Missouri's Olmstead Implementation |
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Activity No. 2: Develop a tool or mechanism for assessing the effectiveness of these services and programs in addressing the needs of individuals with disabilities. Background Information Background Information One charge of the Commission was to develop a mechanism for assessing the effectiveness of these services and programs in addressing the needs of individuals with disabilities. In order to complete this, the activities that have been conducted by state agencies to date were identified. A survey was conducted with the participating state agencies concerning their current outcome measurements and what types of activities they would propose to assure that these services and programs were in fact addressing the needs of individuals with disabilities. Summary of Related Public Comments Some comments were received during public hearings and commission meetings about the need to evaluate any changes that are based on the Olmstead Commission. Dr. James Caccamo, Chair of the Mental Health Commission, led this charge. I think a final challenge facing you all, is to develop an evaluation plan that will help the commission determine if your recommendations are having a positive effect and positive outcomes for our clients who choose community-based living and community-based services. Mental Health Commission strongly urges that you think about evaluation now as we are building an effective system that people with disabilities will have choice in their service provider and in their place of residence. Now is the time to think of evaluation, not after the recommendations are put in place. Evaluation must not be an afterthought but rather an intentional process that informs you. He recommended that the evaluation plan be formative so as we move along over the years, what the evaluation system learns can help inform and change we're not building a system that's firm and cast in concrete. (Commission Hearing 11/13/00) Some participants in the Public Hearings expressed their views on quality assurance and evaluation. If the state develops more community services, the state should consider an accreditation and/or evaluation of these services. One speaker wanted a national system I'm here also to urge the Commission to -- in designing community services to not support a state-operated accreditation system, but rather to look at a national accreditation system. (Columbia). Sometimes when people with disabilities remain in their own home, family members take advantage of them. I've also seen people who are cared for by family members who took advantage of them and only wanted to keep them at home maybe for their Social Security check for some financial means. Our concern is is there going to be monitoring of those people who are going to be caregivers of people with disabilities. State Agency Information The next pages present the findings from the state agencies. Two questions were asked in the state interviews: (1) What quality assurance activities are currently conducted by your agency; and (2) If you were developing a tool assessing effectiveness of services to and programs in addressing the needs of individuals with disabilities, what areas would be looked at (e.g. physical setting of placement, opportunity for inclusion in community, consumer-directed) and what process would you use to do this: a tool (i.e. instrument) or mechanism (process)? In order to develop an effective measure, it needs to be well integrated into the current system of outcome measurement. Therefore, each agency also collected different outcome measures at the time of the survey. Department of Elementary and Secondary Education - The Department of Elementary and Secondary Education, Division of Vocational Rehabilitation utilizes different mechanisms to assure quality and appropriateness of care. These mechanisms include quality assurance, consumer satisfaction surveys, outcome studies, and agency profiles. Quality Assurance Activities Currently ConductedThe following is a description of the quality assurance activities of the Personal Care program of the Department of Elementary and Secondary Education, Division of Vocational Rehabilitation. Several types of activities are currently used to measure the effectiveness of their services. Consumer SatisfactionWhen cases are closed by the Centers for Independent Living, a postcard is sent to the consumer. There are several questions on the postcard that measure overall consumer satisfaction with Independent Living Services. The data from the surveys are compiled on an annual basis by Statewide Independent Living Council. Outcome StudiesAll Centers for Independent Living complete a Federal RSA Section 704 Report which is compiled by the Division of Vocational Rehabilitation, Rehabilitation Services for the Blind and the Statewide Independent Living Council. The report contains data regarding goals met to determine the effectiveness of service provisions. Quality AssuranceVocational Rehabilitation conducts ongoing monitoring activities, such as case reviews, training and technical assistance, and home visits with CIL PAS participants. CILs contact consumers monthly, with face-to-face consumer contacts required on a quarterly basis for a minimum of 12 contact hours per year. There is an appeal process available to each PCA applicant/recipient who feels they were denied service or if they disagree with an agency decision. How Agency Would Develop Assessment ToolThe Division of Vocational Rehabilitation has been working toward expanding these efforts. The Division has asked the Statewide Independent Living Council (SILC) to examine this issue and come up with recommendations. They would like to begin working on a continuous improvement model. Two recommendations the Division would like to work on first include:
Department of Mental Health - Division of Alcohol and Drug Abuse The Department of Mental Health, Division of Alcohol and Drug Abuse utilizes different mechanisms to assure quality and appropriateness of care. These mechanisms include quality assurance activities, consumer satisfaction surveys, ombudsman activity, outcome studies, appeal process, and agency profiles. Quality Assurance Activities Currently ConductedThe Missouri Department of Mental Health over the last several years has had an initiative looking at outcome studies. Both consumer satisfaction and outcome studies are part of the outcome measures. Consumer SatisfactionRegular site visits monitor contract compliance, billing reviews, and certification site surveys, which include interviews with clients. Once a year consumer satisfaction surveys are conducted of all individuals who seek care during the month of April. Outcome StudiesThe Center for Substance Abuse Treatment (CSAT) has made funding available for states to conduct studies of the need for treatment of substance abuse in their communities. Substance Abuse Prevention and Treatment (SAPT) Block Grant funds have been dependent in part on documentation of the need for such services. Missouri, with assistance from the Research Triangle Institute designed a "family of studies" to provide reliable and valid data to estimate the prevalence of substance abuse treatment need, facilitate planning such treatment, and aid in the implementation of effective and cost-efficient services. The needs assessment in Missouri consisted of a series of six studies that included both primary data collection and secondary analysis of existing data. Findings from these studies were combined with what was known in the literature on treatment needs to provide a comprehensive picture. Findings from quality assurance studies that assist the Division in determining its treatment programming and client needs include:
These findings are being computerized on the web and are repeated on a regular basis. Agency ProfilesThe Division of Alcohol and Drug Abuse also develops profiles of individuals served. Appeals ProcessFollowing the Leake process, anyone who applies for services with Department of Mental Health has the right to appeal many aspects of their care, if they are not satisfied. If they are deemed not eligible for services, they may appeal. If they disagree with service recommendations on the service plan, they may appeal. If they are getting a service and the service is taken away or reduced, the consumer has the right to appeal. Department of Mental Health - Comprehensive Psychiatric ServicesThe Department of Mental Health, Comprehensive Psychiatric Services utilizes different mechanisms to assure quality and appropriateness of care. These mechanisms include consumer satisfaction surveys, ombudsman activity, outcome studies, and agency profiles. Quality Assurance Activities Currently ConductedConsumer Satisfaction SurveysConsumer satisfaction surveys are conducted annually. During the month of April, all consumers who receive services receive a consumer satisfaction form. Ombudsman ActivityThe Department of Mental Health is planning to pilot an Ombudsman program in one region of the state for the Divisions of Comprehensive Psychiatric Services and Alcohol and Drug Abuse before the end of the fiscal year. Appeals ProcessFollowing the Leake process, anyone who applies for services with THE Department of Mental Health, has the right to appeal many aspects of their care, if they are not satisfied. If they are deemed not eligible for services, they may appeal. If they disagree with service recommendations on the service plan, they may appeal. If they are getting a service and the service is taken away or reduced, the consumer has the right to appeal. Outcome StudiesFor those receiving case management, several outcome measures are used. The CPS Adult Outcomes Assessment Packet includes an adult status report and the Multnomah Community Ability Scale. This outcomes information is obtained at admission, annually, and at discharge. For children, Comprehensive Psychiatric Services conducts a Child/Youth Status Report and Child Behavior Checklist (CBCL) at admissions, six months, and discharge. The Division is beginning to compare service providers based upon the outcome data that is being collected. Reports that describe findings from these activities are also being developed. How Agency Would Develop Assessment ToolThree elements should be included:
Department of Mental Health - Division of Mental Retardation/Developmental Disabilities The Missouri Department of Mental Health, Division of Mental Retardation/ Developmental Disabilities (MRDD) has established a number of quality assurance and outcome measures. The following are some of the salient components of the outcome system of the Division of MRDD: Quality Assurance Activities Currently ConductedSome of the key quality assurance activities that are being conducted are: Consumer SatisfactionConsumer Satisfaction Survey:
Appeals ProcessFollowing the Leake process, anyone who applies for services with Department of Mental Health, has the right to appeal many aspects of their care, if they are not satisfied. If they are deemed not eligible for services, they may appeal. If they disagree with service recommendations on the service plan, they may appeal. If they are getting a service and the service is taken away or reduced, the consumer has the right to appeal.
Quality EnhancementSeveral quality enhancement processes are conducted:
Ombudsman Activity: The Division of MR/DD has developed several ombudsman activities:
Outcome Studies: Outcome measures are currently under development.
In addition, there is some compliance measures that have been instituted by the Division of MR/DD. These include Abuse and Neglect Investigations, Quality Improvement Teams, and Division of Medical Services quarterly review of waiver programs. How Agency Would Develop Assessment ToolThe Division of MRDD had certification and survey staff until July 1, 2000. The survey staff, along with consumers, regional center staff, and other providers reviewed waiver programs to ensure that certification principles were being met. The actual licensure surveys are now conducted through the DMH Office of Quality Management (formerly licensure and certification). Staff from the Office of Quality Management review health and safety aspects, and consumer legal rights. A document, Core Requirements, is being written. It will describe the review process. This document, which includes a section on consumer rights and responsibilities, will be used by providers and DMH staff. The role of division staff, in relation to quality, is being revised as well. A new document, Missouri Quality Outcomes, was recently completed. This document describes the process and principles that will be followed by consumers, families, staff, and providers. The following list includes activities to develop additional quality assurance measures:
Department of Health - Bureau of Special Health Care Needs/Adult Head Injury Program The Department of Health, Bureau of Special Health Care Needs, Adult Head Injury Program utilizes different mechanisms to assure quality and appropriateness of care. The following enumerates the current and proposed quality assurance measures. Quality Assurance Activities Currently ConductedThe Adult Head Injury Program has conducted consumer satisfaction surveys during the past year. Outcome studies and quality assurance activities are currently in the process of being developed by the Department of Health. Guidance for Service Coordinators and providers for knowing when to transition consumers out of current services to new services, so the consumer does not linger in services, is being examined. The Department of Health has developed reports that describe some of the findings from some of these activities. How Agency Would Develop Assessment ToolThe Department of Health, Adult Head Injury Program, is currently looking at all of the areas listed in this question as possible outcome measures. In addition, infrastructure or environmental supports must be looked at. A focus would be put on natural supports. The person-centered approach would be examined in developing this instrument, as well as natural and environmental supports. Department of Social Services - Division of Aging The Division of Aging (DA) utilizes different mechanisms to assure quality and appropriateness of care. These mechanisms include quality assurance activities, consumer satisfaction surveys, ombudsman activity, outcome studies, and agency profiles. Quality Assurance Activities Currently ConductedQuality AssuranceEach agency under contract with DA receives technical assistance, provider training, and regular opportunities for policy updates through regional meetings hosted by DA. Additionally, each agency receives, at a minimum, an on-site evaluation of agency operations at least every two years. DA also utilizes Management Advisory Teams (MATs) to obtain input from field staff on a variety of topics, including proposals for improving services. Consumer SatisfactionDA currently has two formal processes to determine consumer satisfaction with service delivery. The first involves a ten-day follow up with new clients and clients transferred to a new provider. This contact ensures that services have been initiated according to information provided in the care plan and the annual reassessment visit and verifies that the current service plan remains appropriate to the person's needs. The case manager also assesses this issue any time the condition, circumstances, or situation of the individual changes significantly. In addition, DA has a Provider Complaint process whereby complaints about in-home service or their aides are forwarded to the Provider Monitoring Unit in Central Office for review and necessary action. Ombudsman ActivityThe Long-Term Care Ombudsman Program assists individuals in choosing a long-term care facility, including referring them to the MCO Program to ensure that facility placement is the appropriate setting for them. The program also refers residents of facilities to the MCO Program if they wish to leave the facility or move from a nursing facility to a Residential Care Facility. Outcome StudiesDA compiles and publishes the annual MCO report which illustrates the savings afforded by home and community based services as opposed to nursing facility placement. This report also details the number of pre-long term care screenings handled by staff and provides important demographic information for use in future program-planning efforts. Agency ProfilesCertain requirements must be met for an in-home provider agency to receive a contract with DA. These include the following: agency manager must be at least 21 years of age, and be a registered nurse licensed in Missouri or have at least a bachelor of science or bachelor of arts degree; or be a licensed practical nurse currently licensed in Missouri with at least one year of experience with the direct care of the elderly, disabled and infirm; or have at least three years of experience with the direct care of the elderly, disabled and infirm. How Agency Would Develop Assessment ToolThe Division of Aging Home and Community Services are currently initiating plans to assess consumer satisfaction. Effectiveness and quality care are program attributes, that should be defined first and foremost by consumers themselves. With definition of what consumers, caregivers, and helping professionals establish as measures of effectiveness in service delivery and support, DA would develop survey tools to capture this information. We would also engage other strategies to obtain feedback on programs, such as focus groups, random telephone calls, and home visits. Department of Social Services - Rehabilitation Services for the Blind Quality Assurance Activities Currently ConductedSeveral consumer satisfaction surveys with consumers have been conducted. Mississippi State University does the evaluation of the Older Blind Independent Living program. In response to a federal mandate, the Rehabilitation Council meets quarterly and public hearings are held at these meetings in the evening all over the state. The Assistant Deputy Director in charge of field operation acts as the designee agency ombudsman. A number of reports that describe evaluations are produced on a regular basis. Recommendations:The following are recommendations to address Activity 2:
Timelines and Responsible Parties to Implement Recommendations:The following table summarizes recommendations, identifies agency(ies) responsible for planning and initiating activities to realize each recommendation, and identifies the calendar year in which the results will be achieved. The code for the state agencies is:
Recommendations:1. Identify one department or other entity that will take the leadership on the development of outcome measures that will assure that services are effective and addressing the needs of individuals with disabilities. The assessment should be integrated into the existing outcome measures of each department. Any assessment instrument that is developed should have extensive consumer input.
2. Measure the rate of persons moving into the community at the end of the year. This should look at how many individuals, who are currently living in an institution but are waiting to move to the community, were moved into community settings. This evaluation should also look at the reasons why those who wanted to live in the community, but who are still in institutional settings, have not been moved to the community.
3. Develop process evaluation that will assess whether the plan activities have been met. This evaluation should look at outcomes at the end of next year.
4. Develop a provider agency listing or profile that could be used by consumers. This profile will, where feasible, identify staff turnover, consumer residential movement, consumer satisfaction, and other factors that had been reported as important in assuring that the needs of the individual are best met. Assure that the listing is in multimedia formats (e.g., manual, CD-ROM, website) to best disseminate the information.
5. Identify the number and type of individuals trained on informed choices. Survey individuals trained on issues related to the Olmstead decision (e.g., informed choice) to determine what information they received and how they are putting this into practice.
6. Develop processes to interview individuals who entered the system during last year to determine if they had informed choice.
Budget Action, Federal Action, and Statute Changes. The following budget action, federal action, and/or statute changes are required to successfully complete the proposed activities. Needed Budget Action:
Federal Action:None required. Statute Changes:None required. Index | Acknowledgements | Introduction | Activity 1 | Activity 2 | Activity 3 | Activity 4 | Activity 5 | Activity 6 | Activity 7 | Activity 8 |
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