Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services

The goal of the Home and Community-Based Services (HCBS) measure scan was to identify extant, tested, and prevalent performance measures that could be used or modified to assess and compare the quality of Medicaid (Title XIX) HCBS programs nationwide. The measure scan is the first step in the much larger constellation of activities related to assessing HCBS quality that were mandated in the Deficit Reduction Act (DRA) of 2005. Section 6086(b) of the law directs the Agency for Healthcare Research and Quality (AHRQ) to:

1. Develop, in consultation with relevant stakeholders, measures of program performance, client functioning, and client satisfaction with respect to HCBS services provided through State Medicaid programs.
2. Assess the quality of HCBS services and their outcomes, along with the overall system for providing such services through the Medicaid program.ⁱ
3. Disseminate best practice information distilled from a comparative analysis of the system features of each State.ⁱⁱ

To conduct a thorough environmental scan of existing and potential measures, Thomson Healthcare, under contract to AHRQ, used a variety of complementary sources and methodologies. These included a review of electronic and academic resources, consultation with knowledgeable experts and key informants, a formal solicitation, and a review of tools in current usage by State Medicaid HCBS programs. Specifically, to identify measures we:ⁱⁱⁱ

• Reviewed more than 50 relevant Web sites, including databases such as HCBS.org and the National Quality Measures Clearinghouse. A list of Web sites reviewed can be found in Appendix I.
• Conducted a literature review of peer-reviewed journals, using search engines such as Medline, PsychINFO, Ageline, and the New York Academy of Medicine Grey Literature Report. Appendix I also includes a complete list of the journal articles reviewed for potential measures, as well as the search engines and keywords used in the literature search.
• Issued a formal Call for Measures via the Federal Register, seeking submissions from measure developers, as well as information from States regarding existing tools currently in use, including modification of published instruments.^iv
• Contacted each of the Medicaid 1915c HCBS waiver programs active in the CMS waiver database as of October 2006. Successful contact was made with State staff representing more than 200 waivers. Most of these waiver programs used some type of performance measures for compliance and quality oversight purposes and were able to supply Thomson Healthcare with documentation.
• Convened a technical expert panel (TEP) representing different areas of expertise, including: selected disability populations (aging, physical disabilities, intellectual and developmental disabilities, mental health, and children with special health care needs); measurement science; State and national associations representing Medicaid HCBS programs; consumer advocates; and service providers. This panel provided input at various points during the scan and met collectively via conference call on January 29, 2007, and February 1, 2008, as well as in person on June 22, 2007. A complete list of members and their professional affiliations is in Appendix II. A companion group of Federal staff, known as the Federal Partners, also provided regular input. The members of this group are also listed in Appendix II.

As a result of these activities, more than 200 instruments to collect data supporting performance measures, measure sets, and measure databases were identified with potential relevance to Medicaid HCBS quality. Together, they comprise thousands of individual measures. A summary of each instrument, measure set, and measure database was included in the Compendium of Measures and Tools Identified Through the Medicaid Home and Community-Based Services Measure Scan, as of July 5, 2007 (hereinafter the compendium) dated March 7, 2008. This entire document is presented in Appendix III. A preliminary draft of this document was the focus of the in-person meeting of the TEP on June 22, 2007.

The compendium only includes those measures that were in existence as of July 5, 2007, the cutoff date for formal submissions in response to the Federal Register notice. After this date, additional measures were not included in the scan. However, measures identified or submitted after this date were recorded. A list of these measures and sources is in Appendix IV. A final contextual note: the timing of this project overlapped with other quality performance activities undertaken by CMS, the Federal oversight agency for Medicaid HCBS programs. While the mandates of AHRQ and CMS are different, efforts were made to coordinate the complementary quality measurement activities.