California Community Choices Financing Study

1
California Community Choices Financing Study

• Robert Mollica
• National Academy for State Health Policy
• And
• Leslie Hendrickson
• Hendrickson Development
• November 12, 2009

2
Community Choices Project Overview

• Community Choices
• Five-year project funded by CMS
• Focused on improving access to long term services
  and supports to allow individuals with
  disabilities and older adults to stay in their
  homes and communities
• The Community Choices website is
• http//communitychoices.info

3
Community Choices Project Goals

• Improved access to long-term support services
• Transformation of information technology to
  support systems change
• Creation of a system that more effectively
  manages funding for long-term supports that
  promote community living options
• Financing study

4
Goal 3 Financing Study

• Examine laws, regulations, policies and payment
  methodologies affecting long-term care in
  California
• Identify barriers and make recommendations to
• Improve access to home and community based
  services
• More effectively manage funding for services that
  promote community living options
• Report addresses older adults, adults with
  physical disabilities and persons with
  developmental disabilities
• Does not address persons with mental illness

5
Focus

• Medi-Cal services
• IHSS
• HCBS waiver programs (MSSP, ALW, NF/AH, AIDS)
• Nursing Facility services
• ADHC
• Did not include
• State general revenue programs
• Older Americans Act

6
Challenges to Managing Long Term Care

• Fiscal, geographic
• Services covered by multiple state and county
  agencies
• Department of Social Services
• Department of Health Care Services
• Department of Aging
• Department of Public Health
• Department of Developmental Services
• General lack of streamlined access
• No common database across programs

7
Balancing What Is It?

• No standard definition of balance
• System enables consumers to choose services and
  settings based on their preferences
• Defined by state policy
• Possible measures
• Percent of spending on HCBS
• Percent of people served in community settings
• Months in the community vs institutional settings
• Percent of new users who receive HCBS

8
Comparing States

• CMS 64 expenditure data released annually by
  Thomson Reuters
• Under-reports HCBS spending in some states
• Expenditures not included in rankings
• State plan Adult Day Health Care
• Targeted Case Management
• State general revenue services
• Defining Institution and Community Settings

9
Key Findings Rankings

• Participant rankings
• 1st in number of personal care participants/1,000
• 42nd in HCBS waiver participants/1,000
• 6th in total HCBS participants/1,000
• Per capita spending (all populations)
• Personal care 4th
• Total HCBS 18th
• HCBS waivers 48th
• Nursing facility 41st
• ICF-MR 33rd

10
Percentage HCBS Spending

• Population CA NAT AVE
• Percent HCBS (all populations) 54 42
• Older adults, individuals with 52
  31physical disabilities
• Individuals with developmental 62
  63disabilities

11
Key Findings

• Programs spread across multiple agencies
• Only DDS has a single entry point system
• No agency-wide long-term care strategic plan
• Institutional bias in financial eligibility for
  nursing facility and HCBS waiver services
• Limited organizational base to build or expand
  new programs (eg statewide transition program)

12
Key Findings

• Progress relocating individuals from
  Developmental Centers
• Nursing home supply and Medi-Cal use declined
  from 2001 to 2008
• California National
• Supply - 6.0 -1.6
• Medi-Cal census -.4 - 8.3
• Nursing facility rate does not control for low
  occupancy
• Rates exceeded inflation

13
Cost effectiveness/woodwork effect

• Change the service mix to meet expanding need
• Reduce the spending growth rate
• Set aside waiver slots for persons relocating
  from institutions
• Conduct a break even analysis
• Cost avoidance through diversion

14
Use of the Report

• Continue status quo
• Formulate a transition plan
• Incremental changes
• Broader changes

15
Recommendations 28

• Time to implement
• General
• Short-term (12 months)
• Medium-term (12 24 months)
• Longer-term (24 months or longer)
• Category
• Financing
• Access/delivery system
• State-level organization

16
General Recommendations

• Establish a philosophy and legislative intent
  for all long-term services and supports
• Currently only described for specific programs
• No overall statement of intent for the system
• Develop a strategic plan for long-term services
  and supports
• Populations addressed
• Timetables, responsibilities and measureable
  goals

17
Financing
18
Budget Flexibility

• Create a unified long-term care budget for
  aged/disabled services
• Nursing facility services
• In Home Supportive Services
• Multipurpose Senior Services Program
• Other HCBS waivers

19
Reinvest Savings in HCBS

• Waiver programs are cost effective and should be
  expanded
• Transfer savings to HCBS programs from
  individuals who transition from nursing
  facilities
• Allow appropriations for nursing facilities to
  pay for HCBS for waivers with waiting lists

20
Rental Assistance Voucher

• Addresses need for affordable housing for
  individuals who want to transition from an
  institution
• Convert a portion of the state share of savings
  in a nursing home to a temporary rental
  assistance subsidy
• Individuals must be on a waiting list for a
  housing choice voucher

21
Nursing Facility Reimbursement

• Adopt nursing facility case mix reimbursement
  system for the staffing component of
  reimbursement rate
• Creates incentives to serve higher acuity
  residents and divert lower acuity applicants to
  community programs
• Reimbursement level for property costs seems too
  low
• Examine reimbursement level for insurance which
  might need cap on size of per diem costs

22
Reduce Payments for Vacant Nursing Facility Beds

• Establish a nursing facility occupancy provision
• Based on a flat percentage of licensed beds or
  the statewide average occupancy rate
• GAO report on 19 states found the average nursing
  facility occupancy provision used by other states
  was 88.6
• 25 of CA nursing facilities have occupancy rates
  below 85

23
Convert labor driven operating allocation

• Now used as incentive or bonus for hiring staff
  instead of contracting for staff
• Some or all of labor offset can be converted to
  support other policies
• Incentivize homes to support transition efforts
• Promote Culture Change
• Pay for Performance for meeting quality of care
  and quality of life goals, e.g. example of
  Colorado
• Restructure physical plants, build residential
  options
• Promote more staff training

24
Managed Long-Term Care

• ASPE report most studies and officials report
  that managed LTC reduces use of institutional
  services and increase use of HCBS relative to fee
  for service programs
• Consumer satisfaction is high
• Improves coordination of health and long term
  care needs
• Reduce hospital use, emergency room visits, lower
  overall costs

25
(No Transcript)
26
Increase Scope of Provider Fees

• Add Medicare revenue to Quality Assurance Fee
• Added after study was completed
• Identify provider groups interested in
  establishing QAFs for HCBS

27
Access/Delivery System
28
Streamline Access to HCBS

• Create single entry points for older adults and
  adults with physical disabilities
• Scope of programs and activities
• Possible entities
• Regional or County based organizations
• ADRC
• MSSP sites
• Area Agencies on Aging
• Co-locate financial eligibility workers in
  SEPs/ADRCs

29
Diversion

• Work with hospitals to provide preadmission
  screening/options counseling for individuals who
• Seek admission to a nursing home
• Discharged from a hospital with health
  supportive service needs
• Provided by single entry points, ADRCs, community
  organizations
• Priority groups
• Medi-Cal beneficiaries
• Likely spend down within 3 or 6 months

30
Transition Program

• Establish a statewide nursing facility case
  management function to support residents who can
  relocate to the community
• Support and expand Money Follows the Person
  project
• Provide funds to help Independent Living Centers,
  MSSP sites, Area Agencies on Aging, other
  non-profits and counties to expand transition
  programs
• Takes several years to build an effective
  infrastructure

31
Eligibility Changes to Increase HCBS Use

• Addresses institutional bias
• Add the 300 of SSI eligibility group to HCBS
  waivers
• Allows people who would spend down in a nursing
  home to be eligible for HCBS waivers in the
  community
• Establish maintenance allowance/share of cost

32
Help Individuals in Nursing Facilities Keep a Home

• Increase the home maintenance allowance
• Allows individuals admitted to a nursing home to
  retain income to maintain their home
• Must expect to return home within 180 days
• Current allowance is 209 a month
• Options Exempt up to 100 FPL Percentage of the
  SSI/SSP payment Total SSI/SSP payment

33
Keep a Home

• Maintain the SSI/SSP eligibility status for
  short-term nursing home admissions
• Allows individuals in a nursing home for less
  than 90 days to receive their full SSI/SSP
  payment to maintain their home

34
Services in Residential Settings

• Offers options for people who need access to
  services for unscheduled needs, oversight and
  supervision
• Program options
• Allow IHSS payments in RCFEs
• Expand assisted living waiver statewide
• Add assisted living services to MSSP, NF/AH waiver

35
Expedite Financial Eligibility

• Allow case managers to presume financial
  eligibility and enroll applicants in an HCBS
  waiver to avoid nursing facility admission
• Fast track the eligibility process
• Co-locate financial eligibility workers with
  single entry points/ADRCs

36
State-level Organization
37
New Department

• Create a Department of Long-Term Services and
  Supports
• Little Hoover Commission recommendation
• Possible components
• In Home Supportive Services
• Multipurpose Senior Services Program
• Assisted Living Waiver Program
• Other HCBS waivers
• Nursing home level of care
• Nursing home licensing
• RCFE licensing