1 State Initiatives in State Initiatives in Nursing Facility Nursing Facility Transitions Transitions Susan C. Reinhard Susan C. Reinhard Co-Director Co-Director Rutgers Center for Rutgers Center for State Health Policy State Health Policy Michigan’s LTC Michigan’s LTC Conference Conference Detroit, Michigan Detroit, Michigan March 23-24, 2006 March 23-24, 2006
Transcript
Slide 1
1 State Initiatives in Nursing Facility Transitions Susan C.
Reinhard Co-Director Rutgers Center for State Health Policy
Michigans LTC Conference Detroit, Michigan March 23-24, 2006
Slide 2
2 Goals Highlight key developments in Nursing Facility
Transition across the country. Offer state examples Share Michigan
State Policy in Practice brief
Slide 3
3 Information about LTC options Crucial for consumers, their
families and the professionals who counsel them Once people enter a
nursing facility and give up their community supports, it is hard
to leave. Without information, people cannot make an informed
decision about where to receive services. States are looking at the
best ways to provide information
Slide 4
4 Improving Access to LTC Nursing Home Transition programs
Large statewide programs (WA, NJ, Oregon) State employees (NJ, WA)
Smaller programs for most challenging situations (SC, CT, MA)
Locally based organizations (Centers for Independent Living, Area
Agencies on Aging) Hospital Diversion Programs Indiana (see Rutgers
brief)
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5 CMS Nursing Facility Transition Grants 12 Demonstration
Grants funded 1998- 2000 $160,000 - $175,000 in 1998; thereafter
$500,000 33 NFT grants funded (to 27 states) in 2001 and 2002 23
grants to state programs; 10 grants to Independent Living
partnerships (6 states received grants to both) State programs got
up to $800,000; ILCs got up to $450,000 30 states total funded in
some way
Slide 6
6 Washington: A Pioneer State funded chore services since 1970s
1980s budget crises lead to greater reliance on Medicaid LTC
benefit 1983 Medicaid Waiver Program 1989 Medicaid Personal Care
Program 1993 legislature approves relocation of 750 nursing home
clients to HCBS 95-97 budget reduces NH caseload by 1,600
clients
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7 Legislative direction Nurse delegation legislation and
ongoing changes Global budget provides significant management
flexibility Caseload Forecasting Council projects NH & HCBS
trends NH caseload is falling while HCBS absorbs growth in service
demand
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8 Washingtons Aging and Disability Services Administration
(ADSA) Manages all state-supported long- term support services for
older adults and people with physical disabilities. Administers
long-term support services through regional offices and 13 AAAs.
ADSAs and AAAs use common database.
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9 ADSA Regional Offices Staffed by state-employed nurses and
social workers. Conducts initial assessment for Medicaid- funded
services, functional eligibility determination, care plan
development. Provides on-going case management and reassessment for
consumers in nursing facilities, adult family homes, and assisted
living settings.
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10 Area Agencies on Aging Help consumers identify, understand,
and access available resources through information and referrals.
Provide case management and reassessments for consumers living at
home.
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11 Comprehensive Assessment Reporting Evaluation (CARE) Single
automated system used by both ADSA regional offices and AAAs to:
Assess functional, health, cognitive and behavior status. Determine
long-term care eligibility. Develop plan of care. Determine maximum
number of authorized service level.
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12 Care Plan Development Completion of assessment generates
report of programs the consumer is eligible for. Assessor describes
programs to consumer. Most HCBS are provided using consumer
direction.
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13 Authorized Service Level Determination CARE system
authorizes number of in- home hours consumer can receive each
month. Maximum 420 hours/month. Standardized service limits. Based
on consumers clinical and functional characteristics. Payment
levels established for services in adult home or assisted living
facility.
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14 Medicaid Financial Eligibility Determination Initiated at
the same time as functional eligibility determination. Quick
determination (internal goal of 15 days): Presumptive eligibility
for an individual being discharged from hospital. Avoid delays that
dictate whether consumer remains in the community or enters a
nursing facility.
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15 Washingtons Nursing Home Relocation Assign case managers
(social workers and nurses) to each nursing facility (one for 2-3
NHs) Priority clients: new admits (within 7 days), 180 day
conversions & others expressing interest Provide assistive
technology and individualized community support services Use civil
penalty fund and nursing facility discharge allowance Promote NH
capacity reduction and bed conversion strategies WA Aging and
Disability Services Administration
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16 Nursing Home Transition Services Case managers contact
residents within 7 days of NH admission to discuss preferences,
care needs and supports available in the community. Comprehensive
assessment completed when consumer is ready to work with case
manager who develops transition plan with consumer.
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17 Washington Nursing Home Transition Grant Strengthen capacity
of independent living centers, providers, and contractors to
provide support and technical assistance on independent living and
consumer-directed services. Expand access to accessible, affordable
housing for people transitioning from nursing homes. Improve
provision of assistive technology services necessary to live in the
community.
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18 Washington: NF caseload trends Figures for July each
year
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19 Washington: HCBS trends Figures for July each year
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20 Washington LTC Spending trends (millions Based on data from
the Washington Aging and Disability Services Administration
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21 WA: Shifting spending balance
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22 WA: Elders and Adults
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23 New Jerseys Three-Pronged Strategy for Systems Change
Consolidation at state level Create more choices for HCBS services
Help consumers find choices New Jerseys Three-Pronged Strategy for
Systems Change Consolidation at state level Create more choices for
HCBS services Help consumers find choices
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24 Help Consumers Find Choices NJ EASE (New Jersey Easy Access
Single Entry) Resource Center Information, assistance, care
management Community Choice Counseling nursing home transition
program
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25 Community Choice Counseling New Jersey has one of the the
largest Nursing Home Transition Programs in the country. Program
uses nurses and social workers to assist people to leave the
nursing home.
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26 Foundations of the Community Choice Counseling A 1988 state
law and its implementing regulations provided the opportunity to
create the Community Choice Counseling program a decade later.
Nursing Home Pre-admission Screening law in 1988 (P.L. 1988,
Chapter 97)
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27Foundations All persons who will become eligible for Medicaid
within six months following NH admission must be assessed or
Medicaid will not pay. Provides the legal framework for the state
to claim a federal match for the salaries of staff performing PAS
for almost all people entering a NH for a projected long stay.
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28 In 2004, did a total of 33,746 PAS assessments (26,686
initial and 7,060 reassessments) to determine Medicaid eligibility
for LTC services 80% of Hospital PAS assessments done within 24
hours. Rest are done within 72 hours (the policy) Pre-Admission
Screening Program: PAS
Slide 29
29Foundations Track I are unlikely candidates for nursing home
alternatives. Track III are those who are diverted from nursing
home residence through community placement. Track II is the
targeted group who cannot be immediately diverted from nursing
homes, but might be able to return to HCBS.
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30Foundations Track II was the target group for the 1998
Community Choice Counseling pilot and the initial roll-out of this
program because the state employed nurses already had a legal
mandate to periodically assess and counsel these nursing home
residents. Important factor in overcoming NH resistance.
Slide 31
31Foundations Started with 2 state nurses in 1998. Ramped up to
73 professional staff now--mainly nurses. Transition fund--state
dollars, now Medicaid waiver. Three CMS grants, starting in 1999.
Currently refining work with younger persons with
disabilities.
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32 CCC Practices State staff members cross-trained to do PAS,
options counseling, and transition support. 61 registered nurses;
12 social workers. Assigned specific hospitals and nursing
homes.
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33 CCC: The Present 2002 pilot with Independent Living Centers
Round Tables to address the broad and complex needs of consumer who
needs substantial assistance to find housing, social services and
other community connections for sustained community residence.
Involves Community Choice counselor, consumer, NH discharge
planner, and others.
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34 CCC Results and Future Goals As of September 23, 2005, 5,583
individuals have been discharged from nursing homes to less costly
alternative living arrangements since March 1998 In SFY05, 503
individuals transitioned from nursing homes to home and community-
based services In SFY06, goal is to discharge 500 individuals
through Community Choice Counseling
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35 Divisions of Aging and Community Services (DHSS) and
Division of Disability Services (DHS), with the ILCs, have worked
together to transition younger disabled adults from nursing homes
into the community In SFY04, 83 younger disabled adults were
transitioned In SFY05, 196 younger disabled adults were
transitioned Nursing Facility Transitions Grant
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36 NF Actual Recipients vs. Recipients Without Reductions
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37 Source: NJDHSS, Sept 15, 2004 Trenton, NJ
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38 Community Choice Counseling Evaluation (Howell White et al)
Focus both on the Former Nursing Home Residents and the Counselors
Perspectives Quality of Life for Former Nursing Home Residents in
terms of Current living situation Use of services Health care
service use Social support network
Slide 39
39 Key Findings Key Findings High satisfaction with their
return to the community Most return home Most are alive and
remained in the community for the full year Returning to a NH or
being deceased seems to be related to frailty and significant
adverse health incidents
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40 Status at One Year After Discharge N=1344
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41 Federal grant of almost $800,000 over 3 years Among first 12
states to get ADRC funding Department of Health and Senior Services
is lead agency with Department of Human Services as partner
Redesign aging and disability service systems: multiple entry
points that are coordinated and standardized Extends to persons 18
years and older with physical disabilities Major component HCBS/CMS
Quality Model & Consumer Satisfaction NJ=A National Model
through Aging & Disability Resource Center Grant (ADRC)
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42 CCC Integration
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43 Nursing Facility Transition Grant MI Choice Assessment Tool
CCC Links to ADRC Initiative
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44 Focus in Warren County ADRC pilot on conducting clinical
needs assessments and counseling consumers on the broad range of
home and community based services (HCBS) Activities include:
Testing MI-Choice: the selected clinical needs assessment tool
Streamlining and coordinating PAS and financial eligibility process
Coordinating and arranging HCBS with community agencies and
Community Choice Counselors MI-CHOICE Clinical Assessment Tool
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45 MinnesotaLong Term Care Consultation Preadmission screening
was revised by the legislature in 2001 into a much broader program
on long term care consultation. It now includes: assessment of
needs assistance in identifying and recommending cost- effective
home and community-based services development of a community
support plan preliminary determination of eligibility for public
program support transition assistance for people who are currently
institutionalized
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46 MinnesotaLong Term Care Consultation Consultation is
available to everyone, regardless of income or acuity levels The
statute includes a mandate to provide information and education to
the general public regarding long term care consultation Service
teams are organized at the county level and consist of at least one
social worker and one public health nurse Consumers must be
assessed within 10 days of the request or referral Consumers under
age 65 must have a face-to- face assessment within 40 days of NF
admission
Slide 47
47 Minnesota--Results Accelerated trend away from institutional
services and toward community-based services
Slide 48
48 MinnesotaData (Source: Minnesota Department of Human
Services)
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49 IndianaPriority Diversion, Transition and Options Counseling
Indiana has diverted over 1,300 consumers from nursing facility
admissions to home and community-based services with its priority
diversion program implemented in 2003 by AAAs working with hospital
discharge planners. These consumers are given a priority for spots
in the HCBS waiver program, which otherwise has a waiting list, so
that they can avoid losing housing and community supports
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50 IndianaPriority Diversion, Transition and Options Counseling
Indiana personnel believe that the state would benefit by changing
its preadmission screening process to emphasize long-term care
options counseling in addition to determining level of care needs
Also looking at restructuring case management payments for
transitions because the current cap on eligible hours may lead to
hiring more expensive formal care instead of trying to work out
informal options.
Slide 51
51 Importance of Evaluation Can help build the case for NHT
programs with policymakers Can provide information to improve the
program Connecticut and Michigan are examples of this
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52 Conceptual Model of Transition Relationships
Slide 53
53 ConnecticutDesign & Evaluation Built evaluation into
design of program Asked state how to measure costs of NF vs. HCBS
State involvement from the beginning, combined with an external
evaluator for the program, meant that results were not questioned
Involved stakeholders with knowledge and decision-making authority
in the steering committee Results showed a savings of $96/day on
average for each person transitioned.
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54 Connecticut--Outcomes Governor requested to sustain program
with funding for transition coordinators and more waiver slots.
State changed its housing plan to set aside Section 8 vouchers for
persons transitioning from institutions. State dedicated $500,000
in bond funds to be used for housing modifications for
transitionees (rental or owner-occupied)
Slide 55
55 Michigans Nursing Home Transition Program One of the first
group of states to receive NHT funding in 1998. Focus on residents
choice to leave NH rather than ability. 41% of NH transitionees
required no government-paid services after transition assistance.
Costs for transitionees enrolled in Medicaid waiver or other
service programs 60-76% less on average than costs to stay in
NH.
Slide 56
56 Michigans Long-term Care Population 1.24 million of 10.1
million residents are 65 years old or older (12%). 40% have some
type of disability. 40,365 nursing home residents in 2004. 67% paid
by Medicaid, 15% by Medicare, 18% private. 10 th highest nursing
home population in the US. 3.4% of residents 65 and older are in
nursing homes. US average: 4%.
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57 Long-term Care Spending in Michigan Michigans total Medicaid
budget in 2004: $8.2 billion. $2.4 billion in total Medicaid spent
on LTC. $1.7 of $2.4 billion (71%) spent on nursing home care.
Percentage of Michigans LTC budget going to nursing homes is
decreasing. 75% in 2000 to 71% in 2004. US average: 51.3%.
Slide 58
58 Improving LTC Access 1998: Nursing Home Transitions
Demonstration Program Grant. 2001: Nursing Facility Transition
grant ($770,000) and Real Choice Systems Change grant ($2.1
million). 2003: Money Follows the Person ($786,000). 2004: Cash and
Counseling (RWJ). 2005: ADRC grant ($800,000).
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59 Nursing Home Transition Program 2001: 2 pilot sites Area
Agency on Aging of Western Michigan (9 counties inc. Grand Rapids)
Detroit Area Agency on Aging As of April 2005, NHT program is
statewide through MI Choice program. 22 waiver agents (AAAs and
others) serving 14 regions.
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60 Michigan Cost Data
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61 Susan C. Reinhard Co-Director Rutgers Center for State
Health Policy Director Community Living Exchange at Rutgers
Technical Assistance for Real Systems Change 732-932-4649
[email protected]