Minnesota State Profile Tool–Quality Chapter
August 15, 2012 DRAFT
I.
Minnesota Quality Goals and Framework
Minnesota has a long-standing commitment to providing quality long-term services and supports
to individuals with disabilities and older individuals in their homes and communities, as an
alternative to institutional care. Currently, the state provides such home and community-based
services (HCBS) through five Medicaid 1915(c) waivers:
 Elderly Waiver (EW)
 Community Alternatives for Disabled Individuals (CADI)
 Community Alternative Care (CAC)
 Brain Injury (BI)
 Developmental Disabilities (DD)
HCBS is also provided through the state-funded Alternative Care program and several state plan
options, including personal care assistance, private duty nursing and home care. More than
75,000 individuals received some type of HCBS in 2010.
Ensuring the quality of these HCBS is a central state goal. The Continuing Care Administration
(CCA) in the Department of Human Services (DHS), which oversees Medicaid HCBS, has
articulated the following vision in its strategic plan:
We see a Minnesota where people have choices in how they receive services and how
they live their lives. The domains of choice include:
Community membership
Health, wellness, and safety
Own place to live
Important long-term relationships
Control over supports
Employment earnings and stable income
There are seven core values which guide both program management and quality oversight:
Choice & Independence for the people we serve
Stewardship of human service resources
Self-determination and personal responsibility by the people we serve
Integrity by ourselves and others
Diversity because our differences make us strong
Partnerships and collaboration, with clear roles, responsibilities, and accountability
for ourselves and others
Accountability
The CMS Quality Framework, first published in 2002, underlies CCA’s approach to quality,
which has the goals of achieving desired outcomes and meeting program requirements. The
state’s data-driven quality strategy is guided by the design, discovery, remediation, and
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improvement model of continuous quality improvement articulated by the Centers for Medicare
& Medicaid Services (CMS). The overall goal is to support and enhance the quality of life for
older people and people with disabilities (children and adults). Minnesota’s HCBS quality
strategy has evolved over time and is continuing to evolve. This chapter provides information on
both the current and planned quality initiatives, measures and data sources comprised in this
strategy. As with the previously completed chapters of Minnesota’s profile of its long-term
services and support system, CCA engaged the HCBS Partners Panel in the review of drafts and
related products and has incorporated the feedback that Panel members provided. CCA will
continue to rely on the HCBS Partners Panel as an ongoing feedback loop regarding its quality
initiatives.
Currently, the Department of Human Service is pursing reform options for its Medicaid program,
including HCBS, as a result of a legislative mandate. While these reform initiatives are expected
to change some of the mechanisms for delivering and funding HCBS, they are not expected to
change the Department’s commitment to quality outcomes and oversight, nor the fundamental
approaches and data sources for measuring and monitoring HCBS quality.
II.
Quality Measures and Data Sources
CCA’s HCBS quality strategy relies on an array of quality metrics. The purpose of these
measures is to:
 assess compliance with statutory requirements;
 assess achievement of desired individual and system outcomes;
 measure individual remediation of any problems discovered;
 guide and evaluate system improvements;
 monitor provider performance; and
 communicate with stakeholders through public reporting.
Measures
Appendix I is a matrix of current and proposed quality measures for HCBS programs and
recipients in Minnesota. This matrix provides information on the following, for each metric:
 Measure description
 Measure type, e.g. outcome, process
 Unit of measurement, e.g. individual, system
 Population with which measure is used
 Data source
 Method of data collection
 Frequency of data collection
 Sampling methodology (where relevant)
 Quality Framework domain
 Reporting requirement measure addresses
 Status of measure (current, planned, retired)
 Measure use
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
Ability to support longitudinal analysis
In addition, explanatory notes are included where relevant. This matrix comprises three broad
sets of quality metrics; each is discussed below.
Performance Measures for Reporting to CMS and for Quality Improvement
The matrix in Appendix I includes a complete list of performance measures for the five 1915(c)
Medicaid HCBS waivers operated by DHS that are reported to CMS to demonstrate compliance
with statutory requirements. These measures are identified in the “Reporting Requirements”
column. Four of the five programs, which serve adults and children with a variety of disabilities,
are operated by the Disability Services Division (DSD) and share a common set of performance
measures. These are the Brain Injury (BI), Developmental Disabilities (DD), Community
Alternatives for Disabled Individuals (CADI), and Community Alternative Care (CAC)
programs. The Elderly Waiver (EW), serving older adults, is operated by the Aging and Adult
Services Division (AASD) and has an overlapping measure set, as well as some metrics unique
to the managed care organizations that serve this population.
Information on the performance measures included in Appendix I is drawn from two sources:1)
The performance measures for DSD-operated programs are from the recently-approved renewal
of the CADI waiver; DSD intends to use these measures across all of its HCBS programs, with
the exception of some service recipient survey items that are currently only used with the CADI
waiver. 2) Performance measures for EWwere taken from the state’s most recent evidence
submission. This waiver is due to be renewed in 2013 using Version 3.5 of the waiver
application, and CCA will submit the entire measure set for approval at that time.
Measures for the Continuing Care Dashboard and Strategic Plan
The CCA’s Strategic Plan currently includes approximately forty measures intended to serve as a
“dashboard” for monitoring the state’s long-term services and supports (LTSS) system;
Appendix I includes those relevant for quality. These measures comprise a subset of the more
than 170 extant metrics identified by the Performance Measures Initiative Team (PMIT) within
CCA, for all long-term services and supports, including institutional settings. The dashboard
includes primarily system-level measures, whose scope is broader than HCBS quality, that assess
processes, access, capacity and outcomes. Since these are tied to the strategic plan, DHS staff
use them to track their progress in meeting the goals of the plan.
Measures for Internal HCBS Quality Monitoring and Improvement
Lead Agency Operating Indicators: These measures are reported to the lead agencies, or
counties, as part of the waiver review process. Some are duplicative of the performance
measures reported to CMS and some mirror those from the Continuing Care dashboard. These
measures are drawn from MMIS, as well as Census data. Benchmarking allows the lead agencies
to compare their performance statewide, as well as with other similar lead agencies, and identify
areas of potential improvement locally.
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Data Sources
The measures listed in Appendix I are drawn from a variety of sources, described below.
Medicaid Management Information System (MMIS): This administrative database includes
claims, assessment, eligibility, and other administrative data from 100 percent of Medicaid
recipients, including those receiving long-term services and supports. Service authorizations and
service use data are also included. Information in MMIS is continually updated and is subject to
multi-functional edits at the individual case level. The purpose of these edits is to support HCBS
waiver policies and operational procedures related to waiver eligibility determinations, waiver
and state plan service authorization, and claims payment. They automatically monitor data input
to ensure compliance with specified policies and procedures.
Lead Agency Reviews: Starting in 2006 DHS, in collaboration with a contractor, initiated a
comprehensive review of lead agencies (counties and tribes). This includes an on-site review of
a sample of more than 5,000 client case files, stratified by HCBS waiver, to extract information
related to the 1915(c) waiver assurances. Before each lead agency visit, MMIS data for that
agency is compared to lead agencies of similar size and to statewide averages. This allows
identification of any issues or patterns that may merit more focused analysis. Information
reviewed from sample case files includes:
 Assessments and reassessments
 Needs assessments and screening document data
 Care plan documentation, including choice
 Frequency of case manager visits
 Data privacy and rights information
 Health and safety planning
 Provider contracts
In addition, DHS staff conduct a follow-up review to verify that any corrective actions arising
from the original case file review are implemented. All of this review data is captured in a
database (the Waiver Review database) and is used to generate evidence reports for CMS, and
for internal review by the Quality Essentials Team as part of the state’s quality improvement
strategy. The first full round of lead agency reviews has just been completed; the next round is
expected to begin soon and take three years to complete.
Annual Care Plan Audit: The managed care organizations (MCOs) that contract with DHS are
required to conduct audits of the care plans they have developed for EW recipients using a
review tool approved by the state. This review tool assesses compliance with CMS and state
requirements. The sampling methodology for these audits follows guidelines from the National
Committee for Quality Assurance: 30 plans are randomly selected and, from those, 8 randomly
reviewed. If any of those 8 files indicate deficiencies, all 30 files are reviewed. Under the terms
of their contract with DHS, the reports submitted by each MCO must describe the results, the
process used by the MCO to conduct the review, any deficiencies and/or concerns raised during
the review and any corrective actions taken by either the MCO or the care system to address
deficiencies or concerns raised during the review.
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Census: The Minnesota State Demographic Center uses state-specific Census data, including the
American Community Survey, to estimate populations potentially in need of HCBS, for internal
planning and monitoring purposes.
Minimum Data Set (MDS): The MDS includes information on all residents in Medicare and
Medicaid certified nursing facilities, collected using a federally-mandated comprehensive
assessment of each resident's functional capabilities. These data are used to estimate nursing
facility usage rates, by age group, for comparison to HCBS use.
Triennial Compliance Assessment: Federal regulations require DHS to conduct triennial on-site
contract compliance validation assessments of each contracted MCO. Through an Interagency
Agreement, the Minnesota Department of Health collects on-site supplemental compliance
information for DHS that serves as a “look-behind” for the MCO self-audit, which includes an
annual care plan audit.
Social Services Information System (SSIS): This database includes information on allegations of
abuse, neglect and exploitation of children and vulnerable adults as reported to the county-based
Common Entry Point system in Minnesota. Counties also use SSIS to enter data about
investigations and disposition of maltreatment reports under their authority as lead investigative
agency. CCA is currently in the process of working with the other two lead investigative
agencies, DHS Licensing and the Minnesota Department of Health, on a data interchange project
which will connect data about the disposition of reports forwarded to these lead investigative
agencies back to the SSIS.
Surveys
 Minnesota Participant Experience Survey: In collaboration with a contractor, DHS
developed and tested two cross-disability surveys assessing individual experience with
waiver services and supports: one for adults and one for minors. Survey domains include
access to services/unmet need, respect, choice, transportation, and employment. DSD has
conducted the survey twice and plans to repeat it annually when resources are made
available.

Consumer Experience Survey: Developed by AASD, this survey has been conducted
three times with a representative sample of EW participants, most recently in 2009.
Survey interviews are conducted by volunteers from the Ombudsman’s office. The next
round of data collection is planned for 2013.
Future Data Sources
DHS is undertaking three initiatives to standardize processes and data collection, which will
offer additional sources for measuring quality. In addition, the State was recently approved to
participate in the CMS Money Follows the Person demonstration, and anticipates additional data
collection for the demonstration population.
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MnCHOICES: This new comprehensive assessment and support planning tool, currently
undergoing beta testing, will replace four separate assessment tools currently in use with HCBS
programs. MnCHOICES will be completed by certified assessors conducting assessments for any
person with LTCC needs, as well as reassessments with recipients of any of the five HCBS
waiver programs and PCA services, as wel as other publicly funded long term services and
supports. The certified assessors will enter data into a dedicated electronic database. This new
tool will significantly expand automated data availability for quality measurement and oversight.
New monitoring questions for assessors and for participants during the reassessment process
will provide additional data on program experience, outcomes, and access, related both to the
CMS assurances and the CHOICE quality domains, for all HCBS recipients. Specifically they
will address:
 Case manager/service coordinator responsiveness and effectiveness
 Participation in service plan development
 Choice in daily activities
 Respectful interactions with staff
 Personal safety
 Satisfaction with providers
HCBS Waiver Provider Standards: DHS is currently developing statewide standards and
enrollment processes for HCBS providers, which upon implemtnation will result in the the
discontinuation of county contracts by 2014. Under this new system, providers will meet state
established standards as a condition of enrollment as a HCBS provider. . Partnerships with the
counties will be established to handle complaints and provider monitoring. Potential indicators
from this new data source may include:
 Percent of providers in full compliance with applicable provider requirements
 Direct care staff turnover
 Substantiated instances of provider maltreatment
Money Follows the Person (MFP): DHS anticipates collection of data in addition to that
collected for HCBS waiver recipients on Money Follows the Person participants. This data
includes implementation of the MFP Quality of Life Survey, which will provide opportunities for
potential new quality measures.
III.
Use of Measures
There are a few distinct groups within CCA that have responsibility for policy development,
management and administration of Medicaid HCBS programs and who use the measures
identified above to inform their work.
Quality Governance Committee
This newly-formed internal group represents quality-related initiatives from across CCA. The
Quality Governance Committee is developing a process to increase communication and
coordination regarding quality initiatives across CCA. The goal of the Committee is to develop a
comprehensive strategy to integrate and manage the portfolio of CCA quality initiatives.
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Quality Essentials Team
The Quality Essentials Team (QET) comprises staff members from the CCA AASD and DSD
who meet periodically to review data related to the waiver performance measures in Appendix I,
and to identify opportunities for improvement. This team embodies the Quality Improvement
Strategy described in the state’s most recent Medicaid 1915(c) waiver renewals.
Performance Measures Initiative Team
The Performance Measures Initiative Team (PMIT) serves as technical advisors in the
development and use of CCA performance measures. Their purpose is to leverage the
considerable data collected by the state to measure and improve performance. In addition, they
publish select metrics for Administrative review, and assist in the interpretation of results in
support of CCA’s “management by results” policy. This team developed the short list of
measures for CCA’s strategic plan, and oversees their use.
State and Regional Quality Councils
Modeled after a similar effort in 2005, recent legislation from the 2011 special session of the
Minnesota Legislature mandated formation of these councils. The councils will have an ongoing
role in reviewing quality data, particularly around any available outcomes measures. Their
mandate will emphasize “people evaluating what is happening to other people” and listening to
actual experience. These councils may also advise CCA administrative staff on policy
development. The State Quality Council is meeting and its membership includes broad
stakeholder representation. It is anticipated that a request will be made during the 2013
legislative session for funding and authority to implement the councils on an ongoing basis.
Measure Reporting
The quality and performance measures included in Appendix I are reported to a variety of
audiences, including:
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CMS, to demonstrate compliance with statutory requirements;
lead agencies who administer waiver programs;
stakeholders, including the Quality Councils;
the legislature; and
CCA staff, in support of policy development and internal initiatives.
In the near-term, CCA will launch the HCBS Report Card to help service recipients make
informed purchasing decisions. This Report Card will be available on www.minnesotahelp.info
and is modeled after the state’s Nursing Home Report Card. The Report Card will initially
include three provider types: housing with services (including assisted living), foster care, and
day training and habilitation. The Report Card will educate individuals about differences among
HCBS services, service providers, and costs; contribute to DHS’ response to federal assurances
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related to access, choice and systems improvement; and support HCBS providers in targeting
improvements in their services.
IV.
Potential Areas of Future Development and Measurement Gaps
The metrics included in Appendix I are primarily process measures that enable CCA to track
compliance with external and internal requirements and assess progress against strategic goals.
CCA’s long-term quality goals include the ability to measure and track progress with regards to
desired individual outcomes and system impacts. According to the CCA Strategic Plan, these
include:
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Access to the right services in the right place at the right time
Effective supports and training for families providing care for a family member
High level of participant satisfaction with their long-term care services
Improved earnings by persons receiving long-term care services
More people are able to remain in their own homes
Reduced incidence of chronic and disabling conditions
Reduced incidence of abuse and neglect
Easily accessible and clear information about long-term care options and assistance in
navigating the service system
People are living in the most inclusive community settings
DHS CCA is currently conducting both internal and external analyses of current measures and
quality oversight activities across the HCBS system, including the five Medicaid Waiver
programs. Analyses are expected to identify opportunities as well as priorities for future data
collection and measure development, and possibly measurement gaps. Specific areas to be
examined may include:
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Remediation
Critical Incidents
Provider Qualifications
Provider Oversight
Service Outcomes/Participant Experience
Provider Performance Measures
Managed Care Measures
Finally, these analyses are also exploring additional opportunities for CCA to develop not just
new measures, but new ways of using the state’s own rich data resources. Such new
opportunities might include more standardized descriptions and documentation of what is being
measured, combined with a single, overarching point of review and accountability for quality
improvement activities. There is also an opportunity for CCA to leverage the considerable data
resources it currently possesses, and link assessment, utilization and outcome/experience data to
more comprehensively assess HCBS quality at the individual and system levels.
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