Why are we redesigning the long-term care system?

1. Why are we redesigning the long-term care system?

2. Concerns and issues... • ACCESS--Can people get the services they need, when they need them? • CHOICE--Do people who need long-term care have a choice, or are they just ‘slotted in’ to what is available in their community? • QUALITY--Do long-term care services work to support a good quality of life? • ECONOMY--Are we spending more money than is necessary?

3. More Wisconsin residents are in nursing homes, considering our 65+ population. Nursing home residents per 1,000 population age 65 and above, 1996 Source: Across the States, Profiles of long-term Care Systems, AARP 1998

4. WI Medicaid spends more per capita on long-term care than the national average. Nursing Homes ICF-MR Home Care Total LTC Per capita Medicaid expenditures for long-term care services, 2000

5. Public spending for elderly and people with disabilities is largely for institutional care. Acute & Primary Care Institutional Care Medicaid Managed Care COP-R & Community Aids Medicaid LTC Card Services Home & Community-Based Waivers Total DHFS CY 2000 Expenditures = $2,348,010,300

6. Wisconsin’s over-65 and over-85 population will soon grow rapidly. Figures for 1990 are U.S. Census estimates (internet release 3/9/2000). Figures for 1995-2050 are based on the U.S. Census population projections.

7. Wisconsin’s adult disabled population will also grow. U.S. Census population projections for 1995-2050 and population estimates for July 1, 1990 based on 1990 Census.

8. Community Options Program (COP) • Make funding available to counties to provide community-based long-term care services • Piloted in 1981; open to all target groups • In 2001, provided services to 2,254 Wisconsin residents

9. C O P • Provides for comprehensive assessments and encourages the use of appropriate professionals • Provides for the development of Comprehensive Service Plans • Aids in the relocation of people from institutional settings • Diverts people from institutional settings

10. C O P • Encourages the maintenance of existing relationships with natural supports • Encourages the maintenance of and/or improvement of the Quality of Life of the people served

11. 1980s - Medicaid Home and Community Based Waivers (HCBWs) • Federal Medicaid funds and state match made available to provide community-based services in place of institutional care • Similar to COP but not as flexible • Includes expanded eligibility for Medicaid • In 2001, provided services to 22,000 Wisconsin residents.

12. H C B Ws • CIP 1A - Relocation of people from State Centers for the Developmentally Disabled • Required bed de-certification • CIP 1B - Relocation and Diversion of people from ICF-MRs • No bed de-certification required

13. H C B Ws • CIP II - Relocates people from nursing facilities • Bed de-certification required • COP-W - Diverts people from nursing home admissions • No bed de-certification required • BIW - Relocates people with Traumatic Brain Injury from rehabilitation facilities

14. Goals of Family Care ACCESS--Improve people’s access to services. CHOICE--Give people better choices about the services and supports available to meet their needs. QUALITY--Improve the overall quality of the long-term care system by focusing on achieving people’s health and social outcomes. ECONOMY--Create incentives and ability for providing and purchasing cost-effective alternatives.

15. A Pilot Program • The Legislature directed DHFS to test a partially integrated* managed-care model for the delivery of long-term care services, which includes both community-based and institutional care, for possible expansion statewide. • Currently, nine Wisconsin counties have implemented aspects of Family Care.

16. What is Family Care? Non-Family Care Counties Family Care Counties • Medicaid (MA) or Medicare Acute & Primary Care • Medicaid (MA) or Medicare Acute & Primary Care • MA Fee-for-Service--LTC Services (i.e. personal care, home health, nursing facility & other institutional care); • Community Options Program-Waiver (COP Waiver) for elders & people w/ phys. disabilities • Waivers for people w/ dev. Disabilities • Community Integration Program II (CIP II) • Brain Injury Waiver • Community Integration Program (CIP 1A) • Community Integration Program (CIP 1B) • Community Supported Living Arrangements(CSLA) • Community Options Program; • Community Aids; • Community Aids--Alzheimer's Caregiver Support Program (AFCSP) • Family Care long-term Care or • MA Fee-for-Service LTC Services • Older Americans Act Services • Independent Living Center Services • Public Health Programs • Older Americans Act Services • Independent Living Center Services • Public Health Programs

17. Why are we redesigning the long-term care system? Family Care goal: Improve consumer access and choice….

18. Old/current system Uncoordinated fee-for-service care, with no safeguards against gaps & overlaps Immediate entitlement to nursing home care; wait list for community care In NH, certain services regardless of need; in waiver, a limited benefit package. Family Care Managed care, with focus of responsibility for quality and cost. Immediate entitlement to long-term care suitable for individual needs Single, expanded, flexible benefit package

19. Old/current system Waiver care management has social work expertise. Waiver assessment limited to need for waiver services Acute/primary care rarely coordinated with waiver services. LTC ‘card services’ not coordinated with waiver services. Family Care Interdisciplinary care management: social work and nursing. Holistic approach to care planning Mandatory contacts with primary health providers. Control, responsibility for all MA-funded LTC services under one local agency.

20. Old/current system No local incentive for intervention & prevention. Person leaves the waiver if condition deteriorates. Service authorization limited by available funds, State approval Family Care Intervention & prevention in care plans; CMO on the hook if condition deteriorates. Service authorization by local teams, asking ‘what is cost-effective?’

21. Federal Issues about Access to LTC Services • Olmstead vs. L.C., U. S. Supreme Court Decision ruled that--”unjustified isolation is properly regarded as discrimination based on disability” under ADA Title II. • Federal CMS staff have noted that Family Care provides key components that would help assure state compliance: • Resource Centers offer Pre-Admission Consultation & Options Counseling for all who enter institutional & residential services. • Enrollees have access to a range of long-term care services, including home and community based care based options--based on need. It ends the institutional bias of Medicaid. • Family Care CMOs are required to develop the services needed by their enrollees. They are monitored to assure individual outcomes are met.

22. Why are we redesigning the long-term care system? Family Care goal: Ensure quality for consumers….

23. Quality: Consumer Perspective • Person-centered, consumer-focused • Measuring outcomes from the perspective of the consumer

24. Family Care Outcomes • Self-determination and Choice • People are treated fairly • People have privacy • People have personal dignity and respect • People choose their services • People choose their daily routine • People achieve their employment objectives • People are satisfied with services

25. Family Care Outcomes, cont’d • Community Integration • People choose where and with whom they live • People participate in the life of the community • People remain connected to informal support networks

26. Family Care Outcomes, cont’d • Health and Safety • People are free from abuse and neglect • People have the best possible health • People are safe • People experience continuity and security

27. Why are we redesigning the long-term care system? Family Care goal: Provide services economically….

28. Cost-Effectiveness=Quality and Economy CMOs Avoid Unnecessary Costs by: • Coordinating benefits and services, including primary health care • Enabling member’s reliance on friends and family • Focusing on prevention of disability

29. Comparing Costs - 2001 Difference = $2,376 per yearper member In 2001, the average Family Care member’s monthly cost was $1,853. In counties without managed long-term care, serving these same people would have cost $2,051 a month.

30. The Organizations of Family Care

32. The organizations of Family Care The Aging and Disability Resource Centers….

33. Resource Centers: Goals • Reach a broad base of consumers, regardless of income or condition • Delay or prevent the need for LTC services • Enable people to make informed, cost-effective decisions about LTC • Identify people at risk and with urgent needs and connect them to services • Serve as the single entry point for publicly-funded long-term care

34. Resource Centers: Services • Outreach and public education • Information and assistance • Benefits counseling & screening for eligibility • Emergency response • Transitional services • Prevention and early intervention activities • Enroll recipients in CMO, in those counties with CMOs. • Provide services over the telephone or in visits to an individual’s home.

35. Where are the Resource Centers? • Fond du Lac • Jackson • Kenosha (One for developmental disabilities; one for elderly and physical disabilities) • La Crosse • Marathon • Milwaukee (elderly only) • Portage • Richland • Trempealeau

36. The organizations of Family Care The Enrollment Consultants….

37. Enrollment Consultants: Purposes • Make sure potential CMO members know their options. • Address federal and state concerns • Cherry-picking and hot potatoes • Conflict of interest • County governments operate both RCs and CMOs.

38. Enrollment Consultants: Services • Enrollment consultants provide unbiased information and advice about long-term care. • Communicate with potential enrollees • Explain managed care • Help with enrollment • The Southeastern Wisconsin Area Agency on Aging, under contract with the Department of Health and Family Services, provides enrollment consultation.

39. The organizations of Family Care The Care Management Organizations….

40. Care Management Organizations: Purpose To support long-term care consumers in achieving their personal outcomes in a cost-effective system of long-term care.

41. Care Management Organizations:Services • Assess clients’ personal outcomes • Involve consumer in decision-making and creating member-centered plan to support outcomes • Provide services, directly or by contract • Coordinate other services not included in the Family Care benefit • Assure quality

42. The Family Care Benefit • Adaptive aids, communication aids, medical supplies, home modifications • Home health, therapies, nursing services, personal care, supportive home care • Residential services, nursing facility services • Transportation, daily living skills training, supportive employment • Meals: home delivered and congregate, • Emergency response system services • Respite Care, adult day care, day services • Case Management

43. Where are the CMOs? Fond du Lac …...899 members La Crosse ……1,399 members Milwaukee……4,363 members (elderly only) Portage…………655 members Richland………..292 members Membership as of September 1, 2003

44. PACE and Partnership • Integrates all Medicare, Medicaid and HCBW services • Benefits are capitated and paid to small, community-based organizations • Contractors are at full risk for all health and long-term care outcomes • Care management is team-based

45. PACE • Most services are provided in an adult day center • Primary care physician and most services providers are PACE employees • Serves frail elderly age 55 and older • Participants must be Medicaid eligible and in need of a nursing home level of care

46. Partnership • Most services are provided in the community • Primary care is provided by an independent physician panel • Serves frail elderly age 55 and older, and adults with physical disabilities • Must be Medicaid eligible and in need of a nursing home level of care

47. PACE/Partnership Enrollment • CCO/CCE (Milwaukee, Racine) PACE 445 Partnership 324 • CHP (Eau Claire, Dunn, Chippewa) 485 • CLA (Dane) 260 • Eldercare (Dane) 453 August 31, 2003

48. Goals of Reform: ACCESS--Improve people’s access to services. CHOICE--Give people better choices about the services and supports available to meet their needs. QUALITY--Improve the overall quality of the long-term care system by focusing on achieving people’s health and social outcomes. ECONOMY--Create incentives and ability for providing and purchasing cost-effective alternatives.

49. Council Role Advise on: • What concerns and issues need to be addressed • What should the implementation strategy be regarding such issues as: • timing? • providers/partners? • target populations?

50. Council Role : Today’s Question What do we want to request in a waiver regarding our goal to: • assure adequate nursing home care and expand community capacity? • improve quality in the existing waiver programs? • pursue steps toward managed care such as pre-Family Care? • diversify the nursing home industry by regulatory change and other strategies?