State Initiatives in Nursing Facility Transitions

1
State Initiatives in Nursing Facility Transitions
Susan C. Reinhard Co-Director Rutgers Center for
State Health Policy Michigans LTC
Conference Detroit, Michigan March 23-24, 2006
2
Goals

• Highlight key developments in Nursing Facility
  Transition across the country.
• Offer state examples
• Share Michigan State Policy in Practice brief

3
Information about LTC options

• Crucial for consumers, their families and the
  professionals who counsel them
• Once people enter a nursing facility and give up
  their community supports, it is hard to leave.
  Without information, people cannot make an
  informed decision about where to receive
  services.
• States are looking at the best ways to provide
  information

4
Improving Access to LTC

• Nursing Home Transition programs
• Large statewide programs (WA, NJ, Oregon)
• State employees (NJ, WA)
• Smaller programs for most challenging situations
  (SC, CT, MA)
• Locally based organizations (Centers for
  Independent Living, Area Agencies on Aging)
• Hospital Diversion Programs
• Indiana (see Rutgers brief)

5
CMS Nursing Facility Transition Grants

• 12 Demonstration Grants funded 1998-2000
• 160,000 - 175,000 in 1998 thereafter 500,000
• 33 NFT grants funded (to 27 states) in 2001 and
  2002
• 23 grants to state programs 10 grants to
  Independent Living partnerships (6 states
  received grants to both)
• State programs got up to 800,000 ILCs got up to
  450,000
• 30 states total funded in some way

6
Washington A Pioneer

• State funded chore services since 1970s
• 1980s budget crises lead to greater reliance on
  Medicaid LTC benefit
• 1983 Medicaid Waiver Program
• 1989 Medicaid Personal Care Program
• 1993 legislature approves relocation of 750
  nursing home clients to HCBS
• 95-97 budget reduces NH caseload by 1,600 clients

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Legislative direction

• Nurse delegation legislation and ongoing changes
• Global budget provides significant management
  flexibility
• Caseload Forecasting Council projects NH HCBS
  trends
• NH caseload is falling while HCBS absorbs growth
  in service demand

8
Washingtons Aging and Disability Services
Administration (ADSA)

• Manages all state-supported long-term support
  services for older adults and people with
  physical disabilities.
• Administers long-term support services through
  regional offices and 13 AAAs.
• ADSAs and AAAs use common database.

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ADSA Regional Offices

• Staffed by state-employed nurses and social
  workers.
• Conducts initial assessment for Medicaid-funded
  services, functional eligibility determination,
  care plan development.
• Provides on-going case management and
  reassessment for consumers in nursing facilities,
  adult family homes, and assisted living settings.

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Area Agencies on Aging

• Help consumers identify, understand, and access
  available resources through information and
  referrals.
• Provide case management and reassessments for
  consumers living at home.

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Comprehensive Assessment Reporting Evaluation
(CARE)

• Single automated system used by both ADSA
  regional offices and AAAs to
• Assess functional, health, cognitive and behavior
  status.
• Determine long-term care eligibility.
• Develop plan of care.
• Determine maximum number of authorized service
  level.

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Care Plan Development

• Completion of assessment generates report of
  programs the consumer is eligible for.
• Assessor describes programs to consumer.
• Most HCBS are provided using consumer direction.

13
Authorized Service Level Determination

• CARE system authorizes number of in-home hours
  consumer can receive each month.
• Maximum 420 hours/month.
• Standardized service limits.
• Based on consumers clinical and functional
  characteristics.
• Payment levels established for services in adult
  home or assisted living facility.

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Medicaid Financial Eligibility Determination

• Initiated at the same time as functional
  eligibility determination.
• Quick determination (internal goal of 15 days)
• Presumptive eligibility for an individual being
  discharged from hospital.
• Avoid delays that dictate whether consumer
  remains in the community or enters a nursing
  facility.

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Washingtons Nursing Home Relocation

• Assign case managers (social workers and nurses)
  to each nursing facility (one for 2-3 NHs)
• Priority clients new admits (within 7 days), 180
  day conversions others expressing interest
• Provide assistive technology and individualized
  community support services
• Use civil penalty fund and nursing facility
  discharge allowance
• Promote NH capacity reduction and bed conversion
  strategies

WA Aging and Disability Services Administration
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Nursing Home Transition Services

• Case managers contact residents within 7 days of
  NH admission to discuss preferences, care needs
  and supports available in the community.
• Comprehensive assessment completed when consumer
  is ready to work with case manager who develops
  transition plan with consumer.

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Washington Nursing Home Transition Grant

• Strengthen capacity of independent living
  centers, providers, and contractors to provide
  support and technical assistance on independent
  living and consumer-directed services.
• Expand access to accessible, affordable housing
  for people transitioning from nursing homes.
• Improve provision of assistive technology
  services necessary to live in the community.

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Washington NF caseload trends
Figures for July each year
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Washington HCBS trends
Figures for July each year
20
Washington LTC Spending trends (millions
Based on data from the Washington Aging and
Disability Services Administration
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WA Shifting spending balance
22
WA Elders and Adults
23
New Jerseys Three-Pronged Strategyfor
Systems ChangeConsolidation at state
levelCreate more choices for HCBS servicesHelp
consumers find choices
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Help Consumers Find Choices

• NJ EASE (New Jersey Easy Access Single Entry)
• Resource Center
• Information, assistance, care management
• Community Choice Counseling
• nursing home transition program

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Community Choice Counseling

• New Jersey has one of the the largest Nursing
  Home Transition Programs in the country.
• Program uses nurses and social workers to assist
  people to leave the nursing home.

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Foundations of the Community Choice Counseling

• A 1988 state law and its implementing regulations
  provided the opportunity to create the Community
  Choice Counseling program a decade later.
• Nursing Home Pre-admission Screening law in 1988
  (P.L. 1988, Chapter 97)

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Foundations

• All persons who will become eligible for Medicaid
  within six months following NH admission must be
  assessed or Medicaid will not pay.
• Provides the legal framework for the state to
  claim a federal match for the salaries of staff
  performing PAS for almost all people entering a
  NH for a projected long stay.

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Pre-Admission Screening Program PAS

• In 2004, did a total of 33,746 PAS assessments
  (26,686 initial and 7,060 reassessments) to
  determine Medicaid eligibility for LTC services
• 80 of Hospital PAS assessments done within 24
  hours. Rest are done within 72 hours (the policy)

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Foundations

• Track I are unlikely candidates for nursing home
  alternatives.
• Track III are those who are diverted from nursing
  home residence through community placement.
• Track II is the targeted group who cannot be
  immediately diverted from nursing homes, but
  might be able to return to HCBS.

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Foundations

• Track II was the target group for the 1998
  Community Choice Counseling pilot and the initial
  roll-out of this program because the state
  employed nurses already had a legal mandate to
  periodically assess and counsel these nursing
  home residents.
• Important factor in overcoming NH resistance.

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Foundations

• Started with 2 state nurses in 1998.
• Ramped up to 73 professional staff now--mainly
  nurses.
• Transition fund--state dollars, now Medicaid
  waiver.
• Three CMS grants, starting in 1999.
• Currently refining work with younger persons with
  disabilities.

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CCC Practices

• State staff members cross-trained to do PAS,
  options counseling, and transition support.
• 61 registered nurses 12 social workers.
• Assigned specific hospitals and nursing homes.

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CCC The Present

• 2002 pilot with Independent Living Centers
• Round Tables to address the broad and complex
  needs of consumer who needs substantial
  assistance to find housing, social services and
  other community connections for sustained
  community residence.
• Involves Community Choice counselor, consumer, NH
  discharge planner, and others.

34
CCC Results and Future Goals

• As of September 23, 2005, 5,583 individuals have
  been discharged from nursing homes to less costly
  alternative living arrangements since March 1998
• In SFY05, 503 individuals transitioned from
  nursing homes to home and community-based
  services
• In SFY06, goal is to discharge 500 individuals
  through Community Choice Counseling

35
Nursing Facility Transitions Grant

• Divisions of Aging and Community Services (DHSS)
  and Division of Disability Services (DHS), with
  the ILCs, have worked together to transition
  younger disabled adults from nursing homes into
  the community
• In SFY04, 83 younger disabled adults were
  transitioned
• In SFY05, 196 younger disabled adults were
  transitioned

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NF Actual Recipients vs. Recipients Without
Reductions
37
Source NJDHSS, Sept 15, 2004 Trenton, NJ
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Community Choice Counseling Evaluation (Howell
White et al)

• Focus both on the Former Nursing Home Residents
  and the Counselors Perspectives
• Quality of Life for Former Nursing Home Residents
  in terms of
• Current living situation
• Use of services
• Health care service use
• Social support network

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Key Findings

• High satisfaction with their return to the
  community
• Most return home
• Most are alive and remained in the community for
  the full year
• Returning to a NH or being deceased seems to be
  related to frailty and significant adverse health
  incidents

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Status at One Year After Discharge
N1344
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NJA National Model through Aging Disability
Resource Center Grant (ADRC)

• Federal grant of almost 800,000 over 3 years
• Among first 12 states to get ADRC funding
• Department of Health and Senior Services is lead
  agency with Department of Human Services as
  partner
• Redesign aging and disability service systems
  multiple entry points that are coordinated and
  standardized
• Extends to persons 18 years and older with
  physical disabilities
• Major component HCBS/CMS Quality Model Consumer
  Satisfaction

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CCC Integration
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CCC Links to ADRC Initiative

• Nursing Facility Transition Grant
• MI Choice Assessment Tool

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MI-CHOICE Clinical Assessment Tool

• Focus in Warren County ADRC pilot on conducting
  clinical needs assessments and counseling
  consumers on the broad range of home and
  community based services (HCBS)
• Activities include
• Testing MI-Choice the selected clinical needs
  assessment tool
• Streamlining and coordinating PAS and financial
  eligibility process
• Coordinating and arranging HCBS with community
  agencies and Community Choice Counselors

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MinnesotaLong Term Care Consultation

• Preadmission screening was revised by the
  legislature in 2001 into a much broader program
  on long term care consultation. It now includes
• assessment of needs
• assistance in identifying and recommending
  cost-effective home and community-based services
• development of a community support plan
• preliminary determination of eligibility for
  public program support
• transition assistance for people who are
  currently institutionalized

46
MinnesotaLong Term Care Consultation

• Consultation is available to everyone, regardless
  of income or acuity levels
• The statute includes a mandate to provide
  information and education to the general public
  regarding long term care consultation
• Service teams are organized at the county level
  and consist of at least one social worker and one
  public health nurse
• Consumers must be assessed within 10 days of the
  request or referral
• Consumers under age 65 must have a face-to-face
  assessment within 40 days of NF admission

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Minnesota--Results

• Accelerated trend away from institutional
  services and toward community-based services

48
MinnesotaData(Source Minnesota Department of
Human Services)
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IndianaPriority Diversion, Transition and
Options Counseling

• Indiana has diverted over 1,300 consumers from
  nursing facility admissions to home and
  community-based services with its priority
  diversion program implemented in 2003 by AAAs
  working with hospital discharge planners.
• These consumers are given a priority for spots in
  the HCBS waiver program, which otherwise has a
  waiting list, so that they can avoid losing
  housing and community supports

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IndianaPriority Diversion, Transition and
Options Counseling

• Indiana personnel believe that the state would
  benefit by changing its preadmission screening
  process to emphasize long-term care options
  counseling in addition to determining level of
  care needs
• Also looking at restructuring case management
  payments for transitions because the current cap
  on eligible hours may lead to hiring more
  expensive formal care instead of trying to work
  out informal options.

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Importance of Evaluation

• Can help build the case for NHT programs with
  policymakers
• Can provide information to improve the program
• Connecticut and Michigan are examples of this

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Conceptual Model of Transition Relationships
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ConnecticutDesign Evaluation

• Built evaluation into design of program
• Asked state how to measure costs of NF vs. HCBS
• State involvement from the beginning, combined
  with an external evaluator for the program, meant
  that results were not questioned
• Involved stakeholders with knowledge and
  decision-making authority in the steering
  committee
• Results showed a savings of 96/day on average
  for each person transitioned.

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Connecticut--Outcomes

• Governor requested to sustain program with
  funding for transition coordinators and more
  waiver slots.
• State changed its housing plan to set aside
  Section 8 vouchers for persons transitioning from
  institutions.
• State dedicated 500,000 in bond funds to be used
  for housing modifications for transitionees
  (rental or owner-occupied)

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Michigans Nursing Home Transition Program

• One of the first group of states to receive NHT
  funding in 1998.
• Focus on residents choice to leave NH rather
  than ability.
• 41 of NH transitionees required no
  government-paid services after transition
  assistance.
• Costs for transitionees enrolled in Medicaid
  waiver or other service programs 60-76 less on
  average than costs to stay in NH.

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Michigans Long-term Care Population

• 1.24 million of 10.1 million residents are 65
  years old or older (12).
• 40 have some type of disability.
• 40,365 nursing home residents in 2004.
• 67 paid by Medicaid, 15 by Medicare, 18
  private.
• 10th highest nursing home population in the US.
• 3.4 of residents 65 and older are in nursing
  homes.
• US average 4.

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Long-term Care Spending in Michigan

• Michigans total Medicaid budget in 2004 8.2
  billion.
• 2.4 billion in total Medicaid spent on LTC.
• 1.7 of 2.4 billion (71) spent on nursing home
  care.
• Percentage of Michigans LTC budget going to
  nursing homes is decreasing.
• 75 in 2000 to 71 in 2004.
• US average 51.3.

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Improving LTC Access

• 1998 Nursing Home Transitions Demonstration
  Program Grant.
• 2001 Nursing Facility Transition grant
  (770,000) and Real Choice Systems Change grant
  (2.1 million).
• 2003 Money Follows the Person (786,000).
• 2004 Cash and Counseling (RWJ).
• 2005 ADRC grant (800,000).

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Nursing Home Transition Program

• 2001 2 pilot sites
• Area Agency on Aging of Western Michigan (9
  counties inc. Grand Rapids)
• Detroit Area Agency on Aging
• As of April 2005, NHT program is statewide
  through MI Choice program.
• 22 waiver agents (AAAs and others) serving 14
  regions.

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Michigan Cost Data
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Susan C. ReinhardCo-DirectorRutgers Center for
State Health PolicyDirectorCommunity Living
Exchange at RutgersTechnical Assistance for Real
Systems Change732-932-4649sreinhard_at_ifh.rutgers
.edu