5 steps to safeguard state Medicaid consumers from critical incidents
Excerpts from the white paper: Critical incident management best practices
States operating Medicaid waivers programs are required by the Centers for Medicare & Medicaid Services (CMS) to safeguard consumers against critical incidents — including abuse, neglect, exploitation, and unexplained death. As you work to protect your citizens and reduce the risk of liability for your state, these five steps can help you develop an effective Critical Incident Management System (CIMS).
1. Select meaningful critical incident types
Critical incidents, sometimes referred to as “adverse,” “serious,” or “sentinel events” are situations that put the health, safety, or welfare of Medicaid participants at risk. These may include:
- physical, sexual, verbal, and psychological abuse
- mistreatment or neglect
- exploitation
- serious injury, death, or other harm
- events that indicate risk such as hospitalizations, medication errors, use of restraints or behavioral interventions
Your state is responsible for defining the types of events that are reportable incidents. Focus on events that are important to the health, safety, and welfare of participants.
2. Create clear policies regarding critical incident reporting requirements
In 2018, the U.S. Government Accountability Office (GAO) released a report on a study of 48 states that covered assisted living services. The study found large inconsistencies among states in their:
- definition of a critical incident;
- ability to report, track, and collect critical incident information;
- standardized definitions and processes for responding to incidents and meeting annual reporting requirements for home and community-based services (HCBS) waivers.
Ideally, as states develop their CIMS’s policies and procedures, they should consider opportunities to evaluate their other oversight systems to create a more robust approach that:
- Standardizes what incidents are and how incidents are collected across populations.
- Provides guidelines for prioritizing what incidents need to be investigated and resolved.
- Allows for the identification, tracking, trending, mitigation, and prevention of incidents.
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Critical incident management best practices
3. Provide sufficient materials to support incident reporting
After your CIMS is in place, you need to provide training materials outlining state requirements for staff, providers, and participants. In addition, the case management systems for all affected providers should include:
- The forms needed to report incidents
- The workflows to ensure timely and complete follow-up
- The reporting needed to track, analyze, and mitigate future potential incidents
States achieve the best incident management outcomes with interagency partnerships across multiple funding sources (SSBG, CSBG, OAA, Medicaid, vocational rehabilitation, CoC). Formal agreements should define each agency’s roles and responsibilities, as well as standardized communications protocols. This may require an information system.
4. Create a single web-based system to track critical incidents
In addition to the state agencies mentioned above, other parties are involved in the overall critical incident management system. You should consider what role that primary, acute, sub-acute, and behavioral health providers can play throughout the incident management process.
For example, Louisiana developed a single web-based system to track critical incidents using WellSky Human Services technology. They included all waiver populations, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), nursing facilities, HCBS providers, and state hospitals. Louisiana also took this opportunity to implement WellSky for Protective Services, which ensures two-way integration with their CIMS.
In this way, the state has visibility into all reports and outcomes from investigations of abuse, neglect, and exploitation for Medicaid populations and can ensure that all members have the level of protection and oversight that is required of the state.
5. Track and analyze meaningful data points to minimize preventable incidents
The 2018 GAO report also noted that every state’s operating HCBS waivers are required to provide assurances to CMS that necessary safeguards are in place to protect the health, safety, and welfare of participants receiving services. For critical incidents, this includes demonstrating an ongoing program to identify, address, and seek to prevent instances of abuse, neglect, exploitation, and unexplained death. A comprehensive CIMS, along with interagency case management and care coordination, can demonstrate compliance with CMS expectations.
An effective Critical Incident Management System safeguards consumers and can improve service quality and results for vulnerable populations. This can support efficient and community-based interventions that reduce the need for institutional long-term care, ultimately empowering better outcomes.