Wis. Admin. Code DHS § DHS 10.46

Current through November 25, 2024
Section DHS 10.46 - Department responsibilities for monitoring CMO quality and operations
(1) MONITORING. The department shall monitor CMO operations to assure quality of services and delivery, including consumer satisfaction. The department shall develop indicators to measure and assess quality in all of the following areas:
(a) Family care benefit effectiveness in increasing consumer long-term care choices, including choice of services, service providers, living arrangement and daily routine.
(b) Family care benefit effectiveness in improving access to long-term care services to support member care and choice of living arrangement.
(c) Family care benefit effectiveness at meeting the expectations of members in care and services received, reliability of the long-term care system and providers, fair and respectful treatment and privacy.
(d) Family care benefit effectiveness in assuring member health and safety, including being free from abuse and neglect, being protected against misappropriation of funds, being safe in chosen living arrangement, and receiving needed health services, consistent with member choices and preferences.
(2) INDICATORS. The department shall measure and assess CMOs' quality based on the areas in sub. (1) by establishing indicators. The department shall use indicators to compare performance within and across CMOs and against other programs to help improve CMO performance and ensure quality. Where possible, the department shall measure indicators against available or created benchmarks and evaluate CMOs' performance. The department shall assess the CMO's performance for the non-quantifiable indicators by using an assessment mechanism based on outcome measurement.
(3) MEASUREMENT INDICATORS. The department shall measure at least the following indicators:
(a) Preventable hospitalizations and emergency room visits.
(b) Voluntary and involuntary disenrollment.
(c) Pressure sores.
(d) Movement of members among residential settings.
(e) Medication management.
(f) Grievances, appeals and fair hearings and their disposition.
(g) Providers with consumers on governance boards and committees.
(h) Change in ability to carry out activities of daily living.
(i) Employment or other activities sought by consumers.
(j) Influenza vaccinations.
(4) ASSESSMENT INDICATORS. The department shall assess CMOs in meeting member needs through qualitative indicators in at least the following areas:
(a) Fair treatment.
(b) Privacy.
(c) Choice of routine.
(d) Maintenance of family involvement.
(e) Satisfactory community contact.
(f) Access to transportation.
(g) Choice of living arrangement.
(5) COST- EFFECTIVENESS. The department shall measure:
(a) CMO cost-effectiveness in meeting member needs within available resources.
(b) CMO financial condition.
(6) COST OF SERVICES. The department shall measure the cost of all department-funded health care services received by CMO enrollees.

Wis. Admin. Code Department of Health Services DHS 10.46

Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (3) (f) Register November 2004 No. 587, eff. 12-1-04.