The Next Wave in Balancing Long- Term Care Services and Supports:

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1 The Next Wave in Balancing Long- Term Care Services and Supports: Top Trends Agency restructuring is common States use of variety of resources to fund the programs Loss of historical knowledge is nationwide Medicaid managed care is expanding rapidly Interest in the affordable care act options remains limited 11/10/2011

2 Demographics of population shifting boomers are arriving Page 2

3 Poverty Among Age 60 and Above is Endemic and Growing WA OR NV CA AK ID UT AZ MT WY CO NM ND SD NE KS OK TX MN WI IA IL MO AR MS LA NY MI PA OH IN WV VA KY NC TN SC AL GA FL ME NH VT MA RI CT NJ DE MD DC Age 60 and above living below 250% FPL (2010) HI 30-34% 35-39% Source: NASUAD Analysis of Current Population Survey Annual Social and Economic Supplements (CPS ASEC) % 45-49% 50-55% Page 3

4 Agency restructuring. Page 4

5 Programs Administered by State Aging and Disability Agencies Home delivered meals Respite Family caregiver support Congregate meals Disease prevention and health promotion ADRC Elder abuse prevention Homemaker Long term care ombudsman (long term care facility) Information and Referral Legal assistance development Transportation Case management Personal care Chore Senior centers Adult day care SCSEP SHIP Senior Medicare Patrol Adult protective services Kinship care 56.5% 56.5% 52.2% 100.0% 100.0% 97.8% 97.8% 97.8% 97.8% 95.7% 95.7% 93.5% 93.5% 93.5% 91.3% 89.1% 87.0% 84.8% 82.6% 73.9% 71.7% 67.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%100.0% Percent of States Page 5

6 Which long-term care programs are the responsibility of the state agency? Planning and development of policy 90.5% Quality for home and community based services 69.0% Eligibility determination Financing Regulation of home and community based providers HCBS provider licensure or certification Other Quality for institutional services 57.1% 50.0% 45.2% 40.5% 38.1% 38.1% Regulation of institutional services 23.8% 0% 20% 40% 60% 80% 100% Percent of States Page 6

7 Waiver Populations Served Older adults (65 years of age and older) 73% Older adults and persons with physical disabilities 73% Individuals with physical disabilities 50% Individuals with developmental disabilities 27% Children 20% Other 13% 0% 10% 20% 30% 40% 50% 60% 70% 80% Percent of States Page 7

8 SPA Waiver Managed LTC Determining Eligibility Quality Case Management Nutrition Evidencebased health promotion Case Management Family Caregiver Support Respite Nursing home diversion SHIP Part D SMP SCSEP WIA Social Security Transitions MFP MDS Section Q Nursing Home oversight State institutions I and R Single Entry Points ADRC APS Ombudsman Legal Services developers 8

9 Funding the programs Page 9

10 State Aging and Disabilities Sources of Funding OAA State Appropriation Medicaid USDA DOL Other SSBG Targeted tax Foundation/private grants State lottery Local (i.e., county or city) funding DOT DOE CSBG DOJ FEMA 30.2% 30.2% 20.9% 20.9% 11.6% 11.6% 9.3% 6.9% 2.3% 72.7% 62.8% 53.5% 44.2% 41.9% 100.0% 97.7% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent of States Page 10

11 Percent Change in State Tax Revenue 2007 to 2011 OR CA AK WA NV ID UT AZ HI MT WY NM CO ND SD NE KS TX OK MN IA MO AR LA WI IL IN MI OH KY TN MS AL GA SC Source: NASUAD s analysis of data from U.S. Census Bureau, Survey of State Government Tax Collections, reports. FL NC ME N V H NY T MA CT RI PA NJ MD DE WV VA Percent Change -30% to -20% -20% to -10% -10% to -5% -5% to -1% 1% to -1% 1% to 6% Above 6% Page 11

12 My agency needed to take a 3 percent reduction. We were able to make the cuts by not filling vacancies, restricting travel, and other administrative reductions. Agency director, FY09 I feel as though we have been 3 percented to death. There is nothing left to cut. Agency director, FY10 The mission and role of government has changed. If the program doesn t keep someone alive today, we can no longer fund it. Agency director, FY11 My new motto is Suck it up cupcake. --Agency director, FY12 Page 12

13 Non-Medicaid, State-Only HCBS Expenditure Changes, FY 11. WA MT ND ME OR NV CA AK ID UT AZ HI WY CO NM SD MN WI NE IA IL MO KS OK AR MS TX LA MI IN OH KY TN AL GA NY PA WV VA NC SC FL NH VT MA RI CT NJ DE MD DC Expenditure Change 21-25% Increase 11-15% Increase 6-10% Increase 5% or less Increase Stayed the Same 5% or less Decrease 6-10% Decrease Data Not Available Page 13

14 Changes in state agencies Page 14

15 Eligible for Retirement (5 years) Less than 5% 36.4% 9.1% 6.8% Between 6% and 10% 15.9% Between 11% and 15% 31.8% Between 16% and 25% More than 25% Page 15

16 Page 16 AK ME. WA OR CA NV ID UT MT WY AZ NM TX ND SD NE KS OK AR MS MN WI IA MI IL MO IN OH KY TN LA AL GA SC FL NC VA WV PA NY CO NH VT MA RI CT NJ DE MD DC HI AK ME. WA OR CA NV ID UT MT WY AZ NM TX ND SD NE KS OK AR MS MN WI IA MI IL MO IN OH KY TN LA AL GA SC FL NC VA WV PA NY CO NH VT MA RI CT NJ DE MD DC HI States that Restructured Since 2009 Yes No Don t Know

17 What is Driving Restructuring? Administrative Simplification Comprehensive vision Quality Management Consistent policymaking Accountability Budget and Personnel Reductions Improved Access to Services (Single Point of Entry) 64.0% 56.0% 48.0% 52.0% 48.0% 44.0% 40.0% Consolidation of Rulemaking Authority Global Budgeting 20.0% 16.0% 0.0% 20.0% 40.0% 60.0% 80.0% Percent of States Page 17

18 Managing Long Term Care. Page 18

19 States that are Engaged in Medicaid Managed Long Term Care for Older Adults and Persons with Disabilities. WA MT ND ME OR NV CA AK ID UT AZ HI WY CO NM SD MN WI NE IA IL KS MO OK AR LA TX MS MI IN OH KY TN AL GA NY PA WV VA NC SC FL NH VT MA RI CT NJ DE MD DC Yes No Don t Know

20 Picking up Affordable Care Act Options. Page 20

21 States Interested in ACA LTSS and Chronic Conditions Options Improved Care for Dually Eligible Individuals 18 Health Homes for Individuals with Chronic Conditions 17 Accountable Care Organizations 13 Amended Section 1915(i) 11 Balancing Incentive Payment Program 7 Community First Choice Number of States

22 Key priorities. Page 22

23 Major Challenges for State Agencies Other Access to Specialty Providers (i.e., geriatric behavioral health, OT/PT, etc.) Core Service Provider Flight (i.e., PCA, Skilled Nursing) The state agency's role in the long term services and support system is limited by state law or policy Aging baby boomer population that will begin seeking services State priorities do not include serving older adults/individuals with disabilities Strongly Disagree Disagree Agree Strongly Agree Lack of technological resources Not enough staff Budgetary (increasing expenses/limited funding) 0% 20% 40% 60% 80% 100% Percent of States Page 23

24 For more information, please visit: Or call us at:

25 Department of Vermont Health Access Choices for Care Vermont s Home and Community Based Care Waiver NAMD Mark Larson Commissioner Dept. of Vermont Health Access November 9, 2011

26 Department of Vermont Health Access What is Choices for Care (CFC)? CFC is an 1115 Waiver approved by the Center for Medicare and Medicaid Services (CMS). Choices for Care offers long-term care services to Vermonters who need nursing home level of care and who need Medicaid to help pay for the care. Individuals must meet clinical and financial eligibility criteria CFC began October 1,

27 Department of Vermont Health Access Choice for Care: Goals Provide choice and equal access to longterm care Create a balanced long-term care system Serve more people Manage the costs of long term care Improve the system Prevention 27

28 Department of Vermont Health Access Choices for Care: Eligibility Be a Vermont resident, Be 18 years of age or older, Have a functional limitation resulting from a physical condition (including stroke, dementia, traumatic brain injury, and similar conditions) or associated with aging, Meet the clinical criteria for the program, Meet all financial and non-financial criteria for VT Long- Term Care Medicaid. 28

29 Acuity of Need Department of Vermont Health Access High Before Choices for Care Nursing Facility Home Based Waiver Enhanced Residential Care Waiver Current Eligibility threshold Below Nursing Home Level of Care Low 29

30 Acuity of Need Department of Vermont Health Access High After Choices for Care Highest Need Entitlement Groups Level of Care for Eligibility High Need Group Low Moderate Need Group 30

31 Department of Vermont Health Access Home: Choices for Care: Options o Flexible Choices o Home Based o PACE Enhanced Residential Care (ERC) option Nursing Home option 31

32 Department of Vermont Health Access Advantages: To the individual More people covered: Prior to September 2005, nursing home was the only Medicaid "entitlement" for long-term care. Maintained maximum number of slots/waiting list More options: Person who meets criteria has the same entitlement to care at home, in a residential care home or a nursing home. 32

33 Department of Vermont Health Access Advantages: To the State Better value for the dollars spent: We serve more people In the setting of their choice For roughly the same amount of money 33

34 Department of Vermont Health Access ,286 Choices for Care: Total Number of Enrolled Participants, SFY SFY 2011 (excluding Moderate Needs Group) Nursing Facility ERC+HCBS Nursing Facilities: 337 fewer people than in October , ,161 1,855 HCBS and ERC: 694 more people than in October Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07 Apr-07 Jul-07 Oct-07 Jan-08 Apr-08 Jul-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 34

35 Department of Vermont Health Access Impacts on providers vary higher demand for providers who offer services in the community the focus on home-based care options might be a disadvantage for nursing homes Nursing homes are being challenged to develop more creative options such as specialized rehab units 35

36 Department of Vermont Health Access Choices for Care: Challenges Access to home-based providers that have enough staff to meet all scheduling demands for care at home. Still managing most of our home-based services in a fee-for-service model. Still not immune to state's budget woes o Creates pressure on what to do with savings 36

37 Department of Vermont Health Access For more information: s-publications/publications-cfc 37

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