Critical Incident Management Solutions in Medicaid Long-Term Care

Medicaid agencies must assure the health and safety of their Home & Community-Based Services (HCBS) waiver program recipients by managing the reporting, investigation, and prevention of incidents.  Failure to do so poses a host of risks around compliance, fraud, and the safety of Medicaid recipients.

States’ Medicaid agencies have administrative authority of their Medicaid Waiver programs, which must operate in accordance with federally mandated quality measures and assurances. To meet these requirements, states must demonstrate that they have systems in place to effectively monitor the adequacy of service plans, the qualifications of providers, and the health and welfare of beneficiaries. Included below is a brief history of long term care (LTC) system failures that led to a call for additional oversight over critical incident reporting. In order to assist states with ensuring compliance with the new standards, we offer a few solutions for state Medicaid agencies looking to improve critical incident monitoring systems.

Ensuring the Health, Welfare, and Safety of States’ Medicaid Beneficiaries

In 2013, the Hartford Courant published an investigative report documenting a series of abuse and neglect cases involving individuals with intellectual and developmental disabilities (IDD) receiving home and community-based supports (HCBS). According to this article, private group homes and state officials frequently failed to report or respond to abuse, neglect, and other critical incidents, including “a man who suffered a broken spine and a woman who repeatedly ingested razor blades and other dangerous objects.”

This piece prompted the US Department of Health and Human Services’ Office of the Inspector General (OIG) to investigate Connecticut’s state Medicaid agency, the Department of Social Services. After issuing its report on Connecticut—which bore out the Courant’s findings—in 2016, the OIG expanded its investigation to Massachusetts, Maine, and Alaska (click to view each state’s official report). Taken together, these widely publicized reports demonstrated a systemic lack of compliance with state and federal waiver requirements to report and monitor critical incidents involving beneficiaries.

Given the hands-on level of care that patients in these LTC settings require, the report highlighted severe shortcomings in states’ responses to potential cases of harm against people with generally limited means to defend and care for themselves. As such, the states failed to demonstrate that a comprehensive system was in place to ensure the health, welfare, and safety of its Medicaid beneficiaries.[i] The OIG continues its review of agencies across the country, and there is good reason to believe that additional reports will be made public.

The Cost of Unreported Critical Incidents

In addition to taking a toll on beneficiaries’ health, welfare, and safety, failure to manage and investigate critical incidents can prove costly. With almost 69 million enrolled individuals, Medicaid serves more enrollees than any other federal healthcare program and represents one sixth of the national health care economy.[ii] The Centers for Medicare and Medicaid Services (CMS) reported that combined federal and state Medicaid expenditures were $565.5 billion for FY 2016.[iii] While unreported critical incidents are not responsible for the lion’s share of these overall costs, the consequences of not monitoring and reporting these incidents does result in higher costs incurred from increased acute and chronic health spend.

When a critical incident goes unreported, facilities evade accountability for enacting appropriate oversight of affected patients and prevention planning for future incidents. Whether it was bed sores or bruises, an initial incident is statistically likely to recur (and often worsen) if left unaddressed by providers—causing the cost of unreported and unaddressed adverse events to swell over time. In expressing concern over statistics like these, health professionals are reacting to cases of true human tragedy. It is often that ultimately preventable minor incidents are left to fester into serious illnesses, or even deaths. The objective of proposed solutions, therefore, is to shift focus to proactive measures. In acting early and getting out ahead of potential problems, states will prevent negative health outcomes and reduce healthcare costs in tandem.

As a result of their findings, the OIG began meeting regularly with colleagues in the Administration for Community Living (ACL) and the HHS Office for Civil Rights, aiming to develop comprehensive recommendations that would improve the health and safety of group home beneficiaries while helping maintain their independence. These sessions culminated in the OIG’s four key compliance oversight components[iv]:

  1. Reliable incident management and investigation processes;
  2. Audit protocols that ensure compliance with reporting, review, and response requirements;
  3. Effective mortality reviews of unexpected deaths; and
  4. Quality assurance mechanisms that ensure the delivery and fiscal integrity of appropriate community-based services.

Data Analytics: A Proactive Approach to Critical Incidents

To comply with these four components, it is vital that states identify and implement reporting systems that can appropriately detect, report, investigate, and remedy critical incidents aggressively and comprehensively. Data analytics can be a tremendous ally in these efforts.

Data analytics provides the necessary tools for identifying, understanding, and addressing systemic problems, and can also help inform the prevention planning and follow-up services that allow states to comply with state and federal requirements. For example, data-driven analyses allow LTC programs to delve into health claims data and critical incident reports to identify and monitor:

  • Beneficiaries whose health demographics and trends place them at high risk for critical incidents, who would benefit from implementation of proactive prevention planning (such as falls prevention);
  • The efficacy of prevention planning and follow-up by case workers and care teams;
  • Providers whose patient care history indicates a high rate of critical incidents;
  • Providers whose trends and history indicate the potential for fraudulent activity, abuse, neglect, and exploitation.

As the above examples illustrate, data analytics can be used to identify at-risk individuals and providers. Source data can be monitored at the individual level—to identify those at risk of critical incidents based on various attributes—or aggregated for study of geographic areas and populations with outlier reporting rates and emergency room visits. Medicaid agencies can use these results to develop specific prevention plans and programs, as well as ensure that resources are allocated appropriately toward the individuals and areas that need them most.

How PCG can help your state?

website_header_pulselight_logoRecognizing the need for, and benefits of, using data analytics to better manage critical incidents in Medicaid long-term care programs, Public Consulting Group (PCG) partnered with Pulselight (a data analytics firm based in Austin, Texas) to bring states comprehensive data analytics and incident management services. These services assist state agencies in meeting federal and state reporting regulations and provide the opportunity for developing quality improvement strategies to augment current critical incident management systems.

In addition to data analytics, PCG’s service offerings include a CMS-aligned critical incident reporting system, assessments, on-site investigations (including mortality reviews), and state and provider training services that can be tailored to specific needs and deployed to ensure results and strengthen reporting requirements. Our PCG subject matter experts and Pulselight partners have supported state agencies in assessing, identifying, and enhancing reporting systems, as well as to proactively educating providers on improving compliance with critical incident reporting requirements in long-term care settings.

If you have any questions about how data can be utilized to improve Medicaid LTC in your state, please contact Jamin Barber at jbarber@pcgus.com.


[i] https://oig.hhs.gov/oas/reports/region1/11600001.pdf

[ii] https://oig.hhs.gov/reports-and-publications/top-challenges/2017/ 

[iii] https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and reports/nationalhealthexpenddata/nhe-fact-sheet.html

[iv] https://www.hhs.gov/sites/default/files/report_joint_report_hcbs.pdf

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