and its vendors, such as:
• An electronic workflow that would allow a warm handoff from CDPHE to HCPF for enrollment to bill for services once survey work is completed, and
• Creation of an identification method for the shared tracking of providers across the two agencies.

 ✅ Initiative 8.05. - Pay-for-Performance for Home Health & HCBS - Completed

(combined 8.05 Pay for Performance for Home Health & 8.03 Pay for Performance for HCBS)

Key Project Activities and/or Achievements: 

HCPF completed research and analysis that will guide future efforts in pursuing a pay-for-performance model in long-term home health and Residential HCBS. Through internal and external stakeholder interviews, a literature review, national scan, and actuarial analyses, HCPF received recommendations for a series of quality measures to employ in unison with a pay-for-performance payment model. 

Project Outcome: 

The team received a menu of potential metrics that could be used for pay for performance in long-term home health and Residential HCBS. If HCPF pursues pay-for-performance models in long-term home health or Residential HCBS services, they will finalize the selection of metrics with stakeholders.

Initiative 8.10. - Criminal Justice Partnership

Note: As of November 2021, this project has been renamed Criminal Justice Partnership, to reflect the engagement of the entire criminal justice system.

The Department has engaged with the Colorado Department of Corrections to address behavioral health services engagement as individuals are released from prison. This project will expand post-release supports to members who are transitioning or may have already transitioned back into the community. The Department will address the following action items:

• Identification of best practices of engaging justice-involved members,
• Review and improve eligibility processes for waiver services,
• Identify most prevalent needs from these members and work with stakeholders to implement best practices,
• Collaborate with justice systems at each level (released from incarceration, parole and probation) to implement best practices,
• Work with state and local government and community-based organizations to identify solutions, develop meaningful metrics and build lasting support systems for individuals involved with the justice system,
• Partner with the Regional Accountability Entities to create member-reported information about the need for justice-specific care coordination. Provide training materials and education to RAEs, and 
• Identify data system opportunities to monitor member enrollments in multiple systems and develop strategies to ensure data system connections are in place to improve coordination activities.

Initiative 8.01. - Provider Scorecards

To support quality performance, the Department will establish metrics and develop public-facing provider scorecards. Scorecards can be used to identify providers that may need more intense oversight and to help consumers and their families make choices about their care. Providers with continuously low scores could face additional corrective action. 

The Department will create provider and CMA scorecards and will add the scorecards to the provider search tool. Applicable performance measures will also be included in the scorecard. The Department will develop metrics and a weighting algorithm incorporating provider input. Providers should understand metrics and underlying data sources and believe that scores accurately and meaningfully represent care quality. Provider input and buy-in can help the Department develop a better methodology, promote higher quality data collection, and encourage providers to improve performance based on findings. The Department will continue to update these scorecards moving forward.

Initiative 8.07 - eConsult to Improve Quality

The Department is implementing an eConsult system in FY 2021-22 to increase the capacity and capability of primary care providers, to reduce unnecessary specialist visits, and to connect appropriate specialist referrals to higher performing specialist providers. The Department will research whether it is feasible to expand the eConsult program to include a broader array of specialists, such as providers that have expertise and good outcomes working with individuals with disabilities. The Department will adjust the overall eConsult design in accordance with federal feedback. 

 ✅ Initiative 8.09. - Waiver Quality Expansion - Completed

Key Project Activities and/or Achievements:  

ARPA 8.09 expanded the waiver quality surveys administered by the Department of Health Care Policy and Financing (HCPF). HCPF partnered with an independent firm, Vital Research, to assist in the development and administration of two surveys, the Children's Waiver Satisfaction Survey (CWSS) and the Case Management Satisfaction Survey (CMSS).  

Summary / Project Outcome:  

Given the importance of case managers in delivering services to residents of the state of Colorado, ARPA 8.09 generated the Case Management Satisfaction Survey to obtain a better understanding of case manager's satisfaction with compensation, benefits, career advancement, training, and overall fulfillment in their positions.  In addition, HCPF hoped this understanding would aid in recruitment and retention of case managers throughout Case Management Redesign. The final survey included 34 items, where case managers were asked close-ended items about their overall engagement and satisfaction in their roles. In addition, an open-ended item for additional comments was included.  

A total of 1,040 potential respondents received a survey link and three reminders to complete the survey via email. Data collection began on 10/27/2022 and was concluded on 11/21/2022​. Of the 1,040 invitations that were emailed to complete the survey, a total of 580 responses were received for a response rate of 56%. Using a 95% confidence interval, the margin of error was +/- 2.7%.

Key findings from the Case Management Satisfaction Survey:

• Most respondents had worked for their current agency for one to two years (31%) and 67% had worked as a case manager for three or more years.
• Nearly 80% of case managers are satisfied with their job and 73% are satisfied with their wages and benefits. Yet based on the open-ended comments, compensation was noted most often as an area that is a source of dissatisfaction.
• Case managers are fulfilled in their jobs.  Case managers think that the work they do is important (99%), they feel a sense of accomplishment (91%) and they find their job enjoyable (82%).  Yet, half of all case managers feel their work environment is very stressful and four in 10 feels emotionally drained from work.  This is supported by open-ended comments where burnout, stress and morale were mentioned as contributing to case manager mental health issues.
• Case managers feel they enjoy a good amount of autonomy in their job.  Case managers have lots of flexibility (94%), they feel their ideas and suggestions are valued (79%) and they believe their current work environment empowers them to accomplish their work in an effective manner (79%).  On the other hand, almost two thirds (63%) of case managers believe they have too much responsibility and not enough authority.​
• When case managers were asked how likely they would be to leave their job in the next year, 37% indicated that it was somewhat or very likely.  In addition, case managers are also not likely to recommend this type of work to a family, friend, or colleague.
• Over 90% of case managers like the people they work with (99%), feel respected by their co-workers (97%) and supervisor (96%) and believe their supervisor is someone they can trust (94%).  Case managers also feel their work is appreciated (83%) and they are respected by upper management and leadership personnel (78%). On the other hand, nearly a third (31%) do not believe they receive adequate resources and materials to execute their assignments, which is supported by workload expectation comments that were mentioned 19% of the time by case managers.

The creation of the Children's Waiver Satisfaction Survey (CWSS) was an effort to expand on the National Core Indicator’s Children’s Family Survey (NCI-CFS) which primarily focused on Colorado’s Children’s Extensive Services (CES) waiver. The new children’s survey received feedback from families and members enrolled on the four children’s waivers, which included the Children's with Life-Limiting Illness (CLLI) waiver, Children's Extensive Services (CES) waiver, Children's Habilitation Residential Program (CHRP) waiver, and Children's Home and Community Based Services (HCBS) waiver. This survey aimed to establish insights into member experience, satisfaction, and report of care needs versus the actual services received. The data will be utilized to recommend changes to the waiver programs and will serve as baseline data to track outcomes of changes in policies and programs in the future.

The project produced two children’s waiver survey instruments, one for members under the age of 18, and one for members 18+. Surveys consisted of 48 items for those under age 16 and 52 items for 16-17-year-olds related to the following topics:

• Accessing + Understanding Child’s Waiver Program
• Case Management + Service Planning
• Child’s Services + Supports
• Family Needs + Supports
• Transition Needs for Young Adults (only answered by those whose children were age 16-17)
• Health Insurance + Other Benefits
• Demographics

The surveys launched in August 2023 and data collection closed in October 2023. 5,259 families enrolled on the Home and Community Based Services (HCBS) children's waivers were sent surveys via mail, and 2,392 families received the survey via email in addition to the mailed survey. 941 surveys were completed and used for analysis; 573 were received by mail, and 361 were received online. Using a 95% confidence interval, the margin of error was +/- 2.9%.

Key findings from the Children's Waiver Satisfaction Survey:

• Generally, results for case management were positive. 90% of respondents reported case managers were responsive to their requests. 89% of respondents were very​ satisfied or somewhat satisfied with their case manager. 98% of respondents reported their case manager respects their family’s choices and opinions. 46% of families did not experience any turnover in their case manager during the year prior to when surveys were completed.
• All respondents were asked if they had received a copy of their child’s service plan. While 68% of respondents had received a copy of the service plan, 32% had not or did not know if they had received a copy.
• All survey respondents were asked to rate the overall quality of the services and supports their family receives on their waiver program. Eighty-three percent of respondents rated the quality of their services and supports as either excellent or good. Just 17% of respondents felt their services and supports were fair or poor.