Long-Term Services and Supports - Resources for Integrated ... · Understanding Long-Term Services...

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Long-Term Services and Supports

DCC Pillars Webinar Series

March 22, 2017

https://www.ResourcesForIntegratedCare.com2

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Introductions

§ Karen Luken, CRT, MS

− Project Director, Medical Health Homes for People with Developmental Disabilities”

− Formerly Associate Director of the Center for Recreation and Disability Studies at UNC and Chapel Hills

§ Christopher Duff− Disability Practice and Policy

Consultant

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Disability-Competent Care Webinar Series Overview

The Lewin Group, under contract with the CMS Medicare-Medicaid Coordination Office, partnered with Christopher Duff and other disability practice experts to create the “Disability-Competent Care Webinar Series”.

§ This is the last session of this seven-part series.

§ Each session has been interactive, with 40 minutes of presenter-led discussion, followed by a 20 minute presenter/participant question and answer session.

§ Video replay and slide presentation are available after each session at:


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https://www.resourcesforintegratedcare.com/


DCC Pillars – Webinar Series

1. Understanding the DCC Model

2. Participant Engagement

3. Access

4. Primary Care

5. Care Coordination

6. Behavioral Health

7. Long-Term Services and Supports

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Agenda

1. Understanding Long-Term Services and Supports (LTSS)

2. Three domains of LTSS− Resources and settings to facilitate inclusion

− Meaningful activity

− Social connectedness and relationships

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Health Disparities

People with disabilities are more likely to:§ Experience worse health outcomes and are less likely to receive the

recommended care1

§ Experience difficulties or delays in receiving the necessary health care§ Not have had recommended health screening tests2 (e.g., breast cancer,

colorectal cancer and diabetes) § Not receive comprehensive preventive care (e.g., BMI assessment,

medication adherence and annual flu vaccine)§ Have reduced access to settings of care due to functional limitations§ Have limited knowledge and access to sexual health information§ Have hypertension and poor nutrition

Sources: 1) Office of the Assistant Secretary for Planning and Evaluation. (2016). Report to Congress: Social Risk Factors and Performance under Medicare’s Value Based Purchasing Programs

2) Disability and Health. Healthy People 2020. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/disability-and-health/ebrs

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Social Factors§ Disability status and health disparities are often associated with poorer

performance on measures that are linked to payment in value-based purchasing programs.

§ On many measures of focus (e.g., cancer screenings, vaccinations, diabetes management), the clinical interventions are straightforward but communications and service delivery for people with disabilities stretch the disability competence of most providers.

§ Residential environments (related to socioeconomic conditions) have been shown to have a significant impact on rates of obesity and related conditions3.

§ Addressing health disparities and social factors can significantly improve outcomes for people with disabilities, and in turn have a direct impact on revenue for many providers and plans4.

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Source: 3) National Research Council and Institute of Medicine. (2013). U.S. Health in International Perspective: Shorter Lives, Poorer Health

4) National Academies of Sciences, Engineering, and Medicine. (2017). Accounting for social risk factors in Medicare Payment, Washington, DC: The National Academies Press. doi: 10.1722


UNDERSTANDING LONG-TERM SERVICES AND

SUPPORTS

Long-Term Services and Supports provide assistance for participants with disabilities to live, integrate, and function in their

community - as they choose.

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Understanding Long-Term Services and Supports

§ Eligibility for LTSS is generally based on whether the participant is “at risk” of institutionalization.

§ LTSS are based on principles of self-determination, person-centered planning and the provision of adequate and appropriate supports and services needed for people to live in the community.

§ LTSS are designed to facilitate community participation and self-determination, so that participants have choices about their living options.

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Understanding Long-Term Services and Supports

§ Effective communication is important between long-term care services and other providers supporting the participant. This is facilitated by a participant-centered, inclusive, and coordinated individualized care plan that supports the participant’s goals and priorities.

§ Effective LTSS require participant choice, control, and access to a full array of services that help ensure independence, health, and quality of life. Supports may vary depending on the participant’s health status, community and the availability of natural supports (e.g., volunteers).

§ LTSS commonly involve a blending of formal services and informal supports that promote community life, health, and integration.

§ LTSS need to be provided in the most integrated setting, with sufficient quality and quantity to meet individual needs, while being cost effective and culturally responsive.

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Examples of LTSS

A range of services are available to support participants in their home and community. In addition to these paid services, it is important to promote the use of informal networks and community services.

Adult day care Homemaker

Assisted living Hospice

Behavioral supports Independent living skills

Care management Private duty nursing (PDN)

Foster care Respite

Habilitation Therapy

Home health Transportation

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Calvin’s Story

§ Calvin was injured in a car accident, leaving him with a spinal cord injury with the use of only one finger on one hand.

§ Prior to the injury, he was divorced, owned and operated a successful business, and had two sons in college.

§ He said his physical challenges were hard to adjust to, but not as hard as his loss of independence.

§ The accident also took his privacy, autonomy and financial security. Mostly, he worried about being a burden on his sons and whether he could ever live on his own.

§ Perhaps his biggest barrier was his belief in himself.§ His IDT hired a relocation specialist to look at his options and

identify a plan.

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Three Domains of LTSS

§ Resources and settings to facilitate inclusion: The level to which resources and involvement in community integrated settings are available to individuals who use LTSS.

§ Meaningful activity: The level to which individuals who use LTSS engage in desired activities (e.g., employment, education, volunteering, etc.).

§ Social connectedness and relationships: The level to which individuals who use LTSS develop and maintain relationships with others.

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LTSS Requirements

Similar to the other pillars of DCC5, LTSS require6:§ Care coordination

§ Member assessment

§ Individualized Care Plan

§ Communication

§ Access to information

§ Focus on transitions

§ Partnerships and collaboration

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Source: 5) Resources for Integrated Care website: https://www.resourcesforintegratedcare.com/concepts/disability-competent-care6) Long Term Quality Alliance (LTQA): http://www.ltqa.org

https://www.resourcesforintegratedcare.com/concepts/disability-competent-care

http://www.ltqa.org/


RESOURCES AND SETTINGS TO FACILITATE INCLUSION

Personal assistance services and supported living are the tools that facilitate community integration.

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Supported Living Settings

As an alternative to institutional or facility-based care, there are a variety of supported living settings where services can be provided.

Community-based settings can include:§ Adult foster care (AFC)

§ Assisted living (AL)

§ Independent living (apartment within a complex)

§ In-home, usually private family dwelling

§ Home modifications

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Supported Living Services

§ The provision of services, specified in the care plan, are based on functional assessments which identify participant needs.− The care plan outlines the activities to be performed and the duties of

the personal care assistant (PCA).

§ The PCA / LTSS provider must be specifically trained in the care required by the participant. If the participant is unable to direct their care, training and supervision must be provided by care partners, a housing provider or another agency.− Some community based services can be provided separately from

the actual housing setting (e.g., apartments / house with roommates, adult foster care, etc.,). It is important to provide the participant the option to choose to receive any support services from an agency other than the housing residential provider.

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LTSS: Self-Directed Option

§ Sometimes referred to as consumer directed, this option gives the participant the flexibility and responsibility to design and direct their services and supports.

§ The IDT helps the participant understand the self-directed option, person-centered planning, and how to develop and monitor their plan.

§ Participants can choose as much responsibility as they want for staffing components and the degree of assistance they receive from a support planner.

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LTSS: Agency Model and Shared Living Option

§ Under the agency model, care and/or the setting are generally provided through a license by the state. The provider assumes all HR functions and responsibilities.

§ When services are provided by shared living staff, the individual needs to be informed that choosing a particular site may limit control over their services, such as choice of staff and scheduling.

§ Involvement of participants in training of direct care workers (PCA) contributes to their active participation in their care; role modeling to look to participant for direction and questions.

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Home Modifications and Equipment

§ Many disability-competent organizations (e.g., health plans, providers, community-based organizations) have occupational, physical, and speech therapists that perform home- and community-based functional assessments, participant education, and training for functional and effective use of equipment.

§ Examples of equipment and modifications include:− Wheelchairs, scooters, and walkers− Wheelchair seating and positioning supports− Communication equipment− Respiratory equipment− Bathroom grab bars and doorway widening− Ramps− Technology

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MEANINGFUL ACTIVITY

A sense of purpose and hope is integral to well being. What this entails is unique to every individual.

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Meaningful Activity

§ There is a wide range of services that can facilitate meaningful activity, including: − Vocational and educational activities− Social and recreational programs− Shared or group meals− Adult daycare

§ Vocational supports can include personal care, behavioral coaching or job coaching (generally funded by vocational rehabilitation).

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Transportation Needs

§ Accessible public transportation can be a cost-effective option for routine or social travel, while individualized and supported transportation (such as wheelchair vans) may be required for medical appointments.

§ Transportation needs are based on the initial participant assessment, which includes a transportation assessment for physical, communication and cognitive requirements of the participant’s medical, social and vocational transportation needs. − The participant’s IPC needs to specify the type of equipment and

assistance needed while being transported.

§ Remember to focus on both “getting to” and “returning from” outings/activities and the time involved in waiting for accessible transportation options.

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Types of Transportation Services

Different types of transportation service possibilities include:§ Ambulance

§ Taxi / Uber / Lyft

§ Paratransit services

§ Accessible public transportation

§ Privately owned vehicles

§ Bariatric vehicles

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SOCIAL CONNECTEDNESS AND RELATIONSHIPS

Interactions with others, be it within the home or the community, are very important to everyone. This is especially true for those who are commonly isolated due to their disability or functional

limitations.

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Role of Care Partners in LTSS

§ Family, peers, and community acquaintances are referred to as care partners.

§ Generally care partners are unpaid yet vital to the participant’s living and functioning in the community of choice.

§ In the DCC model, they are not treated as care givers, but partners, reflecting the two-way nature of the relationship.

§ Usually this is a new role for all parties and may benefit from some coaching or training from the IDT.

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Social Connectedness And Relationships

There is a wide range of services that can facilitate meaningful social interactions and relationships, including:§ Independent living skills

§ Transportation

§ Community activities

§ Telephone reassurance

§ Behavioral supports

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Importance of Mobility Equipment

§ Health status− Appropriate equipment will maintain or improve health status− Reduction of falls and injury

§ Functional independence− Reduces reliance on care partners and providers− Home modifications support independence

§ Community participation− Increases level of involvement in community and family activities− Decreases social isolation

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Social & Recreational Supports

§ Research has shown community participation is a key factor in the health and well-being of persons with disabilities.

§ DCC requires attention to the social and recreational interests of each participant.

§ Upon the identification of community activities, the IDT needs to assist the participant and their care partners to provide the support needed for participation, such as assistance with transportation, toileting and eating, transfers, communication and others.

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Calvin’s Story, Continued

Let’s look at Calvin and his life through the three domains of LTSS:

1. Resources and settings to facilitate inclusiveness§ It was important to Calvin to find a two bedroom apartment so his

sons could visit.§ He was placed on numerous affordable and accessible apartment

waiting lists. Once one was found, he worked with the building manager to have the apartment modified and equipment installed.

2. Social connectedness and relationships§ Now that he is no longer in a facility, his sons and their friends are

more comfortable visiting him regularly.§ He has begun to visit with old friends and participate in the

activities he enjoyed before his injury.3. Meaningful activity

§ He has a part-time job to help with finances and to establish connections in a business environment.

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CONCLUSION

Maintaining participant health and well-being is dependent upon having PCPs that can meet the participant’s needs in terms of

availability, timeliness, and disability competence.

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Key Takeaways

§ The participant’s LTSS needs change over time, and plans need to be viewed as living documents.

§ Independence and achievement of life goals is a journey—not a destination.

§ All involved parties (especially the participant and their care partners) commonly need and benefit from education and coaching.

§ Advocacy is a key part of any relocation and transition.

§ Creating or linking community resources to meet the participant’s individual needs can decrease social isolation and ultimately improve health and quality of life.

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AUDIENCE QUESTIONS & DISCUSSION

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Send Us Your Feedback

Help us diversify our series content and address current Disability-Competent Care training needs – your input is essential!

Please contact us with your suggestions [email protected]

What We’d Like from You:§ How best to target future Disability-Competent Care webinars to

health care providers and plans involved in all levels of the health care delivery process

§ Feedback on these topics as well as ideas for other topics to explore in webinars and additional resources related to Disability-Competent Care

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mailto:[email protected]


Disability-Competent Care Self-Assessment Tool

Disability-Competent Care Self-Assessment Tool available online at: https://www.ResourcesForIntegratedCare.com/

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Thank You for Attending!

§ For more information contact:

§ [email protected]

§ Gretchen Nye at [email protected]

§ Christopher Duff at [email protected]

§ Further information, including webinar resources, are available at:

https://www.resourcesforintegratedcare.com

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