XXI. Quality Management Program and Performance Metrics

The state requires CCO/HHs implement a Quality Management Program (QMP). CCO/HHs are expected to follow the Health Home QMP policy located on DOH’s website.

The information in this policy manual stems from DOH’s Health Home QMP policy and provides an overview of the components, requirements, and activities associated with a CCO/HH QMP.

QMP is a system that documents processes, procedures, and responsibilities for achieving quality practices and objectives – it is a proactive approach rather than a reactive one, identifying and resolving issues before they occur. The QMP is a living, breathing, ongoing, and evolving evaluation of the CCO/HH's ability to continuously improve on overall quality.

An effective QMP includes Quality Assurance and Performance Improvement (i.e., Quality Improvement) (see glossary for definitions) and not only evaluates the ability of the CCO/HH to provide quality person-centered services in accordance with the goals and intent of the core service functions, but also examines the impact of the services on individual and population level health and quality of life outcomes for members. 

In order to track their performance, CCO/HHs must collect, analyze, and report on data in a way that measures the effectiveness of care coordination and chronic disease management looking at:

1. individual-level clinical outcomes (e.g., medical conditions, impact on health or general quality of life, resource utilization, etc.),
2. member satisfaction (e.g., timely appointments, easy access to information in the member’s preferred method, good communication with care managers, etc.), and
3. quality of care outcomes at the population level (e.g., readmissions, etc.).

The CCO/HHs are expected to have a written QMP, and evidence of implementation, that demonstrates they objectively, systematically, and continuously are assessing, assuring, monitoring, evaluating, and improving the quality of processes, activities, and services provided to people served by the CCO/HH in accordance with the core functions of the CCO/HH.

While there is no prescriptive format for the written QMP, the following components must be included:

1. Define the CCO/HH’s mission and how the QMP is integrated.
2. Identify the person(s) and their designees who have the overall responsibility for the daily operation of the QMP, which include:
   • The staff person/position responsible for the coordination, oversight, and implementation of the QMP must be contained within the QMP.
   • Designing, directing, and overseeing implementation of QMP activities to include review of data and performances measures, manage work plans, oversees performance improvement activities, and monitor progress.
   • Facilitating committee meetings, reports on activities and findings of the Committee to leadership and/or management.
3. Develop a QMP Committee.
   • The QMP Committee must be multi-disciplinary, adequately representing all key departments and core service functions, with clearly defined roles and responsibilities. The Quality Management Committee monitors the ongoing effectiveness of the QMP.
   • The following roles must be part of the work of the Committee:
     • QMP Committee Chair: facilitates committee meetings, reports on activities and findings of the Committee to leadership and/or management.
     • QMP Coordinator: designs, directs and oversees implementation of QMP projects to include review of data and performance measures, manage work plans, oversees performance improvement activities, and monitors progress.
     • Various Other Entities: CCO/HHs must consider representation on the QMP Committee by other entities that serve the CCO/HH population. This may include I/DD providers; medical, clinical, technical, financial, operations, stakeholders such as housing providers, CSIDD providers, criminal justice, Self-Direction providers, etc.
     • People Served and Family Members: CCO/HHs must obtain feedback from them and apply their input to the QMP and processes.
     • Other Subcommittees: subcommittees/teams may be established in response to various QI activities.
   • QMP Committee responsibilities and activities include:
     • QMP Committee is responsible for defining, overseeing, and monitoring the objectives, goals and performance of the QMP. This includes:
       • Prioritizing performance improvement efforts using strategic goals, aggregating and analyzing performance and benchmark data, and trend analysis.
       • Identifying barriers and needed resources to support Performance Improvement (i.e. Quality Improvement) implementation.
       • Monitoring performance improvement/quality improvement efforts for effectiveness.
       • Making recommendations for changes in service provision or operations.
       • Preparing written reports to leadership that includes findings, actions, and outcomes of the QMP.
       • The Committee’s responsibilities including the procedures must be outlined within the QMP.

• Committee meeting minutes should demonstrate activities that promote continuous quality improvement and support the objectives and goals of the QMP.  Activities should include all the following (when applicable), but are not limited to:
  • Quality assurance strategies and implementation.
  • Compilation and/or review of audit findings and outcomes.
  • Development, implementation and/or monitoring of Performance Improvement Plans (PIP) with outcomes, identified successes and/or corrective action taken.
  • Recommendations for policy change.

4. Involve leadership and management in QMP processes and evidence of effective support from senior management and leadership.
   • Document organizational leadership supports culture of quality including allocating resources necessary to conduct quality improvement efforts.
   • QMP activities are reported to leadership quarterly and the QMP is approved annually to determine effectiveness and necessary actions needed.
     Leadership is defined as:
     • Agency leadership which includes high level management and executive leadership of the CCO/HH
     • Board of Directors
     • Advisory Board – and/or another documented mechanism within the QMP to obtain feedback from enrollees and family members and apply their input into the QMP processes. A member/family member serving on the QMP Committee does not fulfill this requirement.
     • Subcommittees do not replace the requirements for full representation of leadership but may be established in response to various quality initiative activities.
   • Meeting minutes must show review of the following by leadership:
     • At minimum, quarterly review of effectiveness of current activities supporting QMP goals/objectives.
     • At minimum, quarterly review of recommendations and reports compiled by the QMP Committee’s actions taken to overcome barriers, and effectiveness of actions.
     • At minimum, quarterly review of status of PIP plans.
     • Titles and roles of those present at meetings.
     • Discussion, decisions, and actions related to the QMP.
     • Yearly review and acceptance of a new QMP.
     • As part of the yearly review, parties tasked with review and accepting the QMP must be presented with all required components of the QMP. Meeting minutes must reflect all documents that were presented as components of the QMP, reviewed, and accepted by the required parties.
     • Minutes must reflect data-driven evidence/rationale for inclusion of objectives/goals and the benchmarks set.
     • Minutes must reflect data-driven evidence/rationale for discontinuing/substantially changing objectives/goals or changing benchmarks set.
   • There must be a documented communication loop between the QMP Committee and leadership in which questions, recommendations, inquiries, etc., are documented and responded to.
5. Create a performance improvement plan (PIP) (I.e., Quality Improvement Plan) that follows use of evidence-based quality improvement framework(s) (i.e. root cause analysis and Plan-Do-Study Act, or other evidence-based methodologies) and addresses how negative findings/outcomes/objectives not meeting benchmarks will be addressed. The PIP must include the following:
   • Clear and objective identification of areas where performance areas have not been met, including examples to clarify the patterns or severity of performance issues, and the impact of the unmet performance.
   • Use of root cause analysis and other evidence-based quality methodologies.
   • Identify expectations for improvement using measurable goals.
   • Include a timeline for improvement to be reached.
   • Assignment of tasks to appropriate staff.
   • Identify the need for staff training or support.
   • Expectations for reviewing progress.
   • Identify any barriers to progress.
   • Sanctions that may be imposed if improvements are not made.
6. Identify data management and performance measures used to assess and monitor CCO’s QMP goals, objectives related to quality services and requirements.
   • Goals and objectives must have clearly defined data metrics for how the CCO/HH is assessing and monitoring the achievement of those goals and objectives.
   • The goals and objectives must have benchmarks, not only final achievement goals, to ensure the CCO/HH is making progress towards the attainment of their goals and objectives during the implementation of the QMP.
   • The QMP must clearly identify the data management process and performance measures that will be utilized to assess and monitor progress.
   • The QMP must detail how the information will be aggregated, analyzed, and reported to required parties. At minimum, the following parties must include:
     • Quality Management Plan Committee
     • CCO/HH Leadership / Senior Management
     • Board of Directors
     • Family Advisory Board
7. Create a planned and systemic process for the ongoing monitoring and assurance that the CCO operates and provides services in compliance with OPWDD CCO/HH and regulatory requirements.
   • The QMP must include ongoing monitoring and systems that ensure oversight and acceptable rates of compliance with regulatory requirements.
   • The written QMP includes a planned and systemic process for assessing CCO/HH compliance with OPWDD requirements.
   • This means that the QMP includes:
     • Strategies to assess and/or measure rates of compliance and/or factors influencing the compliance/non-compliance.   
     • Goals and systemic strategies related to maintaining or improving the level of agency compliance.
   • Although there is no prescriptive format, the format must be comprehensive and include all regulatory requirements.
8. Develop activities to review CCO/HH processes that result in the delivery of quality care management services that effectively support the individuals’ desired outcomes.
   • Activities must address person centered services by monitoring that its organizational practices are effective in supporting the individual’s desired/valued outcomes.
   • Activities should be able to identify the CCO’s organizational successes and barriers in helping individuals in the pursuit and achievement of their outcomes.
   • Activities may include input from care management recipients regarding their status regarding desired outcomes.
9. Include activities to oversee and monitor the provision of the six Health Home core services.
10. Review of care manager caseloads as it relates to quality service delivery.
    • The QMP must include a planned and systemic process for monitoring and assessing, on an ongoing basis, the quality and appropriateness of CCO/HH services. This includes having policies and procedures that outline how the CCO/HH is assessing and reassessing the caseloads of Care Managers as part of delivering quality services. Depending on the status and need of individuals receiving care coordination, there are several approaches that the CCO/HH may use in managing caseloads based on the payment tier level of individuals.
    • CCO/HHs must identify in the QMP which caseload model they selected and documented in their CCO/HH policies and procedures. For reference the caseload models are:
      • Direct Assignment of Care Manager (CM) at 1:20 ratio - In this model the assignment to meet the required 1:20 ratio is direct in that there is one Care Manager who provides Care Management to twenty (20) individuals or less.
      • Mixed Caseload - For the purposes of caseload stratification and resource management; a caseload mix of individuals in the Tier 4 payment tier and other tiers is allowable if and only if the equivalent Care Manager to individual ratio is 1:20 individuals or less. This means the weighted equivalent is twenty (20).  This stratification allows for having more than twenty (20) individuals on a caseload but keeping within the 1:20 ratio. Caseload sizes should always allow for adequate time for providing Care Management as outlined in this guidance to individuals with more complex needs, while allowing for thoughtful consideration of the Care Coordination needs of individuals who have been identified as not having more complex needs.
      • Team Approach - A CCO/HH may choose to use a team approach to serve a caseload consisting of individuals in the Tier 4 reimbursement category. The team could consist of clinicians with designated time to support the Care Management role or staff in “assistant” capacities who help complete the CCO/HH services but are not required to meet the Care Manager qualifications and would assist under the supervision of Care Managers.

To assist CCO/HHs and Care Managers, in monitoring quality and performance, as well as tracking and reporting key performance measure to CMS and stakeholder(s), the State has developed a comprehensive set of performance measures.  

The measure set was derived from the measures identified in the NYS Health Home SPA,+ Health Home Core Set and CMS Health Home Core Quality Measures. The CMS Quality Measures were specifically designed to assess the CCO/HH service delivery model. The majority of measures are National Committee Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures or developed by NYSDOH and OPWDD.  

The performance measures monitor overall quality and the degree to which the CCO/HH model, as authorized under the Affordable Care Act (ACA), is meeting its goals, including:

1. Reducing utilization associated with avoidable (preventable) inpatient stays;
2. Reducing utilization associated with avoidable (preventable) emergency room visits;
3. Improving outcomes for individuals with I/DD through care coordination (health as well as personal/social outcomes);
4. Improving disease-related care for chronic conditions;
5. Improving preventive care;
6. Improving transitional care;
7. Reducing utilization associated with inpatient stays. 

Note that these measures do not require separate data collection efforts on the part of the CCO/HH. Measurement of the process and outcome of the CCO/HH program will be necessary to understand the value of the overall program and the effectiveness of any one (1) component. The measurements will also help guide process improvement that may be implemented.  

Performance measures can be located in:

• DOH Health Home Measure Specifications and Reporting Manual
• Core Set of Health Care Quality Measures for Medicaid Health Home Programs (Health Home Core Set)

For additional information on the proposed outcome metrics, quality measures, and CCO/HH core measures, please refer to Part 1 of the CCO/HH Application. 

In addition, the NYSDOH Health Home Performance Management webpage can be found on DOH’s website. 

In addition to these measures, other metrics such as a satisfaction/experience of care survey and/or other mechanisms to review process, structural and/or outcome metrics may be conducted in the future to help guide improvement processes within the program.  The State has also added the following initial performance metrics tailored for individuals with I/DD. These measures will be reviewed and revised as part of the State’s ongoing stakeholder engagement and quality improvement initiatives. 

The CCO/HH will also be expected to collect and report I/DD-specific outcome data demonstrating the degree to which individuals live in the most integrated setting, including the Transformation goals of increasing the number of people employed, self-directing, and living in the community. 

Data regarding evaluating this metric will include:

1. Number of people employed;
2. Number of people supported to self-direct their services;
3. Number of people who are supported in independent, integrated living settings; and
4. Number of people who have moved from a certified setting into a less restrictive environment. 

The State expects the quality measures used to monitor and manage CCO/HH performance will evolve over time, particularly as activities related to the State’s implementation of CMS’s HCBS Quality Measure Set and two Final rules as follows:

1. Ensuring Access to Medicaid Services (CMS-2442-F) and
2. Medicaid and Children’s Health Insurance Program Managed Care Access, Finance & Quality (CMS-2439-F).