Florida Statewide Medicaid Managed Care Long …...7 Final Report May 16, 2019 Background In 2011,...

College of Medicine | College of Social Work | Florida State University

Florida Statewide Medicaid Managed

Care Long-term Care Program

Research Report: Long-term Care

Program Nursing Facility Plans of

Care and Case Management – Final

Report

Deliverable 24

Prepared for Florida Medicaid

MED186 May 16, 2019

2 Final Report May 163, 2019

Florida Medicaid Long-term Care Program Nursing Facility Plans of Care and Case Management

Notes -- Final Report

Executive Summary

Florida’s Statewide Medicaid Managed Care (SMMC) Program has a Long-term Care (LTC) component that

was implemented in August 2013. The FSU evaluation team assessed the quality of care for a representative

sample of Long-term Care (LTC) enrollees residing in nursing facilities (NFs) during state fiscal year 2017-2018

(SFY1718). In addition, the evaluation team assessed how LTC Plan case managers improve the quality of care

for enrollees residing in NFs. To provide recommendations, the Agency and the FSU evaluation team developed

three research questions (RQs):

1. How does quality of care for LTC Plan enrollees residing in a NF differ from NF residents who are

not enrolled in Medicaid?

2. How do case managers improve quality of care for NF enrollees, enrollees recently transitioned

out of NFs, and newly admitted enrollees, based on reviews of plans of care and case notes?

3. How do case managers improve quality of care for NF enrollees based on input from case

managers, enrollees, and enrollee natural supports?

The research team utilized a mixed methods approach to examine these three research questions. RQs 1 and

2 were addressed in the preliminary findings in MED186 Deliverables 13 and 16 (SFY1718), and subsequently

validated during the analytical phase for RQ3. This report addresses RQ3 by assessing the potential influence of

case management on quality of care through interviews with a sample of LTC Plan case managers, enrollees, and

their caregivers. The sample was developed with input from the Agency to ensure that all LTC Plans were

represented in the Plans of Care (POC) and case management analyses.

In the preliminary report, RQs 1 and 2 were addressed by running descriptive statistical analyses of quality

indicators (QIs) using the Minimum Data Set 3.0 (MDS 3.0). The evaluation team found that that there are only

minor differences in MDS data between LTC enrollees and non-LTC NF residents regarding QIs, except in the

prevalence of pain. Because of this preliminary finding, NF residents interviewed for RQ3 were asked if they had

experienced pain or hurting at any time in the last five days. The LTC program enrollees reported less pain than

non-LTC residents. Additionally, the evaluation team asked interviewees if timeliness of services, including case

management, prohibited them from remaining in their communities or returning to their communities. The evaluation

team found that LTC enrollees did not always know about, and therefore, did not always receive services in a timely

fashion that would have allowed them to remain in their communities.

The evaluation team interviewed 43 enrollees, 69 caregivers, and 74 Plan case managers in SFY1819. The

aim of this report was to ascertain the value added by Plan case managers for enrollees residing in NFs. The

evaluation team, in conjunction with the Agency, focused the report on those enrollees who had recently transitioned

to NFs and those who had successfully transitioned from NFs to the community, including Assisted Living Facilities

(ALFs). Interview guides were developed by the evaluation team and the Agency to understand home and

community-based services (HCBS) as well as other elements that might divert enrollees from transitioning into NFs


unnecessarily and support successful transition into the community from NFs (see Appendices 1 - 6). The guides

were developed to garner input from three stakeholder groups (i.e., LTC enrollees, their caregivers, and their LTC

Plan case managers). The evaluation team surveyed stakeholder’s knowledge of, and access to, HCBS and sought

to determine the role of Plan case managers in making transition decisions.

Transition into a NF involves substantial adjustment and is seldom the preferred option of enrollees and their

families. However, findings suggest that while services may be available in the community, the cost of these

services is seen as making them out of reach. This is deeply concerning given that the LTC program is designed to

give enrollees freedom of choice and Plans are required to cover services that are medically necessary. Hence,

enrollees end up in NFs regardless of service availability. An alternative explanation could be that services exist,

but enrollees do not have access to them due to cost prohibition. Further, this finding is counterintuitive as NF

placement is seen as the most expensive option. LTC program enrollees, families, and Plan case managers note

that 24-hour care would enable enrollees to stay in the community. Again, there is little likelihood that 24-hour care

is feasible due to labor and cost concerns. In addition, enrollees whose care requirements exceed the industry

standards of care suggests that these enrollees have medical needs rather than personal care needs.

This report highlights those elements seen as important by the stakeholder groups interviewed. As might be

expected, each stakeholder group had slightly differing perspectives. For example, enrollees who transitioned into

the community indicated that the NF staff were the most important in successful transition. Caregivers saw the

physical environment as the most important element. Plan case managers stated a support system (i.e., a network

of caregivers and other natural supports who provide the enrollee with emotional and social support) was the most

beneficial to successful transition.

Plan case managers were not frequently mentioned as the most important part of transition; however, this may

be misleading. Their main task—assessment prior to NF discharge, including assessing the physical and social

environments—may not be visible to other stakeholders. Overall, the evaluation team concludes that, based on

these data, Plan case managers could work together to develop repositories of service information and use that

information both to divert NF placement and support successful return to the community. Further, cost effective

services are needed and some enrollees will not be appropriate for community-based care.

It is the expert opinion of the evaluation team that Plan case managers could take a more active part in

identifying existing services as both enrollees and their caregivers are unclear on the availability of home and

community-based services that would have diverted LTC enrollees from NF placement. Task-oriented Plan case

manager groups could identify services and maintain a clearinghouse for all LTC program enrollees. Taken

together, these data suggest that cost-effective and timely services are needed to divert community-dwelling

enrollees from NF placement and that some enrollees’ needs may not be met outside the nursing facility.


Report Prepared By Co- Principal Investigator Jean C. Munn, PhD Project Coordinator Margaret M. Holland, MSW Research Analysts Maria Cirillo Victoria Gruber Emily Keeney Jung H. Kim, MSSW Data Manager Glenn Mitchell, PhD Project Manager Michael P. Smith, MA, MPA Project Support Karen Geletko, MPH Principal Investigator Leslie M. Beitsch, MD, JD


Table of Contents

Executive Summary ....................................................................................................................................................2

Report Prepared By ....................................................................................................................................................4

Table of Contents .......................................................................................................................................................5

List of Figures .............................................................................................................................................................6

Background .................................................................................................................................................................7

Long-term Care Plan Case Manager Value-added and Recommendations ........................................................... 10

Purpose ................................................................................................................................................................ 10

Methodology ......................................................................................................................................................... 11

Findings ................................................................................................................................................................ 13

LTC Enrollees Transitioned into Nursing Facilities (N=32) .................................................................................. 13

Summary of Findings: LTC Enrollees Transitioned into Nursing Facilities .......................................................... 21

LTC Enrollees Transitioned into Communities (N=11) ......................................................................................... 22

Summary of Findings: LTC Enrollees Transitioned into Communities ................................................................. 36

Recommendations ............................................................................................................................................... 37

Limitations ............................................................................................................................................................ 39

Conclusions .......................................................................................................................................................... 40

Appendices ........................................................................................................................................................... 42

Appendix 1: Case Manager Interview -- Transition into NF ................................................................................ 42

Appendix 2: Case Manager Interview -- Transition of of NF ............................................................................... 45

Appendix 3: LTC Enrollee Interview -- Transition into NF ................................................................................... 49

Appendix 4: LTC Enrollee Interview -- Transition out of NF ................................................................................ 52

Appendix 5: LTC Enrollee Caregiver Interview -- Transition into NF .................................................................. 55

Appendix 6: LTC Enrollee Caregiver Interview -- Transition out of NF ............................................................... 58

Appendix 7: LTC Enrollee Interview Sampling Flowchart ................................................................................... 61

Appendix 8: Home and Community-based Services Descriptions ...................................................................... 62


List of Figures Transitioned into Nursing Facilities Figure 1. Services That Would Have Helped: Enrollees...………………………………………………………13 Figure 2. Were Services Available: Enrollees ................................................................................... ………14 Figure 3. Why Services Unavailable: Enrollees ........................................................................................... 15 Figure 4. Services That Would Have Helped: Caregivers ............................................................................ 16

Figure 5. Were Services Available: Caregivers ............................................................................................ 16 Figure 6.Why Services Unavailable: Caregivers .......................................................................................... 17

Figure 7. Services That Would Have Helped: Case Managers .............................. …………………………..18 Figure 8. Were Services Unavailable: Case Managers ................................................................................ 19 Figure 9. Why Services Unavailable: Case Managers..................................................................................19

Transitioned into Communities

Figure 10. Who Told Enrollees They Could Transition: Enrollees ............................................................... 21

Figure 11. Who Made the Decision to Transition: Enrollees ........................................................................ 22 Figure 12. What Made Transition Successful: Enrollees .............................................................................. 22

Figure 13. Who Helped You Move: Enrollees .............................................................................................. 23 Figure 14. How Did They Help: Enrollees .................................................................................................... 24

Figure 15. Most Important to Successful Transition: Enrollees .............................. …………………………..24 Figure 16. Who Told Caregivers that Enrollees Could Transition: Caregivers............................................. 25 Figure 17. Who Made Decision to Transition: Caregivers............................................................................26

Figure 18. Who Made Transition Successful: Caregivers ............................................................................ 26

Figure 19. How Did They Help with the Transition: Caregivers ................................................................... 27 Figure 20. Most Important Thing in Making Transition Successful: Caregivers ........................................... 28

Figure 21. How Enrollees were Identified for Transition: Case Managers ................................................... 29 Figure 22. Who Decides that Enrollees Transition into Communities: Case Managers .............................. 30

Figure 23. Case Manager Tasks Performed During Transition: Case Managers .. …………………………..31 Figure 24. Most Important Thing to Successful Transition: Case Managers ............................................... 32


Background

In 2011, the Florida Legislature voted to move most Medicaid recipients, including those receiving long-

term care (LTC) services, into a managed care system. Specifically, House Bill 7107 created Section 409 of Florida

Statutes to establish a statewide long-term care managed care program for Medicaid recipients who are (a) 65

years of age or older, or age 18 or older and eligible for Medicaid by reason of a disability; and (b) determined to

require nursing facility (NF) level of care.1 The Florida Agency for Health Care Administration (AHCA), hereafter

referred to as “the Agency,” subsequently submitted a 1915(b) and 1915(c) waiver application to the Centers for

Medicare and Medicaid Services (CMS) requesting to implement the Florida Long-term Care (LTC) Managed Care

Program. The Agency received approval for both waivers from CMS on February 1, 2013 and began administering

the program in partnership with the Department of Elder Affairs (DOEA).

The Agency used a staggered rollout schedule to successively introduce the program in eleven regions of

the state starting in August 2013 and concluding in March 2014. Approximately 83,000 Medicaid recipients were

moved from the previous multi-waiver, mixed reimbursement system2 directed by the state to a managed care

model using capitated payments to private managed care plans. In addition, approximately 100,000 new3 Medicaid

recipients have been enrolled since the state implemented the program. The Legislature directed the Agency to

adjust managed care plan capitation rates annually to provide an incentive to shift services from NFs to home and

community-based settings.4 Seven5 managed care plans were contracted by the Agency to provide LTC services

to nearly all Medicaid recipients who met the financial qualifications and level of care requirements. Each of the

state’s eleven regions has at least two managed care plans offering services to enrollees.

The Agency contracted with Florida State University (FSU) to conduct annual independent assessments of

the LTC Program. The evaluation team at FSU has previously examined access to care, quality of care, and cost-

1 The following waiver participants were permitted to voluntarily transition into the program if they were also receiving long-term care services and met LTC program criteria: Developmental Disabilities, Model, Traumatic Brain and Spinal Injury, Project AIDS Care, Adult Cystic Fibrosis, and Familial Dysautonomia Waiver participants as well as those receiving services under the Program of All-Inclusive Care for the Elderly. All other eligible Medicaid recipients of LTC services in the pre-LTC era were required to transition into the program. This population included those meeting eligibility requirements who were receiving services under any of the five waivers described in footnote 2 below as well as those receiving Medicaid funded long-term NF care. 2 Pre-LTC reimbursement systems for waivers required to transition by law were structured as follows: the Aged & Disabled Adult waiver used a fee-for-service reimbursement system; the Nursing Home Diversion waiver used a risk-adjusted, capitated monthly rate system; the Assisted Living for the Elderly waiver used a mixed system, with assisted living services reimbursed at a daily rate, case management services reimbursed at a monthly rate, and incontinence supplies reimbursed at a monthly use-based rate; the Channeling for the Frail Elder waiver used a contracted per-person daily rate. 3 For the purposes of this report anyone who enrolled in the LTC program starting in August 2013 through June 2017 and did not receive LTC services

through Florida Medicaid prior to August 2013 is designated a “new” enrollee. 4 Includes assisted living communities 5 In September 2013 Humana received regulatory approval to acquire American Eldercare, Inc. The plans officially merged in July 2015, after which there were only six LTC plans in operation in the state.


effectiveness of care in separate comprehensive reports for state fiscal years (SFYs6) 2013-2014 and 2014-2015.

The evaluation team assessed the quality of care for a representative sample of Long-term Care (LTC) enrollees

residing in nursing facilities (NFs) during state fiscal year 2017-2018 (SFY1718) in its’ preliminary report. In addition,

the evaluation team assessed how LTC Plan case managers improve the quality of care for enrollees residing in

NFs.

To provide recommendations, the Agency and the FSU evaluation team developed three research

questions (RQs):

1. How does quality of care for LTC Plan enrollees residing in a NF differ from NF residents who are not

enrolled in Medicaid?

2. How do case managers improve quality of care for NF enrollees, enrollees recently transitioned out of

NFs, and newly admitted enrollees, based on reviews of plans of care and case notes?

3. How do case managers improve quality of care for NF enrollees based on input from case managers,

enrollees, and enrollee natural supports?

The research team utilized a mixed methods approach to examine these three RQs. RQs 1 and 2 were

addressed in the preliminary findings in MED186 Deliverables 13 and 16 (SFY1718), and subsequently validated

during the analytical phase for RQ3. This report answers RQ3 by assessing the potential influence of case

management on quality of care through interviews with a sample of LTC Plan case managers, enrollees, and their

caregivers. The sample was developed with input from the Agency to ensure that all LTC Plans were represented

in the Plans of Care (POC) and case management analyses.

In the preliminary report, RQs 1 and 2 were addressed by running descriptive statistical analyses of LTC

resident-level quality indicators (QIs) using the Minimum Data Set 3.0 (MDS 3.0). The evaluation team found that

that there are only minor differences in MDS data between LTC enrollees and non-LTC NF residents regarding Qis

(e.g., pressure ulcers, pain, falls, etc.), with the exception of the prevalence of pain QI. Because of this preliminary

finding, NF residents interviewed for RQ3 were asked if they had experienced pain or hurting at any time in the last

five days. The LTC program enrollees reported less pain than non-LTC residents.

In addition, a sample was developed, based on input from the Agency, which ensured that all LTC Plans

were represented in the POCs analyses. POCs were randomly selected and requested via Agency ad hoc requests

sent to the Plans. POCs provide a description of the enrollee’s goals for LTC, the services and supports needed to

6 Hereafter, state fiscal years are denoted by SFY1415, SFY1516, SFY1617, and SFY1718. Each state fiscal year encompasses July through June of two consecutive calendar years.


meet those goals, and the specific service needs of each enrollee. POCs also show the projected duration, desired

frequency, and type of provider furnishing each service, and the scope of the services to be provided. As part of an

independent evaluation of the LTC program, the FSU evaluation team reviewed 340 POCs for enrollees residing in

NFs, representing all six managed care plans. In addition, the evaluation team examined POCs and case notes for

NF enrollees for timeliness, accuracy, person-centeredness, unique goals, measurability, appropriateness, and

other indicators of quality care. Plans are required to develop person-centered POCs for enrollees based upon a

comprehensive assessment, the SMMC LTC Coverage Policy that was promulgated in March 2017, and the SMMC

contract. The evaluation team found that POCs and case notes were seldom “completely” timely, meaning that at

least one monthly, quarterly, or annual contact was late per year. However, POCs were often at least “somewhat”

timely, meaning that less than three contacts per year were late. POCs were deemed appropriate if the

services/interventions identified were justified for the enrollee based on the enrollee’s functional ability and

condition(s) as indicated on part of the comprehensive assessment (701B/701T). Person-centered POCs and case

notes were not achieved by most plans. The desires and values of the enrollee were sometimes missing or not

mentioned in the POC and case notes and/or enrollees were not included in the POC process. Plans varied greatly

in their ability to create measurable goals, which are essential for accountability. However, the Plans generally

identified the enrollees’ Primary Care Providers (PCPs) and submitted the POCs to the PCP. Recommendations to

the Agency are provided in this report to improve the utility of case managers in cultivating quality of care for LTC

enrollees residing in NFs.


Long-term Care Plan Case Manager Value-added and Recommendations

Purpose

The FSU evaluation team assessed how LTC Plan case managers improve the quality of care for

enrollees residing in NFs during SFY1819. In order to provide recommendations, the Agency and the FSU

evaluation team developed the following research questions (RQs) identified in this report as research

question 3 (RQ3):

How do case managers improve quality of care for NF enrollees based on input from case


At the time data analysis began, there were six Long-Term Care (LTC) managed care plans (Aetna,

Amerigroup, Humana, Molina, Sunshine Health, and United Healthcare) contracted by the Agency to

provide LTC services to Medicaid recipients who met financial qualification and level of care requirements.

For this special report, the evaluation team consisted of an Associate Professor (co-PI), a doctoral

candidate (Project Coordinator), a doctoral student, and three graduate student research assistants (GRAs)

from the FSU College of Social Work. GRAs are master or doctoral-level students in social work who are

trained and overseen by the Co-PI and Project Coordinator. The evaluation team contacted 43 enrollees

from an initial sample of 247 (32 transitioned into NFs; 11 transitioned out of NFs), 69 enrollee caregivers7

(48 regarding transitions into NFs; 21 regarding transitions out of facilities), and 74 Plan case managers

(55 regarding transitions into NFs; 19 regarding transitions out of NFs). The methodology is described in

the Methodology section.

7 Caregiver is synonymous with the technical term, “natural support” that is often used by government agencies. A caregiver/natural support is any unpaid

supports that are provided voluntarily to the individual in lieu of home and community-based services and supports.


Methodology

RQ 3: How do case managers improve quality of care for NF enrollees based on input from case managers, enrollees, and enrollee natural supports?

In order to establish a sampling frame, the evaluation team randomly selected 364 LTC enrollees,

as well as their caregivers and case managers from the universe of potential participants (see Appendix 7).

Some Plans were purposely oversampled in order to ensure inclusion of at least one case from each Plan

in each respondent group. While there were no between-group comparisons, the evaluation team sought

heterogeneity in the sample. Oversampling is a standard method for reaching heterogeneity and

representation in groups of unequal size. Further, as the evaluation team explored the phenomenon of

transition into the NF and transition from the NF into the community.

Caregivers of these enrollees were recruited for participation. Enrollees and caregivers were first

contacted by letter, followed by phone calls. Case managers were not contacted by letter; however, Agency

representatives spoke with Plan personnel and explained that case managers would be receiving requests

for interviews by phone. Once the evaluation team reached a potential participant, GRAs explained the

study, gave an opportunity for the individual to ask questions, and, if the individual chose to participate,

GRAs obtained informed consent. Some interviews were conducted immediately; some individuals

requested that GRAs call again to conduct the interview. In total, the evaluation team interviewed 43

enrollees, 69 caregivers, and 74 Plan case managers. Although this sample size would be inadequate for

quantitative data analyses, this sample size is robust for qualitative studies for which sample sizes of 20

interviews are considered adequate.8 That the evaluation team was able to interview more than double that

for each stakeholder group is a strength of the study. In all cases, potential participants’ rights were

explained and all materials were approved by the Institutional Review Board of Florida State University.

Following data collection, interrater reliability was calculated using Cohen’s Kappa.9 Interrater

reliability represents the extent to which collected data are correct representations of the domains

measured. Both raters (Project Coordinator and one MSW GRA) coded interview protocols into variables

using NVivo1210 for every enrollee, enrollee caregiver, and Plan case manager interview. The extent to

8 Cresswel, J. (2013). Qualitative Inquiry and Research Design: Choosing among Five Approaches. Los Angeles: Sage. 9 Cohen's Kappa is a statistic that measures interrater reliability for categorical items. Kappas take into account the possibility of agreement occurring by chance and is, therefore, a robust measure interrater reliability. Generally, if K >.80, the interrater agreement is deemed to be good. 10 NVivo12 is qualitative software that assists in coding data.


which they similarly rated each domain is called interrater reliability. The raters had sufficient agreement on

each of the variables for each of the cases (Kappas ranged from .80 to 1.00).


Findings

RQ 3: How do case managers improve quality of care for NF enrollees based on input from case managers, enrollees, and enrollee natural supports?

LTC Enrollees Transitioned into Nursing Facilities (N=32)

The evaluation team spoke with 32 enrollees who had recently (within 90 days) transitioned into a

NF from a community-based setting or hospital. The underlying purpose of these interviews was to

ascertain if NF placement might have been avoided. Specifically, the evaluation team asked what LTC

program services might have helped the enrollees remain in the community (see Appendix 8 for service

definitions). Enrollees were able to indicate more than one service if they felt that more than one service

was necessary to help them remain in their community. The results are shown in Figure 1. Nine enrollees

indicated that there were no services that would have allowed them to remain in the community. The

remaining 23 enrollees identified 48 community-based services that may have been beneficial. Enrollees

who answered that there were services that might have helped them remain in the community were allowed

to identify more than one service.


The results in Figure 1 show that the 23 enrollees identified a combined 48 community-based

services that may have been beneficial. Attendant nursing care was the most frequently noted service.

Homemaker services, medication administration, and personal care were also mentioned at least 5 times.

Three enrollees mentioned that they would need 24-hour nursing care to avoid NF placement. Taken

together these data suggest that based on enrollee perspectives, personal care services are needed for

enrollees to remain in the community.

Data Source: Enrollee Interviews

Enrollees (n = 23) who indicated that additional services would have been helpful to them remaining

in their communities were then asked if those additional services mentioned were available in their

communities (See Figure 2). Twelve of the 23 enrollees indicated that the services were not available.

9

5

1 1

3

6

2

1 1 1

5

1

3

2

1

5

1

2

3

4

0

1

2

3

4

5

6

7

8

9

10

Figure 1. Services That Would Have Helped LTC Enrollees remain in HCBS


Although services are covered by Medicaid, services are not always available to enrollees in their

communities. Also, service providers often have extensive waitlists for available services, making them

“unavailable” to enrollees at the time they are needed. Oftentimes, enrollees are not able to wait in their

communities for services because of their health condition(s). Ten of the 23 enrollees indicated that the

services were available and one enrollee stated the answer was unknown.


10

12

1

0

2

4

6

8

10

12

14

Yes No Unknown

Figure 2. Were Community-based Services Available


When the 13 enrollees who responded that services were not available, or unknown to them,

were asked why the services were not available, enrollees differed in their knowledge of HCBS (See

Figure 3). Nine enrollees did not know why services were not available. Four of those nine enrollees had

not asked a Plan case manager why services were not available to them. Further, one enrollee was told

by their Plan case manager that the services that would be necessary for them to remain in the

community were not available in their community. In four cases, enrollees reported that the services were

prohibited by the cost of the services. The four “cost prohibitive” responses were perplexing because the

LTC program is able to pay for community services to allow enrollees the freedom to choose to remain in

their communities.


Caregivers of Enrollee Transitioned into NF (N=48)

The evaluation team spoke with caregivers of enrollees who had recently transitioned into nursing

homes. For this group, the evaluation team asked questions similar to those asked of enrollees. Figure 4

describes responses from caregivers regarding services that might have allowed an enrollee (for whom the

caregiver was responsible) to remain in the community. As with enrollee respondents, caregivers were able

to identify more than one service. Figure 4 indicates that 29 caregivers did not believe that additional

4

9

0

1

2

3

4

5

6

7

8

9

10

Cost Prohibitive Unknown

Figure 3. Why Services Unavailable


services would have been beneficial or would have allowed the enrollee to remain in the community.

However, the other 19 caregivers identified 44 services that may have been beneficial. Importantly, all 19

caregivers identified intermittent and skilled nursing services as necessary and 11 of the 19 caregivers

specifically mentioned 24-hour nursing care. Because these caregivers’ enrollees are now receiving 24-

hour care in NFs, the evaluation team believes that the caregivers’ assessment of the necessity of 24-hour

care is valid and an important observation.

Data Source: Caregiver Interviews

29

3 31 2

19

2 1

74

2

0

5

10

15

20

25

30

35

Figure 4. Services That Would Have Helped


When the evaluation team asked the 19 caregivers who had responded positively regarding service

availability, 12 indicated that services were available; six indicated they were not available; and one did not

know (See Figure 5).


Further, the evaluation team asked caregivers if they knew reasons that the services were not

made available (See Figure 6). These caregivers indicated that the most frequent reason that services were

not provided was that they were too costly (n = 15). Because the LTC program is supposed to pay for all

medically-necessary services, the evaluation team believes that this response indicates a discrepancy in

what the LTC program views as medically necessary and what caregivers believe is necessary for the

enrollee to have a good quality of life in the community. In addition, four caregivers said that the enrollees’

needs exceeded the industry standard, meaning that the enrollee required more care, in the view of the

caregiver, than the Plan indicated as necessary. Other reasons given were lack of good service providers

(n = 3); needed service(s) unavailable in their town (n = 2); and needed services unavailable in their ALF.

The evaluation team then asked the caregivers “Have you discovered services that you were not previously

aware of that are available in the community since the move?” Most caregivers (n = 31) indicated that they

had not discovered additional services. Only five said they had found additional services.

12

6

1

0

2

4

6

8

10

12

14

Yes No Unknown

Figure 5. Were Services Available



Plan Case Manager of Enrollee(s) Transitioned into NF (N=55)

Finally, the evaluation team asked Plan case managers questions about topics similar to those

discussed with caregivers and enrollees. When asked about services that would have allowed the enrollees

to remain in the community, only 8 Plan case managers indicated that there were no services that would

have allowed enrollees to stay (See Figure 7). Of the remaining 47 Plan case managers, all believed that

at least one service would have allowed the enrollee to stay in the community. There were 19 Plan case

managers that noted that they believed 24-hour care was necessary for enrollees and would have allowed

the enrollee to remain in the community. These services included personal care (n = 15), adult companion

care (n = 11), and ALF (n = 9). Other services noted included homemaker services, home delivered meals,

and attendant nursing services.

3

15

4

12

0

2

4

6

8

10

12

14

16

Bad Service Providers Cost Prohibitive Required more than"Industry Standard"

Necessary ServicesUnavailable in ALF

Necessary ServicesUnavailable in Town



Data Source: Plan Case Manager Interviews

The evaluation team also asked Plan case managers if those services were unavailable (See

Figure 8). Figure 8 depicts that 19 Plan case managers indicated that necessary LTC program services

were unavailable and 16 Plan case managers said that necessary services were available to enrollees.

Four Plan case managers did not know whether the services were available or not.


8

11

1

9

4 4

2

6

21

2

15

32

0

2

4

6

8

10

12

14

16

Figure 7. Services That Would Have Helped

19

16

4

0

2

4

6

8

10

12

14

16

18

20

Yes No Unknown

Figure 8. Were Services Unavailable


When asked why the services were not available (See Figure 9) there were varying reasons.

Nineteen Plan case managers indicated that the enrollee required more than the industry standard of care.

That is, these enrollees required greater or more complex medical care than is available outside of a NF.

Seven stated that the services were too costly and another seven stated that the enrollee and/or caregiver

preferred NF care. Some (n = 5) did not know why the services were not available. Other reasons included

that ALFs would not accept the enrollee or that services were not available in ALFs.


Summary of Findings: LTC Enrollees Transitioned into Nursing Facilities

Transition into a NF involves substantial adjustment and is seldom the preferred option of enrollees

and their families. However, findings suggest that while services may be available in the community, the

cost of these services is seen as making them out of reach. This is deeply concerning given that the LTC

program is designed to give enrollees freedom of choice and Plans are required to cover services that are

medically necessary. Hence, enrollees end up in NFs regardless of service availability. An alternative

explanation could be that services exist, but enrollees do not have access to them due to cost prohibition.

Further, this finding is counterintuitive as NF placement is seen as the most expensive option. LTC program

3

7 7

1

19

1

5

0

2

4

6

8

10

12

14

16

18

20

ALFs WouldNot Accept

Enrollee

CostProhibitive

Enrollee orCaregiverPreferred

SNF

NotAvailable in

ALF

Requiredmore than"IndustryStandard"

RuralCommunity

Unknown



enrollees, families, and Plan case managers note that 24-hour care would enable enrollees to stay in the

community. Again, there is little likelihood that 24-hour care is feasible due to labor and cost concerns. In

addition, enrollees whose care requirements exceed the industry standards of care suggests that these

enrollees have medical needs rather than personal care needs. However, some caregivers indicated that

intermittent skilled nursing services would have been helpful.

It is the expert opinion of the evaluation team that Plan case managers could take a more active

part in identifying existing services as both enrollees and their caregivers are unclear on the availability of

services that would have diverted them from NF placement. Also, task-oriented Plan case manager groups

could identify services and maintain a clearinghouse for all enrollees. Taken together, these data suggest

that cost-effective services are needed to divert community-dwelling enrollees from NF placement and that

some enrollees’ needs may not be met outside the NF.

LTC Enrollees Transitioned into Communities (N=11)

The evaluation team also spoke with eleven enrollees who were transitioning or had recently

transitioned into the community to understand this transition process and the circumstances that made the

transition possible. The evaluation team asked who had brought up the prospect of transition into a

community (See Figure 10). Most often the Plan case manager indicated that a transfer was possible. Three

LTC enrollees indicated they initiated the transfer. There were three enrollees who responded that two

people told them that they may be able to move home; hence, there are 14 responses. Of those three who

responded that two people told them about transition to HCBS, one said NF social worker and Plan case

manager; another said the doctor and one Plan case manager; and the other said a family member and the

Plan case manager referred them for transition back into the community. In summary, a variety of people

including the Plan case manager, other healthcare personnel (i.e., doctor, NF social worker), family and

friends told the enrollee that they could transfer in to the community. However, some enrollees realized that

for themselves.



The evaluation team asked these enrollees who had made the decision for them to move back into

the community (See Figure 11). The decision to move back into the community is available to enrollees

because they have freedom of choice regarding their location of care. Most enrollees (n = 9) made the

decision themselves to transition back into the community. Two enrollees indicated that they made their

decision with family members and another enrollee indicated that they made their decision with the help of

their NF case manager and a family member. No enrollees indicated that the Plan case manager made the

decision, which would be unusual given the freedom of choice of enrollees to decide between community

services or NF placement.

4

2

1

2 2

3

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Case Manager Doctor Family Friend NF SocialWorker

Self

Figure 10. Who Told Enrollees They Could Transition



All transfers into the community were considered successful based on a benchmark of having

remained in the community for at least 90 days. The evaluation team asked about factors that contributed

to a successful transition (See Figure 12). Responses to the question varied and were somewhat even in

distribution. The largest group (n = 3) indicated that they (the enrollee) were responsible for the successful

transition. Other factors that were noted included Plan services (n = 2) and friends (n = 2). Enrollees also

mentioned the Plan case manager, family, and ALF as contributing to their successful transition.

3

8

0

1

2

3

4

5

6

7

8

9

Joint Decision Self

Figure 11. Who Made the Decision to Transition



When asked specifically, who helped prepare for the move (see Figure 13) the answers were also

varied. The most common answer (n = 4) was family. Case managers (n = 3) and friends (n = 3) were also

mentioned. One enrollee indicated he/she was responsible for preparing to move.


1 1

3

1

2 2

0

0.5

1

1.5

2

2.5

3

3.5

ALF CaseManager

Enrollee Family Friends Plan Services

Figure 12. What Made Transition Successful

3

4

3

1

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Case Manager Family Friends Self

Figure 13. Who Helped You Move


When asked how those people assisted in helping enrollees move (see Figure 14) the answers

were also varied. Help included physically moving (n = 4) and arranging for services (n = 4) for the enrollee.

Other helpful tasks included identifying resources, making changes in the home, and providing emotional

support.


4

1

2 2

4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

HelpedPhysically Move

ProvidedEmotionalSupport

IdentifiedResources

Made Changes inthe Home

Arranged forServices

Figure 14. How Did They Help You Move


There was no single factor that contributed to a successful transition (See Figure 15). NF staff were

identified as being the most important factor in their successful transition by two enrollees as well as Plan

case manager, a transition team, and Plan services.


1 1 1

2

0

0.5

1

1.5

2

2.5

Transition Team Plan Case Manager Plan Services NF Staff

Figure 15. Most Important to Successful Transition


Caregivers of LTC Enrollees Transitioned into Community (N=21)

The evaluation team also interviewed caregivers of enrollees who had transitioned back into the

community. Questions were similar to those asked of enrollees. For example, the evaluation team

requested that caregivers indicate who had identified that the enrollee was able to move back into the

community (See Figure 16). Of the 21 caregivers, four caregivers indicated that a health care professional,

three caregivers indicated that a Plan case manager, two caregivers indicated an enrollee, one caregiver

indicated a family member, and one caregiver indicated that a counselor had raised the possibility that the

enrollee could transition back into the community.


3

1

2

1

4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Case Manager Counselor Enrollee Family Health CareProfessional

Figure 16. Who Told Caregivers that Enrollees could Transition


When asked about who made the decision, only one caregiver indicated that the Plan case

manager decided that an enrollee should be transitioned into the community (See Figure 17). Because of

enrollees’ freedom to choose community services in lieu of nursing facility placement, it would be unusual

for a Plan case manager to make the decision for an enrollee to transition into the community. Four of the

11 caregivers indicated a family member made the decision, three caregivers said the doctor, and three

caregivers said the enrollee.


Further, the evaluation team asked the caregivers who had supported the transition in making it

successful (i.e., enrollee having remained in the community for 90 days). Family (n = 4) and NF staff (n =

4) were the most frequent responses (See Figure 18). Other contributors were doctors (n = 2) and Plan

case managers (n = 2). One caregiver said that home health aides had contributed to the successful

transition. One caregiver did not identify anyone as having contributed to the success.

3

1

3

4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Doctor Case Manager Enrollee Family Member

Figure 17. Who Made Decision to Transition



The evaluation team further asked caregivers to describe how others helped the enrollee in

transition (See Figure 19). Most caregivers (n = 7) stated that someone arranged for services. Similarly,

five caregivers indicated that someone identified resources. Other tasks include transportation (n = 3);

physically moving the enrollee and his/her belongings (n = 2); emotional support (n = 2); and home

modifications (n = 1).


1 1

2 2

4 4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

No One Home HealthAides

Plan CaseManager

Doctor Family NF Staff

Figure 18. Who Made Transition Successful

2 2

3

1

5

7

0

1

2

3

4

5

6

7

8

Helped withPhysical Move

EmotionalSupport

Transportation Made HomeModifications

IdentifiedResources

Arranged forServices

Figure 19. How Did They Help with the Transition


When asked to describe the most important contribution to making the move successful, caregivers

largely credited the physical environment, meaning the home environment (n = 7). Other contributors

included NF staff (n = 3); family (n = 3); and transition team (n = 3). Other contributors were transportation

and the lack of other options that led to enrollees not having a choice but to successfully transition into the

community (See Figure 20).


1 1

3 3 3

7

0

1

2

3

4

5

6

7

8

Not Having aChoice

Transportation Transition Team Family NF Staff PhysicalEnvironment

Figure 20. Most Important Thing in Making Transition Successful


Plan Case Manager of LTC Enrollees Transitioned into Community (N=19)

With some modifications, the evaluation team asked Plan case managers similar questions about

enrollees who transitioned into the community. The evaluation team asked them to refer to their own

experiences when answering these questions. Initially, the evaluation team asked Plan case managers

about how enrollees were identified as having potential to be discharged from the NF into the community

(including ALFs; See Figure 21). The largest number (n = 14) of Plan case managers indicated that

functional ability was the primary factor in identifying enrollees who could transition. Functional ability was

measured using an established set of Activities of Daily Living (ADLs) such as bathing, dressing, toileting,

mobility, transferring, and eating. Functional ability is determined by the enrollees’ ability to perform these

activities independently. Other factors often identified were home safety (n = 6), support system (n = 6) and

enrollee’s desire (n = 5).


1

6 65

3 3

14

0

2

4

6

8

10

12

14

16

Age Assessmentof HomeSafety

Assessmentof Support

System

EnrolleeDesire

EnrolleeRequest

File Review FunctionalAbility(ADLs)

Figure 21. How Enrollees Were Identified for Transition


When asked further about who makes the decision to transition, Plan case managers did not differ

widely (See Figure 22). Plan Case managers noted that in most cases (n = 13) enrollees made the decision

to return to the community. Families were also often the decision-makers (n = 10). However, almost as

many times (n = 9), Plan case managers indicated that they made the decision for enrollees to move into

the community, followed by doctors (n = 4) and nurses (n = 3). This was relatively concerning given the

emphasis on enrollees’ freedom of choice in choosing their own location of care (i.e., NF or community) in

the LTC program.


9

4

13

10

3

0

2

4

6

8

10

12

14

Case Manager Doctor Enrollee Family Nurse

Figure 22. Who Chooses for the Enrollee to Move into the Community


When asked about their direct involvement in the transition process, Plan case managers noted

what tasks they performed (See Figure 23). The most frequent task mentioned (n = 17), was assessing

financial needs of the enrollee along with safety and support. Plan case managers also reported

coordinating with other stakeholders (n = 12) and identifying and ensuring housing (n = 12). Only one Plan

case manager reported physically helping with the move.


17

12

3

12

12

1 1

0

2

4

6

8

10

12

14

16

18

Figure 23. Case Manager Tasks Performed During Transition


As with other respondent groups, the evaluation team asked Plan case managers what they

considered most important in ensuring that transitions from NFs into the community were successful (See

Figure 24). The most frequently mentioned (n = 10) contributor to a successful transition was described as

the enrollees’ support systems. Family (n = 6) and education (n = 4) were also mentioned along with access

to housing, the enrollee’s primary care provider, having a transition team, plan services, and the Plan case

manager.


21 1

3

6

1

2

10

4

0

2

4

6

8

10

12

Figure 24. Most Important Thing to Successful Transition


Summary of Findings: LTC Enrollees Transitioned into Communities

The structure of the LTC Program is designed to encourage transition from the NF to community,

which has stemmed from the desire for LTC enrollees to have the freedom to choose to participate in

community programs in lieu of institutional placement. That is, Plans have incentives to make NF to

community transitions, thus, it is important to understand the transition process. The ultimate goal of

transitions is to be certain that those transitions are successful and that enrollees who return to the

community remain there in safe and secure environments. It also is essential to ensure that enrollees

receive appropriate services so that the quality of their healthcare is not sacrificed for cost benefits. The

evaluation team conducted interviews with three groups of stakeholders (i.e., enrollees, caregivers, and

Plan case managers) in order to further this understanding. The answers to questions regarding transition

into the community differed slightly, depending on the respondent group. Enrollees indicated that family,

NF staff, and the enrollees themselves were key to successful transitions. Caregivers stated that family and

NF staff also were essential, but saw the physical environment as the most important element. Plan case

managers stated that a support system was most important, although details of what constituted a support

system were not described.

It is notable that Plan case managers were seldom mentioned as essential components of

successful transitions. However, Plan case managers note that they performed critical assessments, such

as assessing financial need, safety, and support. In addition, Plan case managers coordinated with other

stakeholders to assure that the health and wellbeing of enrollees was met when they entered the

community, including identifying and securing housing for enrollees (See Figure 23). Thus, Plan case

managers perform indispensable, but less visible tasks for enrollees who had transitioned into the

community. Therefore, Plan case managers’ direct benefit may be less obvious in relation to other

stakeholder groups.


Recommendations

The following section provides recommendations that, if implemented, may improve the utility of Plan

case management within NF settings. Recommendations (RQ1 and RQ2) from the preliminary reports

provided in MED186 Deliverables 13 and 16 were subsequently validated during the analytical phase of

the final report.

RQs 1 & 2:

Recommendation 1: Continue Plan oversight of NF enrollees. These data suggest that NF

enrollees are doing almost as well as or better than non-LTC residents in NF. While these data are not

sufficient to determine why LTC NF residents have slightly different or better QIs than non-LTC residents

in NFs, they provide evidence that NF enrollees are suffering less pain and are slightly less well-off in other

areas.

Recommendation 2: Continue to monitor NF LTC enrollees in comparison to non-LTC residents for

performance on these measures to determine the sustainability of pain reduction and trends among QIs.

Recommendation 3: Examine the caseloads, training, and education of case managers, which are

factors often associated with quality of healthcare delivery. These factors may influence the ability to

produce POCs and case notes that reflect adherence to the domains important to enrollee health and well-

being. This examination could constitute another special report conducted by the evaluation team.

Recommendation 4: Advocate that Plan case managers have access to the MDS 3.0, so that case

managers are better informed to advocate for enrollees. In addition, the evaluation team recommends that

Plan case managers attend NF POC meetings if they are not already doing so. This availability and

interaction with facility staff and access to documentation would provide more seamless care and support

for LTC enrollees residing in NFs.

RQ 3: How do case managers improve quality of care for NF enrollees based on input from case


Recommendation 1: The evaluation team discovered that case managers are performing tasks

necessary for NF enrollees to have a good quality of care. However, these data also showed that enrollees

and their caregivers are not aware of these necessary case management tasks. Therefore, the evaluation

team recommends that Plans maintain repositories of current services available in the community, which


are not required of Plans, but would demonstrate case managers’ utility to enrollees and caregivers. These

service clearinghouses can be useful to enrollees, caregivers, and other Plan case managers within the

same Plan in diverting enrollees from NF placement as well as in transition back into the community.

Recommendation 2: Another recommendation regarding the lack of visibility of Plan case

managers is that they may forge collaborative relationships with enrollees, caregivers, NF staff, and other

Plan case managers. For example, Plan case managers may better involve enrollees, their caregivers, and

NF personnel when performing assessments of financial and service needs, including housing. These

assessments are critical to successful transitions into the community. These data suggest that enrollees

and caregivers are less aware of services provided by Plan case managers. While 12 Plan case managers

do report coordinating with other stakeholders, involving multiple stakeholders in every case serves two

purposes: a) providing the best possible care; and b) demonstrating in a transparent way how Plan case

managers add value, safety, and quality to the quality of healthcare and lives of the enrollees, wherever

they reside.


Limitations

As with all research, there are some limitations. In the interview process (RQ 3), there is a sampling

bias in that those who wish to participate may be different from the population. Unfortunately, in the NF

population, many potential enrollee respondents were unable to answer questions, especially in phone

interviews. Also, caregivers and Plan case managers were part of a purposive sample. Often research

participants may have stronger opinions than those who choose not to participate. Finally, the evaluation

team does not have matched samples of participant groups. That is, each enrollee participant was not part

of a dyad or triad with caregiver and Plan case manager. Despite these limitations, this study allowed the

evaluation team to examine the opaque transition process and understand more about how these

stakeholders participate and understand these crucial life choices.


Conclusions

In summary, the previous preliminary reports (MED186 Deliverables 13 and 16) found that there

are slight differences between LTC enrollees and non-LTC NF residents regarding quality indicators (Qis),

except in the prevalence of pain. QIs are most likely associated with the quality of the NF where an enrollee

resides rather than the case management provided to an enrollee. In this regard, LTC enrollees reported

less pain than non-LTC residents.

Regarding how case managers improve the quality of care of LTC enrollees, several areas for

improvement were noted for the Plans. The evaluation team reviewed more than 300 POCs and case

notes and found that POCs and case notes were seldom “completely” timely, meaning that at least one

monthly, quarterly, or annual contact was late per year. However, POCs were often at least “somewhat”

timely, meaning that less than three contacts per year were late. Person-centered POCs and case notes

were less than ideal for most plans, meaning that the desires and values of the enrollee were sometimes

missing or not mentioned in the POC and case notes. Plans varied greatly in their ability to create

measurable goals, which are essential for accountability. However, the Plans generally identified the

enrollees’ PCPs and submitted the POCs to the PCP. This is a critical step in providing a continuum of care

that is consistent and could be improved by also allowing Plan case managers to attend NF POC meetings

and receive vital information regarding enrollees’ progress and needs.

Additional insight into the experiences of case managers and the care planning processes of the

Plans was needed to fully understand how case managers improve the quality of care for LTC enrollees in

NFs. Due to this need, qualitative interviews with case managers, enrollees, and care givers were

conducted in SFY1819. Findings were informative; however, the value of Plan case manager involvement

is less visible. When interviewing enrollees or their caregivers, it was discovered that Plan case managers

were not among the most frequently identified sources of support during transitions. However, Plan case

managers were able to identify critical tasks that they performed such as performing assessments prior to

transfer. However, other stakeholders (i.e., enrollees and their caregivers) did not recognize these crucial

case management services and may be remedied by case managers including enrollees and their

caregivers in the performance of their tasks and by sharing how their tasks contribute to successful

transition. For example, the tasks of finding appropriate housing and assessing for the environment for


safety are among the most important tasks in ensuring successful transitions from the NF into the

community. The evaluation team recommends that Plan case managers involve multiple stakeholders in

performing these tasks, especially enrollees and their caregivers.

The evaluation team also found that some services were familiar to caregivers that were not familiar

to Plan case managers. This indicates a need for a repository of community services available to Plan case

managers, caregivers, and enrollees. Another finding is that even when services were available, they were

not affordable; this is confusing as NF placement is considered among the most expensive of options.

However, these findings may be understood in light of the need for 24-hour nursing care as necessary—

an option that is both expensive and likely not available. In these cases, community-based care is probably

not realistic for those enrollees.


Appendices

Appendix 1: Case Manager Interview -- Transition into NF

Introductory Script and Questions for Case Managers of Enrollees Transitioning into Nursing

Facilities

Hello, my name is [INTERVIEWER NAME], and I am calling from Florida State University on

behalf of the Agency for Health Care Administration. I was hoping you would have some time

to talk to me about some of your enrollees moving into nursing facilities.

We recently sent you a letter regarding the study. However, before we start, I would like to

restate a few things about this survey and give you the opportunity to ask questions. The goal

of this survey is to help us understand how case managers assist Long-term Care enrollees in

their transition into nursing facilities. We would like to use this information to identify best

practices that may be used to improve the transition process of enrollees by providing our

findings to AHCA in terms of actionable items.

If you agree to participate, we would like to ask you some questions about the transition

process. We would also like to record our interview, so your answers may be transcribed at a

later date. Once your interview is transcribed, the audio file will be deleted and you will only

be identified by a number to ensure your anonymity.

This interview will take about 20 minutes. Your participation is completely voluntary. This is a

confidential interview, so your name will not be connected to your answers in any way. You

can skip over any questions and can stop participating at any time. Please speak from your

experience. There are no right or wrong answers.

Would you like to participate in this survey at this time?

Yes

Yes, but at a later time

No

[IF THE INTERVIEWEE AGREES, YOU CAN CONTINUE TO THE SURVEY. IF THE INTERVIEWEE DOES

NOT HAVE TIME TO PARTICIPATE IN THE INTERVIEW AT THIS TIME, ARRANGE AN

APPOINTMENT TO CALL BACK LATER. IF THE INTERVIEWEE DOES NOT WANT TO PARTICIPATE,

THANK THE INTERVIEWEE AND HANG UP.]

Do you have any questions before we start?

[ANSWER ANY QUESTIONS, THEN GO TO QUESTION 1]


We know that some enrollees do not remain in the community, despite their desire to do so.

The following questions relate to enrollees who transfer into nursing facilities from the

community. Please speak from your experience as a case manager.

1. What usually prompts transition from living in the community to residing in a nursing

facility?

Enrollee hospitalization

Caregiver problem(s) [CIRCLE ALL THAT APPLY] stress, finances, health issues, other: __________

Enrollee sense of burden

Other __________

Other __________

Other __________

2. Describe a typical situation that would prompt an enrollee to transition from living in the

community to a nursing facility.

[INSERT FIELD NOTES]:

In thinking about [ENROLLEE’S NAME], please answer the following questions.

3. In the case of [ENROLLEE’S NAME] what prompted him/her to move into the nursing

facility?


4. Did [ENROLLEE’S NAME] have a primary caregiver?

Yes Was it a friend or family member? [Yes or No] _____

No

5. Who made the determination that it was time for [ENROLLEE’S NAME] to transition into a

nursing facility?

Enrollee

Family member Relationship to enrollee _________

Case manager

Other _________

6. What services might have allowed [ENROLLEE’S NAME] to remain in the community?

Adult companion care

Adult day health care

Assisted living

Assistive care services


Attendant nursing care

Behavioral management

Care coordination/ Case management

Caregiver training

Home accessibility adaptation

Home-delivered meals

Homemaker

Intermittent and skilled nursing

Medical equipment and supplies

Medication administration

Medication management

Non-emergency Hospice

Nursing facility

Nutritional assessment/ risk reduction

Personal care

Personal emergency response system

Respite care

Therapies: occupational, physical, respiratory and speech

Transportation 7. Were those services unavailable?

Yes

No

8. Do you know why those services were not available for the enrollee?

Yes

No [IF NO, CONCLUDE THE INTERVERVIEW] 9. Why were those services not available?


[AT THE CONCLUSION OF THE INTERVIEW, THANK THE INTERVIEWEE FOR THEIR TIME AND

RESPONSES AND HANG UP.]


Appendix 2: Case Manager Interview -- Transition of of NF

Introductory Script and Questions for Case Managers of Enrollees Transitioning out of Nursing

Facilities



to talk to me about some of your enrollees moving out of nursing facilities.

We recently sent you a letter regarding the study. However, before we start, I would like to

restate a few things about this survey and give you an opportunity to ask questions. The goal of

this survey is to help us understand how case managers assist Long-term Care enrollees in

their transition out of nursing facilities. We would like to use this information to identify best

practices that may be used to improve the transition process of enrollees by providing our

findings to AHCA in terms of actionable items.






confidential interview, so your name will not be connected to your answers in any way. You

can skip over any questions and can stop participating at any time. Please speak from your



Yes


No







1. Based on your experience, how are nursing facility enrollees identified as being eligible for

transition into the community?



2. Who usually makes the decision to transition from the nursing facility to the community?

Enrollee


Case manager

Other _________ 3. What characteristics did [ENROLLEE NAME’S] have that contributed to [HIS/HER] successful

transfer?


4. What are some common characteristics among enrollees who have successfully

transitioned from NFs to the community?


5. What are the caregiver characteristics associated with [ENROLLEE NAME’S] successful

transfer?


6. What are some common characteristics among caregivers of enrollees who have

successfully transitioned from NFs to the community?


7. What are other factors commonly associated with successful transfer?


8. What tasks do you perform to assist in transitions from nursing facilities to the

community?


9. What factors have prohibited transfers despite the desire of the enrollee to return to the

community?

Lack of resources

Problems finding or communicating with the primary care provider [MEDICAL DOCTOR]

Failure of agencies to follow through

Timeliness of services

Other: __________

Other: __________

Other: __________


10. In your experience, what is most important in successful transitions of enrollees from NFs

into the community?

Transition teams [NURSES]

Family

Nursing facility staff involvement in discharge planning

Primary Care home

Physical environment [SINGLE STORY HOME/BUILDING; WHEELCHAIR ACCESSIBLE]?

Available transportation?

Other: __________

11. Describe the training you have received in administering the supplemental assessments

(i.e., the Plan authored natural support assessments)?


12. Do you feel the training you received on how to administer supplemental assessments

(i.e., the Plan authored natural support assessments) was adequate?

Yes

No

13. Do you think that you need more training in administering supplemental assessments?

Yes

No [SKIP TO Question 15]

14. What additional training would be beneficial? In what areas would you like additional

training?


15. Are there factors or circumstances that have made it difficult to do a supplemental

assessment for transfer into the community?

Yes

No [SKIP TO QUESTION 17]

16. What factors or circumstances have made it difficult to do a supplemental assessment for

transfer into the community?


Before we end the survey, I am going to ask you some questions about the supplemental

assessment tool (i.e., the Plan authored caregiver assessment).


17. How effective did you feel in administering the supplemental assessment (i.e., the Plan

authored caregiver assessments)?


18. If you did not feel effective, why? [SKIP IF INTERVIEWEE ANSWERED POSITIVELY TO

QUESTION 17.]


19. In your opinion, does the supplemental assessment (i.e., the Plan authored caregiver

assessments) cover all of the aspects you think are necessary?

Yes

No If not, what areas should be added? [INSERT FIELD NOTES]:

20. Was it overly burdensome to the enrollee or caregiver? In your opinion, are there items

that should be left off? Is the assessment to long? Are questions too hard to understand? Are

questions inappropriate?





Appendix 3: LTC Enrollee Interview -- Transition into NF

Introductory Script and Questions for Enrollees Who Recently Transitioned into a Nursing

Facility



to talk to me about moving into [NAME OF NURSING FACILITY].

Before we start, let me tell you a few things about this survey. The goal of this survey is to help

us understand how individuals move into nursing facilities. We would like to use this

information to improve the process of how individuals move out of nursing facilities.






confidential interview, so your name will not be connected to your answers in any way. This

means that your care will not be affected by your participation. You can skip over any

questions and can stop participating at any time. Please speak from your experience. There

are no right or wrong answers. Would you like to participate in this survey at this time?

Yes


No







1. What was the reason you moved into [NAME OF NF]?


2. Did you have a primary caregiver, a person who helped you with things like grocery

shopping, laundry, or preparing meals?

Yes Was it a friend or family member? [Yes/No] _____

No


3. Who made the determination that it was time to move into [NAME OF NF]?

Enrollee


Case manager

Other _________

4. How was the decision made to move into [NAME OF NF]?


5. Were there circumstances that contributed to the move into [NAME OF NF]?

Health issues

Hospitalization

Caregiver problem(s) [CIRCLE ALL THAT APPLY] stress, finances, health issues, other: __________

Did you feel like a burden to others?

Other __________

Other __________

Other __________

6. How important was staying at home to you? To your family?


7. What services might have helped you to remain in the community?




Assisted living





Caregiver training



Homemaker






Nursing facility


Personal care


Respite care


Transportation

9. Were those services available?

Yes SKIP TO QUESTION 11

No

I Don’t Know SKIP TO QUESTION 11

10. Do you know why these services that would have allowed you to remain at home were

not available?


11. Was there anything [else] that would have allowed you to stay at home that was not

available to you?





Appendix 4: LTC Enrollee Interview -- Transition out of NF

Introductory Script and Questions for Enrollees Who Recently Transitioned out of a Nursing

Facility



to talk to me about moving out of [NAME OF NURSING FACILITY].


us understand how individuals can successfully move out of nursing facilities. We would like

to use this information to improve the process of moving out of nursing facilities for

individuals.







means that your care will not be affected by your participation. You can skip over any

questions and can stop participating at any time. Please speak from your experience. There

are no right or wrong answers.


Yes


No







1. How did the decision to move back home come about?



2. Who told you that you may be able to move home?

Enrollee


Case manager

Other _________

3. Who made the decision to move from [NAME OF NF] back home and into the community?

Enrollee


Case manager

Other _________

4. What made your move back home from [NAME OF NF] successful?


5. Specifically, who helped you get ready to make this move?


Case manager

Other _________

Other _________

Other _________

6. How did they help?

Identified resources

Arranged for services

Made changes in the home

Other _________

Other _________

Other _________

7. Based on your experience, what was most important in making your move successful?

Transition teams (nurses)

Family


Primary Care home

Physical environment (e.g., single story home/building; wheelchair accessible)?


Other: _________


8. Thinking back to the time when you talked to [CASE MANAGER NAME] about [EXAMPLES OF ITEMS ON SUPPLEMENTAL ASSESSMENT], how helpful did you find having that discussion before the move home? [INSERT FIELD NOTES]:

9. Did [CASE MANAGER NAME] ask you questions that were important about your move

home? If not, what questions should have been asked?


10. Were the questions difficult for you to answer? For example, should [ITEM ON

SUPPLEMENTAL ASSESSMENT] have been left off?





Appendix 5: LTC Enrollee Caregiver Interview -- Transition into NF

Introductory Script and Questions for Caregivers of Enrollees Who Recently Transitioned into

a Nursing Facility


behalf of the Agency for Health Care Administration. We would like to ask you some

questions regarding [NAME OF ENROLLEE]’s move to [NAME OF NF].


us understand how Long-term Care enrollees move out of nursing facilities. We would like to

use this information to develop best practices that will improve the transition process for

enrollees.


process. We would also like to record our interview, so your answers may be transcribed.

Once your interview is transcribed, the audio file will be deleted and you will only be

identified by a number to ensure your anonymity.



means that [NAME OF ENROLLEE]’s care will not be affected by your participation. You can

skip over any questions and can stop participating at any time. Please speak from your



Yes


No [IF THE INTERVIEWEE AGREES, YOU CAN CONTINUE TO THE SURVEY. IF THE INTERVIEWEE DOES






1. What prompted [NAME OF ENROLLEE]’s transition from living at home to residing at

[NAME OF NF]?



2. Were you the primary caregiver? If yes, are you a friend or family member?

Yes [CIRCLE:] family, friend, other: _____

No

3. How were you caring for [NAME OF ENROLLEE]?


4. Were you living together?

Yes

No

5. Were there other caregivers (family or friends) who were helping you?

Yes

No

6. Who made the determination that it was time to move into [NAME OF NF]?

Enrollee


Case manager

Other _________

7. How was the decision made to move into [NAME OF NF]?


8. Were there other circumstances that contributed to the move?

Enrollee hospitalization

Caregiver problem(s) (circle all that apply) stress, finances, health issues, other: __________

Did [NAME OF ENROLLEE] indicate that he/she felt like a burden to others?

Other __________

Other __________

Other __________

9. How important was [NAME OF ENROLLEE]’s staying at home and in the community to you?

To your family?



10. What services might have allowed [NAME OF ENROLLEE] to remain in the community?



Assisted living





Caregiver training



Homemaker






Nursing facility


Personal care


Respite care


Transportation

11. Were those services available?

Yes

No

12. Do you know why these services that would have allowed [NAME OF ENROLLEE] to

remain at home were not available?


13. Have you discovered services that you were not previously aware of that are available in

the community since the move?





Appendix 6: LTC Enrollee Caregiver Interview -- Transition out of NF

Introductory Script and Questions for Caregivers of Enrollees Who Recently Transitioned out

of a Nursing Facility


behalf of the Agency for Health Care Administration. We would like to ask you some

questions regarding [NAME OF ENROLLEE]’s move out of [NAME OF NF].


us understand how Long-term Care enrollees move out of nursing facilities. We would like to

use this information to improve the transition process for enrollees.


process. We would also like to record our interview, so your answers may be transcribed.

Once your interview is transcribed, the audio file will be deleted and you will only be

identified by a number to ensure your anonymity.



means that [NAME OF ENROLLEE]’s care will not be affected by your participation. You can

skip over any questions and can stop participating at any time. Please speak from your



Yes


No







1. How did the decision to move back home come about?



2. Who told you that [ENROLLEE’S NAME] was able to move back into the community?

Enrollee


Case manager

Other _________

3. Who made the decision to move from the nursing facility to the community?

Enrollee


Case manager

Other _________

4. Who are the people or supports that have made this move successful?


5. Specifically, who helped [ENROLLEE’S NAME] get ready to make this move?

Enrollee


Case manager

Other _________

Other _________

Other _________

6. How did they help?

Identified resources

Arranged for services

Made changes in the home

Other _________

Other _________

Other _________

7. Based on your experience, what was most important in making [ENROLLEE’S NAME]’s

move successful?


Family


Primary Care home



Other: __________


8. Thinking back to the time when you talked to [ENROLLEE’S CASE MANAGER NAME] about

[EXAMPLES OF ITEMS ON NEEDS ASSESSMENT], how helpful did you find having that

discussion before [ENROLLEE’S NAME] moved home?


9. Did [ENROLLEE’S CASE MANAGER NAME] ask you questions that were important to

[ENROLLEE NAME’S] move home? If not, what questions should have been asked?


10. Were the questions difficult for you to answer? For example, should [ITEM ON

SUPPLEMENTAL ASSESSMENT] have been left off?


11. In your experience, what is most important in making the move from a nursing facility

back home and into the community successful?


Family


Primary Care home



Other: __________




Appendix 7: LTC Enrollee Interview Sampling Flowchart

Sampling Flowchart


Appendix 8: Home and Community-based Services Descriptions

Home and Community-Based Services Descriptions

Adult Companion Care – The provision of non-medical care, supervision when necessary to protect the

health, safety, and well-being of the enrollee, or social enrichment of a functionally impaired enrollee. This

includes assistance or supervision with meal preparation, laundry, and light housekeeping tasks

incidental to the care and supervision of the enrollee.

Adult Day Health Care - The provision of social and health related therapeutic services and activities,

self-care training, nutritional services, and respite. Nutritional meals are included as part of this service

when the enrollee is at the adult day health care center during meal times. This service includes medical

screening emphasizing prevention and continuity of care, including routine blood pressure checks and

diabetic maintenance checks. Physical, occupational, and speech therapies indicated in the enrollee’s

plan of care are furnished as components of this service. Nursing services, which include periodic

evaluation, medical supervision of self-care services directed toward activities of daily living, and personal

hygiene are also a component of this service.

Assisted Living - The provision of personal care, homemaker, chore, attendant care, companion care,

medication oversight, periodic nursing evaluations, and therapeutic social and recreational programming

in a home-like environment to enrollees residing in a licensed assisted living facility. This service includes

twenty-four (24) hours onsite response staff to meet scheduled or unpredictable needs in a way that

promotes maximum dignity and independence and provides supervision, safety, and security.

Behavioral Management - The provision of evaluation services to determine the origins and triggers of

persistent problematic behavior; development of strategies to address the behavior; implementation of

interventions to improve and maintain the improved behavior; and orientation and assistance for the

caregiver.

Case Management - The provision of services that assist enrollees in gaining access to LTC waiver

services, Florida Medicaid-covered services, and other medical, social, and educational services,

regardless of the funding source. To provide identification, outreach, contact and visits, immediate

(immediate care needs) and ongoing (care needs necessary after immediate care needs are stabilized)

needs identification, information to the enrollee, coordination of 701-B comprehensive assessment and

LTC supplemental assessment, development of the plan of care and ongoing care coordination,

coordination with appropriate service providers, assistance to enrollees living in the community in

developing a personal emergency plan, and advocacy on behalf of the enrollee.

Caregiver Training - The provision of training and consultation services for a natural support who

provides uncompensated care, training, guidance, companionship, supervision, or support to an enrollee.

Training includes instruction about treatment regimens and other services included in the plan of care,

use of equipment specified in the plan of care, updates as necessary to safely maintain the enrollee at

home, and consultation to assist the natural support in meeting the needs of the enrollee.

Home Accessibility Adaptation - The provision of physical adaptations to the home to ensure the

health, safety, and welfare of the enrollee, or to enable the enrollee to function with greater independence

in the home, without which an enrollee would require institutionalization. Such adaptations may include

the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or

installation of specialized electric and plumbing systems to accommodate the medical equipment and

supplies necessary for the welfare of the enrollee. All adaptations must be compliant with applicable state

and local building codes.

Home Delivered Meals - The provision of nutritionally sound meals delivered to an enrollee’s home when

an enrollee has difficulty shopping for, or preparing food, without assistance. All meals must provide a

minimum of 33.33% of the current Dietary Reference Intake. The meals must meet the current Dietary


Guidelines for Americans, the Unites States Department of Agriculture My Pyramid Food Intake Pattern

and reflect the predominant statewide demographic.

Homemaker Services - The provision of general household activities (such as meal preparation) and

routine household care (including laundry and pest control) by a trained homemaker, when the individual

regularly responsible for these activities is temporarily absent or unable to manage these activities.

Medication Administration - The provision of services in accordance with section 429.256, F.S. 4.2.1.11

Medication Management - To provide a review by a licensed nurse or pharmacist in conjunction with the

enrollee’s physician, of all prescriptions and over-the-counter medications taken by an enrollee. The

review shall be conducted annually (at a minimum) or on an as needed basis (upon a significant change

in the enrollee’s condition) to assess prescription accuracy, optimum dosage(s), and laboratory

monitoring (if applicable), and to assess and prevent drug interactions.

Nursing Facility - In accordance with Rule 59G-4.200, F.A.C. 4.2.1.13

Nutritional Assessment or Risk Reduction - The provision of an assessment, hands-on care, and

guidance about nutrition and an enrollee’s health to the enrollee and caregivers to follow dietary

specifications that are essential to the enrollee’s health and physical functioning, to prepare and eat

nutritionally appropriate meals, and to promote better health thorough improved nutrition, including

instructions on shopping for quality food and preparing food.

Personal Emergency Response Systems - For installation and service monitoring of an electronic

device connected to an enrollee’s phone that includes a portable “help” button, when provided to an

enrollee at high risk of institutionalization to secure help in an emergency.

Respite Care - The provision of services on a short-term basis due to the absence of, or need to relieve,

the enrollee’s natural supports on a planned or an emergency basis.

Assistive Care – The provision of an integrated set of 24-hour services only for enrollees residing in

adult family care homes.

Attendant Nursing Care – The provision of nursing care of both a supportive and health-related nature,

specific to the needs of a medically stable, physically handicapped enrollee age 21 and older who

requires more individual and continuous care than an intermittent nursing visit.

Hospice - In accordance with Rule 59G-4.140, F.A.C.

Intermittent Skilled Nursing - The provision of skilled nursing services at intervals of more than one

hour apart, and for the length of time necessary to complete the service, for enrollees who do not require

continuous nursing care (see attendant nursing care services).

Medical Equipment and Supplies - The provision of medical equipment and supplies specified in the

plan of care, including: devices, controls, or appliances that enable the enrollee to increase the ability to

perform activities of daily living; devices, controls, or appliances that enable the enrollee to perceive,

control, or communicate with the environment in which he or she lives; items necessary for life support or

to address an enrollee’s physical conditions, along with ancillary supplies and equipment necessary to the

proper functioning of such items; such other durable and non-durable medical equipment not available

under the State Plan that is necessary to address enrollee needs, including consumable medical

supplies, such as adult diapers; and repair of such items or replacement parts.

Personal Care – The provision of assistance with ADLs and IADLs, including assistance with preparation

of meals, and housekeeping chores which are incidental to the care furnished or are essential to the

health and welfare of enrollees under the age of 21 years.


Occupational Therapy – The provision of treatment to restore, improve, or maintain impaired functions

(as determined through a multi-disciplinary assessment) to increase or maintain an enrollee’s ability to

perform tasks required for independent functioning and to improve an enrollee’s capability to live safely in

the home setting.

Physical Therapy – The provision of treatment to restore, improve, or maintain impaired functions by the

use of physical, chemical, and other properties of heat, light, electricity or sound, and by massage and

active, resistive, or passive exercise.

Respiratory Therapy - The provision of ventilator support, therapeutic and diagnostic use of medical

gasses, respiratory rehabilitation, management of life support systems, bronchopulmonary drainage,

breathing exercises, and chest physiotherapy.

Speech Therapy - The provision of services to identify and treat neurological deficiencies related to

feeding problems, congenital or trauma-related maxillofacial anomalies, autism, neurological conditions

that affect oral motor functions, or when provided to evaluate and treat problems related to oral motor

dysfunction.

Transportation - The provision of transportation to and from the LTC covered services and expanded

benefits as described in the LTC plan’s contract with AHCA.

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