Designing a TA Program: Lessons from the Medicaid IAP
Technical assistance (TA) can be a vital component of system and program upgrades, but the TA must be tailored to the recipient.
While the literature on effective TA is sparse, it’s identified some common challenges: defining expectations, agreeing on priorities, establishing collaboration, and having staff capacity to implement recommended changes. In addition, readiness-to-change theory posits that different organizations are at different stages of readiness to receive and act on TA. Abt’s work on the Medicaid Innovation Accelerator Program (IAP), a collaboration between the Center for Medicare and Medicaid Innovation (CMMI) and the Center for Medicaid and Children’s Health Insurance Program (CHIP) Services (CMCS), suggest some best practices.
IAP was created in 2014 to provide TA “to improve the health and health care of Medicaid beneficiaries and to reduce costs by supporting states’ ongoing payment and delivery system reforms.” The IAP helped state teams make progress toward their delivery system goals. IAP coaching and tools offered unique resources to state Medicaid agencies and implementing the recommendations gleaned from an IAP evaluation can help to ensure the success of future TA programs for state officials.
Based on the existing TA literature and the results of a qualitative evaluation of participants’ experiences with the IAP, Abt identified the following recommendations for setting up a TA program.
Recommendation 1: Define expectations at the outset.
Many states entered the IAP with unclear expectations and lacking a specific plan or goal(s). Initiatives could begin more quickly if states were required to demonstrate an understanding of their populations, goals, and necessary partnerships prior to the start of TA.
For HUD’s Community Compass and One Community Planning and Development Cooperative Agreements, Abt developed a detailed and structured work plan with HUD and (to the extent possible) the TA recipient. The work plan included the scope, tasks, budget, milestones, deliverables, learning objectives, and expected outcomes for the engagement. Abt developed the work plan collaboratively. This approach helped ensure that the goals, outcomes, and milestones for the engagement were responsive to both HUD’s and the recipient’s needs and supported rigorous evaluation of TA outcomes and impacts.
Recommendation 2: Assess state staff’s capacity to participate in TA.
CMS gathered basic information on state staff capacity on the IAP application forms. However, a tailored discussion with each state team about how to ensure team members have the expertise, authority, and resources to further reforms could also be incorporated into a program’s solicitation, orientation, and onboarding activities. This would help ensure the selected state teams have the necessary time and skills to succeed in their delivery system reform efforts.
Abt provides ongoing design, implementation, and management support to MassHealth's Delivery System Reform Incentive Program (DSRIP) TA Program. The voluntary TA program aims to build the capacity of MassHealth Accountable Care Organizations (ACOs) and Community Partner (CP) organizations while improving beneficiary experience and health outcomes, and lowering total costs of care. The Abt team collaborated with MassHealth to ensure the TA program was accessible, felt distinct from required aspects of the DSRIP program, and was not perceived as a burden on ACOs’ and CPs’ limited bandwidth. As a result, the participation rate in the program has been high, with 42 out of 43 ACO or CP organizations taking advantage of the 1:1 TA opportunities available.
Recommendation 3: Conduct a readiness assessment to apply TA.
States brought different levels of prior knowledge, experience, and technical skills to their IAP teams. This variation led to challenges in delivering peer-to-peer and coach-led support that could engage all participants. A readiness assessment could help TA providers to gauge the range of experiences across states to calibrate TA accordingly. Using the assessments to provide background information would enable participants to prepare for robust project implementation. To further clarify the commitment and readiness needed for success, TA providers can ask states to sign a memorandum of understanding (MOU) that outlines expectations.
Abt recruited health care systems across the country to receive TA as part of the CDC Quality Improvement (QI) Collaborative and AHRQ’s Six Building Blocks projects. To determine interest and readiness to participate, Abt held telephone calls with system leads. The calls entailed describing the expectations, honoraria, and timeline; determining the extent of leadership support, available organizational resources, IT staff capabilities and availability, and champion(s); and identifying potential barriers that could impede implementation. To secure commitment, Abt asked system leaders to sign a MOU outlining expectations, the timeline, what Abt would provide, and what was expected of each system and its participating practices.
Recommendation 4: Create opportunities to hold in-person meetings.
IAP participants and coaches alike stressed the benefits of in-person meetings as an opportunity for networking and peer-to-peer discussions. Post-COVID, if limited resources prohibit dedicated in-person TA meetings, conveners may be able to create TA opportunities in conjunction with other in-person meetings (e.g., CMS Quality Conference) that state officials are likely to attend.
Prior to the COVID-19 pandemic, Abt provided TA through in-person meetings to nursing home staff participating in the Massachusetts Department of Public Health’s Medication Assisted Treatment in Long-Term Care TA project. Meetings were grouped around communities of practice so that participants could interact with staff at nursing homes with similar resident backgrounds. Participants were enthusiastic about having the opportunity to meet, network with, and learn from peers in their communities in a face-to-face format. In response to the overwhelmingly positive feedback, the MDPH extended Abt’s contract to offer additional in-person learning events once it is safe again to do so.
Recommendation 5: Assist participants with establishing relationships and fostering collaboration beyond the state team.
IAP teams that had the opportunity to do so found great value in collaborating with partners and stakeholders from other agencies. TA providers can design activities that facilitate interactions with stakeholders beyond the participating agency, such as provider groups that will be impacted by delivery system and payment reforms.
Abt’s TA provided through the HRSA contract for Strengthening and Improving the HIV Care Continuum within Ryan White HIV/AIDS Program Part A Jurisdictions is an example of a program that fosters cross-agency partnerships. Abt is helping jurisdictions develop tailored, innovative approaches to scale-up interventions to improve HIV outcomes by stimulating action across city/county health departments and the many public and private partners along the HIV Care Continuum in each jurisdiction. Abt developed an interactive online portal that allows file sharing, webcam supported dialog, and virtual collaboration among participants receiving technical assistance.
TA can be an important aspect of program implementation, quality improvement, and system change, but it must be tailored to the recipient to make it easy to engage with, actionable, and applicable to states’ unique circumstances. Abt’s TA programs for clients such as HUD, MDPH, CDC, AHRQ, and HRSA, reinforce how the practical application of specific recommendations helps create an environment for TA successes.
