Home Care Ombudsman Expansion

1. Home Care Ombudsman Expansion Lyle VanDeventer, Deputy State Home Care Ombudsman

2. Legislative Action

3. Adult Protective Services • On July 1, 2013, legislation was signed into law to expand the Department’s Elder Abuse and Neglect Program (now Adult Protective Services Program - APS) • APS was expanded to prevent abuse, neglect and financial exploitation of people with disabilities between the ages of 18-59 living in the community.

4. Move to Service Integration • February 22, 2013, the Centers for Medicare and Medicaid Services (CMS) and the State of Illinois entered into a Memorandum of Understanding • Intent was to provide integrated benefits to Medicare-Medicaid enrollees in targeted geographic areas in Illinois • Project will alleviate fragmentation and improve service coordination

5. Expansion of Long-term Care Ombudsman Program • On August 16, 2013 the Illinois Act on the Aging was amended to expand the LTCOP to cover seniors and adults with disabilities who are: - on a medical assistance waiver administered by the State; and/or - served by a managed care organization providing care coordination and other services.

6. Home Care Ombudsman Coverage • Expansion of the LTCOP now makes it possible to bring ombudsman advocacy services to consumers of Home and Community Based Services (HCBS) • HC Ombudsman services will remain essentially the same as provided to nursing home residents

7. Who is a Home Care Ombudsman Participant? • An older person, or an adult with disabilities ages 18-59 who is eligible for services under a state medical assistance waiver program for the delivery of long-term care services and supports in the home and community or managed care organizations. • A projected 137,734 individuals are included in this population.

8. Managed Care and Waivers

9. Medicaid-Medicare Alignment Initiative (MMAI) • Medicaid-Medicare Alignment Initiative makes it possible for individuals who are eligible for both Medicaid and Medicare to receive managed care services. • Dually-eligible (MMAI) recipients receive healthcare services, and may get extra benefits by enrolling in this program.

10. Managed Care Coverage • Department of Healthcare and Family Services (HFS) selected eight health plans to serve MMAI clients • Coverage: - Chicago and Cook County - Quad Cities to Vermilion County - Metro East St. Louis

12. Home and Community Based Services (Medicaid Waivers) • Medicaid waivers are federal/state funded home care programs for Medicaid recipients. • Waivers provide a variety of supports to enable the individual to remain at home. • In order to be eligible for waiver services, individuals must be at risk of nursing home placement, but also can be safely served at home with proper supports.

13. Home Care Participants • 18-59 years of age and disabled • 60+ years of age • Living in the home

14. Home and Community Participants Adults and Seniors Enrolled in Medicaid Waivers: • Aging - Community Care Program • Department of Human Services - Disability - Brain Injury - HIV/AIDS - Developmental Disabilities

15. MMAI and Waivers • Some participants may be enrolled in both a Medicaid waiver and an MMAI managed care plan.

16. Participants vs. Residents • Individuals in nursing homes are still identified as “residents” • The home care population group are labeled as “participants”

17. Home Care Ombudsman Role

18. Home Care Ombudsmen • Home Care Ombudsmen will maintain the continuum of care by advocating for residents and participants alike.

19. Home Care Ombudsman • Home Care Ombudsmen are professional problem solvers and advocates, whose primary role is to investigate complaints from residents of long‐term care facilities, and more recently, individuals living at home in the community. • Home Care Ombudsmen draw on strong problem solving skills, knowledge of the relevant rights and regulations, and effective relationships with consumers, service providers, and other agencies.

20. Home Care Ombudsman Responsibilities • Response to inquiries • Identification, investigation & attempts to resolve complaints for or on behalf of participants • Access to participants and their records with permission

21. Home Care Ombudsmen Responsibilities (cont.) • Educating consumers and stakeholders • Advocating and investigating complaints on behalf of enrollees • Collecting complaint data and outcomes • Identifying and reporting systematic problems • Making policy recommendations to improve the delivery of integrated care to enrollees

22. Home Care Bill of Rights (1) • Have assistance to help you to understand your rights; • Be treated with dignity and respect at all times; • Be free from harm. This includes physical, sexual, verbal or mental abuse, neglect and exploitation, including if someone steals your money or Social Security check; • Receive respect for your personal property by your home care provider, and request an investigation if there is theft or loss of that property; • Receive treatment and services to help you live at home and support your independence;

23. Home Care Bill of Rights (2) • Receive care from properly trained staff that have the education, experience and proper license or certification to carry out the services for which they are responsible; • Get help, if you need it, using the Medicare and Medicaid complaint and appeal processes, and exercising your civil and other legal rights; • Be protected against discrimination. No one can discriminate against you or mistreat you because of your race, color, religion, sex, national origin, ancestry, age, marital status, citizenship status, genetic information, sexual orientation, military status, physical or mental disability or source of payment for your health care (for example, Medicare or Medicaid);

24. Home Care Bill of Rights (3) • Get correct, easy to understand information and have someone help you make informed health care decisions; • Have someone help you if you have difficulty with language or communication so you can understand all information given to you; • Access information about available home care services provided in your community, and choose from those services; • Choose your own primary care physician and, if needed, specialists within your managed care organization (MCO) network;

25. Home Care Bill of Rights (4) • Fully participate in all treatment decisions related to your health care. If you cannot fully participate in your treatment decisions, and you want to have someone you trust help you, you have the right to choose that person; • Have all treatment options explained to you in a language you understand before being treated and be fully informed of your health status and how well you are doing; • Refuse services, treatments or medications. If you choose not to get a service or treatment or take your medication, you must be told how it will affect your health; • Participate in making and carrying out your plan of care to help you live at home and support your independence;

26. Home Care Bill of Rights (5) • Be informed of the cost of services prior to getting those services, whether the cost of those services is covered under health insurance or other private or public programs, and any charges you will be expected to pay and be given advance notice of any changes to those costs or services; • Talk with health care providers in private and have all your personal, financial and medical information kept private as protected under state and federal laws; • Have access to your medical records, and be given copies upon request, at a charge determined by the medical provider; • Request changes to your medical records;

27. Home Care Bill of Rights (6) • Receive information on advance directives and receive assistance to help you make an advance directive. An advance directive is a written document that says how you want medical decisions to be made in case you cannot speak for yourself; • A full explanation of the complaint and appeals process, and who you may contact in order to have those complaints addressed in an proper and timely manner; • Complain about the services or treatment you receive, or that you need and do not receive, the quality of care, number of service hours or any other concerns or problems you have; • Be encouraged, and helped, to freely explain your complaints to persons of your choice. You must not be harmed in any way for telling someone your concerns. This includes being punished, threatened or discriminated against; and • To know the name and address of the state agency to contact for additional information or assistance.

28. Complaint Process • Participant call to Senior Help Line • State Home Care Ombudsman • Enter case in OmbudsManager • Refer to region • Regional Ombudsman • Call, possible home visit • OmbudsManager update • 30-day follow-up • Closure • CTM Process

29. Case Scenarios • Examples of possible inquiries and complaints

30. Related State Activities

31. Duals Demonstration Grant • Effective 12/2/2013, the Department on Aging was awarded a three-year demonstration grant from the federal Department of Health and Human Services to expand the LTCOP to cover MMAI. • Project period: 12/2/2013 - 11/30/2016. • Total grant award = $939,124 • First year funds = $267, 556.

32. Project Purpose • Department on Aging will approve grants to provide expanded ombudsman services to individuals served by managed care (MMAI) • Additional funds will be utilized to ensure expanded coverage for individuals in Medicaid waivers

33. Illinois Grant Activities • FY14: 10 MMAI demonstration ombudsman grants - MMAI recipients  • FY15: 18 MMAI demonstration ombudsman grants - MMAI and Waiver recipients • FY15: 13 MFP grants (PSAs) – transition of nursing home residents to the community, sub-granted to 17 regional programs

34. National Collaboration • LTCOP staff are working closely with federal agencies including the Health and Human Services - Administration for Community Living, and the Centers for Medicare and Medicaid Services • LTCOP have been collaborating with other state LTCOPs • State LTCOP MMAI demonstration grantees will meet in Washington D.C. in September for collaboration

35. Training • New staff have begun to receive training for Levels One and Two ombudsman certification. • Training was provided to ombudsmen during the Adult Protection and Advocacy Conference in Oakbrook Hills. • OmbudsManager training webinars have been provided. • Level Three ombudsman training being developed for home care ombudsmen.

36. Public Awareness • A pamphlet is being produced that highlights the home care expansion • A “bill of rights” brochure is being produced that describes the rights of individuals residing in the home and receiving home care/MMAI • An informational video is being developed that promotes the availability of the ombudsman program in community settings

37. Discussion