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California Community Choices Financing Study

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California Community Choices Financing Study Powered By Docstoc
					A Presentation to the Achieving Olmstead Implementation in
                     California meeting

                    Leslie Hendrickson
                 Hendrickson Development
                   September 29, 2010
           Policy Arctic Zone
 Policy freezes in waning months of an administration.
 Governor is fund raising for new library to store papers.
 Legislators busy running for reelection.
 Key staff leave for lucrative lobbying jobs.
 Printing costs go up because of resume copying.
 Secretaries begin shredding documents.
 Campaign workers fantasize about possible state jobs.
What to Do from Advocate’s
       Point of View
 Good time to plan and organize.
 Need to have coherent strategy and asks for next
 Coherent strategy contains clear tasks, alternatives,
  timelines, and implementation ideas.
 Not enough to have asks, must also show how to meet
  Where Asks Come From?
 What is Olmstead in 2011?
 What has been achieved?
 What needs to be achieved?
 How to bridge the gap from what is to what should be?
Home and Community
Based Long‐Term Care
 Big report, 300 pages, not beach reading.
 1,300 hits on it since November 2009 not counting
  hard copies.
 Two authors, but in reality is group effort.
 Reviewed all California long-term living programs.
 Emphasis on finance.
 Suggested both incremental and broader changes.
 Time to implement
    General
    Short-term (12 months)
    Medium-term (12 – 24 months)
    Longer-term (24 months or longer)
 Category
    Access/delivery system
    State-level organization
    Financing
  If you know where you are
 going it is easier to get there
 Establish a philosophy and legislative intent for all long-
  term services and supports.
    Currently only described for specific programs
    No overall statement of intent for the “system”
 Develop a strategic plan for long-term services and
    Populations addressed
    Timetables, responsibilities and measureable goals
            New Department
 Create a Department of Long-Term Services and Supports.
 Little Hoover Commission recommendation.
 Possible components.
    In Home Supportive Services
    Multipurpose Senior Services Program
    Assisted Living Waiver Program
    Other HCBS waivers
    Substance abuse and mental health programs
    Housing component
    Eligibility and level-of-care determination
    Nursing home, residential, and RCFE licensing
       Everybody has a dual
 Need to stop slicing and dicing by diagnosis.
 Who is responsible for 64-year old person with intellectual
  disability, Alzheimer's, and a mental health issue?
 Inefficient policy to think of these as separate programs.
 Same persons served by different programs
 Movement of persons through programs is masked by data
  systems and organizational boxes that do not record or
  describe relations among programs. Oregon example.
 Think of it as a long-term living population that use
  medical, behavioral, long-term services as need changes.
       Functional Equivalent
 Informal organizations now span departments
 Can build formal organizations that span Departments.
 Management databases spanning programs.
    Examples of Washington and Oregon
 Collect data on all persons regardless of program:
    Acuities ADLs, IADLs, medical conditions, ID and MH
    Establish service levels
    Record and monitor services and costs
 Programs are managed as one program even though they span
Diversion and
 Diversion is about improving hospital discharge planning.
 Work with hospitals to provide preadmission
  screening/options counseling for individuals who:
    Seek admission to a nursing home
    Discharged from a hospital with health & supportive service
 Provided by single entry points, ADRCs, community
 Priority groups:
    Medi-Cal beneficiaries
    Likely spend down within 3 or 6 months
    Current Diversion Efforts
 Medical Case Management Program.
 Hospital-to-Home (H2H) Project. Operations begin in
  2011. Helps person leave hospital well. To be
  implemented in four ADRCs. Four week intervention,
  low-cost, low- intensity model. Test of Coleman
  Transitions model. Coach is employee of ADRC. Serves
  all persons regardless of payor source. Prevents
  readmission to hospital.
 CalCareNet.
 Nursing Facility AH waiver.
 Transition is about improving nursing home discharge
 Establish a statewide nursing facility case management
  function to support residents relocating to community.
 Expand Money Follows the Person project.
 Provide funds to help Independent Living Centers, MSSP
  sites, Area Agencies on Aging, other non-profits and
  counties to expand transition programs.
 Takes years to build an effective infrastructure.
  Pennsylvania program is now 11 years old.
   Current Transition Efforts
 Money Follows the Person
   Encouraging report to July 15, 2010 Olmstead Advisory
   216 transitioned, 341 in pipeline.
   Now 15 MFP lead provider agencies serving 44 counties.
   The 12 “seasoned’ providers have 20 full and 4 part time
    workers, the three new agencies have 1 worker each and the
    Developmental Centers have 11.
   Have approval to fund 34 positions to help 100 persons
    transition from Lanterman on 2011, then rest of
    approximately 300 persons in 2012 and 2013.
Expanding Transition Efforts
 Heart of Olmstead implementation is transition ask.
 Based on PA, NJ and TX efforts, reasonable California
  goal is transitioning 2,000 a year from NFs.
 Number transitioned is a function of labor input.
 Average transition worker helps 22-23 aged persons per
  year. Average transition worker helps 9-10 persons with
  disabilities per year.
 Number of workers needed depends on spilt between aged
  and persons with disabilities. E.g. if 80% and 20% would
  need about 115 FTE transition workers, given vacations
  and sick leave say 135 workers + or – to get to 2,000.
  Work With Nursing Homes
 Need cooperation of homes with transition efforts.
 Help nursing home by transitioning residents nursing
  home does not want.
 Homes might need help to do subacute or change business
  model. E.g. Nebraska grants to convert to assisted living.
 Need implementation of new MDS Section Q on
  discharge planning. Help homes improve discharge
  planning and develop referrals to local contact agencies. Q
  requirements came with no additional funding.
 Carrot and stick is more effective than only the stick.
      Understanding Budget
 Budget analysts are always working on the budget and
  there is never a good time to talk with them.
 If you wish to talk with a budget analyst do not use words.
  Budget analysts do not write memos. They do fiscal
  impacts. Talking about your good program wastes time.
 Unspoken rules you might encounter
   The answer is always No.
   If given estimates by program, before you begin work, add
    10% to their costs, cut their savings estimate 10%.
   Nothing is cost effective.
                 The Engine
 Need to manage the programs as though they are one
 Savings from reducing use of expensive services are put
  back into funding alternatives from expensive services.
  Successful states, Texas, Pennsylvania, Oregon,
  Washington have figured out how to do this.
 Transition programs are cost effective. Waiver programs
  can be cost effective and should be expanded.
 Transfer savings from individuals who transition from
  nursing facilities to HCBS programs
          Cost effectiveness
 Question should be under what conditions are alternatives
  to institutions cost effective.
 Alternative programs have substantial cost avoidance
  impact on nursing facility budget. IHSS probably has
  primary impact.
 Waivers are probably cost effective if you look at a “break
  even” analysis. Cost differences are so large that waivers
  would be cost effective if only a small number would have
  been in the institution.
 Nursing home transition programs are very cost effective,
  e.g. $200m. in savings in Pennsylvania.
Streamline Access to HCBS
 Create single entry points for older adults and adults with
  physical and mental disabilities.
 Scope of programs and activities
 Possible entities
    Regional Centers are single point of entries.
    San Diego close
    ADRCs – Now seven covering ten counties. State now
     focusing on ADRC expansion since AoA
    MSSP sites
    Area Agencies on Aging
 Need to co-locate financial eligibility workers in
  SEPs/ADRCs e.g. Riverside.
  Help Individuals in Nursing
   Facilities Keep a Home
 Increase the home maintenance allowance.
    Allows individuals admitted to a nursing home to retain
     income to maintain their home.
    Must expect to return home within 180 days.
    Current allowance is $209 a month, unchanged since July
    Options: Up to actual monthly cost of home, Exempt up to
     100% FPL; Percentage of the SSI/SSP payment; Total
     SSI/SSP payment.
              Keep a Home…
 Maintain the SSI/SSP eligibility status for short-term
  nursing home admissions.
    California is “1634” state meaning Social Security
     Administration does SSI eligibility.
    Need to be sure individuals in a nursing home for less than
     90 days receive their full SSI/SSP payment to maintain their
Services in Residential Settings
 Offers options for people who need access to services for
  unscheduled needs, oversight and supervision.
 Program options:
   Change current law to allow IHSS payments in RCFEs
   Expand assisted living waiver statewide. Currently has
    1,000 waiver participants, 70 providers in 4 counties. Had
    186 participants in 2006
   Add assisted living services and adult foster homes to all
    other waivers, why restrict to one waiver.
   Add behavioral health services to all waivers.
Expedite Financial Eligibility
 Allow case managers to presume financial eligibility and
  enroll applicants in an HCBS waiver to avoid nursing
  facility admission.
 “Fast track” the eligibility process.
 Co-locate financial eligibility workers with single entry