Quality of Care Home and Community-Based Services (HCBS) Waivers

The Centers for Medicare & 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 payer 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.

In 2014, new modifications to the quality review process were released. CMS, with significant involvement by stakeholders, has refined the reporting expectations of states.

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: 

  • Summary Report from the DEHPG 2014 LTSS Research Summit:  The Disabled and Elderly Health Programs Group (DEHPG) hosted a Federal Research Summit on November 3 and 4, 2014 at CMS. This summit brought together representatives from nine different Federal agencies, including CMS, to share a broad range of current and emerging research and to discuss research gaps and collaborations to address those gaps. The goal of the summit was to help DEHPG develop a research agenda for the future that furthers the group’s commitment to support state efforts to transform their systems and rebalance their Medicaid expenditures for long-term services and supports (LTSS) so that more people have the option of receiving LTSS in home and community settings

  • 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.

    On June 17, 2014, DEHPG hosted the 2014 HCBS Quality Measures Summit. View the Presentation Slides from the Summit.
  • 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.
  • 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 sampling methods
    • Measurement management
    • Risk management and quality in HCBS waivers
    •  Participant experience survey
    • HCBS quality workbook
    • Quality grid listing the quality requirements for each HCBS program authority
    • Two monographs on continuous quality improvement (CQI).