Enhance Quality Outcomes

The Need

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A primary responsibility of the Department is ensuring the health, wellness, and safety of our members. As such, we must implement quality standards and maintain strict oversight of provider agencies. The Department proposes a series of projects to develop quality frameworks and oversight requirements, resulting in anticipated cost savings, provider accountability, and improved 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

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

Home Health

The Department will develop a pay-for-performance methodology for Long Term Home Health services. The changes will embrace the guidance in the proposed federal rule that accelerates the shift from paying for home health services based on volume, to a system that incentivizes value and quality. The proposed changes address challenges facing Americans with Medicare who receive health care at home. The proposed rule also outlines nationwide expansion of the Home Health Value-Based Purchasing (HHVBP) Model to incentivize quality of care improvements without denying or limiting coverage or provision of Medicare benefits for all Medicare consumers, and updates to payment rates and policies. The Department will look to this new proposed rule to design and develop methodologies and models to select the best value-based payment options for the Colorado Medicaid program.

HCBS

The Department currently pays for most services under a fee-for-service methodology, which rewards for volume of services rather than the quality of the care provided. The Department will shift to pay-for-performance programs within a few program areas. By supporting these pay-for-performance programs, the ARPA funds will serve as a catalyst to expand and sustain new performance-based models of care. First, the Department will develop a pay-for-performance rate methodology for the HCBS Residential programs. The Department will work with states that use pay for performance to identify key performance indicators to accomplish policy directives such as ensuring proper placement and care planning. Recommendations will be developed on performance benchmarks, bonus pay amounts, and per diems.

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

To better understand where there are quality gaps in the HCBS waiver programs, the Department will expand waiver quality surveys and metrics. This will provide insights into member experience, member satisfaction, and whether members received care that they reported needing. The Department will utilize the data to recommend changes to waiver programs.

The Department will research and recommend the most appropriate member surveys to determine member experience, health outcomes, satisfaction, and quality outcome analysis measures. The Department will design and/or procure the surveys and implement member outreach, engagement, and survey completion. Waiver amendments may be required if modifications to performance measures are made as part of this initiative.