MANAGING CHANGE PART II: SERVICE DELIVERY TRENDS

STRENGTHENING THE AGING NETWORK Building Leadership in the Long-Term Services and Supports Network MANAGING CHANGE PART II: SERVICE DELIVERY TRENDS Thursday, April 14, 2011 3:00 4:00 PM EDT Funded by 1

Today s Speakers and Agenda Participant Direction Lori A. Gerhard, NHA, Director Office for Program Innovation and Demonstration, U.S. Administration on Aging Mark Sciegaj, Ph.D., MPH, Associate Professor of Health Policy and Administration, Pennsylvania State University Rebalancing Krista Hughes, Director, Arkansas Division of Aging and Adult Services Managed Long-Term Care Mike Cheek, Senior Director for State Services 2

PARTICIPANT DIRECTION 3

Participant-Directed Long-Term Services and Supports: Changing Systems, Changing Lives Basics of Managing in a Changing Environment Service Delivery Trends NASUAD Webinar Thursday, April 14, 2011 4

Presenters Lori Gerhard Director Office of Program Innovation & Demonstrations, Administration on Aging Lori.Gerhard@aoa.hhs.gov 202-357-3443 Mark Sciegaj Senior Training Consultant National Resource Center for Participant- Directed Services, Boston College Sciegaj@bc.edu 5

What is Participant Direction? Traditional Services Participant-Directed Services Needs are assessed Makes decisions based on budget Provides feedback to the agency Asked questions Determines goods and services purchased Hires, manages, dismisses workers Participant Participant Assigned hours of services Informed of resources Assigns hours of service Trains, or arranges for training of, workers Given an option of agencies Evaluates workers 6

Why Participant Direction? Comparative effectiveness research on participant-directed programs found: No increase of fraud or abuse over the traditional system More positive health outcomes Cost effective -can decrease use of more expensive services over long term Participants were up to 90% more likely to be very satisfied with how they led their lives 7 Significantly reduced unmet personal care needs 7

Changes in Federal Law, Regulation, and Policy 2001 New Freedom Initiative 2005 Deficit Reduction Act 2010 Affordable Care Act 2006 Reauthorization of Older Americans Act 2007 Aging and Disability Resource Center Program 2010 Affordable Care Act 2008 Veterans-Directed Home and Community -Based Services Program 8

Prevalence of Participant-Directed Programs AK Hawaii CA OR WA NV ID AZ MT WY CO NM ND SD NE KS OK MN IA MO AR WI IL MI IN KY TN AL OH GA WV SC PA VA NC NY ME VT NH MA RI CT NJ DE MD DC MS TX LA States with employer authority PD programs FL States with employer and budget authority PD programs States with employer authority PD programs and VD-HCBS programs States with employer, budget authority PD programs, and VD-HCBS programs 9

AoA s Long-Term Vision Use research to develop a LTSS system that delivers participant-directed programs Participant-directed programs are available in every community in the nation Through various AoA programs Core Programs, ADRC, EBDP, VD-HCBS, and LTSS Core Competency drive the culture and systems changes that enable participant direction to be the primary way people access, obtain, and receive LTSS 10

AoA & NRCPDS Long-Term Services and Supports Workforce Participant-Directed Core Competencies Project Environmental Scan and Literature Review Stakeholder Involvement Identify Core Competencies Develop Workforce Self- Assessment Tool Catalog Course Curriculum to Develop Core Competencies 11

Department of Labor Long-Term Supports and Services Competency Model The Participant Direction Competency Model builds on the Department of Labor Long-Term Supports and Services Competency Model (LTSS-CM [Figure 1]). The LTSS-CM consists of a set of nine tiers of work force competencies. The nine tiers are divided into blocks representing the skills, knowledge and abilities considered essential for successful job related performance. The tiers include: Tier 9: Management Competencies: These competencies domain are specific to supervisory and managerial occupations. Tier 8: Occupation-Specific Requirements: This domain includes requirements such as certification, licensure, and specialized educational degrees, or physical and training requirements. Tier 7: Occupation-Specific Technical Competencies: The detailed skills required for work in a specific occupation. Tier 6: Occupation-Specific Knowledge Competencies: The detailed knowledge areas required for work in a specific occupation. Tier 5: Industry-Specific Technical Competencies: Competencies included in this domain represent the knowledge, skills, abilities and other characteristics needed by all occupations within an industry segment (e.g. AAAs, ADRCs). Tier 4: Industry-Wide Technical Competencies: Competencies included in this domain represent the knowledge, skills and abilities needed by all occupations within an industry (e.g. LTSS). Tier 3: Workplace Competencies: Competencies included in this domain represent those skills and abilities that allow individuals to function in an organizational setting. As with the Academic Competencies, these are generally applicable to a large number of occupations and industries on a national level. Tier 2: Academic Competencies: Basic academic skills of reading, writing, etc apply to all organizations represented by a single industry or industry association nationwide. Tier 1: Personal Effectiveness Competencies: These competencies are the base tier because they are essential for all life roles not exclusive to the competencies needed for a successful career or role in the workplace. 12 Figure 1: Long-Term Supports and Services Competency Model

Relationship of Participant Direction Core Competencies Project to Other Participant-Directed Activities DHHS: AoA-NRCPDS: Consumer Direction Core Competencies Project Identify the competencies necessary to assist and support participants in managing their services effectively through informed decision-making DHHS: AoA ADRC DHHS DHHS: CMS DHHS: Office of Minority Health DHHS: Office of Disability DHHS: SAMHSA Veterans Health Administration Supports Options Counseling National Standards Project Supports DHHS Provisions of Patient Protection and Affordable Care Act Supports Taxonomy Supports National Standards on Culturally and Linguistically Appropriate Services (CLAS) Supports Community Living Initiative Activities Complements developing recovery competencies for individuals working in behavioral health care project Supports the Veteran- Directed Home and Community-Based Services Program (VD-HCBS) Develop national minimum standards to guide how options counseling is delivered Section 2402(a): Common framework establishing principles and process elements supporting participant direction; the Community Living Assistance Services and Supports (CLASS) Program; Community First Choice (Section 1915(k)), and revisions in the 1915(i) authority; Money Follows the Person (MFP) ; Aging and Disability Resource Centers (ADRCs); Care Transitions; Health Homes Information and assistance in support of participant direction (supports brokerage) The CLAS standards are primarily directed at organizations, but individuals are also encouraged to use the standards, to make their practices more culturally and linguistically accessible: the Participant Direction Core Competencies Project supports Standards 1 (respectful and appropriate care), 3 (ongoing training and education), 6 (oral communication), 7 (written communication), and 12 (participatory, collaborative partnerships) Affirming the right of persons with disabilities to obtain services in the most integrated setting appropriate to meet their needs Identifying competencies needed of staff to operationalize guiding principles of recovery (including being person-driven) in everyday practice VD-HCBS is a program that purchases a package of participantdirected services from an entity in the Aging Network; through VD-HCBS, Veterans decide for themselves what mix of services and goods will best meet their needs to live independently in the community 13

REBALANCING 15

Arkansas s LTSS Development Krista Hughes, Director krista.hughes@arkansas.gov (501) 682-2441 Arkansas Department of Human Services 16

Arkansas Department of Human Services (DHS) Division of Aging and Adult Services (DAAS) Ranks 9 th in population over age 65, with 14% Ranks 2 nd in adults ages 18-64 reporting any disability; ranks 3 rd in adults age 65+ reporting a physical disability, with 39% Has 3 HCBS waivers (elderly, adults with physical disabilities, assisted living) Has a strong Consumer Direction model Medicaid is primarily fee for service model but change is eminent 17

Arkansas s LTC Portrait 21,000 elderly & adults with physical disabilities use Medicaid LTSS monthly In 9/2009, 38% used waiver services & 62% used nursing home care Medicaid LTSS users account for only 7% of all Medicaid enrollees, but 52% of the Medicaid expenditures 73% of AR Medicaid LTC budget is directed to institutional care 18

Arkansas Medicaid LTSS Recipients, 2003-2010 14,000 12,000 13,429 13,058 12,920 13,014 12,639 11,972 12,127 12,284 10,000 8,000 7,404 7,723 8,399 8,761 8,951 9,551 10,359 10,547 HCBS 6,000 NH 4,000 2,000 0 2003 2004 2005 2006 2007 2008 2009 2010 19

HCBS Participants, 2003-2010 6,000 5,000 4,000 3,000 2,000 EC AAPD LC IC 1,000 0 2003 2004 2005 2006 2007 2008 2009 2010 20

The Evolution of LTSS in AR Older Americans Act (OAA) Medicaid Agency-Directed LTSS: Personal Care; 1915 (c) waivers Consumer-Direction: 1915 (b) waiver; State Plan J authority; Veteran Directed Transition: MFP; Options Counseling; Section Q 21

Medicaid Agency-Directed Programs 1915 (c) Waivers: ElderChoices (elderly): Initiated with an AoA Planning Grant in the late 1980s Statewide waiver application approved in 1991 Serves approximately 7,000 unduplicated people each year, growth rate of only ~ 2% annually 22

Medicaid Agency-Directed Program cont. - Assisted Living (Living Choices): Initiated with a RWJ grant in 1999 Led to passage of Act 1230 in 2001 First licensed ALF opened in 2002 This is primarily a private pay market, but between 2004-2010, we have seen average annual growth rate of 100% in our waiver program 23

Consumer Direction Independent Choices: First of the three Cash & Counseling Demonstration states to implement in December 1998 RWJF grant Operated as an 1115 Research and Demonstration waiver until April 2008 Is now offered as a state plan service under 1915(j) Average annual growth since 2005 is 14.35% 96% of total Medicaid cost is used to support participants Participant s budget plus contract cost is $10.09 per hour compared to agency hourly cost of $16.76 24

Consumer Direction cont. Alternatives for Adults with Physical Disabilities Implemented in 1997 Includes both agency-directed and consumerdirected models, counseling support mgmt, and environmental modification/adaptive equipment Growth rate was ~ 15% per year until reaching the cap. Unduplicated recipient cap is 2600 First waiver to hit and hold at the cap with a wait list implemented in 2010 25

Transitioning Money Follows the Person (MFP) grant One of the most significant benefits associated with MFP is the administrative funds. Uses to date include: Staff to develop Adult Family Home industry Consultative services to help successfully close a HDC (ICF-MR) Consultative services to develop transitioning curricula and infrastructure 26

LTC Balancing Initiatives Universal Assessment statewide Assessment, care plan management, provider management, electronic records, movement into more of a case mix methodology Conflict Free Case Management Single Entry Point improvement of access issues 27

Medicaid Bending the Curve Medicaid Transformation Substantive changes from fee for service to episode of care methodology Health home and medical home models received a planning grant to develop 28

Evolving Business Operations DAAS is currently undergoing the largest scope of changes to business operations in over 20 years, including: Databases (moving from Access to web based) Reimbursement methodology shifts Electronic records (moving to paperless we re not kidding this time ) Staffing to new skill sets (IT, QA) 29

Questions? Krista Hughes, Director krista.hughes@arkansas.gov (501) 682-2441 30

MEDICAID MANAGED LONG- TERM CARE 31

MMLTC Is a Delivery Model States Use in Lieu of Fee-for-Service Capitated MMLTC Medicaid agency and contractors enter into agreement under which contractor accepts risk of providing defined Medicaid LTC services Alternative types of MMLTC capitation packages: Medicaid-covered LTC services only All Medicaid-covered acute and LTC services All Medicare and Medicaid-covered services (additional plan contract with CMS required for Medicare portion) State Medicaid Agency Capitated Payment Managed Care Contractor Negotiated Payments (FFS, Per Diem, etc.) Providers 1 Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005. 32

There Are Three Basic MMLTC Models Medicaid Services for Which Managed Care Contractor is at Risk Medicare Services for Which Managed Care Contractor is at Risk MODEL 1: Medicaid LTC Only Home and Community Based Services (HCBS) Nursing Home Care MODEL 2: Medicaid-Only HCBS Nursing Home Care Medicaid-Covered Primary Care Services Medicaid-Covered Acute Care Services Medicaid-Covered Pharmacy MODEL 3: Medicaid-Medicare Integration HCBS Nursing Home Care Medicaid-Covered Primary Care Services Medicaid-Covered Acute Care Services Medicaid-Covered Pharmacy None None Medicare Acute Care benefits Medicare Prescription Drug Benefit Dual eligibles may also be enrolled in Medicare managed care and receive Medicaid LTC services in either FFS Medicaid, or in MMLTC Models 1 or 2 Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005. 33

Models One and Two Rely on a State-Only Contracting Structure HCBS State Medicaid Agency Capitated Payment Managed Care Contractor Case Manager Assigned by Contractor to Individual Alternative Residential Settings Nursing Facilities ICF/MR (DD Only) Hospice Medicaid Acute Care Services Case Management Behavioral Health 34

Model Three Requires Several Contracting Vehicles and Sophisticated Administrative Infrastructure CMS Medicare Advantage Special Needs Plan Contract Medicare Capitation Payment State Medicaid Agency Medicaid Capitation Payment Managed Care Contractor Medicaid and Medicare Acute Care Services HCBS Alternative Residential Settings Nursing Facilities Hospice MA developed state Medicaid Managed Care Plan Contract language intended to coordinate with CMS Medicare requirements to reduce administrative burden on plans and the state 35

MMLTC Market has Grown but is Less Prevalent Than Primary/Acute Managed Care Notes: 1) Does not include PACE; 2) Rhode Island s program includes managed primary and acute care LTC remains fee-for-service; 3) Wisconsin also operates a Medicare-Medicaid Integration program called the Wisconsin Partnership Program; and 4) Some states require their Medicaid managed care plans to also be SNPs -- only historical integration state program are noted above Sources: CMS Waiver database at http://www.cms.gov/medicaidstwaivprogdemopgi/mwdl/list.asp ; Saucier, Paul, Brian Burwell, and Kerstin Gerst, The Past, Present and Future of Managed Long-Term Care, prepared for the DHHS Office of the Assistant Secretary for Planning and Evaluation, April 2005; NASUAD Research 36 Statewide MMLTC MMLTC in Portions of State Medicare-Medicaid Integration with MMLTC

Multiple Avenues for States to Create MMLTC Programs MMLTC Enrollment and Program Authorities Section 1115 Demonstration Waivers Section 1915(a) Medicaid Managed Care State Plan Amendment (SPA) With or without Section 1915(c) or Section 1915(i) Section 1932(a) State Plan Amendment Section 1915(b) Managed Care Waivers Section 1915(b) and HCBS 1915(c) Combination Waivers Program for All-Inclusive Care for the Elderly (PACE) MMLTC and Medicare-Medicaid Integration Initially Social Health Maintenance Organizations (S/HMO) and Section 222 Medicare Waivers Replaced by Medicare Modernization Act authority for Medicare Advantage Special Needs Plans (SNP) 37

SNPs are MA-PD Plans but With Special Requirements SNPs are similar to MA-PDs because they Must be an MA-PD plan and use the MA-PD application process Offer all MA services including the Part D drug benefit Generally must follow MA plan marketing guidelines Paid using the same risk-adjusted payment system as MA-PD SNPs differ from regular MA-PD because they Have been reauthorized by Congress several times but with additional requirements Must provide services tailored to their special needs population that go beyond standard Medicare services May limit enrollment to certain populations Have a variety of Part D Special Election Periods (SEP) that allow Medicare beneficiaries to enroll throughout the calendar year 38

Some States Using SNPs To Deliver Integrated Medicare and Medicaid Services Current Delivery System Medicare and Medicaid administered by different units of government No vehicle for beneficiary health care information exchange Medicare and Medicaid cover some of same services but with different service definitions and limits Integrated SNP Delivery System Plans contract with CMS for Medicare Advantage services; state contracts for Medicaid MCO services Care coordination provides assistance with service access, tracking, utilization management SNP gets capitated payments for duals from both Medicare and Medicaid Medicaid covers key services Medicare does not 39

Several Actions are Necessary When MMLTC is Under Consideration Strategic Options LTC provider and consumer advocate perspectives Study State Medicaid Managed Care landscape SNP Current plan marketplace Penetration rates Enrollment of ABD populations Same as above but also state contracts with SNPs Required Decision Points/Actions Mandatory versus Voluntary Scope of Capitated Benefits Target Populations Geographic Coverage Payment Methods Enrollment Authority Quality Oversight Contract development Operational resources 40

Managing Change Part II: Service Delivery Trends Open Discussion 41

Next Just the Basics Calls Medicaid Managed Long-Term Care Part II: Overview of Medicaid Managed Long-Term Care Marketplace Mary Kennedy, Medicare Vice President, Association for Community Affiliated Plans Wednesday, April 20, 3PM 4PM EST 42

Next Just the Basics Calls Data Systems and Communicating with Legislators Secretary Gloria Lawlah, Maryland Department of Aging Katherine Mason, National Conference of State Legislatures Maria Greene, NASUAD Senior Consultant Mike Cheek, NASUAD Senior Director for State Services Thursday, April 21, 3PM 4PM EST 43