Impact Feature Issue on Enhancing Quality and Coordination of Health Care for Persons with Chronic Illness and/or Disabilities

In 2001, Delmarva Foundation was awarded a four-year contract to help the State of Florida develop a quality assurance system for evaluating services provided to people with developmental disabilities. Two independent processes were developed and implemented by Delmarva over the next few months. One focused on interviews with people receiving services to determine the desired outcomes and supports present in their lives. The other focused on evaluation of service and support processes utilized by support coordinators and direct service providers. Over the next two years, thousands of interviews and provider reviews were conducted, resulting in an extensive quantity of data. The findings showed that the providers of support coordination and other services adapted their systems of operation and documentation such that their processes were rated highly in relation to Medicaid handbook requirements. Conversely, the people receiving services reported either a stagnant or even a decreased presence of desired outcomes and supports in their lives. How does one account for this disconnect? Why were provider scores not predicting quality of life for the people they were so passionately serving?

Though policies and procedures, hiring practices, staffing ratios, documentation modalities, and a myriad of other “process” oriented aspects of running a business may certainly lay the foundation for efficient operations and help meet funding requirements, they do not guarantee results for those receiving services. In fact, the infrastructure produced by the above mentioned items might not emphasize the need for results. Providers entering the field for all the right reasons have in many instances become buried and even lost in process, with no system to evaluate the true effectiveness of their service delivery.

The magnitude of these realizations was felt immediately as Delmarva Foundation, its contract partners, and a group of stakeholders (including people receiving services and representatives of the Agency for Persons with Disabilities) began to revamp the provider review process. Development of this new review process began with an agreed upon emphasis being placed on outcomes, with outcomes being defined as results that reflect communicated choices and preferences that matter most to the person. Not only does this definition demand accountability in that services need to generate results, it specifically speaks to the need for those results to be something of importance, value, and priority as defined by the person receiving the services. Thus began the six-month experience of converting an evaluation approach from one that was process based, to one that is results based, and implementing it for a system serving over 24,000 Floridians with developmental disabilities.

The remainder of this article will focus primarily on the development of a results-oriented evaluation of support coordinators, titled the Waiver Support Coordination Consultation (WiSCC). However, it is critical to note that concurrent with this activity, the measurement of success for providers of residential, vocational, and other direct support services was also being shifted to emphasize results. With similar accountability at all levels within the service delivery system, each stakeholder has had to realize the importance of teamwork and collaboration in generating success. This is at the very heart of the service culture changes in Florida.

The New Evaluation: WiSCC

The WiSCC begins with interviews of people receiving services to determine whether or not they are receiving the support necessary to achieve that which is important to them. Using the Personal Outcome Measures developed by The Council on Quality and Leadership, information is gathered not only to determine the presence of desired outcomes and supports, but also to generate discussions with support coordinators regarding their organizational practices and systems for generating results for the people they serve. The intent of the WiSCC process is to provide recommendations to support coordinators about the sample of individuals interviewed, and to identify strengths that can be capitalized upon and challenges that can be addressed so that the support coordinators can generate desired results for all the people they serve.

Developing a new tool to capture and report upon the performance of support coordinators required a fresh way of thinking when incorporating a results orientation. Delmarva had been scoring support coordinators on roughly 180 elements with the original provider review tool that focused primarily on process. The new WiSCC tool has only 11 elements. Five elements continue to focus on process-oriented topics such as background screening, training, and billing. The remaining six speak to the very essence of what Florida is trying to accomplish, as each element builds upon the previous elements, ultimately focusing upon the generation of results:

• Expectation 1: The support coordinator has an effective method for learning about the people they serve.
• Expectation 2: The support coordinator is aware of the health, safety, and well-being of the people they serve.
• Expectation 3: The support plan is developed with the person and reflects what the person wants.
• Expectation 4: The support coordinator has evaluated the effectiveness of all supports.
• Expectation 5: The support coordinator uses education, exposure, and experience to support informed choices.
• Expectation 6: The support coordinator has assisted the individuals they serve to accomplish positive results.

The “simplistic relevance” incorporated into the WiSCC approach enables both the support coordinator and the Delmarva consultant to easily see the big picture goal of results generation and avoid what historically has been a mundane focus – the “monitoring” of details that have little to no impact on what is important to the people being served. The possibility of a more creative and less scripted approach fosters an environment more likely to generate a meaningful end.

Several activities have been included in the WiSCC that are consistent with its consultative intent. Support coordinators are invited to observe interviews conducted by Delmarva consultants, with the consent of the person being interviewed. The goal is that out of this modeling activity the support coordinator will develop additional skills that can be applied when communicating with the people they serve. Additionally, Delmarva consultants are responsible for collecting detailed health and safety information during the individual interviews, utilizing this information to generate recommendations and insights directed towards the support coordinator or general support network. Delmarva has a developmental disabilities registered nurse (DDRN) on staff who not only validates the recommendation process, but who can also be incorporated into discussions with the support coordinator during the WiSCC process via conference-call technology. Real-time health, safety, and behavioral discussions provide concise feedback to support coordinators striving to provide the best possible services. Delmarva’s DDRN additionally has the ability to compare WiSCC results to Medicaid claims data, and to request additional information from individuals, service providers, and physicians if inconsistencies are identified.

Support coordinators are no longer required to complete Quality Improvement Plans to address areas of “non-compliance.” The Delmarva consultant instead works with the support coordinator to develop a three-month plan. This plan focuses on ways to address challenges to the support coordinator and barriers preventing the generation of results. At the completion of the WiSCC, the consultant provides both a report of WiSCC findings and a manageable strategy to address the challenges that were identified. With these tools in hand, the Support Coordinator can quickly and effectively implement changes which will enhance the likelihood of results being generated for the people they serve.

One Provider’s Reaction

Leigh Meadows is the Director of District 3 Operations for People Systems, a support coordination agency serving people with developmental disabilities in north central Florida. She was a member of the stakeholder work-group challenged with the task of shifting the statewide support coordination evaluation process from a process to a results orientation. People Systems recently experienced a WiSCC, and of the new evaluation approach she had the following to say:

First and foremost, I was very pleased to observe that the focus of this process was as it was conceived to be, in that support coordinators (SC’s) learned from the experience how to better do their jobs. Observing the process of interviewing consumers was the most educational, as the interview methods demonstrated by consultants through this process showed new methods for interviewing consumers not learned through previous training. In being interviewed by consultants on how SC’s perform their jobs, we have also learned that while being consumed with solving crisis situations and handling state-imposed deadlines for consumers, we have missed opportunities and lacked time to develop much needed natural and community supports. We have learned that consumers can express choices in many areas that were previously unexplored.As I watched the process unfold, I must admit that it worked better than I had imagined. I expected much more of an authoritative hand from Delmarva. However, we were respected as professionals, with no “gotcha” mentality. We were guided and instructed on ways to better handle information gathering and address provider issues. Barriers were acknowledged and addressed. The benefits from this process and how it will affect future training and quality improvement are invaluable.I am sure if you asked each SC from our company who went through this process, they would agree that the experience was a good one for them and that they learned how to more effectively do their jobs, which from my perspective, having a hand in the development, was the whole purpose behind it all. I have great faith in the WiSCC process and the potential for positive change and growth within our overall system.

Conclusion

It is anticipated that this fundamental shift to a results-oriented, consultative evaluation system in Florida will not only serve to evaluate existing services, but will also become the impetus for culture change and quality of life improvements for people with developmental disabilities.