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Missouri

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Title: Missouri


1
Missouri
  • Comprehensive Entry Point for Long Term Services
    and Supports
  • Presented by Barbara Edwards, Principal
  • Health Management Associates
  • May 27, 2008

2
Why LTC Reform?
  • Context and Tools

3
People with Long-Term Care Needs, 2005
58 are age 65 and 42 are under age 65
  • Approx. 10.3 million Americans need assistance
    with ADLs or IADLs
  • Generally a consequence of aging
  • LTC provided informally and formally
  • Government estimates suggest that the number of
    people using paid long-term care could nearly
    double

Under Age 65 4.2 million (41)
65 or Over 4.6 million (45)
Total 10.3 Million
SOURCE J. Feder, H. Komisar R. Friedland,
Long-Term Care Financing Policy Options for the
Future, Health Policy Institute, Georgetown
University, June 2007, analysis of the 2005
National Health Interview Survey and the 2004
National Nursing Home Survey. NOTE Community
residents with long-term care needs are defined
as people unable to perform at least one activity
of daily living or instrumental activity of daily
living. Numbers may not add due to rounding.
4
Medicaid Expenditures Per Enrollee,by Acute and
Long-Term Care, 2007
13,400
11,600
2,400
2,000
29
61
99
94
Source Health Management Associates estimates,
based on CBO March 2007 baseline. Per-enrollee
expenditures do not include DSH, adjustments, or
administrative costs. Allocation of long-term
care and acute care shares based on historical
data.
5
Baby Boomers Will Drive Growth
  • By 2020, 1 in 5 Missourians will be age 60
  • The fastest growing segment of the population is
    age 85 expected to double by 2020 nationally.
  • Current LTC strategies financially
    unsustainable!

6
Americans with Disabilities Act
  • ADA enacted in 1990 focus on public access,
    employment, public services
  • Olmstead v. L.C.
  • Supreme Court ruling (1999) finding that the
    unjustified institutional isolation of people
    with disabilities to receive public services is a
    violation of the Americans with Disabilities Act
    of 1990 (ADA)
  • Medicaid has become a major tool of ADA
    implementation for people with disabilities

7
Federal Response
  • New Freedom Initiative
  • An Executive Order issued on June 18, 2001 from
    the President requiring all Executive Branch
    agencies to take steps to comply fully with the
    requirements of the Olmstead decision.
  • For Medicaid, a commitment to combat the
    institutional bias of the program

8
Federal Response
  • Real Choice Systems Change Grants (CMS)
  • Support improvements in community LTC support
    systems to enable people with disabilities to
    live and participate in community life
  • 256M in grants (FFYs 2001-2006) to build the LTC
    infrastructure
  • nursing home transition grants
  • Money Follows Person grants

9
Federal Response
  • Aging and Disability Resource Centers (DMS and
    AOA) Grants
  • Since 2003
  • Support development of citizen-centered one-stop
    shop entry points
  • Accessible in local communities
  • Individuals who need LTC, caregivers (family,
    professional), those planning for future needs
  • Hospital discharge planning

10
ADRCs a set of SEP expectations
  • Enhance I A infrastructure (consumer tells her
    story one time use of internet, technology)
  • Engage critical pathways and standardized,
    individualized options counseling
  • Access to same, comprehensive resource data base
  • Single organization or close coordination among
    partners
  • Standardized intake and screening across sites
  • Assist with eligibility (financial and/or
    functional) track eligibilty process
  • Case management as needed track, monitor outcomes

11
ADRC Grants
  • Grey2003 Yellow2004 Blue2005

12
Federal Response
  • Deficit Reduction Act
  • Money Follows the Person Demonstration Grants
    1.75B over 5 years in the form of enhanced match
    for services.
  • Self-Directed Personal Assistance Option
    removed the requirement that states must apply
    for and be granted a Section 1115 or 1915(c)
    waiver before adding a Cash Counseling option
    to their Medicaid programs

13
Federal Response
  • Deficit Reduction Act (contd)
  • 1915 (i) state plan option to offer waiver-like
    services, without requirement that people meet NH
    LOC
  • Community waiver option for children otherwise in
    MH treatment facilities

14
State LTC Rebalancing Efforts
  • Spurred by consumer demand, the ADA, judicial
    rulings and cost containment strategies
  • Encouraged by federal grants, new options
  • HCBS waivers
  • Global budgeting TX, VT, WI, NM, NJ, OH
  • Single state agency subunit manages waiver
    institutional budgets OR, WA, VT
  • ADRC outreach, information, referral,
    assessment, etc.
  • MFP grants

15
CMS Regulations New Challenges
  • Increasing CMS focus on program integrity, state
    financing arrangements, redefining allowable
    Medicaid services
  • Seven troubling regulations proposed in 07-08
  • Some regs will force changes in how states serve
    those with disabilities (including design of
    single entry point for LTC)
  • Congress has voted to place under moratorium
    until March 09 veto fight likely

16
Case Management Regulations
  • Interim regulations took effect March 3, 2008,
    final regulations expected in August
  • Impacts LTC waivers, many SEP models
  • Included in moratorium by Congress
  • Defines case management
  • Comprehensive assessment
  • Plan of care
  • Referral to services
  • Monitoring and follow-up
  • Does not include services to which referred

17
Case Management Regulations
  • Other provisions
  • Case manager cannot authorize services
  • Case management cannot be billed under Medicaid
    administration
  • Limits when TCM can be offered to those
    transitioning from institutions
  • Requires single case manager by 2010
  • Must be billed in 15 minute units
  • Consumer can refuse CM/TCM services

18
A Word about Terminology
  • That which we call a rose by any other name
    would smell as sweet.
  • Shakespeare

19
Terminology
  • Single Entry Point for LTC (43 states)
  • An integrated service delivery system that aims
    to streamline access to LTC services and supports
  • One contact by consumer to receive information,
    assistance, access
  • Models vary!

20
Terminology
  • One Stop Shop (one concept of a SEP)
  • A single local or regional agency (with one or
    several geographic locations) that provides
    comprehensive information and support regarding
    home, community, and institutional care options
    to consumers

21
Terminology
  • No Wrong Door (one concept of a SEP)
  • Multiple agencies serve as entry points to LTC,
    but regardless of where consumer seeks services,
    she receives the same intake processing and
    information about the full range of services
    available

22
Terminology
  • ADRC
  • A specific federal grant that focuses on
    encouraging a SEP that uses standardized
    processes and tools to offer a comprehensive set
    of information and assistance to all who seek or
    provide LTC services and supports

23
Senate Bill 577
  • Comprehensive Point of Entry (CPE)
  • Delivery system easy to understand with access
    through multiple points
  • Offer an array of LTC choices, info assistance
  • Efficient - reduce duplication, streamline access
    to multiple funding sources and programs
  • Strengthen QA and QI
  • Timely access to, payment for cost effective
    care
  • Study one-stop shopping for seniors

24
Components of SEP
  • It isnt what you CALL it but what it IS that
    matters.

25
CPE Components
  • Populations served (some or all)
  • Elderly
  • People with disabilities, including
  • Physical disabilities
  • MR/DD
  • Mental illness
  • Other, such as traumatic brain injury, cerebral
    palsy

26
CPE Components
  • Functions performed (some or all)
  • Information and referral
  • Initial screening
  • Assessment
  • Benefits counseling
  • Nursing home pre-admission screening

27
CPE Components
  • Functions performed (contd)
  • Development of plan of care
  • Determination of eligibility (financial,
    functional)
  • Authorization of services
  • Monitor service delivery
  • New CMS regs impact this

28
CPE Components
  • Types of organizations as entry point (some or
    all)
  • Area Agencies on Aging
  • Centers for Independent Living
  • County public health departments
  • Community-based organizations
  • State regional, area or local offices

19
29
CPE Components
  • Accessibility (some or all)
  • Face-to-face
  • Telephone
  • Internet
  • Second party referral

20
30
Other State Practices
31
Other State Practices
  • Variables affecting design of entry point models
  • Use of 2-1-1
  • Funding
  • Technology
  • State structure
  • Pilot/statewideness

32
Florida
  • State Structure
  • Agency for Health Care Administration is Medicaid
    Agency
  • Department of Children Families performs
    financial eligibility for all public assistance
    programs, including Medicaid
  • Agency for Persons with Disabilities

33
Florida
  • State structure
  • Dept. of Elder Affairs administers OAA, some home
    and community-based waivers, state funded program
    for the elderly CARES state employees perform
    functional eligibility determination and
    pre-admission screening
  • Contracts with AAAs
  • AAAs do not perform direct services contract
    with providers for case management and direct
    services

34
Florida
  • Awarded ADRC grant in 2004 - 2007, plus one year
    no-cost extension
  • Serves all 60 also 18 with severe and
    persistent mental illness
  • No wrong door approach
  • Three ADRCs operated by AAAs
  • State legislation requires remaining AAAs (8) to
    be Aging Resource Centers

35
Florida
  • ADRCs/ARCs provide access to
  • Information and Referral
  • Screening and assessment
  • Crisis intervention
  • Eligibility Determination
  • Benefits counseling
  • Accessible through multiple locations senior
    centers, AAAs, housing authorities, mental health
    centers, etc.

36
Florida
  • Implemented physical or virtual co-location of
    eligibility determination staff
  • All AAAs purchased a common IR software system,
    ReferNET (abandoned previous IR software)
  • Planned interface between ReferNET and client
    data management system
  • 2-1-1 system contracted in two areas and provides
    front door to IR

37
Florida
  • State funds appropriated for continuation
  • First year 3.3 million in general revenue
  • Following years, half of funds drawn through
    federal Medicaid administrative match for proper
    and efficient administration of Medicaid
  • Strong volunteer involvement, local coalitions
    provided buy-in
  • Oversight by legislative monitoring body

38
Tennessee
  • State structure
  • Department of Finance and Administration is
    Medicaid agency, administers TennCare
  • Department of Human Services financial
    eligibility
  • Department of Mental Health and Developmental
    Disabilities
  • Commission on Aging and Disability administers
    waiver, state funded program and OAA, performs
    assessment for functional eligibility
  • AAAs perform intake, assessment and case
    management (either directly or through contract)

39
Tennessee
  • Awarded ADRC grant in 2005-2008 will request a
    no cost extension
  • 2 pilot sites
  • Serves all 60 also 21 with physical
    disabilities
  • One-stop single entry points for access to
    information, counseling, assistance and linkages
    to services and living options
  • Arrangements for needed services
  • 2-1-1 service will refer to ADRCs

40
Tennessee
  • ADRCs
  • Have reduced time for waiver services from 200
    days to 45 days
  • Plan to go statewide, but funding is issue
  • State has 500 million deficit
  • Will apply for grants
  • Electronic client tracking system based on
    current system to enable client data transmission
    between offices was planned, but challenges with
    different state agencies, forms have caused state
    to re-think

41
Kansas
  • State structure
  • Kansas Health Policy Authority is Medicaid Agency
  • Department of Social and Rehabilitative Services
    determines financial eligibility (will move to
    KHPA with new IT system support)
  • Department on Aging determines functional
    eligibility based on CARE assessment
  • AAAs employ or contract for case management and
    perform CARE assessment

42
Kansas
  • Awarded ADRC grant 2005-2008
  • Started with serving persons 60 added services
    for 18 with mental disabilities
  • No wrong door approach between AAAs and CMHCs
  • Two pilot sites one urban and one rural

43
Kansas
  • Web-enabled virtual resource centers and
    web-based resource manual for access to current
    information.
  • Streamlined financial eligibility determination
    process
  • Using added resources from the Department of
    Social and Rehabilitation Services (SRS) Real
    Choice Systems Transformation grant

44
Arkansas
  • State structure
  • Department of Human Services is umbrella agency
  • Division of Medical Services Medicaid
  • Division of Aging and Adult Services determine
    functional eligibility
  • Division of County Operations determine
    financial eligibility
  • AAAs provide direct services, including Medicaid
    funded services, administer OAA at local level

45
Arkansas
  • ADRC grant awarded in 2004, a no cost extension
    approved
  • Primarily information, referral and assistance
  • Pilot in rural AAA in southwest Arkansas
  • Co-located with senior center and a housing
    office for seniors and disabled adults.
  • Did not pursue replicating, cost prohibitive.

46
Arkansas
  • Received 5-year Systems Transformation grant in
    2005 for 2.8 million
  • Complete establishment of one-stop service system
    statewide
  • Quality management system
  • Develop statewide primary care case management
    program
  • Will pilot with a AAA

47
Arkansas
  • January 2008, a statewide multiple entry system
    opened for long term care services and supports
    regardless of payer source.
  • Target audience is seniors and adults with
    disabilities with secondary focus on physicians,
    hospital discharge planners, social workers, and
    others in community involved in service planning.
  • In 2007, legislation passed requiring
    post-admission screening, to begin June 1, 2008
  • 2-1-1 just now coming on-line, so no interaction
    with ADRC at this point

48
Arkansas
  • Propose to transform from paper-based
    application, assessment, plan of care and case
    record processes into web-based
  • Challenging aspect of this project
  • Plan to submit APD for 90 federal match

49
Arizona
  • State structure
  • Arizona Health Care Cost Containment System is
    Medicaid agency provides services in managed care
    environment and determines functional eligibility
  • Department of Economic Security
  • Division of Aging and Adult Services administer
    OAA funds
  • Division of Benefits and Medical Eligibility
    determine financial eligibility
  • Division of Developmental Disabilities
  • AAAs administer OAA, do not do direct services

50
Arizona
  • Awarded ADRC grant in 2005 through 2009, with a
    no cost extension
  • Started with serving all 60 as well as 18 with
    physical disabilities
  • Added adults 18 with developmental disabilities
  • No wrong door approach using virtual resource
    center
  • Screening tool available in two counties, with
    plan to go statewide
  • Integrate existing programs using 2-1-1 system

51
Arizona
  • Developing the IT system is challenging due to
    multiple users with differing systems.
  • Training for the stakeholders was one of the
    best things done under this project.

52
Observations
  • Technology is a key component to full
    implementation, also a challenging component
  • not always part of first phase
  • Requires high degree of collaboration and
    cooperation among state officials and state aging
    and disability networks
  • Input and buy-in from community partners is
    required for successful implementation
  • Can be phased in

53
Discussion Questions
  • Missouris Approach

54
Senate Bill 577
  • Comprehensive Point of Entry (CPE)
  • Delivery system easy to understand with access
    through multiple points
  • Offer an array of LTC choices, info assistance
  • Efficient - reduce duplication, streamline access
    to multiple funding sources and programs
  • Strengthen QA and QI
  • Timely access to, payment for cost effective
    care
  • Study one-stop shopping for seniors

55
Lt. Governors Charge
  • Statewide, universal information and assistance
    system for all ages, disabilities
  • Integrated with MO HealthNet via web-based
    electronic patient health record
  • Pre-admission screening mechanism and care plan
    assessment tool to help guide consumers, families
    and caregivers to appropriate services and
    providers
  • Case management or care coordination system
    available as needed

56
Questions for Missouri
  • How do people learn about LTC options today in
    Missouri? What works well in Missouris current
    system of outreach, I R system? Does it work
    well for all populations?
  • What doesnt work well or needs to be improved?

57
Questions for Missouri
  • What populations should be served through
    Missouris SEP?
  • What services should be part of (accessible
    through) a SEP in Missouri? What processes
    should be standardized (the same for all who
    enter, at all sites)?

58
Questions for Missouri
  • What are the logical entry points/agencies in
    Missouris system?
  • Is Missouri looking for a physical site of entry?
    What services should be available through a
    virtual system?

59
Questions for Missouri
  • What best practices in other states are of
    greatest interest to the group?

60
Recapping
  • Populations Who is to be served?
  • Functions What services are to be provided?
  • Locations Where (what agency/ies) will serve
    as entry point?
  • Accessibility How will people contact the
    entry point?
  • Implementation Pilot? Phased? Statewide?
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