The Centers for Medicare and Medicaid Services (CMS) works with states to assure and improve quality across the Medicaid authorities that support long term services and supports, including the Medicaid 1915(c) HCBS waiver program-- the largest single payor of long term care services in the country. Current approaches to quality have expanded to include managed care, 1115 waiver demonstrations, and state plan services. Through cross-cutting initiatives, these programs and services seek to maximize the quality of life, functional independence, health and well being of individuals served by the HCBS programs. 

CMS Quality Design and Review Processes for 1915(c) Waivers

In response to recommendations from the General Accounting Office in 2004, CMS initiated a structured and transparent quality oversight process with states related to section 1915(c) waiver programs. At that time CMS established an evidentiary approach to quality reviews of HCBS waiver programs using a continuous quality improvement process applied to the waiver assurances. CMS clarified the role of the Single State Agency as having first line responsibility for quality reviews and established a waiver cycle timeline in which the reviews were regularly conducted.

In 2007, a second revised iteration of the quality review process was released. CMS standardized three key steps in the review cycle, clarified the site visit policy, and included a worksheet and checklist to improve consistency of reports across regional offices. Concurrently, CMS released version 3.5 of the section 1915(c) application, which further clarified the design of the state quality improvement strategies with a focus on performance measures, sampling, and the continuous quality improvement process (discovery, remediation, and system improvement). CMS also established a tracking system for the timeliness of internal processes associated with the quality review, in an effort to facilitate effective waiver renewals.

Cross-Cutting Initiatives

CMS has ongoing initiatives to support and facilitate continuous quality improvement across all HCBS programs. Examples of some of the cross-cutting initiatives include: 

• HCBS Quality Measurement Projects:  Four key quality measurement projects are currently underway in HCBS programs. The projects test a variety of measurement sets that address quality of life, health, satisfaction, impact of program design, and system balancing. Efforts to coordinate the outcomes of the those projects also being considered.
• Cross-Cutting Quality Efforts in HCBS: HCBS cross-cutting teams work to align quality across HCBS program authorities. Cross-cutting quality goals are focused on advancing quality integration, continuous quality improvement, and information technology.
• National Technical Assistance:  Under the National Quality Improvement initiative, states may request technical assistance from the CMS-designated national TA provider, the National Quality Enterprise (NQE). The NQE provides on-site assistance to states to address specific concerns such as development and implementation of HCBS quality improvement strategies, sampling, evidence gathering, and addressing quality issues that arise in regional office waiver quality reviews.
• CMS National Background Check Program: The 1915(c) waiver programs can include providers covered in the CMS National Background Check Program. The CMS National Background Check program was enacted under the Affordable Care Act (Section 6201) and is a multi-year, nationwide program for national and state background checks on direct patient access employees of long term care facilities and providers. Questions on the National Background Check program can be sent to background_checks@cms.hhs.gov . 
• Education and Training:  CMS conducts educational forums with regions, states and providers via webinars, teleconference calls, videoconferencing, and on-site visits to clarify CMS quality requirements and processes for improving quality of HCBS programs.
• Tools for States: CMS developed and disseminated tools to help states improve quality systems including: technical assistance monographs on Ssampling methods, measurement management, risk management, and quality in HCBS waivers, a participant experience survey, an HCBS quality workbook, a quality grid listing the quality requirements for each HCBS program authority, and most recently, two monographs on continuous quality improvement (CQI).