Best Practices in Health and Safety

By Valerie BradleyHuman Services Research Institute

Signs of Change in Performance Management

No longer just better than the institution Rooted in outcomes Emphasis on enhancement Changing role of the state Changes in experiences of families

and people with mental retardation Changes in accreditation

approaches

Outcomes

Expectations

Inclusion

More Signs of Change

Movement away from prescriptive standards

Emphasis on CQI Exploration of self-assessment Collaborative development of

standards Inclusion of customer satisfaction

Satisfaction

CQI

Consensus

Person-CenteredSystems: Facilitate individual choice Support relationships and community

membership Encourage natural supports Encourage health, well-being and safety Foster productivity and participation in

meaningful work Maximize self-determination Support families Build staff and provider capacity

Public Quality Assurance Responsibilities

Assuring that individuals are free from abuse, neglect, and exploitation;

Protecting the rights of individuals and families; Assuring accountability in the use of public dollars; Assuring that individuals have access to necessary

professional services; Evaluating the effectiveness if service and

supports; Assessing the performance of service providers

Changing Quality Landscape

Exposure of fault-lines in the system (e.g., HCFA and the press)

Expansion of supports to individuals on the waiting list

Emergence of self-determination Olmstead decision Struggles with MIS applications Direct support staff shortages

Critical Constraints

Consolidation of providers Management of multiple systems “Generic” approaches to quality Increasing gray areas in public

jurisdiction Pressure from HCFA Lack of collaboration with sister

agencies

Emergence of Performance Indicators First appeared in behavioral and

acute care Provide some “cues” for managing

these complex systems Highlight impact of cost

containment Illuminate what’s working Provide early warning signs For more information: www.hsri.org (Core Indicators Project)

Project Beginnings

NASDDDS and HSRI collaboration Launched in 1997 Seven field test states + steering

committee ~60 candidate performance

indicators Development of data collection

instruments

Current Participating States

Arizona Connecticut Delaware Hawaii Illinois Iowa Indiana Kentucky Massachusetts Montana

Nebraska North Carolina Oklahoma Pennsylvania Rhode Island Utah Vermont Washington West Virginia Wyoming

What will CIP accomplish?

• Nationally recognized set of performance and outcome indicators for developmental disabilities service systems

• Benchmarks of performance• Trend data at the state level• Broad dissemination to all

stakeholders

What are the Core Indicators?

Consumer Outcomes: Satisfaction, choice, employment, community

inclusion, natural supports, family supports… System Performance:

Service expenditures and utilization, access… Protection of Health and Safety:

Injuries, crime victimization, mortality data… Provider Agency / Workforce Stability:

Staff turnover…

Data Sources

Consumer Survey Family Support Survey (plus new

version for families with kids) Family/Guardian Survey Provider Survey (limited) DD System MIS

Consumer employment data

Where people work:Duplicated countsAggregate N = 3900 (11 states)

27.7% -- supported employment 21.7% -- group employment

(enclave/crew) 40.4% -- facility-based employment 36.8% -- non-vocational day supports

0%

10%

20%

30%

40%

50%

60%

70%

80%

1 2 3 4 5 6 7 8 9 10 11

SEP

GRP

FAC

Types of Employment Supports by State

Community Inclusion

93.71%

91.50%

90.15%

84.15%

72.47%

55.93%

0% 20% 40% 60% 80% 100%

errands

shopping

eat at restaurants

go out forentertainment

exercise/sports

attend religiousevents

Choice and Decision-Making

89.46%

75.30%

70.53%

51.13%

50.23%

32.17%

30.77%

29.49%

11.29%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

choose freetime activities

choose schedule

chose job

chose home

chose day program

chose people to live with

chose home staff

chose job staff

chose service coordinator

Consumer Outcomes

Access

81% of respondents reported that they almost always have a way to get where they want to go

Safety

93% of respondents report feeling safe in their neighborhoods

96% report feeling safe at home

Health Outcomes

Last OB/GYN Exam

Over a Year Ago14%

Never Had an Exam9%

Within Past Year54%

Don't Know23%

Health Outcomes

Last Physical Exam

Don't Know8%

Over a Year Ago6%

Within Past Year86%

Health Outcomes

Last Routine Dental Exam

Over 6 Months Ago26%

In Last 6 Months55%

Don't Know19%

Family Survey Comparisons

More positive responses on Family/Guardian Survey (this group was generally older and received more supports)

Out-of-home families more satisfied with individual supports than those with family members living at home (84% vs. 64%)

Much greater variation on satisfaction ratings for the in-home group (50% to 70%)

Staff Stability

Day support providers report: Lower turnover Current staff have been employed longer Half as many vacant positions (both FT and PT)

Both types of agencies report: Staff who left within the last year were

employed on average about 19 months Part-time position vacancies are much higher

than full-time position vacancies

For more information…

Visit HSRI’s website:www.hsri.org/cip/core.html

Pennsylvania OMRIndependent Monitoring

Project Provides an independent evaluation of the provided by the

PA mental retardation system Based on personal interviews with consumers and families Reports issued to counties and the state containing with

findings and recommendations for program improvements.

The Mission of the Independent Monitoring Project is to: ID outcomes achieved by persons receiving supports Measure achievements Recommend improvements Continually promote the values of Every Day Lives

Pennsylvania OMRIndependent Monitoring Project

Continued How does the process work?

Monitors have a contract with the local County MH/MR facility

Interviewing teams are made up of consumers, families, and other interested people

Reports prepared by Temple University Reports are used by providers, counties, and the

state to improve the quality of services provided and to make changes where necessary

Reports also reviewed by a state wide steering committee that advises the Office of Mental Retardation on actions to be taken.

Massachusetts DMR Risk Management System

Implemented in 1999 Mission is to balance the responsibility of a public agency to

keep individuals with mental retardation safe while promoting independence and self determination. This involves:

Creating a foundation of trust between the state and individuals that does not limit freedom assists the individual to make safe choices.

Insuring that there is a strong management system and framework that the level of supervision and oversight is appropriate.

Emphasizing safeguards and strategies that result in reasonable risk, and a balance between risks and responsibilities.

Massachusetts DMR Risk Management System Continued

The DMR Risk Management System has 4 basic components: Risk Identification and Prevention

A review process conducted by service coordinators. Risk Assessment and Planning

Persons determined to be at-risk will have a risk management planning meeting with their planning team.

Risk Training, Consultation, and Support Training for DMR staff working with person at-risk; also

provider training and public education efforts. Risk Management System Oversight Activities

A standardized process coordinated by the Central Office Risk Management Director.

California DDSWellness Initiative

A 1996 statewide initiative by DDS to promote quality medical, dental, and mental health services for all Californians with DD.

Activities include: Regional Projects

funding of 86 regional projects that address Abuse, Aging, Behavioral, Dental, Health Documentation, Health Assessment, Medication, Mental Health, Nutrition, Telemedicine, Training, and Women’s Health

Publications includes the Wellness Digest Newsletter and The Road to

Wellness, a booklet on accessing Medical Services Partnership Activities

Provide training & resources for medical professionals, universities, regional centers, care providers, consumers, and families

New Mexico Continuum of Care Project

Mission: to provide quality health care for people with DD including:

Creating learning opportunities, Promoting best practice policies, and Offering specialized developmental disabilities services.

Assumptions: Health care services should be available and delivered in

a comprehensive and coordinated manner from infancy to adulthood

Health services should be multidisciplinary Health care professionals need to becoming more

knowledgeable and competent in dealing with developmental disabilities

Health care should honor personal values, promote quality of life, and respect cultural differences.

Healthy People 2010:Disability & Secondary

Conditions Healthy People 2010 (released by HHS in 2000) is a

set of health objectives over the first decade of the new century.

Chapter 6: Disability and Secondary Conditions was developed by the Center for Disease Control and Prevention, the U.S. Dept. of Education, and the National Institute on Disability and Rehabilitation Research.

The objectives of this chapter are to: promote the health of people with disabilities, prevent secondary conditions, and eliminate disparities between people with and

without disabilities in the U.S. population.

Healthy People 2010:Disability & Secondary Conditions

Misconceptions

Four main misconceptions about people with disabilities: all people with disabilities automatically have poor health, public health should focus only on preventing disabling

conditions, a standard definition of “disability” or “people with

disabilities” is not needed for public health purposes, and the environment plays no role in the disabling process.

Lead to an under emphasis on health promotion and disease prevention and an increase in the occurrence of secondary conditions.

Challenging these misconceptions will clarify the health status of people with disabilities and address the environmental barriers that undermine the health, well-being, and participation in life activities of people with disabilities.

Healthy People 2010: Disability & Secondary Conditions

Objectives Summary of Disability Objectives for 2010:

Include standard definition of people with disabilities in data sets

Reduce feelings of depression among children with disabilities

Reduce feelings of depression interfering with activities among

adults with disabilities

Increase social participation among adults with disabilities

Increase sufficient emotional support among adults with disabilities

Improve satisfaction with life among adults with disabilities

More Recommendations

Reduce congregate care of children and adults with disabilities

Create employment parity between adults with and without disabilities

Increase the number of children and youth with disabilities included in regular education programs

Increase accessibility to health and wellness programs for people with DD

Increase access to assistive devices and technology for people with DD

Reduce environmental barriers affecting participation in activities

Increase public health surveillance and health promotion

Resources: To find more info on the projects presented you can visit the

following web sites:

PA Independent Monitoring Project www.dpw.state.pa.us/omr/omrImt.asp

MA Risk Management System www.qualitymall.org (QA Store, Monitoring

Health & Safety Dept.) CA Wellness Initiative

www.dds.ca.gov/Wellness/main/Well01.cfm NM Continuum of Care

star.nm.org/coc/ Healthy People 2010

www.health.gov/healthypeople/Default.htm

Important Next Steps

Place individual outcomes at the center of the system

Enlist assistance of consumers and families

Identify key areas of performance

Link technology with need for information

Look at the costs and benefits of existing approaches

Make results available and accessible

Get serious about uniform reporting of critical health and safety events

Develop staff credentialing and expand training options

Reassess roles of case managers

Refine performance contracting

Expand understanding of person-centered planning

Final Words

“Beware the Continuous Improvement of Things Not Worth Improving”

W. Edward Deming