Network in Aging of Western New York “Aging Services in the 21st Century: National, State and Local Perspective Greg Olsen, Executive Deputy Director New York State Office for the Aging Thursday November 6, 2014 Williamsville, New York
Transcript
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Network in Aging of Western New York Aging Services in the 21st
Century: National, State and Local Perspective Greg Olsen,
Executive Deputy Director New York State Office for the Aging
Thursday November 6, 2014 Williamsville, New York
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The PAST
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Passed in 1965 The primary federal discretionary funding source
for home and community based services for older adults The goal:
keep older adults healthy and independent, and living in the
community. Established the Aging Services Network Focused on
multi-disciplinary partnerships at community level Adjusted/Amended
12 times, about once every 4 years Evolution of the role of the
network over time The Older Americans Act Countervailing Force to
Medicare and Medicaid
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The Past Older adults are a drain on resources Older adults not
valuable Care and assistance focused primarily on clinical/skilled
care Prevention not priority Direct Line Hospital to NH instead of
home first Social determinants of health not
understood/incentivized/valued Role of caregivers not recognized
Major issues preventable and manageable Chronic conditions Falls
and injury related falls
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Results of The Past policies focused on paying for
interventions that address medical needs, not social needs Payers
had little incentive to cover social interventions that provide
long term clinical and financial rewards Payments based on
procedures/tests, visits and discharges not clinical outcomes
Community supports lacking Innovation stymied Silos created
Accountability lacking Waste and fraud Prevention not priority High
expenses, poor outcomes Quality of care poor
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The Present 3.7 million people 60+ - rank #3 nationally Very
diverse group physically, culturally, ethnically, economically,
educationally, health status, etc. 1.8 million people age 75+ -
fastest growing cohort in NYS 330,000 with Alzheimers Disease
700,000 individuals age 60+ contribute 119 million hours of service
at economic value of $3.35 billion 64% of individuals age 60+ own
their own homes, 64% have no mortgage 4.1 million caregivers at any
time in a year economic value if paid for at market rate is $32
billion, average age is 64 $90 Billion in lost productivity to
businesses due to caregiving 6
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The Present - Aggregate Income by Age - NYS Ages Aggregate
Income % of Total Less than 24 $22,434,274,582 4.17% 25 to 44
$204,658,371,951 38.01% 45 to 64 $235,878,868,294 43.81% 65 and
over $75,498,394,809 14.02% TOTAL $538,469,909,636 In addition to
the billions in income generated from this age group, according to
the AARP, persons over the age of 50 control half of the country's
discretionary spending. Hold over $7 trillion in wealth Source -
Current Population Survey, March Supplement, 2011.
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Erie and Niagara Counties ErieNiagara 2015202520152025 Total
Population 907,099884,405214,450211,625
0-17189,803185,53744,63844,160 18-44308,485298,63367,92364,816
45-59196,268152,03449,29737,905 60+212,543248,20152,59264,744
45+408,811 (45%)400,235 (45%)101,889 (48%)102,649 (49%) Home
Ownership Own No Mortgage Own No Mortgage 75% 66% 77% 70%
Volunteers# 60+Hours Value # 60+Hours Value 37,548 2,627,804
$73,5785122,462 172,315 $4,824,820
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Erie and Niagara County - Economics ErieNiagara Social Security
(annual)$2.9 trillion$742 million Personal Income Generated
Total$24,917,804,500$5,385,440,700
25-44$7,672,822,000$1,673,449,300
45-64$12,213,372,800$2,679,181,400 65+$4,565,454,000$962,465,200
45+$16,778,826,800 (67%)$3,641,646,600 (68%)
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The Present
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County Data Proportion of County Population Aged 60 and Over
Number of Counties with Specified percent of Older Persons 20102020
Less than 20%334 20% to 24%2632 25% to 29%122 30% and over24
Source: Woods & Poole Economics, Inc., 2011 State Profile New
York State 62 Counties Change in Population Aged 60 and Over 2010
to 2020
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Demographic Change Foreign Immigration 100,000 each year come
to NYS 1.4 million legal, permanent since 2000 2.4 million people
not proficient in speaking English Race and Ethnic Diversity Growth
in all categories Migration Young workforceout of state New
retireesout of state Frail older adultsback to NY Young peopleout
of rural areas Minoritiesinto suburban and rural areas
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What We Know - Social Factors Directly Impact Health Spending
Income, access to food, educational status, housing, employment
affect health and longevity. Research attributes as much as 40% of
health outcomes to social and economic factors (University of
Wisconsin Population Health Institute) Food insecurity and diabetes
related admissions Living conditions and asthma Physical activity
and obesity Health policy has focused on paying for interventions
that address medical needs, not social needs Payers had little
incentive to cover social interventions that provide long term
clinical and financial rewards Payments based on procedures/tests,
visits and discharges not clinical outcomes
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Social Supports and Health Care Older Adults largest consumers
of health care 65+ population spends 2x more than 45-64 Spends 3-5x
more than all adults under 65 Medical Care controlled by insurers,
doctors, hospitals, drug companies and skilled nursing facilities
Social Supports community and family assistance, good nutrition,
exercise, transportation, safe housing, volunteering not reimbursed
Medical Community - have not traditionally seen the benefit in
social supports and dont understand their importance 14
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Social Supports Older adults 80% have at least one chronic
condition 50% have at least 2 Means more visits to health
professionals, more medications, decline in overall wellbeing and
quality of life Means limited mobility, social isolation and need
for LTSS more common Health care cannot solve the problem Need
Communities to plan for and accommodate, map assets and
opportunities and design a new paradigm Livable/Age Friendly
Communities - Erie 15
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Other Costs Associated with Chronic Conditions Cost of an
individuals independence and quality of life?? Costs for long-term
care exceed $500 billion nationally Out of pocket costs for
individuals Co-pays, premiums, deductibles Prescriptions, then run
risk of adverse interactions Spend-down DME Business costs loss
productivity and health spending Economic costs local and state
economy, income, assets
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The Future
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Retain and attract boomers/retirees in our communities Economic
Development: Gray Gold States court retirees as a "clean" growth
industry for every couple that leaves a state 1.5 jobs associated
with supporting an older couple. 25,000 retirees leave NYS annually
12,000 come to NY = (-13,000) The "graying" of the U.S. population
creates substantial opportunities for businesses that target their
products and services at older consumers. Increasingly, economic
development experts - regard affluent, mobile retirees as a key
customer base with a stable stream of income to be spent on local
purchases and investments. Just as states have competed in
"smokestack chasing" for years, many have begun to focus on
attracting and retaining retirees.
http://www.window.state.tx.us/comptrol/fnotes/fn9611.html 18
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What do We Really Want? To make our own decisions or, at least,
be empowered to be active part of decisions about us To stay in our
homes/communities To be as independent as possible To have choices
To maintain relationships, have purpose To be able to assume
personal risk, be in control To receive assistance as needed, on
our terms and schedules Not be vilified for asking for and
receiving help To access support services transportation, snow
removal, lawn mowing, home modifications, etc. To have help
maneuvering various systems that are complex i.e., bills, health
plan/Medicare info, application assistance 19
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What Services Meet that Goal Case management Home delivered
meals (HDM) Congregate meals Nutrition counseling & education
NY Connects (ADRC) - LTSS I&A/R, options counseling, benefits
and application assistance Health Insurance Information, Counseling
and Assistance (HIICAP) Personal Care Level I and II (non-Medicaid)
Senior center programming Health promotion and wellness Evidence
Based Interventions CDSMEs, fall prevention, etc Volunteer
opportunities Caregiver support services for those caring older
adults, older adults caring for adult children with disabilities,
grandparents raising grandchildren 20
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What Services Meet That Goal? Respite Support groups Public
education and outreach Information and Assistance, benefits
application assistance Ancillary services such as PERS and
assistive devices Social adult day services Transportation to
needed medical appointments, community services and activities
Employment Title V Legal Services Home modifications, repairs Bill
paying Long Term Care Ombudsman 21
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Changes Are Occurring ACA covering more low income via Medicaid
and middle income via subsidy New payment models holding providers
accountable for patient health and treatment costs (i.e. capitated,
global, bundled, shared savings, penalties for hospital
readmissions, etc.) social determinants CMMI Innovations fund - $10
billion over 8 years to test innovative payment and service models
Patient centered medical homes must integrate social supports into
their care models triggers higher levels of reimbursement BIP
Balanced Incentive Payment Program rebalance LTSS, break down silos
Stronger business case to invest in social interventions 22
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Changes Are Occurring - Federal and State Direction Rebalance
LTSS Stay in Community Olmstead Plan Medicaid Redesign Team (MRT)
Health Homes Fully Integrated Dual Advantage (FIDA) Managed Long
Term Care (MLTC) Community First Choice Option (CFCO) Money Follows
the Person (MFP) Center for Medicare and Medicaid Innovation (CMMI)
Delivery System Reform Incentive Payment Program (DSRIP)
Accountable Care Organizations, etc.
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Managed Long Term Care WHICH SERVICES ARE PROVIDED BY THE MLTC
PLANS - Benefit Package of "Partially Capitated" Plans MLTC Benefit
Package (Partial Capitation) (Plan must cover these services, if
deemed medically necessary. Member must use providers within the
plan's provider network for these services). Home Care, including:
Personal Care (Home attendant or Housekeeping) Certified Home
Health Agency Services (home health aide, visiting nurse, visiting
physical or occupational therapist) Private Duty Nursing Consumer
Directed Personal Assistance Program Adult Day Health Care (medical
model and social adult day care) Personal Emergency Response System
(PERS), Nutrition -- Home-delivered meals or congregate meals Home
modifications Medical equipment such as wheelchairs, medical
supplies such as incontinent pads, prostheses, orthotics,
respiratory therapy Physical, speech, and occupational therapy
outside the home Hearing Aids and Eyeglasses Four Medical
Specialties: Podiatry Audiology + hearing aides and batteries
Dental Optometry + eyeglasses Non-emergency medical transportation
to doctor offices, clinics (ambulette) Nursing home care
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Balancing Incentive Program
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What Will a NWD Hub Do? NWD Hub will: Assist individuals of all
ages and populations over the phone or in-person; Provide
information about LTSS; Conduct NWD Screen as appropriate;
Coordinate and share information with Specialized NWD through
secure database as needed; Coordinate applications for public
benefits and other services; and Provide information to Specialized
NWDs for comprehensive assessments and care planning. 12
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How to Access the NWD Hub? Any individual will be able to
access the NWD Hub by: NY Connects website, 1-800 Number, or
In-person. The NY Connects website will have an expanded resource
directory where an individual can search for services by county
without assistance. NY Connects website will also have an optional
online questionnaire which will help determine what services an
individual may need. 13
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DSRIP Medicaid Waiver designed to reinvest $6.4 billion for the
purpose of promoting multi-systems community collaborations that
achieve the goal of 25% reduction in avoidable hospital use over 5
years. Includes health care, behavioral health and social services
public private partnerships. PPS Performing Provider Systems Are
required to engage all relevant stakeholders Required to develop an
integrated delivery systems May implement 5-7 projects each in
appropriate domains Can apply to become Accountable Care
Organizations May apply for regulatory relief (waivers of
regs)
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DSRIP DSRIP Projects All projects must be derived based on a
Community Needs Assessment (CAN) A comprehensive assessment of
health care resources and community based resources currently
available in the service area and the demographics and health needs
of the population to be served Identifies gaps Identifies excesses
Community Resources Supporting PPS Approach includes Community
outreach agencies Transportation services NFP health and welfare
agencies Self-advocacy and family support agencies Community
service agencies Local government social service programs Family
support and training
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Caregiving The National Caregivers Library
(http://www.caregiverslibrary.org/Portals/0/Business_Caregiving_Bottom_LineJune2009NATIONAL.pdf)
estimates that the costs exceed $90 billion because the MetLife
study only included caregiving for individuals age 60 and
older.http://www.caregiverslibrary.org/Portals/0/Business_Caregiving_Bottom_LineJune2009NATIONAL.pdf
Recruitment, Retention and Training At any given time, more than
20% of the workforce is dealing with a caregiving situation. 33% of
caregivers decrease the number of hours they work 29% quit their
job or retire early 22% take a leave of absence 20% change their
job status or go part-time Lost Productivity 53% of caregivers
admit that their job performance is negatively affected 84% make
caregiving related phone calls during business hours 68% arrive
late or leave early 67% take time off from work during the day
Increased Healthcare Cost Even when your employees are caring for
someone not covered by your health plan, the employers healthcare
cost can go up. 75% of working caregivers report an adverse affect
on their own health 50% report 8 additional visits per year to a
health care provider (for themselves) as a result of their
caregiving responsibilities 22% report a significant impact on
their own health (Statistics taken from National Caregivers
Library)
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JAMA March 12, 2014 Caregiver Burden Clinical Review Highlights
the despair that family and friends (caregivers) can feel when
supporting frail or disabled relatives and the failure of the US
Healthcare system to recognize and support them. Highlights need
for support due to advanced age and change drivers Health care has
not adapted to the needs of Aging Americans Unpaid and untrained
caregivers must handle medical devices, medications and treatments
that were once restricted to clinicians. Family caregivers provide
most of the hands-on-care often for years without a break, without
pay, without a vacation, without recognition, without backup,
without help. The result widespread and unnecessary suffering,
isolation, fear, error, and at times, bankruptcy, affecting the
care receiver and the family
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Did You Know The Network of Aging Service Providers Served
almost 600,000 people last year Served over 13,000 Medicaid clients
(duals) Served more than 7,200 older adults with a diagnosed mental
health condition Served more than 3,000 older adults with
alcohol/substance abuse problem All AAAs now screen for
alcohol/drug use and misuse (CAGE) Many screen for depression
(PHQ9) and anxiety (GAD7) Dementia screen will be rolled out in
2014 Caregiver screen rolled out in 2014/2015
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The Future - What We Need To Do Recognize the social,
intellectual and economic capital of older adults - -plan for it
and put it to use Better integrate social supports with medical
care Take seriously the role of caregivers screen and support
Develop new and innovative financing models not solely based on
health interventions Finance social supports Finance offices for
the aging Community Planning aging in place Livable NY Age Friendly
neighborhoods 33
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How to Fund Social Supports 1. Non-profit hospitals are
required to provide a community health benefit usually equal to the
value of their tax exempt status estimated at $13 billion annually
(GAO) Since much of this money was spent on care for the poor, and
given that ACA is covering man of these individuals now might be
able to shift funds to social supports 2. ACA requires tax-exempt
hospitals to conduct a community needs health assessment and
develop an implementation strategy for addressing the needs once
every 3 years o US Center for Disease Control and Prevention
recommended that the assessment include information on social
determinants of health o IRS requires (Schedule H-990) tax-exempt
hospitals to report spending on activities benefitting the
community. 34
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Offices for the Aging and other human/social service agencies
can and are contracting with: managed care Managed long term care
Accountable Care Organizations Health Homes VA Hospitals care
transitions Health systems for EBIs Could be for: Medicare (FIDA)
DSRIP (delivery system reform incentive payment) Commercial
Insurance Businesses Relationship building and trust demonstrate
value 35 How to Fund Social Supports
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How do We Increase Service Capacity Non-Medicaid/Pre- Medicaid?
o Current Tools o Long term care insurance/ Partnership o Reverse
mortgages o Savings o Trusts and other legal tools New Financing
Mechanisms for Network Independence Savings Accounts/Family
Accounts Independence Insurance Independence Credit Tapping Home
Equity for network services Private Pay Development Cost Sharing
for OAA
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Cost-Sharing & Private Pay NYSOFA is exploring cost-sharing
for OAA programs as well as state funded programs Model could be
similar to EISEP Target is middle income older adults/family
members/caregivers Additional revenue generated folded back into
programs to expand services and reduce waiting lists Nutrition
programs not allowable under federal cost- sharing but could be
allowable using state and local funding Looking at developing
policies, protocols and standards in 2015 Would like it to be
optional for counties
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Cost-Sharing & Private Pay NYSOFA is developing policies,
procedures and protocols on developing private pay models in NYS
Large number of middle income older adults, families and caregivers
Limited state/federal funding Current waiting lists Demand will
increase with implementation of BIP and SFY2014-15 language
directing all health care practitioners in NYS to provide NY
Connects phone number if they believe their patients would benefit
from LTSS Goal is to ensure some standardization of how private pay
models work Protect individuals Value Reduce
exploitation/scams
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Summary Older adults are valuable economically, intellectually
and socially tap them Care models must move away from strictly
medical models they dont work Financing models must include social
supports and non-medical LTSS New Financing models must be
developed to focus on types of services offered by OFAs Communities
are in best position to plan for and develop livable and healthy
communities for all ages 39