Enhanced Nursing Home Transition

1
Enhanced Nursing Home Transition

• NHT Collaborative Partners
• Regional Meetings
• August 2006

2
Goals

• Provide a context for discussing change in
  Pennsylvanias Long Term Living system
• Provide key information for state staff to
  support Enhanced Nursing Home Transition

3
Drivers of LTL System Change

• PA, Nation and the World are aging.
• Federal policy is promoting community living for
  people of all ages and disabilities--Americans
  with Disabilities Act, Olmstead Decision, New
  Freedom Initiative.
• Consumers of LTL services want to remain in their
  homes and communities.

4
Drivers of LTL System Change

• Advocates are pushing for Home and
  Community-Based CareADAPT, AARP and others.
• Consumer Direction is sweeping the states.
• States are seeking ways to help people of all
  income levels find affordable options for both
  private pay and publicly supported services.

5
National Policy

• For the first time ever, the Centers for Medicare
  Medicaid Services (CMS) and the Administration
  on Aging (AOA) are partnering
• and they are urging the states to do more to help
  people live in their homes and communities.

6
Dr. Mark McClellan, Administrator Centers for
Medicare Medicaid Services

• We are about to enter a new era of personal
  control, of New Freedom, in the Medicaid program.
  With a concerted effort, every state can
  rebalance its Medicaid program. With the tools
  we have now, it is time to end the institutional
  bias.

7
Josefina Carbonell, Assistant Secretary for Aging

• This is an exciting time to be involved in
  long-term care. It is clear we are witnessing a
  fundamental change in federal policy that is
  guided by the New Freedom Initiative and directed
  at giving people more control over their care, as
  well as providing more support for community
  living.

8
States are either Leading or Followingbut most
are Moving

• Listening to older adults and people with
  disabilities.
• Balancing public dollars spent on long term care
  (living).
• Informing people about their options.
• Emphasizing the critical pathways to a nursing
  home admission.
• Assertively reaching out to people in nursing
  homes to help them return home.

9
People in Nursing Homes Need Information about
LTL Options

• Crucial for consumers, their families
• People enter a nursing home for many reasons
  many can leave.
• Without information and help, many people in
  nursing homes cannot make an informed decision
  about where to receive services outside of an
  institution.

10
Myth Most People in Nursing Homes Need to be
There

• Those who resist change say People in
  nursing homes today are too frail to live in the
  community. Only a few of them can really leave.
• Fact For every person in a nursing home who
  needs assistance with 3 or more activities of
  daily living, there are 1.83 people living in the
  community who have the same level of disability.
  

11
Improving Access to LTC Options

• States are looking at best methods to avoid
  unwanted institutionalization
• Managed Care (Arizona, Texas, New York)
• Various Nursing Home Transition programs
• Nursing Home Transition programs
• Large statewide programs (WA, NJ, Oregon)
• State employees (NJ, WA)
• Contracted organizations (CO)
• Small programs for most challenging (SC, CT)
• Locally based organizations (Centers for
  Independent Living, Area Agencies on Aging)

12
Culture Change Philosophy of Person-Centered
Planning and Choice

• For Nursing Home Transition to work, all
  long-term living stakeholders have to see it as
  possible and desirable that consumers can choose
  and direct their services.
• Need to confront ageism and institutional bias.

13
Summary

• Federal policy and consumer activism are fueling
  historic, fundamental change in long-term living
• States are developing various models for making
  community living a real option
• Nursing home transition is a crucial component to
  balancing the LTL system
• Not Easy, Not Fast, Worth it, Possible

14
The Pennsylvania Picture

• Three Imperatives to Balance the Long Term Living
  System in PA
• Demographic trends
• Consumer choice
• Fiscal challenge

15
Demographic Trends85 Population in PA
Fastest-growing segment in the U.S., 9 increase
since July, 2003Medicaid long-term living
utilization is consistent with demographic trends
Source Penn State Data Center and PA Department
of Public Welfare
16
Consumer Choice

• The vast majority of people with disabilities
  want to live independently and with dignity, free
  from the restrictions of institutional settings.
• Nine out of ten older adults prefer to age in
  place in their homes and communities.

17
Fiscal Challenge
The Elderly and Persons with Physical
Disabilities Use the Greatest Share of Medicaid
Resources
Chronically Ill Adults 1.0 billion 8
Elderly 4.7 billion 35
Elderly 4.7 billion 35
Children Families 3.2 billion 24
Disabled 4.3 billion 33
Disabled 4.3 billion 33
Children Families 3.2 billion 24
Chronically Ill Adults 1.0 billion 8
Source PA Department of Public Welfare
18
Long-Term Living Spending
Increasing investment in long-term living
services to serve Elderly and Persons with
Physical Disabilities
Source PA Department of Public Welfare
19
Nationwide Comparison of LTC users in NF versus
HCBS
Nationwide trends show sustained commitment is
necessary to rebalancing
Sources Thomson Medstat and Kaiser Family
Foundation, 2002
20
Pennsylvanias Progress
Share of HCBS waiver users have increased since
2002-2003
Source PA Department of Public Welfare
21
Long Term Living Council
Subset of Governor Rendells Health Care Reform
Cabinet

• In November of 2005, Governor Rendell established
  the Long Term Living Council aimed at
• Accelerating reforms of the Commonwealth Long
  Term Living System, building on successful
  initiatives implemented to-date
• Positioning the Commonwealth to meet future
  demand for services while addressing the
  short-term and long term fiscal challenge this
  will entail
• Improving coordination across state departments
  in support of LTL reform agenda.
• Council Members include Cabinet Secretaries from
  Aging, DPW, Budget, and Policy Director of the
  Office of Health Care Reform and Deputy Chief of
  Staff
•  
• Michael Nardone named as Executive Director
  cross-agency staff teams formed to support work
  of the Council

22
Rendell Long-Term Living Reform Agenda
Governor Rendells vision is to offer consumers
choice as to where they receive long-term living
services, ensuring high-quality care in the most
clinically-appropriate, most cost-effective
environment

• To achieve this goal, the LTL Council will work
  to
•  
• Enhance and expand efforts to assist nursing home
  residents who wish to leave a facility-based care
  setting, and can safely return to their home or
  community
• Ensure that the supply of nursing home beds
  appropriately meets the need for such care, while
  providing opportunities for facilities to expand
  their continuum of care
• Ensure consistency in the application of
  eligibility criteria for long-term living
  services, while removing barriers to receiving
  home and community-based waiver services
• Maximize available waiver resources to serve as
  many consumers as possible, while ensuring
  provision of high-quality care and services

23
Enhanced Nursing Home Transition
24
Enhanced Nursing Home Transition

• Focus on new admissions
• MDS Data
• LTL Counseling
• Strengthened collaborations
• Active engagement of AAAs and DPW NHT partners
• Incentives for agencies to achieve successful
  transitions

25
Focus on New Admissions

• NHT program has demonstrated that the loss of
  housing and community supports is major barrier
  to successful transition
• Need to inform and educate consumers, families
  and caregivers before resources and supports
  disappear

26
MDS Data

• Collected by nursing homes on all new admissions
  to develop plan of care
• 06-07 rate agreement requires data to be
  submitted within 7 days of completion
• MDS data will be used to focus NHT efforts on new
  admissions

27
LTL Counseling

• Provide information and guidance to consumers in
  need of LTL services
• Ensure that all options are explained fully
• Enable consumers to make informed choices about
  where and how they receive LTL services.
• Ensure that scheduled discharges occur as planned

28
Strengthened Collaborations

• Opportunity to strengthen and expand existing
  collaborations
• Clearly define roles and responsibilities
• Increase and improve inter-agency communication
• Include additional community partners to support
  NHT, e.g. housing agencies, faith based
  organizations, community service organizations,
  other county agencies

29
AAA NHT Responsible for transition services and
supports to over 60 consumers actively works
with each consumer to complete a successful
transition
Coordination between LTL and NHT activities

• Long Term Living Counselor
• Provide information and guidance to consumers
• Ensure that all options are explained fully
• Enable consumers to make informed choices about
  where and how they receive LTL services

Local Collaboration Shares knowledge, expertise,
and resources to support successful transition
case conferencing around difficult transitions
other activates depending on local arrangements
OSP Agency NHT Responsible for transition
services and supports to under 60 consumers
actively works with each consumer to complete a
successful transition
30
Active Engagement of All Partners

• AAAs will conduct LTL Counseling
• AAA will be responsible for over 60 transitions
• DPW NHT partners will be responsible for under 60
  transitions
• Collaborative partners will share experience,
  expertise and resources to support successful
  transitions

31
Unified Data Tracking

• Module has been created in OMNIA to collect LTL
  Counseling and transition data
• All agencies will use the same system
• Real time data collection to allow ready access
  to critical information

32
Technical Assistance

• Roll-out Meetings
• Monthly Regional TA Calls
• NHT Conference in October
• Regional Housing TA Meetings
• State Staff
• PDA Tim Hoskins, [phone]
• DPW Kim Kramer, [phone]
• GOHCR Lynne Miles, [phone]

33
Summary of Enhanced NHT

• Identification of NH Admissions through MDS Data
• Early LTL counseling
• Active engagement of AAA and DPW NHT agencies in
  transition activities
• Strengthened collaborations
• Incentives for successful outcomes

34

• Nursing Home Transition
• Incentive Plan

35
Proposed Incentive Plan

• The Commonwealth is proposing to invest in AAAs
  and DPW NHT agencies through the incentive
  program
• Agencies will have the opportunity to earn
  additional dollars in incentive payments through
  this incentive pool
• Two part system rewards performance and provides
  support for agency restructuring

36
Incentive Plan Principles

• It is meaningful for agencies large and small
• It will result in necessary restructuring
• It strengthens partnerships
• It balances these needs with existing agency
  capacity and 
• It will not require a recurring expenditure for
  success.

37
Incentive Plan Components

• Restructuring Incentive
• Goal is to reward agencies for meeting transition
  goals
• Incentives are based on agencies performing
  specific functions and to restructure operations
  to support Enhanced NHT
• One-time, non recurring expenditure

38
Incentive Plan Components

• Goal Based Incentives
• Each agency has been given specific transition
  goals
• Incentive funds will be earned based on
  successful attainment of goals

39
AAA Total Incentive Examples
40
BHCBS Partners Total Incentive Examples
DRAFT