On the Edge of Crisis

1
On the Edge of Crisis

• Florida Assisted Living Facilities a Critical
  Link to Recovery

2
Floridas Limited Mental Health ALF Program -
Overview

• Over 90 of residents have a diagnosis of
  schizophrenia
• 5379 Mental Health residents who also received
  Optional State Supplementation (OSS)

3
Overview - continued

• Florida has lost 980 LMH-ALF beds over the last
  four years.
• Medicaid Assistive Care Services Program pay
  9.28/day for care.
• The number of people served has declined from
  15,913 in 2004 to 11,675 in 2007

4
Limited Mental Health ALF - facts

• The OSS budget has been reduced over the last 2
  yrs by 48 from 25 million to 15 million
• The Medicaid ACS Program was reduced from 32
  million to 25 million.

5
Limited Mental Health ALFs - facts

• The average funds paid to the ALF was 5.67/day
  as opposed to the 9.28/day.
• This is the actual funds being invested in the
  care at the facility.
• There has been no rate adjust since 2001.

6
Limited Mental Health ALF - facts

• The rise of admissions to forensic mental health
  facilities has increased from 1206 in 2004 to
  1530 in 2008.
• This change in rates of admission has coincided
  with the loss of ALF bed capacity.
• The numbers of mentally ill in Florida prisons
  has doubled during same period from 9 to 17 of
  total inmate population.

7
Optional State Supplementation (OSS)

• Florida OSS is provided to individual who also
  receive Medicaid
• In 2001 there were 10,645 in 2008 only 8221.
  This is a loss of 2424 state funded ALF beds
• This number includes the beds for low income
  elders and disabled adults.

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OSS what is this?

• OSS funds are transferred to AHCA to pay for the
  state match to leverage federal Medicaid funds.
• Residents receive a personal needs allowance of
  54/month.
• ALF receives 20 towards room and board each
  month.

9
OSS How does Florida compare to other states?

• In New York residents receive 179 in the PNA.
• In South Carolina the resident receives
  71/month.
• In New Jersey the PNA is 67.50/month
• In Florida it is 54/month

10
Limited Mental Health ALF residents

• Over 90 have a diagnosis of schizophrenia
• Individuals with schizo affective disorders move
  in and out frequently.
• GAF scores on average are 45 non ALF residents
  are 55 on average

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Limited Mental Health ALF - residents

• In 2005 over 750 individuals migrated from the
  LMH-ALF setting to the nursing home setting.
• The cost of this migration was 9.8 million
• The cost of care in the ALF was 800,000.
• The average age of these residents was 75 yrs old.

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Limited Mental Health ALF answers to care

• Of 5379 residents on average 26 per year go to a
  forensic mental facility.
• Residents spend 70 of their time at the ALF.
• Medication compliance is better in a supervised
  living arrangement.

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Why do we have a CRISIS?

• Due to low rates of reimbursement the business
  model is now under water.
• It is more profitable to operate an unlicensed
  facility.
• Operation spot check and aggressive action by
  municipal governments to close down housing for
  these individuals. (S. Florida)

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What is the IMPACT of the Crisis?

• Increased numbers headed to jails and state
  prisons.
• Increased migration of the mentally ill to the
  nursing home setting.
• Increased numbers among the homeless.
• Increased utilization of crisis services like the
  Baker Act.

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Who is affected by the ALF Crisis?

• The non Medicaid eligible increasingly cannot get
  access.
• The loss of beds is impacting the emergency rooms
  psychosis is now the 3 dx seen.
• The need for law enforcement involvement has
  grown because the system is now being driven by
  crisis.
• Residents with emerging medical needs must seek
  care in unlicensed facilities until they can
  access a nursing home bed.

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How will this CRISIS affect Florida?

• The AARP agreement with AHCA contemplates a
  transition plan to less restrictive settings.
  Many of the people who would eligible for
  alternative placement are adults with mental
  illness in the nursing home. The loss of bed
  capacity eliminates this as an option and leaves
  these people in a nursing home in violation of
  Olmstead.

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New Threats on the Horizon

• Elimination of the meds AD waiver program.
• Federal health reform mandated expansion of
  Medicaid would adversely affect optional services
  that help these people remain in the community.
• Reduction in access to care via managed care
  plans Medicaid reform and pre paid mental
  health plans. Problems with compliance FS
  394.4574.
• Over regulation by state agencies growth in
  regulation has divert dollars from care to
  regulatory management.
• Further raid on the budget for residential care
  will continue to erode capacity.
• Medicare part D co-payments adults with
  disabilities will not receive relief under the
  proposed federal plan.

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What Steps are needed NOW?

• We need an OPPAGA study to follow up on 2/17/97
  report.
• We need a FMHI follow up report to examine access
  to care.
• We need to examine new ideas to help address the
  funding crisis and improve the quality of care

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The Solutions

• Advocate for an increase in the Medicaid
  Assistive Care Services rate with an index to
  cost of living. A 2 rate increase would cost 3
  million.
• Create a residential care trust fund to protect
  the funding streams. This would not create a
  fiscal impact.
• Improve review and enforcement of the district
  planning provision under FS 394.4574 to ensure
  improved access to care.
• Improve compliance review of managed care plans
  for compliance with requirements that relate to
  access to services detailed in the community
  living support plans.

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Solutions

• Maintain the meds AD waiver for residents of
  LMH-ALF facilities over 2000 people could be
  displaced.
• Allow the LMH-ALF to recycle the medications that
  are unused through the pharmacy to be used for
  the non Medicaid eligible.

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Solutions

• Increase the resident personal needs allowance
  from 54 to 80 - 6 million.
• Ask not for profit mental health agencies to
  provide greater levels of staff training to help
  improve the soft skills of the ALF team.
• Ask AHCA to consider a three tier reimbursement
  model for ACS Medicaid based on level of need.
• Ask the TD Commission to consider changes to the
  transportation disadvantaged service plan to
  require a plan on how residents of ALF will
  access non emergency transportation.
• Ask AHCA to consider a a different rate of
  reimbursement for limited mental health ALF for
  the stepped up supervision being provided.

22
Answers to forensic needs?

• ALFs can be effective partners in transitioning
  people from 916 facilities into the community.
• The ALF setting with proper support can help
  address the rising number of people charged with
  misdemeanors and need supervised residential
  placement options.
• The ALF setting can offer Solutions at a lower
  rate and allow more people to be served with the
  same funding.

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Why is the ALF setting important?

• We need a full continuum of housing.
• Residents in ALFs have protections under a
  resident bill of rights which can be enforced
  with lawsuits.
• The ALF is a capitated residential setting that
  can help reduce the need for institutional care.

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ALFs save taxpayers money

• 50 of the nursing home diversion patients are
  referred to ALFs.
• For one fee each month the ALF accepts the risk
  associated with each case.
• The ALF provides access to schedule care which
  reduces the need for crisis care.
• The improved level of supervision of medications
  reduce the need for institutional care.
• ALFs care for people who have greater needs that
  what can be cared for in other settings.

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Steps today will pave the future

• OPPAGA study of the ALF crisis.
• FMHI data review and examination of access and
  barrier issues associated with managed care.
• Changes to the ALF funding model Housing Trust
  Fund and a three tiered model for reimbursement.

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Questions/ Answers

• Douglas D. Adkins
• Executive Director
• Dayspring Village, Inc.
• Hilliard, Florida
• www.dayspringvillage.org