Delaware's Care Transitions Program. Home and Community Based Services Conference September 11, 2013

Transcription

1 Delaware's Care Transitions Program Home and Community Based Services Conference September 11, 2013

2 Today s Topics Overview the picture in Delaware The need for change Initiatives underway Care Transitions Program Progress and successes Barriers

3 The Picture in Delaware It is true we are small Division of Services for Aging and Adults with Physical Disabilities Delaware s State Unit on Aging DSAAPD part of the Department of Health and Social Services which includes Medicaid, Mental Health and Substance Abuse, Developmental Disabilities Services, and Public Health facilitates collaboration and problem resolution Three State operated nursing facilities

4 Overview of Services Provided Assistance for Caregivers Home and Community Based Services Information and Support Rights and Protections Adult Day Services Alzheimer s Day Treatment CARE Delaware Respite Care Attendant Services Home Delivered Meals Personal Care Home Modification Case Management Delaware Aging and Disability Resource Center (Information and Assistance, Options Counseling, Service Enrollment Support, Diversion and Transition Services) Money Management Program Adult Protective Services Legal Services Long Term Care Ombudsman Medicare Patrol Program

5 The Need for Change Fast Growing Older Population Age 60+ Age 75+ Age 85+ ** By 2030, Delaware is projected to have the 9thhighest proportion of people age 65 and older in the U.S

6 The Need for Change Long Term Care Expenditure Patterns Institutional Bias in Delaware Costs for institutional care Community care costs About 87.5% of long-term care dollars for aging and physical disabilities are spent in facilities. Institutional Bias in the US Costs for institutional care Community care costs About 66% of long-term care dollars are spent in facilities.

7 The Need for Change Market demand and choice - the overwhelming majority (86% plus) of Delawareans want services that support them in their own home Cost - for every person we serve in a long-term care facility, at least three people can be supported in the community (AARP estimate) The Americans with Disabilities Act mandates that public agencies provide services in the most integrated setting appropriate to individual needs as affirmed by the US Supreme Court s Olmstead decision.

8 Initiatives Underway - Aging & Disability Resource Center Single point of entry for accessing long term care information and support services Statewide call center: info & assistance/referrals Website with a searchable database: DelawareADRC.com ADRC support services: options counseling, discharge planning & service enrollment support Transition/discharge planning with hospitals and long-term care facilities Diversion of admissions to long term care facilities

9 Initiatives Underway Diamond State Health Plan Plus (DSHP Plus) Medicaid funded long term care services integrates nursing facility services with community-based services for older Delawareans and those with physical disabilities - implemented April 1, 2012 incorporated long-term care services into existing managed care delivery system enhanced benefit package increases choice of setting and service improve access to community-based services, improve coordination of care, and supports to improve health status enables shift of resources from institutional care to community-based services

10 Initiatives Underway PACE (Program for All-Inclusive Care for the Elderly) Saint Francis Life located on the Wilmington riverfront integrated system of care for those 55 and over who have a nursing home level of care comprehensive long term services for Medicaid and Medicare enrollees (capitated rate) all inclusive care plan: 24/7, 365 days a year extensive package of services provided on site participants return home each night focus on preventive care and maximum level of physical, social and cognitive function

11 Initiatives Underway Housing supports (SRAP housing vouchers; case work supports to find housing) Money Follows the Person transition residents of facilities to the community (incorporated into DSHP+) Care Transitions providing access to community-based services for those applying for placement in a state facility Partnership with hospitals on discharge planning Expanding community-based mental health services

12 Care Transitions-History Started in 2/2011 after community-based staff attended a State LTC facility admissions meeting Admissions seemed unnecessary for most people referred Not medically complicated Low level of care No community options explored No caregiver support

13 Care Transitions-History Why are people really getting placed? Hospitals under pressure to discharge quickly No place to go Caregiver burnout No housing Sub-standard/unstable housing Electric is turned off Hoarding Bugs Mental Health/ Substance Abuse Bariatric Criminal record Victim of Abuse

14 Care Transitions-History Informal team of facility admission staff and community case mangers & nurses formed. Existing tools use to try to divert people from NH placement Options counseling Enrollment in LTC community-based LTC services See slide 4 Caregiver support groups Some success with diversion In many cases too little, too late

15 Care Transitions Gets Formal The Care Transitions Program, falls under the umbrella of the ADRC. The program extends community living for individuals who are in the community or in the hospital and are seeking admission to one of the state long term care facilities by creating a flexible spending pool to facilitate access to services and products by mitigating immediate risks and stressors that are prompting a move to a nursing home offering discharge planning support to acute-care and behavioral health hospitals.

16 Flexible spending pool Care Transitions Gets Formal Provide traditional LTC services more quickly and above caps Fee for service model MOUs with providers Open purchase orders Retrospective review Provide non- traditional supports Extermination Heavy cleaning Repairs (roof, septic tank) Budget authority to move spending from facilities to community

17 Care Transitions (continued) Mitigate immediate risks and stressors that are prompting a move to a nursing home Rapid response, stabilizations, ongoing case management Formalizing partnership hospitals, Medicaid, Substance Abuse, Developmental Disabilities, Department Leadership Revision of policies/procedures that restrict access to/slow down services Established discharge planning best practices Changes to ADRC referral process Development of referral tools/ toolkits Support decision making on the ground- empower state to do the right thing

18 Care Transitions Gets Formal Offer discharge planning support to acute-care and behavioral health hospitals Meet with acute care in-patients, hospital social work staff, and, as appropriate, family members or other interested parties, to discuss post-discharge questions, issues, needs, options and preferences. Identify issues which might present unique barriers to postdischarge service delivery, such as homelessness, language barriers, substance abuse problems, mental illnesses, or other concerns/conditions.

19 Care Transitions Gets Formal Research the availability of post-discharge services which meet the unique needs and preferences of the patients. As needed, coordinate with service providers to advocate for the delivery of needed post-acute care services. Assist hospital social workers in the development of discharge plans which address the needs and preferences of patients and are consistent with the availability of services to meet their unique situations. Contact patients following discharge to ascertain whether or not follow-up options counseling and/or service enrollment supports are needed.

20 Care Transitions- The Flow Hospitals make referrals via the ADRC secure referral All referrals are screened to determine if the are active with any DHSS programs (Medicaid, SNAP, OAA services, etc) Referrals are routed to the CTT The CTT hosts a weekly call. Hospitals, Medicaid and others call in to discuss mutual cases. Regular calls between Delaware s largest hospital and the Deputy Director of DSAAPD to discuss systemic gaps and barriers.

21 Care Transitions Team Adult Protective Services Division of Medicaid & Medical Assistance Eligibility Determination Office of the Public Guardian Division of Medicaid and Medical Assistance Managed Care Organization Deputy Director Social Service Chief Administrator Social Service Administrator Supervisor Case Managers Case Managers Division of Substance Abuse and Mental Health Options Counselors Money Management Division of Medicaid & Medical Assistance Eligibility Determination Division of Developmental Disabilities Services Long-Term Care Community Ombudsman Acute Care Hospitals Nurses Caregiver Supports DSAAPD Employee Support as Needed Behavioral Health Hospitals Nurses DSAAPD Employee Full Time Ad Hoc team members case by case basis

22 Diversion from State LTC facilities Progress and Success Program Year 1 (February December 2011) Total Number of Referrals Processed 192 Total Number of Clients Diverted from 162 Placement Percentage of Clients Diverted 84% Program Year 2 (January December 2012) Total Number of Referrals Processed 167 Total Number of Clients Diverted from 153 Placement Percentage of Clients Diverted 92% Program Year 3 (January 2013-December 2013) Total Number of Referrals Processed 65 Total Number of Clients Diverted from Placement Percentage of Clients Diverted 60 92%

23 Progress and Success Facility Dec 2010 Census Aug 2013 Census DE Hospital for the Chronically Ill Emily P. Bissell Governor Bacon Total The average # of monthly admission dropped from 8 to 3 Reallocation of staff from facility to community Reduction in overtime

24 Progress and Success A man in his 20s acquires a disability in prison. He has very long hospitalization. He gets discharged from corrections. He has no housing and no family supports in Delaware. The hospital refers him for state nursing home placement. Family in NJ (including his young daughter) want to provide care with appropriate supports. Case manager worked with DE probation and parole staff to transfer his probation to New Jersey so that her could return home with his family. Assisted with Medicaid eligibility in NJ. Shared history for the development of a care plan.

25 Progress and Success A woman in her 80s is receiving home-delivered meals and a few hours of personal care each week. APS receives a call from a neighbor concerned about her living conditions. APS investigates and finds that the septic system has backed up into home and she cannot afford to pay for the full repair. The protective placement process (admission to state facility) starts. The CTT gets the referral. They work with an independent living provider to get temporary housing. They arrange to have the septic system fixed and the home cleaned. The woman returns home and services are put back in place.

26 Progress and Success (continued) Hospitals now regularly refer patients with extensive discharge planning needs to DSAAPD even when state facility placement is not requested prevents repeated hospitalizations & eventually referral to facility Discharge planning overall is improving across Delaware

27 Barriers Barriers to State Nursing Home Diversion Care Transitions Program Year 1 (February December 2011) 192 referrals processed 162 people diverted 30 people admitted to a State LTC facility Care Transitions Program Year 2 (January October 2012) 152 referrals processed 139 people diverted 13 people admitted to a State LTC facility Primary Barrier to Number of people impacted Initiatives underway to remove barriers Diversion Housing 7 SRAP APS Safe Haven Adult Foster Care II Dual Diagnosis Physical Disability and Mental Health Caregiver will not accept HCBS No Primary Care Provider 3 Medically Complex 8 Not eligible for Medicaid 5 (financial) 2 (citizenship status) *APS Protective 2 Placement Total 43 8 Case by case collaboration with DSAMH Planning to formalize collaboration and increase access for the dually diagnosed is in progress. 8 Options Counseling Caregiver Support and Education

28 For further information: Bill Love, Director, Division of Services for Aging and Adults with Physical Disabilities (302) , Lisa Bond, Deputy Director, Division of Services for Aging and Adults with Physical Disabilities, (302) ,