States Roles in Rebalancing Long-Term Care: Findings from the Aging Strategic Alignment Project

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1 States Roles in Rebalancing Long-Term Care: Findings from the Aging Strategic Alignment Project Linda S. Noelker, PhD Katz Policy Institute Benjamin Rose Institute on Aging Fairhill Road, Suite 300 Cleveland, OH Presented at Marymount Hospital October 9,

2 Objectives To what extent are home- and community-based services (HCBS) offered by the states under five funding sources? What major initiatives are states using to rebalance Long Term Services and Supports (LTSS)? What policies should states enact to strengthen their infrastructure for LTSS? What is Ohio doing? 2

3 Rebalancing 3

4 Introduction to HCBS: Why the predominance of nursing home care over home care? Federal financial incentives for nursing home construction in the 1960s Strength of the nursing home lobby in Ohio Nursing home care is an entitlement under Medicaid Dominance of medical model for long term care Game changers: Olmstead Decision (1999) and other court decisions Cost of nursing home care under Medicaid long term care Number of dual eligibles (Medicaid/Medicare) 4

5 Aging Strategic Alignment Project (ASAP) Funded under a cooperative agreement between the Administration on Aging (AoA) and Benjamin Rose Institute on Aging Purpose To obtain information about HCBS programs for the elderly & adults with physical disabilities under five funding streams To use the information to profile each state s HCBS programs and make policy recommendations to advance rebalancing 5

6 Aging Strategic Alignment Project: Participating States (Orange) CA OR WA NV ID UT MT WY CO ND SD NE KS MN IA MO WI IL IN MI KY OH WV PA VA NY VT NH ME RI CT NJ DE MA AZ NM OK AR MS TN AL GA SC NC MD TX LA FL AK HI State Units on Aging (SUAs): completed the data collection process SUAs: did not participate 6

7 Total of 157 informants from 47* states Number of informants per state: Range = 1 to 9 Average = 3.3 Total number of contacts = 836 (47 states) Contacts = information gathering through phone, or fax Mean = 17.8 Range = 6-28 * District of Columbia Informants 7

8 Why so many contacts with the States? HCBS programs crosscut state agencies Government structure for these programs evolved piecemeal without centralized strategic planning Lack of coordination among SUAs, state Medicaid unit, and other state units No one entity has the complete picture due to fragmentation Job turnover 8

9 Funding Sources for HCBS 1. Medicaid Waivers 2. State Medicaid Plan 3. State funded programs 4. Older Americans Act 5. CMS Demonstrations 9

10 Number of 49 States Offering Each Service Under Any HCBS Funding Stream Caregiver Services/ Respite/ Education Case Management/ Care Coordination Chore/ Homemaking Home Health/ Personal Care Transportation Equipment/ Supplies/ Modifications/ Asst Tech. Information/ Assistance/ Referral Nutrition/ Meals Adult Day Care/ Adult Day Health Legal Assistance/ Financial Advice Nursing Personal Supports for Community Living/ Transitioning Rehabilitation/ Therapy Health Promotion Activities Companion Services/ Socialization Activities Medical/ Dental/ Medication Care Other/ Unspecified HCBS Assisted Living Residential Services Mental and Behavioral Health Services Employment Number of states 10

11 Number of States Number of 21 Service Types Offered in All HCBS Programs in States Under Any Funding Stream AL AZ DE IL NC RI TN KY LA MD NH SC AK KS NE NM ND OR WY CT ID IN MA MI NY AR DC FL MN NJ TX UT WA CA CO GA IA OK VT MS MO WV NV VA ME OH MT PA WI Number of Services 11

12 What can states do to increase access to HCBS and avoid nursing home use? Incentivize nursing homes to convert NH beds to assisted living beds Fund assisted living under Medicaid Use presumptive eligibility for Medicaid enrollment Rethink the functional and financial eligibility for HCBS programs Do in-person assessments of every person applying for NH care (and not by NH personnel) Encourage long term care planning in advance of need Expand the direct care workforce in long term care and improve their skills 12

13 Consumer Direction in HCBS 13

14 Illustration: Traditional Service Delivery CASE WORKER SERVICE PROVIDERS SERVICES AGENCY 14

15 Consumer Direction in HCBS SERVICE PROVIDERS CASE WORKER AGENCY SERVICES 15

16 Consumer Direction in HCBS Shifts decision-making & control over services from providers to consumers & families Traditional service delivery: provider or payer decides what is needed/covered. Consumer Direction: Consumer can hire, supervise & fire caregivers. Can pay family members & friends to provide care. Chooses from an array of services. Goals: To address the shortage of direct care workers To enhance consumer choice & control. 16

17 Consumer Direction in HCBS Traditional Agency Model Service-based Identify risk Pre-determined set of services and providers Consumer Directed Model Needs-based Reinforce choice, acknowledge risk Supports tailored to individual preferences Care managers/nurses create and monitor care plans Individual designs the care plan 17

18 Number of States Available Models of Consumer Direction Modified Cash and Counseling Traditional Cash and Counseling Other Models Vouchers Cash Note: States can offer more than one model 18

19 Number of States Service Providers Permitted Under Consumer Direction Other Family Members Adult Children of Consumer Friends Provider Agencies Spouses Note: States can permit more than one type of service provider Other 19

20 Aging & Disability Resource Centers (ADRCs) 20

21 Aging & Disability Resource Centers (ADRCs) Help coordinate existing aging and disability service systems by forming State and local partnerships Provide objective information and assistance regarding full range of available options Empower individuals of all ages, incomes and disabilities, and their families, to make informed decisions Older adults Persons with cognitive impairment Persons with physical disabilities Persons with developmental disabilities Veterans 21

22 States Reports of ADRC/SPE Status (2008) No ADRC or SPE ADRC or SPE Not Statewide ADRC or SPE Becoming Statewide ADRC or SPE Statewide (3) (28) (6) (12) Delaware Alaska New York Alabama Arkansas Nebraska Arizona North Carolina District of Columbia Florida Oklahoma California North Dakota Georgia Indiana Colorado Ohio Idaho Iowa Connecticut Oregon Illinois Kentucky Kansas Pennsylvania Utah Louisiana Maine South Carolina Massachusetts Maryland Tennessee Minnesota Michigan Texas New Hampshire Mississippi Vermont New Mexico Missouri Virginia Rhode Island Montana Washington West Virginia Nevada Wisconsin New Jersey Wyoming 22

23 Comments on the Importance of ADRCs The ADRC has led to collaboration. Started to change the system dramatically. Will bring consumer direction into everything, when the ADRC becomes statewide. Consumers will have the ability to really be the driving force to the who, the what, the when and how (and that is all, however, based on the outcome of [an] assessment). 23

24 State ADRC/SPE Examples 24

25 Current/Future Initiatives States Are Undertaking to Rebalance Long-Term Care Building infrastructure to support expanded HBCS (streamline enrollment, consolidate state units) Advocacy for political support for HCBS Establishing ADRCs statewide Broadening Consumer-Directed Care Programs Expanding service types under HCBS Money Follows the Person/Nursing Home Diversion Programs New target populations (e.g., Traumatic Brain Injury) 25

26 Evidence of Rebalancing Outcome: the percentage of Medicaid Aged and Disabled LTC $ spent on HCBS vs. institutional care Ranges from a low of 10.5% (ND) to a high of 63.9% (NM) 26

27 Policy Questions If rebalancing results in serving persons with higher acuity levels in the community instead of institutions, what services and supports will states have to provide to make this feasible? How can primary care services be integrated with LTC services and supports for persons with complex, multiple chronic health conditions? 27

28 Policy Recommendations to Advance States Rebalancing Efforts State requires in-person pre-admission screening by non-nursing home staff to determine functional eligibility for Medicaid State requires nursing home pre-admission assessment by non-nursing home staff for non-medicaid consumers State has a PACE or PACE-like program(s) State-wide System 28

29 Policy Recommendations (con t) HCBS program(s) under managed care health plans State-wide Single Point (s) of Entry and/or Aging & Disability Resource Center(s) State has mechanisms in place to control number/use of nursing home beds State has more home and personal care aides per 1,000 persons aged 65+ in population State has health promotion and chronic disease management programs widely available 29

30 What s the situation in Ohio? Ohioans spend more per person on health care than residents in all but 17 states Rising health care costs are eroding paychecks and profitability Higher spending is not resulting in higher quality or better outcomes for Ohio citizens 36 states have a healthier workforce than Ohio Sources: Kaiser Family Foundation State Health Facts (December 2011), Commonwealth Fund 2011 State Scorecard on Health System Performance 30

31 What are Ohio s problems? Medicaid is Ohio s largest health payer, covering 1 in 5 Ohioans and almost half of all births Ohio Medicaid consumes 30% of total state spending and 3.6% of the total Ohio economy Over use of ERs, too many hospital re-admisssions, unnecessary transfers from NHs to hospitals Dual eligibles receive fragmented care and lack of preventative care Uncovered lives (no health care insurance) Inadequate number of primary/family care physicians Poor transitions between levels of care and care settings Lack of accountability for errors/omissions 31

32 Ohio s Vision for Better Care The vision is to create a person-centered care management approach not a provider, program, or payer approach Services are integrated for all physical, behavioral, long term care, and social needs Services are provided in the setting of choice Easy to navigate for consumers and providers Transition seamlessly across settings as needs change Link payment to person-centered performance outcomes 32

33 Ohio Current Initiatives: Improve Overall System Performance Pay for health care based on value instead of volume Encourage Patient-Centered Medical Homes Accelerate electronic Health Information Exchange 33

34 Ohio Current Initiatives: Streamline Health and Human Services Consolidate ODADAS and ODMH Create a cabinet-level Medicaid department Modernize eligibility determination systems Integrate HHS information capabilities Share services across local jurisdictions 34

35 Ohio Current Initiatives: Modernize Medicaid Reform nursing facility reimbursement Integrate Medicare and Medicaid benefits Rebalance spending on long-term care services and supports Create health homes for people with mental illness Restructure behavioral health system financing Improve Medicaid managed care plan performance 35

36 Want more information on ASAP & states HCBS programs? ->Policy ->Projects 36

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