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Ohios Unified Longterm Care Budget

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Title: Ohios Unified Longterm Care Budget


1
Ohios Unified Long-term Care Budget
  • Building a Cost-Effective, Consumer Friendly
    Long-term Services Supports System

2
Purpose
  • To develop a comprehensive, flexible and
    transparent process for effective and efficient
    budgeting and service delivery that
  • Encompasses both facility-based and home- and
    community-based long-term services and supports
  • Is based on consumer choice and differing levels
    of service need
  • Includes a seamless array of service delivery
    options
  • Features a consolidated policymaking and budget
    authority to simplify decision making and
    maximize the states flexibility

3
Desired Outcomes - Consumers
  • Consumers will be satisfied with the services
    they receive and experience a higher quality of
    life.
  • Ohioans will be encouraged to plan ahead for
    future service and support needs, as well as be
    better prepared to make informed decisions about
    their options.

4
Desired Outcomes - System
  • A transparent budget for policymakers.
  • A cost-effective system that links disparate
    services across agencies and jurisdictions.
  • Consistency in provider rate-setting.
  • Accurate expenditure forecasts.

5
Ohios Unified Long-term Care Budget
  • Building a Cost-Effective, Consumer Friendly
    Long-term Services Supports System

6
Promoting Flexible Funding to Support Long Term
Living Susan C. ReinhardDirectorAARP Public
Policy Institute
Columbus, Ohio August, 2007
7
Goals
  • Overview of Global/Unified Budgets
  • Important components that will lead to success
  • Specific State examples
  • Key indicators of success

8
Key Concepts
  • Balancing LTC Achieving more parity in funding
    community and institutional options so consumers
    have more real choice.
  • Set of Balancing Strategies, including increasing
    community capacity, informing people of options,
    funding/budgeting, nurse delegation and
    workforce, etc.

9
Financing
  • Money Follows the Person financing for
    services and supports moves with the person to
    the most appropriate and preferred setting.
  • Global budgeting
  • Texas MFP
  • Deficit Reduction Omnibus Reconciliation Act
  • Rebalancing (Balancing) reduced reliance on
    institutional options, increased community
    options.

10
Key Concepts
  • Flexible Funding is essential but not sufficient
    force for change.

11
Key Building Blocks
12
Budget Strategies
  • Money Follows the Person (MFP)
  • Planned Parity
  • Global Budget (Pooled Financing Unified Budget)

13
MFP Strategy
  • Money Follows the Person financing for
    services and supports moves with the person to
    the most appropriate and preferred setting
  • Commonly starts from nursing home to HCBS--State
    example is Texas
  • Useful when long HCBS waiting lists and low
    occupancy in nursing homes

14
Indicators of Success CMS Benchmarks
  • Statutorily Mandated
  • Number of eligible individuals in each target
    group of eligible individuals assisted in
    transitioning from an inpatient facility to a
    qualified residence each year.
  • Qualified expenditures for HCBS during each year
    of the demonstration program.

15
Indicators of Success CMS Benchmarks
  • Potential Additional Benchmarks
  • Percentage increase in HCBS versus institutional
    long-term care expenditures under Medicaid.
  • Utilization rates for a one-stop shops.
  • Flexible financing strategies, such as global or
    pooled financing or other budget transfer
    strategies that allow money to follow the
    person.

16
Indicators of Success CMS Benchmarks
  • Potential Additional Benchmarks
  • Increases in available and accessible supportive
    services (i.e., progress in achieving the full
    array of health care services for consumers,
    including the use of one-time transition
    services, purchase and adaptation of medical
    equipment, housing and transportation services
    beyond those used for MFP transition
    participants).

17
Planned Parity Strategy
  • Can be separate LTC budgets (nursing home, HCBS)
    mandates reductions in nursing home budget and
    transfer of those savings to fund HCBS
  • Aggressive policy and program actions required
    (universal screening, level of care criteria,
    pre-admission processes, etc.)
  • Examples--Maine, Vermont in 1990s

18
Vermont Systems Change
  • Small state with steady drive to change
  • Total population 608,823
  • An aging state - 5th oldest in the nation
  • Known for stakeholder meetings
  • Shifting the Balance law led by a key
    legislator (also a nursing home administrator)

19
Vermont Act 160
  • Shifted funds from nursing home to the HCBS
    appropriation
  • Goal 60-40 institution/community
  • Strategies NF moratorium, expand residential
    alternatives, one time investments
  • Five percent drop in NF supply

20
Act 160
  • The reductions required shall be redirected in
    FY 1997 to fund home and community-based
    services. For fiscal year 1998 and thereafter,
    the reductions required ... shall be redirected
    to fund both home and community-based services
    and any programs designed to reduce the number of
    nursing home beds.
  • Any general funds redirected but not spent during
    any fiscal year shall be transferred to the
    long-term care special administration fund...

Department of Aging and IndependentLiving
Services
21
Patrick Flood, VT DAILS
22
Vermont 1115 Waiver
  • Provide maximum choice of services and settings
  • Eliminate institutional bias
  • Promote early intervention
  • Break link between 1915 (c) waivers and NF level
    of care

23
Goals for Vermonts 1115 Waiver
  • Serve more people (within their cap)
  • Develop a more balanced LTC system
  • Reduce NF use
  • Manage the LTC costs

24
Vermonts Plan
  • Slow, incremental steps
  • Before Choices for Care waiting lists and
    entitlements
  • Now 3 Eligibility Groups
  • Highest
  • High
  • Moderate

25
CURRENT SYSTEM ELIGIBILITY
Nursing Facility Home Based Waiver Enhanced
Residential Care Waiver
High
Current Eligibility threshold
Acuity of Need
Below Nursing Home Level of Care
Low
26
Choices for Care Eligibility
Proposed Level for Entitlement Group
Highest Need
High
Acuity of Need
Current Future Level of Care for Eligibility
High Need Group
Moderate Need Group
Low
27
Choices for Care Eligibility Groups
  • Highest, High, and Moderate Need Groups
  • Highest Need Group
  • Funding for services is always available
  • Consumer chooses services at home, Enhanced
    Residential Care Home, Assisted Living Residence,
    nursing facility or other approved location

28
Choices for Care Eligibility Groups
  • High Need Group
  • Serve most, if not all, but enrollment depends on
    availability of funds
  • This group may access nursing facility care if
    funds are available.

29
Choices for Care Eligibility Groups
  • Moderate Need Group
  • Not nursing home level of care
  • Preventive services, like Homemaker and Adult Day
  • Case management
  • Enrollment limited to available funds

30
Global Budget
  • Consolidating all of the components of long term
    care spending into a single state agency budget
  • Funding can follow the person as they move
    between services
  • Placing the nursing facility, HCBS and
    state-funded personal care programs and budgets
    into a single division

31
Global Budgeting
  • Global Budgeting provides a budget appropriation
    format that allows LTC dollars to be used in the
    most cost-effective manner

32
Goal of Global Budgeting
  • Move from a provider-based system to a consumer-
    based system
  • With appropriations attached to each program
    provider? to appropriations attached to each
    client
  • Individuals receiving supports drive resource
    allocation decisions, as they move through the
    long term care system
  • Milne, 2005

33
Global Budget
  • Set a total LTC spending budget based on
  • projected LTC needs and preferences
  • planned policy and program initiatives
  • Provide full administrative freedom to manage
    costs within the spending limit to respond
    quickly to consumer preferences

34
Global Budget
  • Does not change nursing home entitlement (unless
    1115 waiver)
  • Does not entitle consumers to HCBS, but can help
    move in that direction
  • Works best if no waiting lists, but can help with
    nursing home transition efforts

35
Global Budget--State Examples
  • See Hendrickson Reinhard, 2004
  • Oregon
  • Washington
  • New Jersey
  • Colorado

36
Oregon A Pioneer with a Blueprint
  • Legislature set forth philosophy of Choice,
    Independence and Dignity in 1981
  • Serve more people and lower cost per case
  • Home and community care for private and public
    pay--stimulate the market, pay independent
    providers (including family members), allow
    nurses to delegate to paid lay caregivers

37
Oregon A Pioneer with a Blueprint
  • Single entry access and partnerships with local
    government, Board of Nursing, providers
  • Single state agency to administer Medicaid LTC,
    Older Americans Act and state funded programs
  • Foster prevention and primary health care

38
Washington A Pioneer
  • Legislature set forth philosophy
  • .establish a balanced range of health, social
    and supportive services that deliver long term
    care services to chronically, functionally
    disabled persons of all ages and to ensure that
    services are provided in the most independent
    living situation consistent with individual
    needs (Revised Code of Washington (RCW)
    74.39.005) and to the extent of available
    funding, the department shall expand cost
    effective options for home and community services
    for consumers (RCW, 74.39A.030).

39
Washington.
  • .The legislature further recognizes that persons
    with functional disabilities should receive
    long-term care services that encourage individual
    dignity, autonomy, and development of their
    fullest human potential. (RCW 74.39.001)
  • The legislature further finds that the public
    interest would best be served by a broad array of
    long-term care services that support persons who
    need such services at home or in the community
    whenever practicable and that promote individual
    autonomy, dignity, and choice. (RCW 74.39A.005)

40
Washington
  • 1993 legislature approves relocation of 750
    nursing home clients to HCBS
  • 1995-1997 budget reduces NH caseload by 1,600
    clients
  • NH bed need assessment includes availability of
    home/community care

Aging and Disability Services Administration
41
Washington
  • Global Budget Budget structure consolidated
    with significant management flexibility
  • Caseload Forecasting Council projects NH HCBS
    trends

Aging and Disability Services Administration
42
Washington Success NF Caseload Trends
Figures for July each year
43
Washington Success HCBS Trends
Figures for July each year
44
Washington Success LTC Spending Trends
Based on data from the Washington Aging and
Disability Services Administration
45
WA Shifting spending balance
46
WA Elders and Adults
47
New Jersey StrategyBudget
and Policy Consolidation at state level for older
adultsCreate more choices for HCBS
servicesHelp consumers find choices easily
through single entry point (NJ EASE) and
Community Choice Counseling (nursing home
transition)
48
Long Term Care You Decide Where! AARP Long Term
Care Summit, March 23, 2004
AARP NJ 2004 Social Impact Agenda
1. Follows Person 2. Fast Track Eligibility 3.
Global Budget 4. Bill of Rights
49
Current NJ Policy and Budget Initiatives
  • Global Budgeting per 2004 and 2005 Executive
    Orders to provide the Department of Health and
    Senior Services with the authority and
    flexibility to move beneficiaries to the
    appropriate level of care based on their
    individual needs
  • Parity legislation

50
New Jersey Success
  • 3,500 fewer Medicaid beneficiaries in nursing
    homes
  • 10.4 reduction in census, surpasses almost all
    states in recent years

51
Source NJDHSS, Sept 15, 2004 Trenton, NJ
52
Global BudgetingThe Colorado Experience
  • By Dann Milne, Ph.D.
  • Consultant
  • Ph 303-399-6736
  • dann_milne_at_hotmail.com

53
Vision for LTC --1990
  • View Long Term Care as a System
  • To design a system to efficiently allocate scarce
    resources for LTC
  • A planned effort to reduce the growth in Medicaid
    spending and to give clients choices of LTC
    services and settings
  • Administrative reorganization/consolidation
    removes fragmentation of program authority,
    state budget process barriers, and program
    operations barriers

54
Before
  • Appropriations were on a service by service
    basis. Expenditures controlled for each program
    budget item
  • Administrative barrier was lack of budget
    transfer authority
  • Agency could not overspend its HCBS program
    budget, even if the nursing facility budget was
    decreasing
  • Milne, 2005

55
After Global Budget in 1991
  • ne appropriation for all LTC services by
    Elderly, SSI/Disabled, TANF, etc. eligibility
    categories
  • Automatically allows funds to follow clients as
    they move from service to service as their needs
    and preferences change

56
Indicators of Success in Colorado
  • Reduced the rate of growth in LTC spending saved
    17 over projected LTC budget in 1994. Served 21
    fewer in nursing facilities than projected.
    (Lewin Group study)
  • In 1996, began serving more clients in HCBS than
    in nursing facilities (cross-over point)
  • Milne, 2005

57
Indicators of Success in Colorado
  • Spent 51.1 of LTC budget on HCBS in 2001, Ranked
    5th in US (Profiles of LTC-2002, AARP)
  • Spent 32.7 of Elderly/Disabled LTC budget on
    HCBS, Ranked 8th is US in 2003
  • Milne, 2005

58
Critical Elements to Support Transformation
  • Vision, Mission
  • Leadership and Partnerships
  • Access to multiple financing sources (Medicaid
    HCBS state plan, OAA, state general revenues)
  • Streamlined financial and functional eligibility
  • Comprehensive/single entry point
  • Strong quality management system, including
    information systems

59
What We Know About Change
  • Not Easy
  • Not Fast
  • Worth it
  • Possible

60
Guiding PrinciplesChange DynamicsDialogueConse
nsusCouragePersistence
61
Ohios Unified Long-term Care Budget
  • Building a Cost-Effective, Consumer Friendly
    Long-term Services Supports System

62
The Changing Face of Long-Term Care Ohios
Experience 1993-2005
  • Robert Applebaum
  • August 17, 2007
    .
  • Scripps Gerontology Center
  • Miami University
  • Oxford, Ohio

63
Ohio Fast Facts
  • The population in Ohio who are most likely to
    need long-term care (those over age 85) has
    increased by 55,000 (38) over the last 12 years
    (1993-2005).
  • Despite the population increase the number of
    nursing home beds in service has been reduced
    from a high of 99,000 in 1997 to about 94,000 in
    2005.
  • By 2050, there will be one million Ohioans over
    age 85.
  • By 2020, Ohio will have more than 220,000 older
    people with severe disabilities, almost 26 more
    than 2005.
  • The number of residential care facility beds has
    increased from 8,700 in 1993 to about 43,000 in
    2005.

64
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67
Estimated Proportion of Ohio's Population with
Severe Disability in Different Long-Term Care
Settings
68
Ohio Medicaid 2005
  • Ohio spent 11.5 billion on Medicaid.
  • Medicaid was 24 of Ohios annual budget.
  • 42 of Ohios total Medicaid budget was spent on
    long-term care.
  • Ohio spent 2.6 billion on Medicaid nursing homes
    (ranks 9th) 1 billion on Medicaid ICF/MR
    facilities (ranks 5th).
  • Ohio spent 950 million on Home and Community
    Based Care Waivers (ranks 26th).
  • Ohio ranked 47th in home care/nursing home
    expenditure ratio.

69
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71
Short-Term Stay
  • More than 56 of all those admitted to
    nursing homes are no longer residents after 3
    months almost 7 in 10 are no longer residents
    after 6 months by year end only one out of every
    6 still there.

72
Cumulative Length of Stay as a Nursing Home
Resident for a Cohort Admitted between Jul-Aug
2001, and then Followed until June 30, 2004
73
Proportion of Total Medicaid Nursing Home
Residents Still Living in a Facility
74
Nursing Home Utilization in Ohio 1993-2005
75
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76
Over the Twelve Year Period (1993-2005)
  • Occupancy rates dropped from 90.7 to 86.4.
  • The average daily nursing home census dropped by
    5,700 individuals per day.
  • The average daily Medicaid nursing home census
    dropped by 3,840 individuals per day.
  • The private pay average daily census dropped by
    7,440, while daily Medicare Census has increased
    by 5,580.
  • Proportion of under 65 residents increased from
    6.8 in 1994 to 14.1 in 2004.

77
Ohios nursing home residents are very impaired,
they are more disabled than they were 12 years
ago.
78
PASSPORT Ohios Major Medicaid Home
Community-Based Long-Term Care Services Program
for 60 Population
79
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80
Demographic Characteristics of Ohios PASSPORT
Consumers1994-2004
81
Functional Characteristics of Ohios PASSPORT
Consumers 2004 (Percentages)
82
Distribution of 12 Month Service Plan Cost
(Annualized)
83
PASSPORT consumers needs for assistance have
remained relatively constant over the past
twelve years.
84
Reasons for Disenrollment from the PASSPORT
Program
85
Average Per Diem for Nursing Home Residents in
2005 Dollars1992-2005
86
Medicaid PASSPORT Nursing Home Annual
Expenditures
  • Average annual PASSPORT expenditures per
    consumer were 15,590 (2,280 of that was for
    assessment, administration case management).
  • Average nursing home expenditures

87
Private Pay Nursing Home Residents Who
"Spent-Down" to Medicaid, Over a Three Year
Period (2001-2004)
88
Proportion of Nursing Home Residents Using
Medicaid, Over a Three Year Period (2001-2004)
89
Comparison of PASSPORT, Assisted Living, and
Nursing Home Consumers (Demographic
Characteristics)
PASSPORT Assisted Living Nursing
Home Average Age 76.7
78 82.8 Gender
Female 76.7 77.6
71.1 Race White 78.7 87.1
83.0 Marital Status Married 19.8
9.7 14.3
90
Comparison of PASSPORT, Assisted Living, and
Nursing Home Consumers (Functional
Characteristics)
PASSPORT Assisted Living Nursing
Home ADL Bathing 96.0
94.0 91.6
Dressing 60.1
64.2 81.8
Eating 10.9 9.7
33.3 Toileting
21.1 35.1
76.3 Grooming
32.9 39.6
81.9 Number of ADL Impairments 0
0.8 0.0
7.2 1
3.5 6.0 7.2
2 34.5 20.1
4.7 3
33.6 25.4
5.7 4 27.5
48.5 75.3 Average Number
of ADL Impairments 3.0
3.3 4.4
Incontinence
14.1 23.1
62.3
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93
Ohios Unified Long-term Care Budget
  • Building a Cost-Effective, Consumer Friendly
    Long-term Services Supports System

94
The Process
  • The Governor will appoint a workgroup.
  • Legislative leadership will appoint four members
    of the General Assembly.
  • The plan is to be completed by June 1, 2008, and
    must be submitted to the Joint Committee on
    Medicaid Technology and Reform.
  • Seven subcommittees, building on existing
    efforts, will assist the workgroup.

95
Decision Roadmap
  • Who will be served by the long-term services and
    supports budget?
  • What does long-term services and supports
    include?

96
Questions for theSubcommittees
97
Front Door Subcommittee
  • What will be the design of the front door to
    long-term services and supports?

98
Care Management Subcommittee
  • What is the role of care management?
  • Who benefits from care management?
  • How will we interface with Medicare Special Needs
    Plans?

99
Quality Subcommittee
  • How will we incorporate the CMS quality
    framework into all aspects of long-term services
    and supports, including nursing facilities?

100
Unmet Needs Subcommittee
  • What unmet needs currently exist and what
    additional long-term services and supports should
    Ohio offer?

101
Consumer Direction Subcommittee
  • How will we incorporate the key principles of
    consumer direction into the system?

102
IT Systems Subcommittee
  • How will existing and planned IT systems be
    modified to accommodate a unified budget?

103
Budgeting Subcommittee
  • How will the budget be built and what model will
    be used?

104
Ohio Department of Aging
  • 1-800-266-4346
  • odamail_at_age.state.oh.us
  • www.goldenbuckeye.com/ultcb
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