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Measuring and Improving Quality in Home and Community-Based Services (HCBS)

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 section 1915(c) HCBS waiver program—the largest single payer of long term services and supports (LTSS) in the country. Through cross-cutting initiatives, we seek to maximize the quality of life, functional independence, health and well-being of individuals served by the HCBS programs.

HCBS Quality Measure Set

In September 2020, CMS released a request for information (RFI) seeking public input on a draft set of recommended measures for Medicaid-funded HCBS. This RFI requested feedback on the potential benefits of and challenges that could result from a nationally available set of recommended quality measures for voluntary use by states, managed care organizations, and other entities engaged in the administration and/or delivery of HCBS. CMS also requested stakeholder comment on the purpose and organization of the recommended measure set, the criteria used to select measures, and a preliminary draft set of measures for assessing the quality and outcomes of Medicaid-funded HCBS.

On July 21st, 2022, CMS issued a State Medicaid Director Letter to release the first official version of the HCBS Quality Measure Set. The HCBS Quality Measure Set is a set of nationally standardized quality measures for Medicaid-funded HCBS.  It is intended to promote more common and consistent use within and across states of nationally standardized quality measures in HCBS programs, create opportunities for CMS and states to have comparative quality data on HCBS programs, drive improvement in quality of care and outcomes for people receiving HCBS, and support states’ efforts to promote equity in their HCBS programs. 

CMS is available to provide technical assistance to states on the implementation of the measure set.  Additional guidance on how states can use the measure set to meet federal reporting requirements for HCBS programs, such as required reporting on section 1915(c) waiver assurances and sub-assurances, is forthcoming.

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 and version 3.6 of the section 1915(c) application were released. CMS, with significant involvement by stakeholders, refined the reporting expectations of states. CMS utilizes the updated quality review process to conduct oversight of states’ 1915(c) waiver and 1915(i) State Plan programs. CMS is building off of these foundational activities to streamline processes related to HCBS quality measurement and reporting and to improve the quality of services and outcomes for people who receive HCBS.

HCBS 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: 

  • Health and Welfare Special Reviews Team Project: In response to recommendations in a 2018 joint report issued by the Health and Human Services (HHS) Office of the Inspector General (OIG), Administration on Community Living (ACL), and the Office for Civil Rights (OCR), CMS formed the Health and Welfare Special Reviews Team (HWSRT). This team has been tasked with: conducting health and welfare focused site visits across states during years 2019-2022; providing technical assistance based on the on-site visits; identifying and sharing states’ promising practices; and working with states to proactively improve health and welfare issues. The project offers assistance to states to improve how the health and welfare of HCBS participants is assured on both an individual and national basis.
  • HCBS Consumer Assessment of Healthcare Providers and Systems (HCBS CAHPS®): The HCBS CAHPS® Survey is the first cross-disability survey to assess the HCBS beneficiary’s experience receiving and the quality of their long-term services and supports. It is designed to facilitate comparisons across the hundreds of state Medicaid HCBS programs throughout the country that target different adults with disabilities, including older adults, individuals with physical disabilities, persons with developmental or intellectual disabilities, those with acquired brain injury, and persons with severe mental illness. The HCBS CAHPS® Survey consists of 69 core items that ask beneficiaries to report on their experiences with:
    • Getting needed services
    • Communication with providers
    • Case managers
    • Choice of services
    • Medical transportation
    • Personal safety
    • Community inclusion and empowerment
  • Through the Testing Experience and Functional Tools (TEFT) demonstration, CMS provided grants to nine states to test new quality measurement tools and demonstrate e-health in HCBS. The TEFT demonstration, spanning the period 2014-2018, produced the HCBS CAHPS Survey and the Functional Assessment Standardized Items (FASI) (available in the CMS Data Element Library and in LOINC Version 2.68), demonstrated personal health records, and created an electronic long term services and supports (eLTSS) service plan standard. More information on the demonstration can be found on the Testing Experience & Functional Tools page.
  • CMS has released Technical Specifications for eight standardized quality measures for managed long-term services and supports (LTSS) programs. The measures include:
    • LTSS Comprehensive Assessment and Update
    • LTSS Comprehensive Care Plan and Update
    • LTSS Shared Care Plan with Primary Care Practitioner
    • LTSS Re-Assessment/Care Plan Update After Inpatient Discharge
    • Screening, Risk Assessment, and Plan of Care to Prevent Future Falls
    • LTSS Admission to an Institution from the Community
    • LTSS Minimizing Institutional Length of Stay
    • LTSS Successful Transition After Long-Term Institutional Stay
    If you have technical questions about these measures, please contact MLTSSmeasures@cms.hhs.gov. Additional information on the measures is also available on the Managed Long Term Services and Supports page.

HCBS Quality Measure Issue Briefs

This issue brief series summarizes major developments in HCBS quality measures, covering three critical processes and outcomes of high quality care:

These briefs are intended to increase access to information on and support states, managed LTSS plans, and providers with implementing tested and validated quality measures in their HCBS programs.