State of Alaska Division of Legislative Audit

Long Term Care Improving Administrative Functions Recommendations Table

Recommendation NumberRecommendation
1.1The Department should consider altering the Continuum of Care document to reflect a consistent top-to-bottom approach. The document could provide more information if it were done in a tabular format without the info-graphics. Each program could be shown in a row and the information could be placed in columns. With the extra data space, SDS may consider providing additional details to the budget document such as comparisons to previous years or future projected growth. This will enable the readers to see the document less as a single point in time and more as a living document that enables comparisons to past and future years. This will also let viewers easily make comparisons and see how the level of services provided has evolved over time. Additionally, SDS may consider adding additional program descriptions to the document. Legislative staff may not be familiar with “DD Grants” and a brief description may provide an increase in understanding. Another consideration maybe to add in the number of providers that provide services in each of the areas. This will help readers to properly gauge scope and size of each of the programs.
1.2The Department should consider adding in historical budget data (beyond FY 2014 actuals) to each of the Results Delivery Units (RDUs). Again this will help the reader see trends across years and see how the program has either been growing or decreasing in size. Providing historical costs increases will also enable the readers to make relative comparisons across multiple years to see how the program has evolved. Finally, the Department may consider summarizing outcomes data as well in this section. Demonstrating results and outcomes is an important step in justifying programming and the associated dollars; however this is not included in the budget document. Nor is historical information on LTSS programs readily available on the Department’s websites. Outcomes data will help readers connect with where and how dollars are being spent. It is easier to justify dollars being spent when direct outcomes can be persuasively described.
1.3The Department should consider adding additional program information in the discussion of the each of the RDUs. This section of the budget document is the only place the Department has the opportunity to present additional unstructured narrative and the Department should take advantage of this opportunity to present full and complete program descriptions.
2.1The Department should hire a vendor and take a random sample of persons that were denied service or had services discontinued to identify the impact of these reductions.
2.11The Department should modernize its assessment instruments to incorporate person-centered assessment data. This will be accomplished by adopting a single assessment process to determine eligibility for LTSS, allowing a collection of information that will flow into care plan development. The continued use of multiple instruments is administratively inefficient.
2.12The Department should discontinue the use of the ICAP by replacing it with a tool that is not proprietary. The ICAP is a proprietary tool whose continued use creates ongoing inefficiencies for the Department.
The State of Alaska should enroll in the National Core Indicators (NCI) study. While the NCI program focuses on persons with intellectual and developmental disabilities, CMS is moving towards implementing similar surveys for use with older persons and persons with physical disabilities. Alaska apparently did not apply for a CMS Testing Experience and Functional Tools (TEFT) grant. The nine states that received such grants have the opportunity to develop consumer experience surveys before CMS mandates their use by state Medicaid programs. Surveys like this, which are currently not done in Alaska, support and help build the kind of person-centered programs that are required in federal health planning. This recommendation is further addressed under Review Objective 08: Information Technology.
3.9The Department should take an active role and recommend changes to minimum requirements for job classes and collective bargaining agreements to permit longer training periods for contract managers. These changes should allow employees to have a complete first year of training prior to allowing them to be a program manager. Seeing the entire grant cycle through for an entire year will help new employees understand and visualize the complete cycle. This will help ensure new employees are properly trained and understand the entire process.
3.10The Department should implement a stand-alone or carve-out policy for evaluations of proposals that are more subjective in nature. Some procurements are challenging to evaluate within the given constraints. These procurements typically involve work submitted around creativity or media creation. The Department may consider having respondents consider either judging respondents on past work of similar nature. Additionally, the Department may consider not scoring sections that are based purely on creativity as they are overly subjective and are hard to backup through reviewer scores and notes.
3.11The Department should include a user manual to accompany training videos. A physical or web-based manual will help communities in rural areas who may have poor or limited internet bandwidth. A training guide similar to the DHSS Grant Budget Preparation Guide would be an improvement to the overall system use.
3.12The Department should update the GEMs system to allow PEC members access to the proposals outside of the state network. To ensure proper security virtual private networks (VPN) solutions may be considered so all proposals remain private and secure.
3.13The Department should fix the year-end report to focus further on outcomes and performance metrics as opposed to simply the dollar amounts spent or tasks accomplished.
3.14The Department should provide proper contract and vendor management training to all Department contract managers. This training should ensure managers are adequately and properly trained in contract management. While some training is in place, staff would benefit from a more intensive program. In addition, in all cases staff workloads should be considered and monitored to ensure all managers have appropriate bandwidth to handle additional contract management tasks.
3.15The Department should consider adding in a simple dashboard into the process that visually demonstrates tracking of program goals and percent completion. Although it is often hard to track exact qualitative measures, simple graphics demonstrating percent completion are useful to ensure all grantees are on track. Grant measures and outcomes are often complicated and having a simple tracking measurement will go a long way in tracking progress.
3.16The Department should consider additional performance measures to the overall reporting structure. This will help further ensure that funds are spent in the most appropriate manner.
3.17The Department should develop formalized policies and procedures for handling deficiencies. These policies can be tailored based on grant size and / or provider numbers.
3.18Formalized timeframes should be developed for the issuance of a deficiency notification.
4.1A provision of additional details surrounding the list of reductions should be made. Having half of all the suggested cutbacks come from two large unspecified areas is not fully responsive to the Legislature’s request for a list of programs or elements of programs since program-level reductions were not specified.
5.1The Department should consider the overall need for the CON application. It is no longer a federal requirement, and currently 14 of 50 states do not operate a CON recommendation. The program is effective in rural areas at controlling healthcare costs, but it is not necessarily needed in urban areas.
5.3The Department should amend the regulatory language surrounding the ambulatory surgery centers to not allow for the moving of a facility without a CON. This exception undermines the overall effectiveness of the CON program in that facilities can be moved without having to first demonstrate the community need within a given geographic area.
5.4The $1.5 million threshold for differing facilities should be adjusted. Thresholds should vary depending on their size and scope (raising the threshold for larger facilities, and lowering for smaller facilities). The $1.5 million dollar CON application threshold should be adjusted annually to stay in line with the inflation of the dollar.
5.5The CON application process should be limited to rural areas. The Department may consider limiting the application process to rural areas as the demonstration of need provides more value. Rural areas have significantly smaller population size in Alaska and an extra provider or facility will have significant impact on the community and the overall quantity of services provided. This will indirectly lead to increases in costs in that region. Urban areas tend to regulate more through economic controls and have a reduced need for a formalized CON Application. The Department consider ending the CON process in the urban areas.
5.6The Department should update the NPV calculation in application and regulations. Modify to a uniform and actuarial accepted standard. The current definition allows applicants to depreciate their entire lease in determining their NPV.
5.7The Department should change the CON application fee to a fee that covers the cost of processing the application. A maximum fee of $75,000 generates more in revenue to the state than the state incurs in costs to process the application.
5.8The Department should update and reform the CON application process as the application is repetitive and inefficient. Several sections are duplicative including portions of Section II and Section III. For a complete breakdown of all sections, please see Appendix 02: Certificate of Need Application (Summary of Sections). The application was last updated in 2005 and is a non-writeable PDF that still contains tracked changes in the final posted version. Additionally, The Department should consider an online based electronic submission process which will assist in further streamlining the application.
5.9The Department should have regulatory authority increased to enforce CON violations. Currently, the Department has limited enforcement ability to regulate providers who do not appropriately comply with the CON process. The Department’s only option is to file injunctive relief with the Alaska Supreme Court. The Department should increase enforcement ability through statute to enforce regulations, especially in situations where a CON was not filed.
5.10CON standards and methodologies should be updated and re-baselined. The Department should review and update assessment criteria as they have not been updated since 2005 to ensure metrics in alignment with current standards and population needs. For a more detailed breakdown of the standards and methodologies, please see Appendix 03: Alaska Certificate of Need Review standards and methodologies. A thorough review of the standards and methodologies will help ensure criteria are in alignment with best practices of today. Additionally, new types of facilities, scanners, and service trends may need to be added to the standards and methodologies as medicine has quickly evolved over the past decade.
5.11The Department should increase public involvement in the application review process and should streamline public noticing. In order to increase public involvement in the application review process, an online email noticing system should be considered. This would encourage public participation and feedback on the overall review process. Currently applications are posted in newspapers, however as readership is slowly declining an online forum may also double as an effective medium of communication.
5.12The Department should consider creating an exception or allowance to CON regulations regarding renovating a facility. Currently, renovating a room is possible, but renovating a facility (ex: changing the layout of a floor) requires a CON application, as it falls under: construction of a healthcare facility. This exception would allow facilities to make renovations which improve patient care through a physical restructuring of where, within the facility, the services are offered, especially if bed capacity and services rendered do not change. The focus of the CON should be placed toward meeting the needs and comforts of patients as opposed to strictly being concerned about renovation costs, or whether the layout of the facility has changed.
7.1The measure stating: “Increasing the number of Alaskans with disabilities who are living safely in the least restrictive environment” should be amended. Changes in the number of individuals receiving LTSS is a useful fact, but expressing this as a percentage of total Alaskans creates the need to understand what a reasonable percentage is. The Department should consider expressing this as a percentage of Alaskans with disabilities rather than the total number of Alaskans.
7.2Discussions of the effectiveness measure titled “Number of Residents Who Access the Medicaid Waiver” and the efficiency measure titled “Total Medicaid Waiver Receipts” should be expanded to identify what constitutes a good performance. For example, are lower receipts better, or are higher receipts better?
7.3The Department should consider an alternative effectiveness measure. Abuse and neglect are often repetitive. An effective adult protective service does not simply count the number of abusive situations, it stops the abuse from happening again. The Department should consider measuring recidivism of abuse.
7.4PCG recommends altering the following measure “Average Cost for Waiver Eligible Alaskans Living in ICFMR or Nursing Homes Versus Those Living Independently,” as the data seems to contain all non-institutional costs, possibly including assisted living. However, the wording of the measure refers to “living independently.”
7.5A text discussion of what constitutes good performance should be added along with an explanation of current percentages would strengthen the use of safety assessments concluded within required time frames. Interviews with staff indicate that the population of individuals who are supposed to have safety assessments performed has varied over the years and fluctuations in the data could be due to changes in policies, as not everyone in past years was supposed to receive a safety assessment.
7.6Discussion of each measure should include a description of what constitutes a “good” score on the measure. Only a few measures, such as time elapsed before an abuse investigation starts, are unambiguous. For example, increases in the number of individuals receiving services and expenditures are good to an extent but there are limits on the reasonability of such increases and the text needs to demarcate these limits clearly.
7.7The Department should include a fuller explanation of how to interpret all performance measures. For example, the rate of identification of substantiated abuse has all of the familiar problems associated with crime reporting. Is the crime rate increasing or is crime reporting getting better? Textual discussions are needed to set a context for interpreting the statistics provided.
7.8The Department must be cognizant of the fact that measures are interrelated and need to be explained well, lest readers understandably form a plausible but probably incorrect interpretation of the data. There is a tendency for the performance measures to be discussed in isolation.
7.9The Department should add in metrics where outcomes are tied to reimbursements. Measuring outcomes to reimbursements will help compare the quality of care to dollars spent in determining the efficiency of service delivery.
7.10The 26 indicators in the AARP scorecard of LTSS programs should be reviewed with the intent of determining if any of them might be suitable for inclusion in its performance measures. The following performance measures are suggested for special attention: percent of nursing home residents with low care needs, percent of home health patients with a hospital admission, percent of long-stay nursing home residents hospitalized within a six-month period, Percent of nursing home residents with moderate to severe dementia with one or more potentially burdensome transitions at end of life, percent of new nursing home stays lasting 100 days or more, and percent of people with 90+ day nursing home stays successfully transitioning back to the community.
8.2The Department should adopt a single assessment process to determine eligibility for LTSS services.
8.3The State of Alaska should join the NCI project.
8.5 The Department’s IT plan should be amended to contain substantive planning and analysis of what IT work needs to be done in order to improve the effectiveness and efficiency of Department operations.
9.1The Department should consider providing and presenting more quality of care data.
9.2The Department should consider implementing a Minimum Data Set (MDS) system in its AKPHs to track quality of care.
9.3The Department should consider aggregating its medical care information from each of the AKPHs into one database and use that database to manage the health of the entire population of persons using AKPH Services instead of operating each home separately.
9.4The Department should improve its reporting on LTSS programs by publicly reporting quality of care information on Department websites.
9.5The Division of Seniors and Disabilities Services should develop a “dashboard” permitting persons to query utilization data on LTSS programs by eligibility group, age, and geography. This dashboard database could be merged into the new Cube project, which is being developed for implementation with the Master Client Index (MCI).
10.1Provider enrollment activities should be strengthened.