Future of Home- & Community- Based Services in Maine

1. Future of Home- & Community- Based Services in Maine Diana Scully, Director, Office of Elder Services Maine Department of Health & Human Services 20th Annual Maine Geriatric Conference Bar Harbor, Maine June 11, 2010

3. Many Tables & Charts in Presentation are from: Chartbook— Older Adults & Adults with Disabilities:Population & Service Use Trends in Maine (2010)Published by University of Southern Maine Muskie School of Public Service Funded by Department of Health & Human Services Offices of Elder Services & MaineCare Services www.maine.gov/dhhs/oes/publications.htm

4. What I Will Talk about Today • Facts about long-term care (LTC) • Home- & community-based services (HCBS) quality improvement process • Drivers of LTC reform • Vision for future

5. Facts: Needs Assessment • OES asked Muskie School to conduct LTC needs assessment. • Gathered demographic trends & info about use of services over time. • Includes MaineCare & state-funded programs for elders & adults with physical disabilities. • Must understand entire LTC system in order to make informed decisions about any part. • See Chartbook…

6. Facts: Aging Demographics • Maine has one of oldest populations in US. • 1st in median age (42 years). • Age 65+ as % of Maine’s population: • 2008 15%; Maine ranked 4th in US • 2015 18+% • 2020 21+%; Maine expected to rank 2nd after Florida • 65-74 year-olds = Maine's fastest growing age group: 104,000 in 2008 & 184,000 by 2020.

7. Projected Changes in Maine's Age Profile 2008 - 2020

8. Facts: People Receiving Services Ageof people in different settings: • Residents of LTC facilities = average age 81+. • People receiving home care services are younger than residents of facilities. • Home Care—people receiving state-funded services (average age 77) are older than people receiving MaineCare services. • People with physical disabilities receiving home care services under 2 MaineCare programs are youngest…but not that young (average age 50+/-).

9. Average Age of Maine Long-Term Care Users by Setting (SFY 2008)

10. Facts: People Receiving Services Single people receiving services at home: • Varies widely by program. • Nearly 2/3 of people receiving MaineCare Personal Care Services live alone. • More than half of people receiving state-funded home care services live alone. • Smaller % of people served under MaineCare home-based programs live alone.

11. Maine LTC Service Users Who Live Alone, by Program (SFY 2008)

12. Facts: People Receiving Services Diagnoses of Maine LTC Users: • Hypertension is most common diagnosis in all settings. • Depression is common in all settings. • Dementia is common in LTC facilities & much less common at home. • Arthritis is more common in home care settings.

13. Diagnoses of Maine LTC Users,by Setting (SFY 2008)

14. Facts: People Receiving Services MaineCare LTC users, by setting: • Between 2000 & 2008, MaineCare LTC users grew by 2.1% (from 11,941 to 12,190). • Residential care facilities increased their share of LTC users by 9 percentage points. • Nursing facilities’ share of LTC users fell by 6 points. • Home care’s share of LTC users fell by 5 points.

15. Average Monthly # of MaineCare LTC Usersby Setting (2000, 2006, 2008)

16. Facts: LTC Expenditures • MaineCare expenditures growing for facility-based care, but not for HCBS. • 2000: 82% spent for facilities & 18% for HCBS • 2008: 87% spent for facilities & 12% for HCBS • 2000: 5% of total expenditures were for state-funded home care; in 2008 only 3%. • Good News!!! 124th Maine Legislature approved addition of $1 million extra proposed by Baldacci Administration for home-based services.

17. Annual MaineCare LTC Expenditures by Setting (2000, 2006, 2008)

18. Annual LTC Expenditures by Setting— MaineCare & State-funded: 2000, 2006, 2008

19. What I Will Talk about Next • Facts about long-term care (LTC) • Home- & community-based services (HCBS) quality improvement (QI) process • Drivers of LTC reform • Vision for future

20. QI Process • LEAN = improvement process that looks at “current state” & desired “future state” & how to get from here to there. • 4 bills before 124th Legislature resulted in DHHS LEAN process for HCBS: • LD 400 (Sen. Craven) • LD 1059 (Sen. Sullivan) • LDs 1078 and 1364 (Rep. Peterson) • Since summer 2009, DHHS staff & many others have devoted many hours to process.

21. QI Process • 2 LEAN groups: 18-member Core Team & 17-member Direct Care Worker Task Force. • 18 organizations represented. • 15 objectives & 100+ actions identified to implement LEAN recommendations. • 2 LEAN reports: Direct Care Worker report to DHHS and DHHS LEAN report to Legislature.

22. QI Recommendations • Goal: 50% of all LTC expenditures should be for HCBS. • Combine multiple programs into fewer. • Create greater equity across programs. • Design all programs to include both agency-provided services & self-directed services. • Develop single self-directed model across programs with budget authority.

23. QI Recommendations • Maximize flexibility in care plans & delivery of services. • Improve awareness of options among consumers & providers, especially during discharge planning process. • Provide livablecompensation for direct care workers. • Require consistency inrate-setting approaches & cost components across programs.

24. QI Implementation • DHHS leaders have carefully considered QI recommendations. • Work is underway to improve self-directed options to better allow consumers & families to direct & manage their own care. • Other changes will provide for greater flexibility for program participants. • Our intention: rulemaking in play by October.

25. QI Implementation • Changes in HCBS must take into account National Health Care Reform & Maine’s managed care initiative. • Before any major restructuring, more input from people receiving services is needed. • DHHS will reconvene Direct Care Worker Task Force to perform tasks required by LD 1364 (enacted version of Rep. Peterson’s bill) on policies, training & compensation for “direct support aides”.

26. What I Will Talk about Next • Facts about long-term care (LTC) • Home- & community-based services (HCBS) quality improvement (QI) process • Drivers of LTC reform • Vision for future

27. Drivers of LTC Reform #1Mainers are old & getting older. #2 Older Mainers would rather be in their own homes than go to LTC facilities. #3 Home care services cost less than LTC facility services. #4 Maine’s LTC system lacks balance. #5 LTC facilities are aging; financial implications are huge. # 6 National Health Care Reform will play a role.

28. Drivers of LTC Reform #1 Mainers are getting older. Watch out for Boomers! #2 Older Mainers would rather be at home than go to LTC facilities. • Recent AARP survey confirms this. • In early 2010, 401 Maine residents were asked where they’d prefer to receive LTC. • Responses: 79% at home, 7% at home of family member/friend, 9% residential care/assisted living, 2% nursing home.

29. Mainers’ LTC Setting Preference (2010 AARP Survey)

30. Drivers of LTC Reform #3 Home care services costless than LTC facility services. Average MaineCare costs (per member per month): • $4,229 nursing facilities (NFs) • $2,045 residential care • $1,833 NF-eligible people under “waiver” • $541 Private Duty Nursing • $483 Personal Care Assistance

31. Drivers of LTC Reform #4 Maine’s LTC system lacks balance. Uneven distributionofbeds across Maine counties (per 1,000 persons age 65+ in SFY 2008): • Nursing facility beds range from 49 in Aroostook to 16 in Waldo. • Residential care beds range from 36 in Androscoggin to 3 in Sagadahoc. • Total beds range from 71 in Aroostook to 28 in Sagadahoc.

32. Drivers of LTC Reform #4 Maine’s LTC system lacks balance. Homecaredeclined (SFY2000 - SFY 2008): • MaineCareusers of home care services dropped from 38% to 32% of total MaineCare LTC users. • MaineCareexpenditures for home care dropped from 18% to 12% of total MaineCare LTC expenditures. • State-fundedexpenditures for home care dropped from 5% to 3% of total MaineCare & state-funded LTC expenditures.

33. Drivers of LTC Reform #5 LTC facilities are aging; financial implications are huge. • 47 nursing facilities with 2,498 beds (36% of total beds) are in need of renovation or replacement. • 40 residential care facilities with 1,257 beds (41% of total beds) are in need of renovation or replacement. • These #s are based on estimates by DHHS Division of Licensing & Certification.

34. Drivers of LTC Reform #5 LTC facilities are aging; financial implicationsare huge. Total costs could exceed $233million: • Cost of replacing nursing facility beds is $109,000-$130,000 per bed. Replacing 457 beds = estimated $50-$59 million. • Cost of replacing residential care beds is $80,000-$95,000 per bed. Replacing 530 beds = estimated $42-$50 million. • Substantial rehabilitation costs run $70,000-$80,000 per bed. If cost were only $50,000, estimated cost of renovating all 2,677 nursing facility & residential care beds in need of rehab = $133+ million.

35. Drivers of LTC Reform #6 National Health Care Reform will play a role: • Patient Protection & Affordable Care Act creates new opportunities for states to balance their Medicaid LTC system by expanding access to HCBS, including: • HCBS State Plan option expansion. • Community First Choice option. • State Balancing Incentive Program. • CLASS Program (voluntary insurance). • See publication #8079 at Kaiser Family Foundation website at www.kff.org.

36. What I Will Talk about Finally • Facts about long-term care (LTC) • Home- & community-based services (HCBS) quality improvement process • Drivers of LTC reform • Vision for future

37. Vision for Future: Projection Model • Lewin Group, with assistance of Muskie, developed projection model for Maine. • Tool helps us plan for LTC services. • Model uses 4 factors: • Changes in population, by age & by county. • County-specific use rates for each service. • Changes in nursing facility use rates by MaineCare members & other payers. • # of residential care beds.

38. Vision for Future: Projection Model • Can vary assumptions and plug them into model to get: • Statewide & county-specific estimates of use for each year between 2009 & 2015. • Expenditures by multiplying estimated # of users by cost per person in base year. • Model does not tell us what to do. Model = tool to help us make decisions.

39. Vision of Future: Year 2020 • HCBS will represent more than 50% of all LTC expenditures. • More people receiving home care services will direct their own personal care services & have flexibility. • There will be much more support for family caregivers, including more adult day services. • There will be greater access to evidence-based programs by people with LTC needs. • There will be more affordable housing with services for Maine’s elders.

40. Vision of Future: Year 2020 • There will be several smaller, homelike places for people who need nursing facility-level of care (e.g. Green House). • There will be greater access to specialized services & facilities for people with dementia. • Most people will no longer believe that nursing home is inevitable for old people when they can no longer take care of themselves. • Direct care workers will receive livable wages & benefits that recognize the great value of their work.

41. Vision of Future: Year 2020 • How can we get there? • Take advantage of opportunities presented by Health Care Reform. • Do not replace every aging LTC bed. • Shift economics of LTC through statewide managed care or local PACE programs. • Provide greater support to families to help care for their loved ones. • Make sure people know all possible options.

42. Questions ? Contact Diana Scully: diana.scully@maine.gov 207 / 287-9200