Why are we redesigning the longterm care system

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Why are we redesigning the long-term care
system?
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Concerns and issues...

• ACCESS--Can people get the services they need,
  when they need them?
• CHOICE--Do people who need long-term care have a
  choice, or are they just slotted in to what is
  available in their community?
• QUALITY--Do long-term care services work to
  support a good quality of life?
• ECONOMY--Are we spending more money than is
  necessary?

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More Wisconsin residents are in nursing homes,
considering our 65 population.

• Nursing home residents per 1,000 population age
  65 and above, 1996
• Source Across the States, Profiles of long-term
  Care Systems, AARP 1998

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WI Medicaid spends more per capita on long-term
care than the national average.
Nursing Homes
ICF-MR
Home Care
Total LTC
Per capita Medicaid expenditures for long-term
care services, 2000
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Public spending for elderly and people with
disabilities is largely for institutional care.
Acute Primary Care
Institutional Care
Medicaid Managed Care
COP-R Community Aids
Medicaid LTC Card Services
Home Community-Based Waivers
Total DHFS CY 2000 Expenditures 2,348,010,300
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Wisconsins over-65 and over-85 population will
soon grow rapidly.
Figures for 1990 are U.S. Census estimates
(internet release 3/9/2000). Figures for
1995-2050 are based on the U.S. Census population
projections.
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Wisconsins adult disabled population will also
grow.
U.S. Census population projections for 1995-2050
and population estimates for July 1, 1990 based
on 1990 Census.
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Community Options Program (COP)

• Make funding available to counties to provide
  community-based long-term care services
• Piloted in 1981 open to all target groups
• In 2001, provided services to 2,254 Wisconsin
  residents

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C O P

• Provides for comprehensive assessments and
  encourages the use of appropriate professionals
• Provides for the development of Comprehensive
  Service Plans
• Aids in the relocation of people from
  institutional settings
• Diverts people from institutional settings

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C O P

• Encourages the maintenance of existing
  relationships with natural supports
• Encourages the maintenance of and/or improvement
  of the Quality of Life of the people served

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1980s - Medicaid Home and Community Based Waivers
(HCBWs)

• Federal Medicaid funds and state match made
  available to provide community-based services in
  place of institutional care
• Similar to COP but not as flexible
• Includes expanded eligibility for Medicaid
• In 2001, provided services to 22,000 Wisconsin
  residents.

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H C B Ws

• CIP 1A - Relocation of people from State Centers
  for the Developmentally Disabled
• Required bed de-certification
• CIP 1B - Relocation and Diversion of people from
  ICF-MRs
• No bed de-certification required

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H C B Ws

• CIP II - Relocates people from nursing facilities
• Bed de-certification required
• COP-W - Diverts people from nursing home
  admissions
• No bed de-certification required
• BIW - Relocates people with Traumatic Brain
  Injury from rehabilitation facilities

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Goals of Family Care

• ACCESS--Improve peoples access to services.
• CHOICE--Give people better choices about the
  services and supports available to meet their
  needs.

QUALITY--Improve the overall quality of the
long-term care system by focusing on achieving
peoples health and social outcomes.
ECONOMY--Create incentives and ability for
providing and purchasing cost-effective
alternatives.
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A Pilot Program

• The Legislature directed DHFS to test a partially
  integrated managed-care model for the delivery
  of long-term care services, which includes both
  community-based and institutional care, for
  possible expansion statewide.
• Currently, nine Wisconsin counties have
  implemented aspects of Family Care.

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What is Family Care?
Non-Family Care Counties
Family Care Counties

• Medicaid (MA) or Medicare Acute Primary Care

• Medicaid (MA) or Medicare Acute Primary Care

• MA Fee-for-Service--LTC Services (i.e. personal
  care, home health, nursing facility other
  institutional care)
• Community Options Program-Waiver (COP Waiver) for
  elders people w/ phys. disabilities
• Waivers for people w/ dev. Disabilities
• Community Integration Program II (CIP II)
• Brain Injury Waiver
• Community Integration Program (CIP 1A)
• Community Integration Program (CIP 1B)
• Community Supported Living Arrangements(CSLA)
• Community Options Program
• Community Aids
• Community Aids--Alzheimer's Caregiver Support
  Program (AFCSP)

• Family Care long-term Care
• or
• MA Fee-for-Service LTC Services

• Older Americans Act Services
• Independent Living Center Services
• Public Health Programs

• Older Americans Act Services
• Independent Living Center Services
• Public Health Programs

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Why are we redesigning the long-term care system?

• Family Care goal
• Improve consumer access and choice.

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• Old/current system
• Uncoordinated fee-for-service care, with no
  safeguards against gaps overlaps
• Immediate entitlement to nursing home care wait
  list for community care
• In NH, certain services regardless of need in
  waiver, a limited benefit package.

• Family Care
• Managed care, with focus of responsibility for
  quality and cost.
• Immediate entitlement to long-term care suitable
  for individual needs
• Single, expanded, flexible benefit package

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• Old/current system
• Waiver care management has social work expertise.
  
• Waiver assessment limited to need for waiver
  services
• Acute/primary care rarely coordinated with waiver
  services.
• LTC card services not coordinated with waiver
  services.

• Family Care
• Interdisciplinary care management social work
  and nursing.
• Holistic approach to care planning
• Mandatory contacts with primary health providers.
• Control, responsibility for all MA-funded LTC
  services under one local agency.

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• Old/current system
• No local incentive for intervention
  prevention. Person leaves the waiver if condition
  deteriorates.
• Service authorization limited by available funds,
  State approval

• Family Care
• Intervention prevention in care plans CMO on
  the hook if condition deteriorates.
• Service authorization by local teams, asking
  what is cost-effective?

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Federal Issues about Access to LTC Services

• Olmstead vs. L.C., U. S. Supreme Court Decision
  ruled that--unjustified isolation is properly
  regarded as discrimination based on disability
  under ADA Title II.
• Federal CMS staff have noted that Family Care
  provides key components that would help assure
  state compliance
• Resource Centers offer Pre-Admission Consultation
  Options Counseling for all who enter
  institutional residential services.
• Enrollees have access to a range of long-term
  care services, including home and community based
  care based options--based on need. It ends the
  institutional bias of Medicaid.
• Family Care CMOs are required to develop the
  services needed by their enrollees. They are
  monitored to assure individual outcomes are met.

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Why are we redesigning the long-term care system?

• Family Care goal
• Ensure quality for consumers.

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Quality Consumer Perspective

• Person-centered, consumer-focused
• Measuring outcomes from the perspective of the
  consumer

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Family Care Outcomes

• Self-determination and Choice
• People are treated fairly
• People have privacy
• People have personal dignity and respect
• People choose their services
• People choose their daily routine
• People achieve their employment objectives
• People are satisfied with services

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Family Care Outcomes, contd

• Community Integration
• People choose where and with whom they live
• People participate in the life of the community
• People remain connected to informal support
  networks

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Family Care Outcomes, contd

• Health and Safety
• People are free from abuse and neglect
• People have the best possible health
• People are safe
• People experience continuity and security

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Why are we redesigning the long-term care system?

• Family Care goal
• Provide services economically.

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Cost-EffectivenessQuality and Economy

• CMOs Avoid Unnecessary Costs by
• Coordinating benefits and services, including
  primary health care
• Enabling members reliance on friends and family
• Focusing on prevention of disability

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Comparing Costs - 2001
Difference 2,376 per yearper member
In 2001, the average Family Care members monthly
cost was 1,853. In counties without managed
long-term care, serving these same people would
have cost 2,051 a month.
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The Organizations of Family Care
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The organizations of Family Care

• The Aging and Disability Resource Centers.

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Resource Centers Goals

• Reach a broad base of consumers, regardless of
  income or condition
• Delay or prevent the need for LTC services
• Enable people to make informed, cost-effective
  decisions about LTC
• Identify people at risk and with urgent needs and
  connect them to services
• Serve as the single entry point for
  publicly-funded long-term care

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Resource Centers Services

• Outreach and public education
• Information and assistance
• Benefits counseling screening for eligibility
• Emergency response
• Transitional services
• Prevention and early intervention activities
• Enroll recipients in CMO, in those counties with
  CMOs.
• Provide services over the telephone or in visits
  to an individuals home.

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Where are the Resource Centers?

• Fond du Lac
• Jackson
• Kenosha
• (One for developmental disabilities one for
  elderly and physical disabilities)
• La Crosse
• Marathon
• Milwaukee
• (elderly only)
• Portage
• Richland
• Trempealeau

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The organizations of Family Care

• The Enrollment Consultants.

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Enrollment Consultants Purposes

• Make sure potential CMO members know their
  options.
• Address federal and state concerns
• Cherry-picking and hot potatoes
• Conflict of interest
• County governments operate both RCs and CMOs.

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Enrollment Consultants Services

• Enrollment consultants provide unbiased
  information and advice about long-term care.
• Communicate with potential enrollees
• Explain managed care
• Help with enrollment
• The Southeastern Wisconsin Area Agency on Aging,
  under contract with the Department of Health and
  Family Services, provides enrollment
  consultation.

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The organizations of Family Care

• The Care Management Organizations.

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Care Management Organizations Purpose

• To support long-term care consumers in achieving
  their personal outcomes in a cost-effective
  system of long-term care.

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Care Management OrganizationsServices

• Assess clients personal outcomes
• Involve consumer in decision-making and creating
  member-centered plan to support outcomes
• Provide services, directly or by contract
• Coordinate other services not included in the
  Family Care benefit
• Assure quality

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The Family Care Benefit

• Adaptive aids, communication aids, medical
  supplies, home modifications
• Home health, therapies, nursing services,
  personal care, supportive home care
• Residential services, nursing facility services
• Transportation, daily living skills training,
  supportive employment
• Meals home delivered and congregate,
• Emergency response system services
• Respite Care, adult day care, day services
• Case Management

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Where are the CMOs?

• Fond du Lac ...899 members
• La Crosse 1,399 members
• Milwaukee4,363 members (elderly only)
• Portage655 members
• Richland..292 members
• Membership as of September 1, 2003

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PACE and Partnership

• Integrates all Medicare, Medicaid and HCBW
  services
• Benefits are capitated and paid to small,
  community-based organizations
• Contractors are at full risk for all health and
  long-term care outcomes
• Care management is team-based

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PACE

• Most services are provided in an adult day center
• Primary care physician and most services
  providers are PACE employees
• Serves frail elderly age 55 and older
• Participants must be Medicaid eligible and in
  need of a nursing home level of care

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Partnership

• Most services are provided in the community
• Primary care is provided by an independent
  physician panel
• Serves frail elderly age 55 and older, and adults
  with physical disabilities
• Must be Medicaid eligible and in need of a
  nursing home level of care

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PACE/Partnership Enrollment

• CCO/CCE (Milwaukee, Racine)
• PACE 445
• Partnership 324
• CHP (Eau Claire,
• Dunn, Chippewa) 485
• CLA (Dane) 260
• Eldercare (Dane) 453
• August 31, 2003

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Goals of Reform

• ACCESS--Improve peoples access to services.
• CHOICE--Give people better choices about the
  services and supports available to meet their
  needs.
• QUALITY--Improve the overall quality of the
  long-term care system by focusing on achieving
  peoples health and social outcomes.
• ECONOMY--Create incentives and ability for
  providing and purchasing cost-effective
  alternatives.

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Council Role

• Advise on
• What concerns and issues need to be addressed
• What should the implementation strategy be
  regarding such issues as
• timing?
• providers/partners?
• target populations?

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Council Role Todays Question

• What do we want to request in a waiver regarding
  our goal to
• assure adequate nursing home care and expand
  community capacity?
• improve quality in the existing waiver programs?
• pursue steps toward managed care such as
  pre-Family Care?
• diversify the nursing home industry by regulatory
  change and other strategies?