3. What does Any Willing Provider (AWP) refer to in the context of MLTSS?

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1 Overview of Any Willing Qualified Provider (AWQP) Initiative 1. What is Any Willing Qualified Provider? The Any Willing Qualified Provider (AWQP) is a Department of Human Services (DHS) Nursing Facility Quality Improvement Initiative which is being developed and implemented under Managed Long-Term Services and Supports (MLTSS). It will require Medicaid certified nursing facilities (NFs) serving MLTSS participants to meet Quality Performance Standards (QPS) as a means to raise the overall quality of care and provide a basis for future Value Based Purchasing (VBP) of NF services. 2. Why is DHS implementing AWQP? DHS is advancing an AWQP initiative to improve the quality of care for MLTSS members living in NFs. This new initiative is considered to be a foundational step in the DHS evolving VBP strategy with the goal to reimburse providers based on performance and to encourage consumers to select high quality, high value providers. In general, VBP rewards health care providers with incentive payments for the quality of health care they give individuals. VBP is aligned with New Jersey s quality strategy to: Set the stage for VBP the AWQP initiative needs to be aligned with VBP because its focus is also on quality and outcomes of care; Improve NF quality for long-term custodial members by providing regular feedback on performance to NFs so they can design and implement quality improvement plans to improve outcomes for all residents; Provide Managed Care Organizations (MCOs) with a pathway towards stronger network management in addition to sharing provider performance with MLTSS members so they have the information necessary to select high quality, high value service providers, the MCOs will also be able to direct members to facilities that meet the requirements and reward quality through higher reimbursement to quality providers. 3. What does Any Willing Provider (AWP) refer to in the context of MLTSS? When MLTSS was launched on July 1, 2014, DHS agreed that the default rate for NF, SCNF, AL, and CRS facilities during the AWP period would be the higher of: (a) the rate set by the state at this time with the possibility of an increase each fiscal year for inflation, dependent upon available appropriation; and, (b) the negotiated rate between the contractor and the facility. This policy did not preclude volume-based rate negotiations and separate agreements between MCOs and these providers. If a negotiated rate could not be agreed upon, however, the rate would default to the state rate. While AWP continues, this initiative is moving to the Any Willing Qualified Provider (AWQP) program which establishes the ground work for a NF and an MCO to negotiate a payment rate based on quality outcomes. 1

2 4. When does AWQP begin? DHS has designed a multi-year timeline to develop and implement the AWQP initiative. The rollout begins with the pre-baseline data distribution in October In January 2018, DHS will prepare baseline data for distribution along with the requirement for NFs to submit Quality Performance Plan (QPP) Report when they do not meet at least four out of the seven QPS. The initiative fully implements in January 2019 when the NFs will receive their AWQP designation depending on if they meet or exceed the statewide average benchmark as established by CMS on at least four of the seven QPS. The following information provides additional detail pertaining to both the pre-implementation activities as well as the on-going operations timeline of the initiative. Timeline October 2017 January 2018 February 2018 March 2018 July 2018 August 2018 September 2018 January 2019 February 2019 March 2019 April June 2019 July 2019 August 2019 September 2019 January 2020 February 2020 March 2020 April June 2020 Timeline (Abbreviated) Key DMAHS and DoAS Activities Pre-baseline data distribution five (5) MDS quality measures Prepare baseline data for distribution Baseline data and preliminary survey is released Receive NF QPP reports; Receive and review any NF appeals related to data Prepare data for distribution Baseline interim data is released Receive NF QPP reports Prepare 1st annual data for distribution 1st annual data is released Receive NF QPP reports; Receive and review any NF appeals AWQP annual designation is provided for the first time; MCO oversight/collaboration on QPP reports Prepare data for distribution 1st annual interim data is released Receive NF QPP reports Prepare data for distribution 2nd annual data is released Receive NF QPPs reports; Receive and review any NF appeals related to data AWQP annual designation; MCO oversight/collaboration on QPP reports 5. How will the providers and consumers be informed about the implementation of the AWQP initiative? In addition to a letter distributed to the NFs in October 2017, New Jersey will use its stakeholder groups to inform providers and consumers about the implementation of the AWQP initiative as the initiative is being developed and implemented between now and January Future communications will focus on the long-term custodial nursing home members and their 2

3 respective families. At this time, communications are being focused on the NF leadership (owners, administrators, directors of nursing) and key staff, who need to understand the initiative s scope. There is a communication strategy under development with timelines to support the rollout. The communication strategy focuses on education and training of stakeholders in the aging/disability networks including providers and advocates. Information about the AWQP initiative will be available on the MLTSS homepage of the DHS website and will remain largely focused on providers before the initiative is implemented and affects the public. Quality Performance Standards (QPS) 6. What are the QPS which will determine a NF s as AWQP designation? There are seven measures comprising of five Minimum Data Set (MDS) standards and two survey standards. The MDS data is the same information collected by the Centers for Medicare and Medicaid Services (CMS) under its Medicare Nursing Home Compare program. The sixth measure, known as CoreQ, is based on the long-term custodial member s and family s experience of care with a particular NF. The last measure is where each NF must attest to their use of a specific type of software or electronic tool that allows a NF to track, trend, and implement interventions based on hospital inpatient utilization. Quality Measures Data Source Performance Standards QPS 1 Is the percentage of long-stay residents who are immunized MDS against influenza annually at or above the statewide average? QPS 2 Is the percentage of long-stay residents who received an MDS antipsychotic medication at or below the statewide average on a quarterly basis? QPS 3 Is the percentage of long-stay, high risk residents with a MDS pressure ulcer at or below the statewide average on a quarterly basis? QPS 4 Is the percentage of long-stay residents who are physically MDS restrained at or below the statewide average on a quarterly basis? QPS 5 Is the percentage of long-stay residents experiencing one or MDS more falls with major injury at or below the statewide average on a quarterly basis? QPS 6 Resident/family experience in the NF. CoreQ Composite Score QPS 7 Is the facility using INTERACT, Advancing Excellence tools, LTC Trend Tracker sm, or another validated tool to measure 30- day hospitalizations and hospital utilization so that it can share data with the MCOs? Self-reported 3

4 7. Who developed the AWQP initiative and how were these quality performance standards selected? The AWQP initiative was developed in collaboration with the MLTSS Steering Committee s Quality Workgroup which includes representatives from the nursing facility providers, MCOs, and other long-term care stakeholders and advocates. The Quality Workgroup had been involved with the initial development of MLTSS and then was reconvened to provide input into this initiative. The selection of these initial quality performance standards was a collaborative process over the course of several meetings in 2016 involving the stakeholder community. The Quality Workgroup also developed these guiding principles: 1. Improve the residents experience of care and quality of life; 2. Develop a transparent and collaborative environment with the stakeholder community; 3. Implement a consistent approach to quality measurement which can be enhanced over time; 4. Develop a framework that promotes continuous quality improvement and dissemination of best practices; and 5. Build in assurances for the health and safety of residents by providing appropriate oversight and accountability. 8. How does a NF meet the quality performance standards to earn the AWQP designation? To be awarded the AWQP designation, a NF must meet or exceed the statewide average benchmark as established by CMS for at least four of the seven measures. The survey responses are measured every six months. The following table provides additional information about the AWQP measurement set: Influenza vaccination To meet this metric the NF must be at or above the statewide benchmark for the most recently publicly available data. Note: This metric is calculated only once per year. Antipsychotic medication Pressure ulcers Physical restraints Falls - major injury To meet any of these four individual standards, NFs must be at or below the statewide benchmark for at least four out of six quarters for the most recently publicly available data. CoreQ Survey A standardized and validated survey tool to capture the resident and family experience of care. To meet this metric the NF must be at or above the statewide benchmark for the recent reporting period. This metric is collected every six months. Nursing Facility Attestation Question Requires a Nursing Facility to attest to the use of INTERACT, Advancing Excellence tools, LTC Trend Tracker sm, or another 4

5 validated tool to measure 30-day hospitalizations and hospital utilization. This metric is collected every six months along with the CoreQ. 9. Will the statewide averages change? Yes, every six months DHS will analyze the data from CMS and establish NJ s statewide averages by which each of the AWQP measure results will be evaluated; this is called a reporting period. For each reporting period, DHS will share an AWQP report card with each NF. The report card will summarize each NF s progress towards meeting statewide average benchmark as established by CMS. DHS fully anticipates the calculated statewide benchmarks will vary between rating periods. This expectation stems from the continuous quality improvement principles built into the initiative design. As the initiative matures, subsequent revisions to the measure set and benchmarks are expected. Subsequent phases of the AWQP initiative will more fully address VBP mechanisms. As the initiative matures, DHS will engage the Quality Workgroup to discuss any methodological revisions. 10. How frequently will the AWQP designation process be calculated and applied? While data will be pulled and shared with each NF every six months, the AWQP designation will be awarded on an annual basis. The annual AWQP designation will remain with a NF until the next annual report card is issued. Because the measure results are pulled every six months, the report that occurs mid-year is referred to as an interim report. The interim report provides a NF with their progress towards meeting the most recent statewide benchmarks. It will be based on the interventions and participation of each NF s continuous quality improvement efforts. The AWQP designation will begin effective January/February What is the CoreQ survey and how is it distributed? CoreQ is a standardized and validated survey tool, developed and administered through Dr. Nick Castle of University of Pittsburgh, to capture the resident and family experience of care. The CoreQ consists of three questions that when combined as a score represents overall satisfaction as rated by long-term custodial residents or family members. Excluded from the survey are the following long-term custodial residents or family members who: Suffer from dementia impairing their ability to answer the questionnaire which is defined as having a Brief Interview for Mental Status (BIMS) score of seven or lower on the MDS; Have a legal court-appointed guardian (resident) or serve as a legal guardian (family); Are on hospice as recorded on the MDS (O0100K1=1); Have lived in the NF for less than 100 days; Are family members who reside in another country. 5

6 The CoreQ surveys will be distributed and analyzed every six months. The NFs will be responsible for providing Dr. Nick Castle with resident and family information on a regular basis. This information may be collected via an Excel and sent through secure . For more information on CoreQ, please visit the website at What questions are asked in the CoreQ survey and what is the response scale? The three questions for long-stay residents and family members are as follows: In recommending this facility to your friends and family, how would you rate it overall? Overall, how would you rate the staff? How would you rate the care you receive or how would you rate the care your family member receives? The response scale is as follows with one being the lowest and five being the highest: One (1) Poor Two (2) Average Three (3) Good Four (4) Very Good Five (5) Excellent 13. If a NF already uses CoreQ in their satisfaction surveys, can those results count? Yes, one of the reasons CoreQ was selected by New Jersey as the tool to measure resident satisfaction was because some NFs which already have a survey tool can incorporate CoreQ into what they are currently using. The questions and results may be exported and included in the analysis for DHS. 14. Will the use of a tool to measure 30-day hospitalizations and hospital utilization qualify a facility to receive credit for this measure? DHS has determined that validated analytical tools such as INTERACT, Advancing Excellence tools, and LTC Trend Tracker sm, which are used to analyze 30-day hospitalizations and hospital utilization, will initially be sufficient to meet this performance measure. 15. The resident and family experience and hospital tracking tools are unavailable at this time. What happens until those two measures are available? For those two measures, each NF will receive credit for meeting those two measures in the absence of the data. Once the measures are available and benchmarked, they will be included in the interim and annual reporting periods. DHS has finalized a contract for these measures to be collected. These measures will be collected and tallied every six months. 6

7 16. Could a facility s ranking on Nursing Home Compare of four or five stars qualify for an exemption from the AWQP designation process? No, the initiative does not consider the CMS Five-Star Quality Rating System. However, the MDS data used in the Nursing Home Compare ratings is the same data that is used for AWQP. 17. What happens if a facility does not meet the quality performance standards? Based on results of the AWQP initiative metrics, NFs who fail to meet the statewide benchmark as established by CMS on at least four out of seven measures will not be awarded the AWQP designation. NFs who fail to meet this designation will be required to develop a Quality Performance Plan (QPP) Report that addresses all measures that did not meet or exceed the benchmark. AWQP Designation 18. What happens if my facility is not AWQP designated? To the extent that a NF is not able to attain AWQP designation status or if a NF is unable to maintain its AWQP designation status, an array of progressive accountability actions may be taken. These actions range from issuing notices informing members that they are allowed to relocate to another NF to halting new MLTSS long-term custodial care admissions to termination of the NF as a provider in the networks for Managed Care Organizations. The progressive accountability component will begin in January 2019 with the start of the first AWQP designation. 19. Will there be an exception process to admission suspensions? If the process of progressive accountability leads to a suspension of new MLTSS admissions for a NF, potential MLTSS NF residents can request an exception. The exception process allows the MCO to consider a resident s request for admission while ensuring the health and safety of the member. The exception process will consider situations to enable: Continuity of care (transitions from subacute to MLTSS long-term custodial care). Family cohesion (spouse currently resides in the NF). Family support (family visit frequently due to the proximity of the NF). 20. Will Medicaid payment rates by the MCO be different for NFs if they are not designated as AWQP providers? In the initial stages of the AWQP initiative, NF payment rates will not be impacted by the AWQP designation. However, DHS fully anticipates future alignment of cost and quality metrics as the AWQP initiative matures. 21. How does a change in NF ownership affect the AWQP designation? When a change in ownership occurs for a Medicaid certified NF, the measures and designation 7

8 obtained under the prior owner will apply to the new facility. The new ownership will be responsible to establish a Quality Performance Plan (QPP) Report and be subject to any progressive accountability actions as a result of the measure outcomes. Quality Performance Plan (QPP) Report 22. What is a QPP report and why should a facility create one? The QPP report is an action plan created by the NF to address any of the seven measures that fall outside the established benchmark. DHS will designate a standardized form for NFs to submit their QPP reports. Any NF not meeting at least four of the seven AWQP measures must submit a QPP report to DHS within 15 business days of receiving notification of failure to achieve AWQP designation. DHS encourages all NFs to create a QPP report regardless of the AWQP designation. The QPP report can be used to support the NF s continuous quality improvement efforts. 23. Who will be responsible for receiving the QPP report? DHS will be responsible for receiving the QPP reports to review the NF s intended actions to improve outcomes. Once DHS receives the QPP report, it will be shared with all MCOs. 24. Will the MCOs play a part in assisting the facility to meet the AWQP performance benchmarks? The AWQP results and designation will be shared with the MCOs for each reporting period. To reduce the impact of multiple MCOs directing individual NF oversight processes, DHS will direct the MCOs to work together to develop an overarching NF quality collaborative. Examples of this approach include, but are not limited to, the following: MCOs will collaborate with each other on their oversight processes to limit the burden of up to five MCOs performing similar monitoring activities on one NF. MCOs will coordinate their training and technical assistance efforts with a focus on those quality measures most in need of improvement thus minimizing duplication of effort. MCOs will be encouraged to collaborate with the NF associations on these efforts. NFs not belonging to an association can participate in all training and technical assistance opportunities hosted by the NF associations and MCOs. The MCOs will work with the NFs to ensure the individual health and safety of each member and assist in improving the overall system of care delivery. Appeals Process 25. Can a non-designated AWQP facility appeal its designation? 8

9 Yes, non-designated NFs will have a pathway to appeal their designation through DHS. The appeal route will allow the NF to address concerns about the data and/or special considerations which DHS may consider as part of the designation process. For example: A NF can appeal the results if it believes the MDS data, CoreQ survey results, or the self-reported hospitalization tracking software response is not correctly reported, or The NF may present evidence that due to unique circumstances such as special populations or services (e.g., memory impaired or treatment of complex wounds), a particular measure results cannot be benchmarked to the statewide average. More details will be provided in future stakeholders training sessions. Member Choice 26. How will members be informed of a NF s AWQP designation? Members will receive notices informing them of the designation and their rights. The AWQP designation will also be posted on the DHS website. 27. If a Medicaid resident leaves the NF for a hospital stay, will the resident be able to return to the NF at the end of their hospital stay if the facility is not AWQP designated? An MCO MLTSS resident who leaves a NF for a hospital stay may choose to return to the NF or choose to move to another NF due to the lack of AWQP designation. While the goal of this initiative is to ensure a high quality member experience, members will always retain choice of living arrangement. 28. If an MLTSS member in a non-awqp designated NF wishes to transfer to an AWQP designated NF, who will assist them? The MCOs, in collaboration with the NF staff, will facilitate the transfer from a non-awqp NF to an AWQP designated NF. 29. Does the AQWP designation apply to Medicaid Fee for Service or Private Pay residents? No, the AWQP designation and any progressive accountability actions only applies to individuals receiving services under MLTSS, and does not apply to fee for service residents or private pay residents at this time. Quality Performance Standards (QPS) Report 30. What is the QPS Report? The QPS Report consists of five core MDS measures from NJ Medicare and Medicaid certified nursing homes that are part of the long-stay NF measures collected by the Centers for Medicare and Medicaid Services (CMS). These five core MDS measures are a part of the federally 9

10 mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. 31. Are all NFs in New Jersey included in the QPS Report? No, not all NFs in New Jersey are included. The QPS Report provided by DHS excludes Special Care Nursing Facilities (SCNFs) and non-medicaid Certified Nursing facilities. 32. What do the symbols mean on the QPS Report? The asterisk symbol (*) indicates CMS had a footnote of The number of residents is too small to report. Call the facility to discuss this quality measure. A data period with asterisks will be considered as having met the statewide benchmark due to insufficient number of residents. The three dashes symbol (---) indicates CMS had a footnote of The data for this measure is missing. Call the facility to discuss this quality measure. A data period with dashes will be considered as not having met the statewide benchmark due to facility s failure to report. The down arrow ( ) indicates in order to meet this measure the data result must be at or below the statewide average. The up arrow ( ) indicates in order to meet this measure the data result must be at or above the statewide average. Depending on the statewide average, NFs may or may not meet the standard for the measure. 33. Why are some quarters formatted differently? All measures by quarters are replicated as shown on the CMS website. This data is released and available to all NFs by CMS outside the AWQP processes. 10