Primary Home Care PHC Community Attendant Services

							House Committee on Human Services
Department of Aging and Disability Services
Commissioner Chris Traylor
February 22, 2011
Table of Contents
DADS Vision and Mission
Overview
Demographics
Organization
Access to Services
HB 1 Issues
Medicaid Entitlement Services
State Supported Living Centers
Medicaid Community Services 1915 (c) Waivers
Other Federally Funded Services
State Funded Services
Regulatory Services
Promoting Independence Initiative and Money Follows the Person

DADS Vision and Mission
Vision
Older Texans and persons with disabilities will be supported by a comprehensive and cost-
effective service delivery system that promotes and enhances individual well-being, dignity, and
choice.

Mission
To provide a comprehensive array of aging and disability services, supports, and opportunities
that are easily accessed in local communities.

Overview of Services and Programs
The Texas Department of Aging and Disability Services (DADS) provides long-term services
and supports to a wide range of individuals. Long-term services and supports are services to
meet an individuals health or personal care needs over an extended period of time and may
include:
     Assistance with bathing, toileting dressing, eating
     Meal preparation
     Relief for caregivers
     Home modifications and repairs
     Transportation
     Adaptive aids
     Services at licensed facilities
     Nutrition services such as home delivered meals or meals at senior centers



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These populations include:
    Individuals with physical disabilities
    Individuals with intellectual and developmental disabilities
    Individuals age 60 and older, their family members and other caregivers, who are eligible
       for services under the Older Americans Act

DADS also regulates providers of long-term services and supports.

Demographics
Aging is one of the most important demographic trends affecting Texas. Texas has the fourth-
largest population of older adults in the U.S.
     By 2040, older adults will be almost 17% of Texas population, compared to fewer than
        10% in 2000.
     Texas’ age 60 and older population is expected to increase by nearly 50% between 2010
        and 2040, with a more than 50% increase in those aged 85 and older by 2020.
     As trends continue, needs and issues of aging Texans will have an important impact on
        the state’s health and human services system.
     The gradual aging of the population may lead to an increase in the number of people with
        a physical disability or other chronic health condition.

In 2008 there were approximately 2.8 million, or 11.6%, of Texans who lived with a physical
disability.
     Among adults aged 18-64, only 10.2% had a physical disability in 2008. However,
        among adults aged 65 and older, 42.4% live with a disability.

According to test standards and studies, about 2.7% of the Texas population (or about 679,000
people) are at or below an IQ score of 70 and have some degree of intellectual disability.

DADS Organization
DADS is organized into three main functional areas:
   Access and Intake
         o Area Agencies on Aging
         o MR Authorities
         o Community Services and Program Operations
         o Guardianship Services
         o Community Services Contracts
   Regulatory Services
         o Licensing
         o Survey
         o Enforcement
   State Supported Living Centers

Access to Long-Term Services and Supports
Individuals can obtain long-term services and supports through a variety of local access and
entry points. These include:


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      Area Agencies on Aging (AAAs) - help older persons, their family members and other
       caregivers by providing information, benefits counseling and assistance in accessing
       community services
      MR Authorities (MRAs) - provide eligibility determination, assessments and assist
       individuals in accessing appropriate services and supports
      DADS Regional offices - assist individuals with accessing appropriate services, complete
       assessments and determine eligibility for programs that provide alternatives to
       institutional placement

H.B. 1 Issues
Summary of H.B. 1 Issues
   Funding for Medicaid Services
   Service Delivery
   Goal D – Managed Care Expansion Transfer
   Continuation of Movement Toward Community Services
   Increased Demand for Services
   Settlement Agreement with the Department of Justice regarding DADS SSLCs

Implementing H.B. 1
Affordable Care Act provides almost no flexibility to reduce caseloads; provider rate reductions
are an option
     Will take every effort to avoid across-the-board provider rate reductions
     Will take every effort to protect access to care

Historically, when access to community services has been curtailed, caseload growth in DADS’
institutional services programs – nursing facilities and Intermediate Care Facilities for Persons
with MR (ICFs/MR) (which include State Supported Living Centers) has increased.

Medicaid Entitlement Services
 “Entitlement” means that the federal government does not, and a state cannot, limit the number
of eligible individuals who can enroll in the program. Each individual who meets eligibility
requirements must be served, and Medicaid must pay for any service included in the State
Medicaid Plan.

States are not allowed to establish waiting lists for entitlement services.

The long-term services and supports Medicaid entitlements in the Texas state plan include both
institutional and community-based services.

Institutional entitlements
    Nursing facilities
    Intermediate care facilities for persons with MR (ICFs/MR) – includes State Supported
       Living Centers
    Hospice, a service that may be received in a home, community or facility setting



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Community-based entitlements
   Primary Home Care (PHC)
   Community Attendant Services (CAS)
   Day Activity and Health Services (DAHS)

State Supported Living Centers
DADS operates state supported living centers, which are certified as intermediate care facilities
for persons with MR (ICFs/MR).

State supported living centers (SSLCs) provide residential services and supports for persons with
intellectual disabilities at 13 locations:
     Abilene
     Austin
     Brenham
     Corpus Christi
     Denton
     El Paso
     Lubbock
     Lufkin
     Mexia
     Richmond
     Rio Grande (Note: The Rio Grande State Center is operated by the Texas Department of
        State Health Services and provides ICF/MR services through a contract with DADS.)
     San Angelo
     San Antonio

Medicaid Community Services 1915(c) Waivers
Federal laws and regulations also provide flexibility for states to design waiver programs to
address the needs of a specific population.

      A “waiver” is an exception to the usual Medicaid requirements, granted to a state by the
       Centers for Medicare and Medicaid Services (CMS), usually to provide services in home
       and community-based settings rather than an institution.
      A state’s authority for waivers comes from the federal Social Security Act.
      A state must ensure overall cost neutrality of a waiver compared to the cost of the
       institutional entitlement.
      Waiver programs provide community-based services and supports to an individual who
       would have qualified for admission to a nursing facility or an ICF/MR.
      In contrast to the entitlements, which are automatically available to individuals statewide
       who meet the eligibility criteria, waiver programs may limit:
           o Scope of eligibility
           o Geographical location in which services are provided
           o Scope of services
           o Amount of services
           o Number of people served


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           o Delivery model of services

Medicaid community services waiver programs:
   Three waive off nursing facility eligibility:
          o STAR+PLUS
          o Community-Based Alternatives (CBA)
          o Medically Dependent Children Program (MDCP)
   Four waive off ICF/MR eligibility:
          o Home and Community-based Services (HCS)
          o Community Living Assistance and Support Services (CLASS)
          o Deaf-Blind with Multiple Disabilities Program (DBMD)
          o Texas Home Living (TxHmL)
   One waives off both nursing facility and ICF/MR eligibility:
          o Consolidated Waiver Program (CWP)
   Waiver programs are administered by DADS, with the exception of STAR+PLUS, which
      is administered by HHSC.
   An individual can be enrolled in only one waiver program. Legislative appropriations
      determine the availability of waiver services.

Other Federally Funded Services
Eligibility requirements vary by program.

      Services funded with other federal dollars (Services may be funded in part by general
       revenue.)
           o Community Services and Supports (Title XX Block Grant)
                   Adult foster care
                   Consumer-managed personal assistance services
                   Day Activity and Health Services
                   Emergency response (electronic call system)
                   Family Care
                   Home delivered meals
                   Residential care
                   Special services for persons with disabilities
           o Older Americans Act Funding
                   Access and Assistance Services
                   Nutrition Services
                   Services to Assist Independent Living
                   Services for Caregivers

State Funded Services
Eligibility requirements vary by program
     State funded services
             o Guardianship Services
             o In-Home and Family Support – Community Services (IHFS-CS)
             o In-Home and Family Support Services for Persons with MR (IHFS-MR)
             o Community Services for Persons with MR


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Regulatory Services
The State of Texas requires that all providers of long-term services and supports be licensed or
certified and in compliance with all licensure rules.

Providers wishing to participate in Medicare and/or Medicaid programs must be certified and in
compliance with federal regulations under Titles XVIII and/or XIX of the Social Security Act.

DADS is responsible for regulating the following long-term services and supports providers (As
of December 31, 2010):
     Nursing Facilities - 1,195 (licensure and certification)
     Intermediate Care Facilities - 860 (licensure and certification)
     Assisted Living Facilities -1,618 (licensure)
     Adult Day Care Facilities some of which may provide Day Activity and Health Services -
       477 (licensure)
     Home and Community Support Services Agencies, including home health, hospice, and
       personal attendant services – 5,482 (licensure and certification)
     Home and Community-based Services waiver providers - 660
     Texas Home Living waiver providers -111

In addition to regulating providers, DADS administers licensing, certification and permit
services for employability as:
     Nursing facility administrators
     Nurse aides
     Medication aides

Regulatory processes include:
    Survey Process
          o Annual surveys of long-term services and supports facilities and agencies
          o Complaint investigations
    Enforcement Process
          o Appropriate enforcement actions based on the scope and severity of identified
              problem areas
    Appeals Process
          o If, during the regulatory process, a provider disagrees with findings and/or
              recommendations made by a survey team, appeals processes provide due process
              review

Promoting Independence Initiative and Money Follows the Person
Promoting Independence Initiative and Plan
The Texas Promoting Independence Initiative (Initiative) and Plan are Texas’ response to the
Olmstead Supreme Court Decision (1999) which addressed an individual’s right to a choice on
where they want to live to receive long-term services and supports. There are supporting
Governors’ Executive Orders and legislation.




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The Initiative is the state’s effort to identify barriers to community living and make
recommendations for changes to state policy in order to be in compliance with Olmstead.

Original and revised plans are available at:
http://www.dads.state.tx.us/providers/pi/independence_plan.html

Money Follows the Person Demonstration
DADS is participating in the federal Money Follows the Person Demonstration. This program
provided enhanced federal funding to assist Texans across disabilities and age to move back into
their communities from institutional settings. The Texas program includes several pilot projects
to help remove barriers for individuals with complex needs to move back to their community.
Two of the more notable pilots include:

      Voluntary Closure of nine or more bed ICFs/MR
          o All individuals are given their choice of where they want to live
          o 10 facilities have closed or are in the process of closing. This equals 780 beds
              coming off-line with a total census of 490 individuals
      Behavioral Health pilot is a collaboration with the Department of State Health Services
       and the Health and Human Services Commission
          o Provides two additional demonstration services to address substance abuse and
              mental health issues in Bexar County and Austin
          o 74 individuals have moved into the community with these services




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