LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
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1 NASDDDS National Association of State Directors of Developmental Disabilities Services LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT March 8, 2018
2 INTRODUCTIONS Barbara Selter Sharon Lewis Camille Dobson Mary Sowers Vice President Health Services MAXIMUS Principal Health Management Associates Deputy Executive Director NASUAD Director of Special Projects NASDDDS 2 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
3 Today s discussion LTSS in the current environment: challenges and opportunities States efforts to build sustainable systems that meet needs, improve outcomes and deliver quality services Managed LTSS for older adults and people with physical disabilities State innovations in IDD systems Technology: administrative and clinical GOAL: Help states and stakeholders understand innovations states are implementing in financing structures, delivery systems, technology options and person-centered systems 3 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
4 State LTSS challenges Increasing demand for services Aging, low paid, decreasing direct care workforce; aging caregivers Lack of affordable, accessible housing Constrained state funding and need to bend the cost curve Continued implementation of HCBS Settings Regulation Uncertain future: federal funds (potential Congressional changes) 80 % INCREASE in elderly population by MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
5 State approaches to sustainability Financing and management structures: managed care, capped HCBS waivers HCBS provider-led managed models Targeted, limited eligibility under multiple authorities Continued growth of self-direction Meeting lower-level needs earlier (preventative/diversion from 24/7) New technologies New pressures New laws and New growth in government populations leadership and eligibility 5 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
6 Trends and Themes LTSS Delivery Preference for integrated community options Need for truly person-centered systems Integration of behavioral health supports Employment and related services Technology: systemic integration delivery (telehealth, monitoring, coordination) personal/individual Preventative approaches before residential Caregiver supports Relationship-based residential living 6 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
7 STATE LTSS INNOVATIONS MANAGED CARE 7 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
8 State challenges & opportunities driving MLTSS Increasing demand for services Constrained state funding, need for sustainability Focus on quality and outcomes, including SDOH Need for better integration across medical care and LTSS Mismatch between consumer preference and service delivery (rebalancing) 8 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
9 Mismatch Consumer preference & service delivery 9 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
10 States can address challenges through delivery system reforms, program design changes, or BOTH Contract with health plans on at-risk basis (MLTSS) Provide limited benefits before needs trigger Medicaid eligibility (At-risk programs) Measure consumer quality of life and address gap areas 10 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
11 Status of MLTSS Programs MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
12 Why MLTSS? Accountability rests with a single entity Administrative simplification for state Budget predictability Shift services to community settings Innovation and quality Consumer becomes the center, not their services Financial risk for health plan provides opportunity to incentivize/penalize performance Plans can integrate siloed streams of care (primary/ behavioral/long term care) more effectively Eliminates need to contract with and monitor hundreds/ thousands of individual providers Managed care plans take on claims payment, member management, utilization review, etc. Capitation payments greatly minimize unanticipated spending Can more accurately project costs (especially with LTSS as enrollment does not have as much variation based on economic circumstances) Most consumers express preference for communitybased services Health plans have demonstrated effectiveness in diverting and reducing institutional stays MCOs can deliver services more flexibly than states National companies, in particular, can bring best practices from other states/ product lines Local plans are grounded in their communities Demonstrated improvement in quality outcomes (HEDIS) over FFS LTSS interventions can lower acute care costs Increased likelihood of bending the cost curve 12 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
13 MLTSS results Findings from NASUAD/CHCS May 2017 brief 1 include: Florida Reinvested $20 million (avoided NF expenditures) in 2014 to enroll individuals from their waiting list with the most critical needs into its MLTSS program Minnesota LTSS members (compared to FFS) were 48% less likely to have a hospital stay; 13% more likely to receive HCBS and were 6% less likely to have an outpatient emergency department visit Tennessee Had only 19% of total LTSS in community in 2009; by 2016, TN was above the national average at 56% in community MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
14 Early interventions to improve health & quality of life Handful of states use 1115 authority to provide more limited set of LTSS to consumers before they meet clinical eligibility (LOC): Delaware DSHP-Plus at risk group Hawaii At Risk population in Quest Integrated Rhode Island Preventive Need group Tennessee CHOICES group 3 Vermont Choices for Care Moderate Need group Washington Tailored Supports for Older Adults program 14 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
15 Early interventions to improve health & quality of life Washington implemented the Tailored Supports for Older Adults (TSOA) program in 2017 TSOA provides a limited set of services and supports for individuals at risk of spending down to Medicaid eligibility Intended to help individuals avoid or delay the need for Medicaid-funded services 15 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
16 Measuring and improving consumer quality of life National Core Indicators Aging and Disability consumer quality of life survey began in 10 states in 2015; in its 3rd year, 22 states will be using the survey Survey assesses the quality of life, service satisfaction, and outcomes of service recipients Results are parsed based on factors including waiver program, care setting, and/or MCO enrollment (if applicable) 16 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
17 Measuring and improving consumer quality of life Proportion of people whose services meet all their needs and goals (risk adjusted) State with this data might change its person-centered planning processes to improve 17 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
18 STATE INNOVATIONS IDD SUPPORT 18 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
19 State approach to innovation and outcomes Many states have embraced the CMS three-part aim in their efforts at improved outcomes for individuals with I/DD supported with LTSS, and are using Medicaid Home and Community Based Service structures to: improve quality of life outcomes increase budget predictability provide more person-centered supports and services Better Health for the Population Better Care for Individuals Lower Cost through Improvement 19 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
20 State approach informed by federal policy climate CMS, OIG and GAO Emerging Priority Areas Continued emphasis on HCBS regulation implementation Conflict of interest requirements Person-centered planning expectations Financial Accountability - Rate reviews, high levels of scrutiny on state financial submissions Fraud, Waste and Abuse Prevention - OIG Audits - EVV implementation Focus on Abuse, Neglect and Exploitation - Multi-state reviews - Findings from CT, MA, ME additional state reports and engagements expected soon, as well as comprehensive report and recommendations from OIG As of January 15, 2018, 7 states had received final approval of their STP: TN, KY, OK, AR, DE, DC, WA At least 14 states are working to ameliorate issues of identified conflict CMS placing increased emphasis on meaningful person-centered planning 20 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
21 State I/DD Systems Long Term Support State I/DD agencies, in partnership with Medicaid Support across lifespan Support across decades Provide the right supports across the lifespan Design HCBS waivers aimed at supporting individuals who live in family home Design HCBS programs that promote employment and community integration Design strategies to intercede at earlier intervals to avert potential crisis 21 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
22 State I/DD Systems Long Term Support Support Waivers accomplish many of these objectives: Budgetary limits commensurate with the program goals Recent approvals in Pennsylvania and Maryland Active development efforts afoot in the District of Columbia Offer a menu of lower-intensity services to reach individuals at earlier periods to avert potential crisis or more costly interventions, while promoting community integration and choice NEED DIFFERENT PHOTO - DUPLICATE 22 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
23 State I/DD Systems Long Term Support Investing in Peer Networks Supporting Families Focusing on Person Centered Planning Strategies for Sustainability Developing Innovative Supports Relationship based Building on Technology Expecting Employment outcomes 23 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
24 Why employment? Get out of poverty More independence Make friends Make a contribution to the community Positive image and valued role within family and community Opportunities for learning and expanding relationships Because people want to work 24 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
25 Can everyone work? Percent participating in integrated employment of those receiving a day service by state, FY MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
26 National Core Indicators: Adult Survey Has a Job (n=16,375) Yes 19% Would like a Job (n=6,550) 24% took classes, training, or did something to get a job or get a better job No 81% Yes No No 47% Yes 53% Employment goal in Plan (n=2,808) No 59% Yes 41% Yes No Yes No 26 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
27 States continue to emphasize employment as an important key to community integration Employment First not Employment only States are continuing work to develop an array of services that wrap around employment supports while supporting and enabling meaningful community integration 27 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
28 Effective strategies to increase sustainability In Medicaid, nothing stands alone To enable gains in employment specifically and in sustainability more broadly, states must consider all interconnected elements that contribute to the State s overall objectives There are countless interdependencies within State Medicaid Systems 28 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
29 STATE INNOVATIONS TECHNOLOGY 29 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
30 Technology innovating LTSS administratively and clinically Functional Eligibility Financial Eligibility Employment First Support Care Transitions/ Aging In Place 30 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
31 Functional Assessments automated and linked to service authorization Resource Allocation Functional Assessment Care Planning 31 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
32 HOW CAN TECHNOLOGY EXPEDITE FUNCTIONAL ASSESSMENTS? Case study: Mental Health/Disability Screening & Evaluation System States: Connecticut, Indiana, Iowa, Nebraska, North Dakota & Tennessee Task: Algorithm reviews screens for clinical triggers Automated, instantaneous approvals Triaged nurse desk reviews of screens in gray area Face-to-face evaluations and care plans completed only for those with real need 1M + Disability screens conducted 70 % of screens automatically approved via algorithm on average 2 week Reduction in screening turnaround time in one state 32 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
33 HOW CAN TECHNOLOGY STREAMLINE FINANCIAL ELIGIBILITY, WHILE REDUCING FRAUD AND ABUSE? Case study: Automating Financial Transaction Analysis States: Maine & New Jersey Task: Digitize all bank and credit card transactions Analyze financial transactions during 60 month look-back period Identify unreported assets and asset transfers Identify recurring payments such as pension payments 150 Customers replace manual review with automation 99+% Accuracy of data extracted from all bank statements.1% LTSS Eligibility Applications If Medicaid Genius identifies 1 ineligible application out of 1,600 then it pays for itself 33 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
34 Automated financial transaction analysis helps to identify fraud and abuse Analyzes bank and credit card statements Filters and sorts data Detects account transfers Identifies recurring transactions Generates a summary 34 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
35 Case study: Employment Community First HOW CAN TECHNOLOGY SUPPORT EMPLOYMENT COMMUNITY FIRST? States: Tennessee Task: Use mobile app to: Plan transportation routes Identify community resources List specific work tasks and coach on how to perform the tasks Provide schedule of activities Advise participant on appropriate behaviors when unexpected occurs 35 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
36 Customized images for individuals enable increased independence and work success Communicate & record feelings Daily schedules Training videos & instructions Step-by-step task lists Digitized documents library Behavior Support Plans Links to community resources Text access to community care team Directions for any mode of transportation 36 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
37 Telecare/Telehealth enables the elderly to age in place and improve care transitions Extend aging in place, postponing or avoiding nursing facility admission Reduce adverse events hospital readmissions, ER usage, falls and improve chronic care outcomes Improve utilization and better target use of limited health professionals and personal care assistants Encourage family care-giving by offering convenient, safe, and in-expensive respite for family caregivers 37 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
38 Telecare operations model in HCBS environments 38 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
39 Sustainability efforts drive innovation As states explore opportunities for greater sustainability in LTSS systems, innovative approaches to financing, systemic structures and service options have emerged. States are designing structures that promote autonomy and choice, while emphasizing person-centered, individually tailored approaches to supports, including fostering relationship-based services, caregiver supports and self-direction. 39 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
40 QUESTIONS AND DISCUSSION 40 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
41 Thank you! Barbara Selter, MAXIMUS Mary Sowers, NASDDDS Camille Dobson, NASUAD Sharon Lewis, HMA To view the recording of this webinar and others, please visit: 41 MAXIMUS WEBINARS: LTSS INNOVATIONS IN THE CURRENT ENVIRONMENT
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