NCQA Long-Term Services and Supports Standards Framework

Long-term services and supports (LTSS) encompass a wide range of functional assistance that people with functional limitations routinely require in nursing facility settings or at home. LTSS may be provided in nursing homes or in the community, and can include adult daycare programs and transportation. Care coordination and planning services help people and their families navigate the health system and ensure that the proper services are in place in order to meet specific needs and preferences.¹

With the aging of the baby boomers and existing unmet needs, physicians and policymakers are challenged to find more efficient means of providing high-quality, person-centered services and supports across care settings in light of public health care spending growth.¹

The National Committee for Quality Assurance (NCQA), a central figure in driving quality improvement throughout the health care system, is stepping up to tackle this current and growing issue. “Millions of Americans rely on [LTSS] to help them live more independent lives,” said Patricia Barrett, NCQA vice president, Product Design and Support. “For many, LTSS represents a ticket to remain in the home and community.” Researchers at NCQA believe that effective coordination between providers and caregivers in the community could significantly reduce the need for acute medical care as well as prevent, or at least delay, nursing home admission, which would improve quality of life and reduce costs.²

Jessica Briefer French, MHSA, assistant vice president of research at NCQA, is the co-principal investigator of the NCQA’s recent work devevloping standards for LTSS. She has also previously served as principal investigator for a study that sought to understand practices in person-centered, goal-based integrated care for people with complex health care needs. She has over 30 years of experience in health care quality, including for people who are dually eligible for Medicare and Medicaid. Ms Briefer French played an essential role in the development of the LTSS standards, which provide a framework for organizations to deliver efficient, person-centered care successfully for those with complex care needs.

Annals of Long-Term Care: Clinical Care and Aging^® spoke with Ms Briefer French to learn more about the development of the NCQA LTSS standards, the plans for their implementation in communities, and the anticipated impact on beneficiaries.

Can you describe the rationale behind the development of the LTSS standards and what the core principles are? What issues initiated the discussion and development of the standards?

LTSS are services that help people with daily tasks, such as eating, bathing, and dressing. Most LTSS are provided by family and friends. However, many people don’t have enough support from family and friends and require additional paid support to remain in their homes and communities. People’s strong preference to “age in place,” along with a growing need for states to save money on institutional care, has fueled a variety of federal initiatives to “rebalance;” ie, to shift from institutional care to home- and community-based services (HCBS). States have taken advantage of financial incentives and used federal waivers to provide more LTSS in people’s homes and communities. Last year, for the first time, Medicaid expenditures for HCBS exceeded expenditures for nursing home care.

Simultaneous with the shift from institutional care to HCBS, states are also moving the delivery of long-term care from the traditional fee-for-service delivery system to managed care. Under new federal waivers, states have begun to contract with managed care organizations (MCOs) to finance and manage noninstitutional LTSS, either alone or in combination with more traditional nursing facility-based care. The delivery of LTSS through capitated managed care programs is referred to as managed long-term services and supports (MLTSS). Today, nearly half of states are either currently operating, or planning to implement, MLTSS programs. These changes reflect a wholesale reorganization of the systems of care for the frail elderly and others who require LTSS, focused on helping people to age in place and participate in the community as fully as possible. 

A variety of organizations are responsible for arranging for LTSS, including traditional MCOs, MLTSS-only plans, and community-based organizations (CBOs), such as Area Agencies on Aging (AAA; https://www.n4a.org/), which are area-specific associations of aging and disability agencies. With different organizations assuming responsibility for managing LTSS, it is important that both MCOs and CBOs implement best practices for person-centered care planning, effective care transitions, and quality care delivery. Traditional MCOs are broadening their focus from a purely medical model to providing functional and social supports, and, frequently, they do so by engaging the CBOs that have long been responsible for arranging for those services. 

The NCQA’s new LTSS standards are intended to help MCOs and CBOs work together in this changing landscape—to provide person-centered, integrated care for people with complex needs and to ensure that organizations entrusted with serving people with LTSS needs safeguard their rights and continuously improve quality.

Our standards reflect several key principles. First, it is important for standards to reflect the specific accountabilities of the organization being evaluated. Second, health care and LTSS should be person-centered: the individual’s goals, values, and preferences should be primary, and the individual should be involved (to the extent they wish) in developing a plan of care and services. Third, care should be integrated across disciplines and settings, and “whole-person” care should be offered. Providers need to communicate and collaborate to make this happen, and MCOs, MLTSS plans, and CBOs need to develop processes and implement information systems that facilitate such collaboration. Finally, organizations should continuously improve their operations by measuring their performance and acting on opportunities to improve the experience and outcomes of individuals and their families.

How does the shift in the delivery of LTSS from the traditional fee-for-service delivery system to managed care impact older adults and their families, both in long-term care facilities (LTCFs) and outside of LTCFs?

It really remains to be seen how this shift will ultimately play out, and people’s experiences may differ in different environments. The shift to managed care has the potential to better serve people in their preferred setting and to create better integrated systems of care and services that will help people to age in place, remaining in their homes and communities longer. There may be communities where HCBS providers are in short supply, and, in these communities, there may be very little change.

Can you discuss some of the stakeholders that provided input for the LTSS standards? What were their main concerns that the LTSS standards address?

NCQA’s work on the LTSS standards has been guided by the LTSS Advisory Panel, a broad stakeholder group that includes consumer advocates, state Medicaid officials, representaties of MLTSS plans, and representatives of AAAs. NCQA operates additional standing advisory groups to obtain input from a broad variety of stakeholders, including consumers, health plans, public purchasers, providers, and others. One of the values of this diverse stakeholder process is that the concerns of the many interested constituencies are heard and balanced.

Our advisors have been extremely helpful in clarifying the differing accountabilities of MCOs, MLTSS plans, and CBOs and the different resources they can access. For example, while MCOs pay claims and have access to a full set of data about their consumers’ health care utilization patterns, CBOs rely much more heavily on the individual and family for information about health status and needs. It is important to understand these differences as we lay out standards for proactively managing transitions of care. Our advisors have also been helpful in ensuring our language and focus are person-centered and that the standards reflect the social supports people need in addition to medical care.

In addition to vetting the draft standards with our multiple advisory groups, the standards have been piloted in 10 health plans and CBOs that have formed a learning collaborative. These organizations conducted a baseline self-assessment against our first draft of the standards. They used that self-assessment to identify areas for targeted improvement, and they also provided detailed feedback to us about how they understood the standards as well as their feasibility. This “vetting through implementation” has been invaluable in helping us to develop guidelines and examples that are meaningful to the organizations that will be eligible for our accreditation programs. And we couldn’t have done this work without the generous support of The SCAN Foundation and the John A Hartford Foundation.

What impact have the pilot implementations been producing? What are the main challenges of getting health plans and CBOs to work together? 

The pilot has been useful on several levels. As previously stated, the “on-the-ground” implementation of the draft standards has provided timely and practical feedback about what works and what doesn’t work, where language could be clearer, and about the feasibility of the standards in different contexts and settings. For example, it was through the pilot that we learned that CBOs rarely do their own case-finding and, instead, receive a list of individuals who are eligible for their services. As a result, we had to re-think a standard that applies more readily to health plans using data from various sources to identify individuals for case management services.

A second way in which the pilot has helped is in providing concrete examples that we can use to illuminate the standards and further explain their intent. NCQA’s standards are all published as “Standards and Guidelines” and are available for purchase on our website (www.ncqa.org), and they contain explanations and examples that elaborate on the language in standards themselves. The pilot has provided us with useful material that we can use in the guidelines. In addition, one of the final outputs of this project will be an “Implementation Guide,” which can serve as a companion to the Standards and Guidelines. This Implementation Guide will provide additional examples, including forms and templates that our pilot sites use or develop in the course of implementing the standards. In this way, we hope to spread the lessons learned by the pilot sites to other organizations that want to implement the standards.

Finally, the pilot implementation has created a learning community wherein the 10 organizations are supporting each other’s improvement efforts. Each organization has chosen one or more areas of focus, and, as they implement their improvement efforts, they report back to the group and share their successes, challenges, and lessons learned. In this way, the pilot sites that have had to overcome a challenge or barrier can explain to the others how they did it, and the organizations that are still struggling with a problem can get ideas from their peers. In the context of this learning collaborative, we have found that the health plans and CBOs have been eager to work together and learn from each other. 

1. Reaves EL, Musumeci M. Medicaid and long-term services and supports: a primer.  The Henry J Kaiser Family Foundation website. http://kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/. Accessed September 27, 2016.

2. Brock M. Long-term services and support: new quality improvement target. NCQA Blog website. http://blog.ncqa.org/long-term-services-support-comment/. Accessed September 27, 2016.