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The Changing Face of Long-Term Care: Yesterday, Today and Tomorrow

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Title: The Changing Face of Long-Term Care: Yesterday, Today and Tomorrow


1
The Changing Face of Long-Term CareYesterday,
Today and Tomorrow
  • Michael P. Starkowski
  • Commissioner, DSS
  • January 9, 2009

2
Overview of The Department of Social Services
3
State of Connecticut Appropriations (General
Fund)SFY 2009 17.1 Billion(Legend Amounts
in Millions)
4
Core Programs Based on Appropriated SFY 2009
Funds
5
SFY 2009 DSS Appropriation for Core Programs
6
DSS Health Care Appropriations SFY 2009
7
Medicaid Services by Category SFY 2009
8
Long Term Care by Category SFY 2009
9
Total Population that Received Health Care
Services from DSS in November, 2008TOTAL
579,472
Includes waiver and state-funded Includes
CADAP, Refugee, breast and Cervical, etc.
10
Medicaid Nursing Home Expenditure Comparison
numbers in yellow represent costs minus user fee
impact SFY 09 Based on Original Appropriation
11
Medicaid Nursing Home ClientComparison
Average Medicaid Nursing home clients 7/08-12/08
12
Licensed Nursing Home Beds
13
Homecare Client Comparison
14
CON and Rate Setting- Int. Rate Requests
  • Census Issue - 91.4 occupancy as of December
  • SFY 2008
  • 16 facilities
  • Annual impact 4.6 million- requested 11.2
    million
  • SFY 2009
  • 27 facilities received rate relief to date, 7.9
    mil. requested 19.8
  • Approximately 15 pending to date, 6.7 mil.
    requested
  • 10 of the 14 facilities are former Haven, 3.6
    mil. relief, 9.0 requested

15
CON and Rate Setting- Rec./Bankruptcies
  • Receiverships
  • Haven 3 facilities (Danielson, Norwich,
    Waterford-closed, Windham)-transition to Colonial
    Health 2/09
  • Marathon 6 facilities (Prospect, Torrington,
    Norwalk, West Haven, Waterbury, New Haven)
  • Crescent Manor
  • Bankruptcies
  • Affinity Healthcare 4 facilities (Alexandria,
    Blair, Douglas, Ellis Manor)

16
Nursing Facility Closures
  • Facility Closures
  • SFY Facilities Beds Avg. Size
  • 2002 3 267 89
  • 2003 4 324 81
  • 2004 5 498 100
  • 2005 3 487 162
  • 2006 1 59 59
  • 2007 2 180 90
  • 2008 0 0 0
  • 2009 ytd 2 190 95
  • 20 2,005

17
Nursing Facility Closures
  • 2007 Closures
  • Darien Health Center 120
  • Oakcliff, Waterbury 60
  • 2008 0
  • 2009YTD
  • New Coleman Park 100
  • Haven Waterford 90
  • Within 30 days of the filing of a Letter of
    Intent for facility closure, DSS must hold a
    Public Hearing at the nursing home (PA
    07-209).

18
Assisted Living Services In the CT Home Care
Program For Elders
  • To qualify for Assisted Living services,
    applicant must meet functional and financial
    eligibility requirements for the Home care
    Program either State funded or Medicaid Waiver
  • Program pays for services only, not room and
    board
  • Assisted Living is available in 4 different
    settings
  • State Funded Congregates
  • HUD Facilities
  • Private Assisted Living Facilities
  • Demonstration Affordable Assisted Living
    facilities
  • Costs range from an average of 1171 per month,
    per client to 1842 per month

19
Assisted Living Settings
  • State Funded Congregate
  • 17 sites throughout the state
  • 80 participating clients
  • HUD facilities
  • 4 participating-Immanuel House in Hartford,
    Juniper Hill Village in Storrs, Tower One/Tower
    East in New Haven and Welles Country Village in
    Talcottville
  • 150 participating clients

20
Assisted Living Settings
  • Private Assisted Living pilot
  • 33 facilities are participating
  • Pilot serves 75 clients that is the maximum
    allowed by statute
  • Waiting list of103 clients that appear to meet
    eligibility requirements
  • Wait exceeds 1 year
  • Assisted living Demonstration Projects
  • 4 sites- Hartford, Glastonbury, Middletown and
    Seymour
  • 199 participants

21
Money Follows the Person Rebalancing Demonstration
22
Goals of Demonstration
  • Reduce reliance on institutional care
  • Increase effectiveness and efficiency of the long
    term care system

23
What is Money Follows the Person?
  • Individuals participating in Medicaid have a
    choice about where they live and receive
    long-term care services.

24
Two Programmatic Components
  • Design and implementation of a transition
    initiative moving people from institutions to
    communities and supporting them with community
    services for 365 days
  • Design and implementation of infrastructure
    change initiatives supporting the States
    capacity to develop high quality care in the
    community.

25
Rebalancing in ConnecticutKey Focus Areas for MFP
  • Assure pathway back to community for those
    institutionalized
  • Address critical pathways to institutions
  • Address HCBS gaps, capacity, quality and housing
    in community.

HCBS
Institutional Care
25
26
MFP Outcomes
  • Transition 700 people to the community
  • Eligibility
  • Institutionalized for 6 months and,
  • Eligible for Medicaid in the community and,
  • Eligible for one of the community service
    packages.

27
Transitions by Target Population as Approved in
Operating Protocol
Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year Number of People Transitioned by Target Population by Calendar Year
Elderly Physical Disability Physical Disability MI MR MR Chronic Care Total
PCA ABI Ind Comp
2009 95 51 11 46 11 11 2 227
2010 78 41 10 41 10 10 14 204
2011 94 49 13 54 13 13 33 269
Total 267 141 34 141 34 34 49 700
Percentage 38 20 5 20 5 5 7 100
28
Housing Options
  • Qualified Residences
  • Assisted Living
  • Apartment
  • Group home with fewer than 4 unrelated persons
  • Family home

29
MFP OutcomesDecrease hospital discharges to
nursing facilities among those requiring care
after discharge.
Percentage of persons discharged to institutions Percentage of persons discharged to the community
2007 51 49
2008 51 49
2009 50 50
2010 48 52
2011 46 54
30
MFP Outcomes
Increase probability of returning to community
within first 6 months of admission to
institution.
  • Note Estimating 100 persons transitioned per
    year under this initiative

Calendar Year Increased Probability
2008 39
2009 40
2010 41
2011 42
31
MFP Outcomes
Increase percentage of persons receiving long
term care services in the community relative to
the number of persons in institutions.
  • HCBS State Plan Option
  • Waiver for persons with Mental Illness
  • State plan supports and services

Percentage of persons living in institutions Percentage of persons living in the community
2007 48 52
2008 47 53
2009 46 54
2010 45 55
2011 43 57
32
Status of Contract Staff
  • 28 transition coordinators are working at a local
    level within Area Agencies on Aging and
    Independent Living Centers.
  • 20 of the transition coordinators are working
    with MFP applicants
  • 8 are working with applicants not eligible for
    MFP
  • 5 housing coordinators are identifying housing
  • Housing Coordinators are located at FSW, Inc,
    HOME, Inc, and Housing Education Resource Center.

33
Status Update on Applications
  • Program announced on December 4.
  • 330 applications have been received representing
    106 nursing facilities
  • 300 applicants have been pre-screened for
    eligibility
  • 289 applicants are eligible based on pre-screen
  • Expressed desire to return to the community
  • Eligible for Medicaid/Community Service Package
  • Institutionalized for at least 6 months
  • 87 (30) of the applicants are over the age of 65.

34
Transition Process
  • DSS Completes eligibility Pre-screen
  • Institutionalized 6 months
  • Medicaid eligible

DSS refers pre- screened applicants to
Transition Coordinators Establish first meeting
Initial MFP application Received (330)
Informed Consent and Application for Services
Completed at First Meeting Referred to
appropriate waiver manager If housing needed,
contact housing coordinator
Eligibility for target waiver determined If
eligible, care plan developed
Discharge Date Established Housing in place
Transition to community
35
Status on Information Technology
  • Eligibility Management System and Interchange
    modifications in place to track all MFP
    participants
  • This allows us to produce reports and analyze all
    service utilization expenditures for MFP
    participants
  • This also allows us to monitor reinstitutionalizat
    ion including hospitalization.

36
Status MFP Quality Management
  • Emergency Back up Support System
  • 24/7 emergency line staffed by case manager
  • Model developed to address personal care
    emergencies in all areas of the state
  • Implementation initiated week of December 29.

37
Status MFP Quality Management
  • Web based database is completed and in final
    testing. The web based system gives us the
    ability to track and report
  • Variables indicating transition progress or
    delays for MFP participants
  • All critical incidents and abuse for MFP
    participants served by DMHAS, DDS, and DSS
  • Emergency back up staff utilization.

38
Status MFP Quality Management
  • UCONN Center on Aging is under contract as
    external evaluator
  • Collect and analyze data related to
  • Quality of Life
  • Assistive Technology
  • Gaps in long term care system

39
Status MFP Quality Management
  • Data from Interchange, the web based system, and
    UCONN will be analyzed on a regular basis
  • First area of focus is workforce reliability
  • Quarterly reports will be submitted to the
    Commissioner recommending systems improvement
    based on data.

40
Improving Workforce Reliability
  • As we increase demand for community services, the
    supply of direct community workforce must
    increase.
  • Workforce Development Workgroup established in
    December 2008
  • Membership includes UCONN Center on Aging,
    Commission on Aging, DSS Aging Services, DSS
    Bureau of Rehabilitation, DSS Alternate Care
    Unit, Ombudsman, DMHAS, DDS, providers, and
    consumers.
  • Align resources through coordination with
  • Medicaid Infrastructure Grant, Office for
    Workforce Competitiveness, The Connecticut
    Employment Training Commission, Department of
    Labor, etc.

41
Additional Workgroups addressing MFP Focus Areas
  • Transition Workgroup Review/revise nursing home
    resident outreach and identification methodology
    to assure that we meet the goal of 700
    transitions by December 2011
  • Members include DSS Aging Services, DSS Regional
    Office, Connecticut Community Care, Inc, AAAs,
    NAMI, DMHAS, DDS.
  • Hospital Discharge Planning Workgroup Create
    plan to increase number of persons discharged to
    community after hospitalization rather than to an
    institution
  • Outreach to hospitals
  • Members include DSS Aging Services, DMHAS, DDS,
    Ombudsman, Alzheimers Assoc, Acquired Brain
    Injury Association, Hospital Discharge Planners,
    Connecticut Community Care Inc, Area Agencies on
    Aging
  • Housing Workgroup Design and implement MFP
    strategic housing plan
  • Department of Economic and Community Development,
    HUD, Corporation for Independent Living, New
    Samaritan, DSS Housing Unit, HOME, Inc, HERC, FSW
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