Money Follows the Person in Delaware

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Money Follows the Person in Delaware

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Presentation Overview

• Background on the Money Follows the Person Study
• Impetus
• Lewins team
• Overview of the Federal Money Follows the Person
  Framework
• Case study examples of Money Follows the Person
  approaches taken in OR, TX, VT and WI
• How Money Follows the Person could look in
  Delaware

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Impetus for the Study

• Senate Resolution 26, passed by the State Senate
  June 30, 2004
• Directs the Governors Commission on
  Community-Based Alternatives for Individuals with
  Disabilities to create a Subcommittee to
  undertake all necessary steps to fund,
  facilitate and complete a study on the
  feasibility of implementing the Money Follows the
  Person initiative in the State of Delaware.
• The Lewin Group was hired in February 2005 to
  complete the study.

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Our Team for the Project

• Lewin Staff
• Roger Auerbach
• Amy Sander
• Catherine Tsien
• Brandon Maughn
• Technical Advisory Joel Menges and Lisa Alecxih
• Delaware MFP Steering Committee Members

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Money Follows the Person Study Overview

• Section I Introduction
• Section II Synthesis of the Money Follows the
  Person framework
• Section III Background about Delawares LTC
  environment, including
• Access to LTC services in Delaware
• LTC services available in Delaware
• LTC financing mechanisms in Delaware
• Delawares LTC quality assurance and improvement
  activities
• Section IV Case Studies
• Section V Cost Models for possible MFP initiative
  in Delaware
• Section VI Analysis and Recommendations
• Section VII Conclusion

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Methodology for the Study

• The Lewin Group conducted both qualitative and
  quantitative research in developing this report.
  
• A Lewin team visited Delaware and met with a
  variety of DHSS staff, including representatives
  from DSAAPD, DDDS, DSAMH, DMMA, and CMHS.
• Lewin conducted focus groups with Medicaid
  providers, advocates and consumers.
• Lewin reviewed Delawares Medicaid policy and
  provider manuals and the States CMS 372 waiver
  reports.

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What is Money Follows the Person?

• The Centers for Medicare and Medicaid Services
  (CMS) says Money Follows the Person refers to
  a system of flexible financing for long-term
  services and supports that enables available
  funds to move with the individual to the most
  appropriate and preferred setting as the
  individuals needs and preferences change. It is
  a market-based approach that gives individuals
  more choice over the location and type of
  services they receive. A system in which money
  follows the person is also one that can
  incorporate the philosophy of self-direction and
  individual control in state policies and
  programs. (Letter to State Medicaid Directors,
  8/17/04)

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Federal Money Follows the Person Initiative

• A Medicaid initiative that is part of the CMS
  Real Choice Systems Change program and the
  Presidents New Freedom Initiative
• Since 2003, 8.5 million in Money Follows the
  Person and other LTC system rebalancing grants
• 16 states have been awarded Money Follows the
  Person or other LTC system rebalancing grants
• The 2006 federal budget bill authorizes a 1.75
  billion five-year Money Follows the Person
  demonstration beginning January 2009

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Money Follows the Person Federal Framework
Lewin used the Federal Framework to evaluate
Delawares LTC system.
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Explanation of Framework

• Access processes
• Financing and Home and Community-Based Services
  (HCBS)
• Services supporting Home and Community-Based
  Living
• Medicaid (State Plan and Waivers)
• State General Fund
• Quality improvement strategies for HCBS

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Money Follows the Person in Delaware

• Long term care services are provided through
  several divisions DSAAPD, DDDS, DSAMH, DMMA, and
  CMHS.
• Other Delaware departments also provide services
  that are not paid for by Medicaid, but support
  individuals with disabilities lives in the
  community
• The Delaware State Housing Authority, the
  Department of Labor, and the Department of
  Transportation all provide needed supports to
  individuals with disabilities

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Delaware Spends 71 of its LTC funds on
Institutional Care

• U.S. and Delaware Medicaid Long Term Care
  Spending, FY 2004

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But the proportion spent on HCBS is increasing
The percentage of spending on HCBS has risen from
27.2 percent in 1999 to 29.0 percent in 2004.
Delaware Medicaid Long Term Care Expenditures, FY
1999 - 2004
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Access

• Level of care requirements are the same for
  institutional care and the waivers for equivalent
  populations
• There are multiple ways that individuals with
  disabilities learn about the services available
  and apply for services
• Lewin recommendation
• Delaware should create a central, trusted entity
  for the dissemination of information about LTC
  services which allows immediate access to
  information about choice of services and settings

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Services
Key Delaware Medicaid LTC Services

• Delaware also pays for other services, not paid
  by Medicaid
• Transportation
• Housing
• Employment Services
• Assistive Technology

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Financing

• The financing of services in Delaware is budgeted
  for each division within DHSS, including DSAMH,
  DMMA, DDDS, and DSAAPD
• Two Recommendations
• Delaware could consider a new budgeting strategy
  for LTC
• Delaware should consolidate management of LTC

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Quality

• Delaware is engaged in a variety of state-level
  and federal quality assurance efforts, but they
  are not part of a larger quality improvement
  plan.
• Recommendation
• Delaware should refine its quality assurance
  efforts. For example, create a process for
  collecting feedback from individuals about the
  quality of services provided and reporting that
  data review and potentially enhance incident
  reporting procedures develop systems for
  rewarding or penalizing providers based on their
  quality of care

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Money Follows the Person in Other States

• Oregon
• created a consolidated budget to allow money to
  easily transfer between care settings
• Texas
• transfers funds from institutional to HCBS budget
  when a person transitions
• Vermont
• allows the Medicaid agency to use savings from
  the nursing home budget to enhance home and
  community-based services
• Wisconsin
• created an entitlement to LTC services in the
  setting of an enrollees choice uses a
  comprehensive approach to outreach

• Case study states in the report were selected by
  Commission staff for in-depth study.

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Oregons consolidated budget and administration

• In 1981, Oregon consolidated its LTC budget,
  allowing allows program managers to monitor LTC
  expenditures as it expanded HCBS to meet
  individual desire to live at home.
• At the same time, Oregon consolidated the State
  administration of LTC services for adults and
  persons with physical disabilities through one
  division, Senior and Disabled Services (MR/DD
  added in 2001).
• Oregon also has a robust single entry point
  system, which informs individuals about
  community-care choices available to persons with
  a range of incomes.
• In FY 2004, Oregon spent 70.5 percent on HCBS
  compared to 29.5 percent for institutional care.

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Texas transfers funds for community care

• In September 2003, CMS awarded Texas grant of
  730,422 to fund Money Follows the Person efforts
  
• The Texas State Legislature approved Rider 37
  (Sept. 2001), allowing the Texas Department of
  Human Services to transfer funds from the nursing
  facilities budget to the HCBS budget when
  eligible individuals transferred from a nursing
  facility to community care.
• The limitation of the program is that it cannot
  be used for preventing unnecessary
  institutionalization (diversion) a person
  participating in the program must be a nursing
  facility resident who wants to return to the
  community.

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Vermont uses savings to enhance HCBS

• In 1996, Vermont State legislators passed
  legislation that allowed expansion of community
  LTC programs, but only to the extent that nursing
  facility costs decreased.
• Each year, Vermonts Department of Aging and
  Independent Living projects future expenditures
  for nursing facility services and savings can be
  allocated to supplement HCBS services.
• The State has seen a steady increase in the
  proportion of Medicaid LTC spending on HCBS
  (almost 58 in 2004).
• Newly approved Section 1115 waiver -- the Vermont
  Long Term Care Plan will allow the state to
  operate LTC under a global budget .

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Wisconsin allows real choice

• The Family Care program integrates federal,
  state, and local funding to provide Medicaid LTC
  benefits in a capitated environment.
• Family Care serves adults with physical and
  developmental disabilities as well as older
  adults.
• Participating counties have a single entry point
  Resource Center (RC) and, for a subset of
  counties, a Care Management Organization (CMO).
• Family Care participants must meet the nursing
  home or ICF/MR level of care criteria.

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Methodology for MFP Cost Modeling

• Focused on older adults and individuals with
  physical disabilities as well as individuals with
  mental retardation/developmental disabilities.
• In order to model Money Follows the Person
  program changes, Lewin first estimated baseline
  data
• Current enrollment in institutions and waivers
• Costs for the home and community based services
• Costs for nursing facilities and ICFs/MR
• Annual trends for those expenditures
• These were used to predict future expenditures.

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Methodology (continued)

• Lewin examined five states with Money Follows the
  Person programs or demonstrations to determine
  the percentage of eligible individuals who
  participated
• Lewin modeled the effect of transitions from
  institutions (cost savings) along with the costs
  of serving those individuals in the community
  (new costs)
• Lewin developed High and Low models

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Modeling Results

• Delaware could save between 7-12 over estimated
  baseline costs over a 10 year period by adopting
  a Money Follows the Person program
• Delaware could save between 63-104 million in
  state Medicaid funds over the same 10 year period
• Funds could be re-invested in serving more
  people, providing more services, increasing
  provider reimbursement or in other ways

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Contact Information

• Roger Auerbach and Amy Sander
• The Lewin Group
• 3130 Fairview Park Drive, Suite 800
• Falls Church, VA 22042
• [phone]
• roger.auerbach_at_lewin.com
• amy.sander_at_lewin.com