Title: Missouri
1Missouri
- Comprehensive Entry Point for Long Term Services
and Supports - Presented by Barbara Edwards, Principal
- Health Management Associates
- May 27, 2008
2Why LTC Reform?
3People 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.
4Medicaid 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.
5Baby 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! -
6Americans 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
7Federal 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
8Federal 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
9Federal 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
10ADRCs 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
11ADRC Grants
- Grey2003 Yellow2004 Blue2005
12Federal 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
13Federal 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
14State 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
15CMS 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
16Case 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
17Case 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
18A Word about Terminology
- That which we call a rose by any other name
would smell as sweet. - Shakespeare
19Terminology
- 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!
20Terminology
- 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
21Terminology
- 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
22Terminology
- 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
23Senate 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
24Components of SEP
- It isnt what you CALL it but what it IS that
matters.
25CPE 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
26CPE Components
- Functions performed (some or all)
- Information and referral
- Initial screening
- Assessment
- Benefits counseling
- Nursing home pre-admission screening
27CPE 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
28CPE 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
29CPE Components
- Accessibility (some or all)
- Face-to-face
- Telephone
- Internet
- Second party referral
20
30Other State Practices
31Other State Practices
- Variables affecting design of entry point models
- Use of 2-1-1
- Funding
- Technology
- State structure
- Pilot/statewideness
32Florida
- 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
33Florida
- 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
34Florida
- 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
35Florida
- 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.
36Florida
- 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
37Florida
- 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
38Tennessee
- 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)
39Tennessee
- 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
40Tennessee
- 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
41Kansas
- 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
42Kansas
- 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
43Kansas
- 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
44Arkansas
- 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
45Arkansas
- 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.
46Arkansas
- 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
47Arkansas
- 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
48Arkansas
- 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
49Arizona
- 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
50Arizona
- 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
51Arizona
- 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.
52Observations
- 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
53Discussion Questions
54Senate 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
55Lt. 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
56Questions 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?
57Questions 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)?
58Questions 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?
59Questions for Missouri
- What best practices in other states are of
greatest interest to the group?
60Recapping
- 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?