Jul 23, 2024
Blog
Last month, this blog discussed the managed care organization (MCO) scorecards created with review data collected by MetaStar. These scorecards enable enrollees in Wisconsin’s Home and Community-Based Services (HCBS) programs to easily compare MCOs and select one that has been fairly and impartially reviewed. There is another program that falls under Medicaid HCBS in Wisconsin: Include, Respect, I Self-Direct (IRIS). Since 2008, the IRIS program has operated as a self-directed program by the enrollee. “That means you will have the freedom to decide how you want to live your life,” says the WI DHS website. That freedom and independence is important to those who enroll in the program.
Preserving independence can be crucial for older individuals and people with disabilities. According to an article in the International Journal for Equity in Health, “Preservation of independence is among the most important health priorities cited by older adults” (Enogela, Buchanan, et al 2022). Additionally, less independence can lead to increased depressive symptoms in patients with spinal cord injuries and vice versa (Monin, Schulz, et al 2015). We all want to keep our independence and ability to care for ourselves as long as possible. The IRIS program provides more control for enrollees over their care and decisions affecting their bodies, homes, and lives.
Studies have also shown that aging-in-place, or allowing individuals to age at home, provides many benefits, including routine, comfort, and reduced physical and mental strain. The same holds true for those with disabilities. However, most healthcare insurance companies don’t cover the services and needs of older individuals or persons with a disability living in their home. The HCBS waiver allows IRIS enrollees to remain in their home and receive the necessary healthcare and other services, reducing hospitalizations and assisted living fees and preserving their independence.
The IRIS Difference
HCBS programs, such as Family Care (FC), Family Care Partnership (FCP) and the Program of All-Inclusive Care for the Elderly (PACE), use MCOs to coordinate care for enrollees. However, the IRIS program empowers enrollees by allowing them to manage their own care. They are given a budget based on their current needs and long-term goals, and they can spend that money however they see fit within the program’s rules and regulations. IRIS covers a variety of services and commodities, including in-home medical care, house cleaning, errands, assistive devices, and more.
WI DHS’s IRIS website points out, “Joining IRIS does not mean doing things all by yourself. Others will help you along your way.” Others include an IRIS consultant and a fiscal agent, who can advise the enrollee on how to use the budget for current needs and adjust it when future needs arise.
Wisconsin’s IRIS program has over 25,000 people enrolled as of January 1, 2024 (WI DHS). Each individual selects an IRIS consultant agency (ICA) to work with—an important decision essential to smooth and safe service. How can enrollees effectively compare these organizations to determine which one is right for them? Enter MetaStar. MetaStar is essential in upholding IRIS program standards and providing user-friendly scorecards for each ICA, helping enrollees easily determine which ICA to work with.
MetaStar’s ICA Review Process
ICAs have different responsibilities to their participants than MCOs, resulting in different review processes. The IRIS program review focuses on the interactions between the enrollee, consultant, and ICA.
The MetaStar IRIS Record Review team, part of the External Quality Review Department, evaluates the six IRIS consultant agencies in Wisconsin. As noted in the previous blog post, this team is populated by former care workers, including social workers, nurses, and therapists who “come with direct experience in the field and really understand how the system works,” said Alicia Stensberg, MetaStar Project Manager.
The MetaStar IRIS Record Review team reviews over 400 ICA participant files quarterly, looking for a comprehensive care plan, monthly contact by the IRIS consultant with the participant, incident documentation, and other quality indicators. Data collected is converted into scorecards by WI DHS. “It’s a lot of oversight at the participant level to make sure their needs are getting met.” explains Stensberg. The MetaStar IRIS Record Review team helps to make sure the ICAs understand the metrics and requirements. They also provide technical assistance and help solve problems during the review process.
MetaStar’s team helps organizations address “not met” requirements by clarifying requirements, monitoring follow-ups, and documenting improvements. “We have a lot of contact with these organizations,” Stensberg said. “We also work closely with the state to make sure the ICAs are improving, and they are.” She notes that while immediate improvements may not be evident each quarter, significant long-term enhancements in the performance of the ICAs have been seen, which she attributes, in part, to the ongoing reviews.
Hotline for IRIS Participants
MetaStar also operates a hotline for IRIS participants to report grievances or complaints regarding the IRIS program. MetaStar employees staff the hotline during business hours. The MetaStar employee works with the participants and the agencies to find acceptable resolutions. “From a statewide perspective, the [number of] grievances is relatively low, less than 1% of the membership,” Stensberg said. “It’s a healthy amount. No grievances mean people aren’t exercising their rights.” The grievances reported during these calls do not affect the scorecard results.
The IRIS program supports Medicaid enrollees’ dignity and independence. MetaStar provides clear evaluations of the ICAs and a grievance hotline, ensuring enrollees’ care is taken seriously. It’s crucial to consider future medical and personal care—for oneself and loved ones. “Anyone can end up needing Medicaid benefits at any time,” Stensberg explains. She also reminds us that “one of the most important things that we can do as a society is take care of the people who are marginalized. It is our duty, and frankly, it would cost us a heck of a lot more if we didn’t.” Scorecards created by WI DHS with data from MetaStar’s experienced review team enable clear decision-making during difficult times and offer a way for WI DHS and MetaStar to help Wisconsin’s marginalized populations.