Quality Community Managed Care (QCMC) is a project funded by a grant from the Maternal and Child Health Bureau (MCHB). This project, which began October 1, 1994, is intended to address the need for effective, ongoing mechanisms for quality assurance to assure that managed care systems reach,appropriately serve, and improve the health of children with special health care needs(CSHCN). The goal of this project is developing and field testing a model for systematic evaluation of service delivery and outcomes at the community and family levels for (CSHCN), including children eligible for publicly funded programs, under managed care. A model to method to collect and assess selected indicators data, a process for evaluating cost effectiveness and efficiency of the model, and the modification retesting of model elements are being addressed by QCMC staff.

QUALITY ASSURANCE AND CSHCN

Quality assurance, the collection of relevant data for monitoring health outcomes and access to care and for identifying vulnerable populations and gaps in serves, is becoming more critical to the survival of programs that serve CSHCN. State CSHCN programs are in transition from providing direct services to promoting and monitoring comprehensive systems of care. Recent changes in health care financing have led to an increase in the number of CSHCN entering managed care plans, placing them at risk if treatment is not appropriate or specialty care is not provided.

Ideally, managed care health systems improve access to health care for all persons, assure the quality of care provided, and produce cost savings. Effective and ongoing mechanisms for quality assurance are key to assuring that managed care systems reach, appropriately serve, and improve the health of CSHCN. Measures of service delivery for CSHCN under managed care must be integrated with appropriate population-based health status and health outcome indicators, resulting in a uniform set of data that allows both public officials and consumers to evaluate and compare system performance.

Although managed care plans are embracing quality assurance and are making some data available to consumers, existing standards of quality do not address the complex medical, educational, and psychosocial needs of CSHCN and their families. Issues such as continuity of care, comprehensive services, coordination across programs, and access to all levels of care are critical to the delivery of care for CSHCN at the community level.

THE QCMC MODEL

While state CSHCN program have long had a role in developing and monitoring standards of care, including credentialing providers, most of these programs have not implemented data systems capable of generating indicators of quality. Traditionally, these programs have collected client-specific information on utilization of services paid for by the agency.

The QCMC project is developing and testing a quality assurance model that: addresses the consumers, and programs, and collects the appropriate data, and provides a process for joint review by all parties. The model is being tested in the state of Connecticut CSHCN agency.

The QCMC model captures both qualitative and quantitative data from a number of sources,including local contracted managed care entities, local providers, and families with CSHCN. Data collected include client expenditures, demographics, diagnoses, functional status, and sources and types of health care financing (commercial, public, managed care, etc.)referrals and services provided, the status of other vulnerable child populations, barriers to care, needs for additional training, evidence of relevant written policies and family satisfaction.

The QCMC project is evaluating the usefulness,collectibility, validity and costs of implementing the model and will make recommendations regarding its further use and developments. As part of the evaluation, each data item, data collection tools (e.g., client enrollment forms, claims data,family survey, provider survey, and functional status tool), and methods of data collection will be examined. The QCMC model includes an analysis plan which is being developed to guide the ongoing and dynamic process of generating all required indicators of quality, a method for interpretation of the indicators, and the subsequent review process that includes the state program and local contracted managed care agency staff. Outcomes from this review process will include goals and objectives, including corrective measures, reached by consensus. This information will help both the state and local agencies to improve effectiveness, efficiency, accessibility, provider competence, and program management.

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