Ohios Unified Longterm Care Budget

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Ohios Unified Long-term Care Budget

• Building a Cost-Effective, Consumer Friendly
  Long-term Services Supports System

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Purpose

• To develop a comprehensive, flexible and
  transparent process for effective and efficient
  budgeting and service delivery that
• Encompasses both facility-based and home- and
  community-based long-term services and supports
• Is based on consumer choice and differing levels
  of service need
• Includes a seamless array of service delivery
  options
• Features a consolidated policymaking and budget
  authority to simplify decision making and
  maximize the states flexibility

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Desired Outcomes - Consumers

• Consumers will be satisfied with the services
  they receive and experience a higher quality of
  life.
• Ohioans will be encouraged to plan ahead for
  future service and support needs, as well as be
  better prepared to make informed decisions about
  their options.

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Desired Outcomes - System

• A transparent budget for policymakers.
• A cost-effective system that links disparate
  services across agencies and jurisdictions.
• Consistency in provider rate-setting.
• Accurate expenditure forecasts.

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Promoting Flexible Funding to Support Long Term
Living Presentation courtesy ofSusan C.
Reinhard, DirectorAARP Public Policy Institute
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Key Concepts

• Balancing LTC Achieving more parity in
  funding community and institutional options so
  consumers have more real choice.
• Set of Balancing Strategies, including increasing
  community capacity, informing people of options,
  funding/budgeting, nurse delegation and
  workforce, etc.

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Financing

• Money Follows the Person financing for
  services and supports moves with the person to
  the most appropriate and preferred setting.
• Global budgeting
• Texas MFP
• Deficit Reduction Omnibus Reconciliation Act
• Rebalancing (Balancing) reduced reliance on
  institutional options, increased community
  options.

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Key Building Blocks
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Budget Strategies

• Money Follows the Person (MFP)
• Planned Parity
• Global Budget (Pooled Financing Unified Budget)

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MFP Strategy

• Money Follows the Person financing for
  services and supports moves with the person to
  the most appropriate and preferred setting
• Commonly starts from nursing home to HCBS--State
  example is Texas
• Useful when long HCBS waiting lists and low
  occupancy in nursing homes

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Planned Parity Strategy

• Can be separate LTC budgets (nursing home, HCBS)
  mandates reductions in nursing home budget and
  transfer of those savings to fund HCBS
• Aggressive policy and program actions required
  (universal screening, level of care criteria,
  pre-admission processes, etc.)
• Examples--Maine, Vermont in 1990s

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Vermont Act 160

• Shifted funds from nursing home to the HCBS
  appropriation
• Goal 60-40 institution/community
• Strategies NF moratorium, expand residential
  alternatives, one time investments
• Five percent drop in NF supply

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Act 160

• The reductions required shall be redirected in
  FY 1997 to fund home and community-based
  services. For fiscal year 1998 and thereafter,
  the reductions required ... shall be redirected
  to fund both home and community-based services
  and any programs designed to reduce the number of
  nursing home beds.
• Any general funds redirected but not spent during
  any fiscal year shall be transferred to the
  long-term care special administration fund...

Department of Aging and IndependentLiving
Services
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Vermont 1115 Waiver

• Provide maximum choice of services and settings
• Eliminate institutional bias
• Promote early intervention
• Break link between 1915 (c) waivers and NF level
  of care

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Global Budget

• Consolidating all of the components of long term
  care spending into a single state agency budget
• Funding can follow the person as they move
  between services
• Placing the nursing facility, HCBS and
  state-funded personal care programs and budgets
  into a single division

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Global Budgeting

• Global Budgeting provides a budget appropriation
  format that allows LTC dollars to be used in the
  most cost-effective manner

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Global Budget

• Set a total LTC spending budget based on
• projected LTC needs and preferences
• planned policy and program initiatives
• Provide full administrative freedom to manage
  costs within the spending limit to respond
  quickly to consumer preferences

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Washington A Pioneer

• Legislature set forth philosophy
• .establish a balanced range of health, social
  and supportive services that deliver long term
  care services to chronically, functionally
  disabled persons of all ages and to ensure that
  services are provided in the most independent
  living situation consistent with individual
  needs (Revised Code of Washington (RCW)
  74.39.005) and to the extent of available
  funding, the department shall expand cost
  effective options for home and community services
  for consumers (RCW, 74.39A.030).

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New Jersey Strategy

• Budget and Policy Consolidation at state level
  for older adults
• Create more choices for HCBS services
• Help consumers find choices easily through single
  entry point (NJ EASE) and Community Choice
  Counseling (nursing home transition)

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Patrick Flood, VT DAILS
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Washington Success LTC Spending Trends
Based on data from the Washington Aging and
Disability Services Administration
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WA Shifting spending balance
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New Jersey Success

• 3,500 fewer Medicaid beneficiaries in nursing
  homes
• 10.4 reduction in census, surpasses almost all
  states in recent years

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Source NJDHSS, Sept 15, 2004 Trenton, NJ
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Indicators of Success in Colorado

• Reduced the rate of growth in LTC spending
• Saved 17 over projected LTC budget in 1994
• Served 21 fewer in nursing facilities than
  projected
• (Lewin Group study)
• In 1996, began serving more clients in HCBS than
  in nursing facilities (cross-over point)
• Milne, 2005

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Indicators of Success in Colorado

• Spent 51.1 of LTC budget on HCBS in 2001
• Ranked 5th in US
• Profiles of LTC-2002, AARP
• Spent 32.7 of Elderly/Disabled LTC budget on
  HCBS
• Ranked 8th in US in 2003
• Milne, 2005

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Critical Elements to Support Transformation

• Vision, Mission
• Leadership and Partnerships
• Access to multiple financing sources (Medicaid
  HCBS state plan, OAA, state general revenues)
• Streamlined financial and functional eligibility
• Comprehensive/single entry point
• Strong quality management system, including
  information systems

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The Changing Face of Long-Term Care Ohios
Experience 1993-2005 Presentation courtesy
ofRobert Applebaum Scripps
Gerontology CenterMiami University
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Ohio Fast Facts

• The population in Ohio who are most likely to
  need long-term care (those over age 85) has
  increased by 55,000 (38) over the last 12 years
  (1993-2005).
• Despite the population increase the number of
  nursing home beds in service has been reduced
  from a high of 99,000 in 1997 to about 94,000 in
  2005.
• By 2050, there will be one million Ohioans over
  age 85.
• By 2020, Ohio will have more than 220,000 older
  people with severe disabilities, almost 26 more
  than 2005.
• The number of residential care facility beds has
  increased from 8,700 in 1993 to about 43,000 in
  2005.

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Estimated Proportion of Ohio's Population with
Severe Disability in Different Settings
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Ohio Medicaid 2005

• Ohio spent 11.5 billion on Medicaid.
• Medicaid was 24 of Ohios annual budget.
• 42 of Ohios total Medicaid budget was spent on
  long-term care.
• Ohio spent 2.6 billion on Medicaid nursing homes
  (ranks 9th) 1 billion on Medicaid ICF/MR
  facilities (ranks 5th).
• Ohio spent 950 million on Home and Community
  Based Care Waivers (ranks 26th).
• Ohio ranked 47th in home care/nursing home
  expenditure ratio.

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Average Annual Cost per Person FY 2005, Includes
Medicaid Card Costs
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Ohio Nursing Facility Admissions1992-2005
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Short-Term Stay

• More than 56 of all those admitted to nursing
  homes
• are no longer residents after 3 months
• almost 7 in 10 are no longer residents after 6
  months
• by year end only one out of every 6 still there

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Proportion of Total Medicaid Nursing Home
Residents Still Living in a Facility
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Nursing Home Utilization in Ohio1993-2005
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Average Daily Nursing Home Census1993 to 2005
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Demographics of Residents in Ohios Certified
Nursing Facilities June 2004 ()
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PASSPORT Usage
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Functional Characteristics of Ohios PASSPORT
Consumers 2004 ()
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Distribution of Ohios Medicaid LTC Utilization
by Setting 1993-2005
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Number of Older Persons Using Nursing
Facilities or PASSPORT Services
Per 1,000 persons over age 60 in the population
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Process Decisions
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The Process

• The Governor will appoint a workgroup.
• Legislative leadership will appoint four members
  of the General Assembly.
• The plan is to be completed by June 1, 2008, and
  must be submitted to the Joint Committee on
  Medicaid Technology and Reform.
• Seven subcommittees, building on existing
  efforts, will assist the workgroup.

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Decision Roadmap

• Who will be served by the long-term services and
  supports budget?
• What does long-term services and supports
  include?

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Questions for theSubcommittees
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Front Door Subcommittee

• What will be the design of the front door to
  long-term services and supports?

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Care Management Subcommittee

• What is the role of care management?
• Who benefits from care management?
• How will we interface with Medicare Special Needs
  Plans?

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Quality Subcommittee

• How will we incorporate the CMS quality
  framework into all aspects of long-term services
  and supports, including nursing facilities?

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Unmet Needs Subcommittee

• What unmet needs currently exist and what
  additional long-term services and supports should
  Ohio offer?

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Consumer Direction Subcommittee

• How will we incorporate the key principles of
  consumer direction into the system?

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IT Systems Subcommittee

• How will existing and planned IT systems be
  modified to accommodate a unified budget?

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Budgeting Subcommittee

• How will the budget be built and what model will
  be used?

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Ohio Department of Aging

• 1-800-266-4346
• odamail_at_age.state.oh.us
• www.goldenbuckeye.com/ultcb