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A Meeting of the Standing Olmstead Advisory Committee

October 22, 2010

DRAFT 10/14/2010

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Purpose of this Meeting

• Convene the Standing Olmstead Advisory Committee to review aging & disability-related efforts under the Affordable Care Act

• Provide an overview of the Money Follows the Person (MFP) Rebalancing Demonstration– opportunities & challenges

• Review the timeline and the work process for the MFP planning effort over the next two months

• Address questions

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Community First Olmstead Plan

• Commonwealth’s response to Olmstead v. L.C.

• Vision: to maximize the extent to which people with disabilities and elders are able to live successfully in their homes and communities.

• Six major goal areas:– Help individuals transition from institutional care– Expand access to community-based long-term supports– Improve the capacity & quality of community-based long-term supports– Expand access to affordable and accessible housing with supports– Promote employment of persons with disabilities and elders– Promote awareness of long-term supports

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What is the Standing Olmstead Advisory Committee?

• Outgrowth of CMS Systems Transformation Grant

• Purpose:– To provide ongoing monitoring of the Commonwealth’s

progress in meeting the goals of the Olmstead Plan– To provide input for evolving strategies

• Immediate focus: – Money Follows the Person (MFP) Rebalancing Demonstration;– Other opportunities available through the Patient Protection and

Affordability Care Act (ACA)

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Olmstead Plan Opportunities in ACA• Expanding home & community-based care options

– New Medicaid Rebalancing initiatives– Changes to Medicaid state plan options– CLASS

• Integrating Financing & Care Strategies– Primary Care Medical Home– Care Transitions– <65 Duals Innovation– Integrating behavioral health & primary care– Medicare independence at home demo

• Improving disability care outcomes– Information, referral & data collection– Cultural competency training– Wellness access– Health care facility / equipment physical access– Nursing home & community care outcomes projects– Workforce development

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ACA Olmstead Efforts Underway in MAGrants for improving information,

Referral, & care transitions

• Serving the Health Information Needs of Elders - $1M– Insurance & services counseling for elders & people with

disabilities (Medicare Outreach & Assistance in Low Income Programs & Prevention)

• ADRC Options Counseling - $500,000– Strengthen 11 Aging & Disability Resource Consortiums – Expand elder & disabled counseling regarding community-

based care options

• Evidence-based Care Transitions - $200,000– New North Shore ADRC / hospital / nursing home transition

services

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ACA Olmstead Efforts Underway in MAGrants to Improve the Direct Care Workforce

• Massachusetts Healthcare Advisory Committee (EOLWD) - $150,000• Includes long term / direct care workforce planning

• Personal & Home Care Statewide Training Grant - $2.3M• PHCAST National Goal: Develop core competencies for direct care

workforce– MA Model

– Two-pronged curriculum development & training• MA Home Care Council; proprietary curriculum

– agency-based care model• PCA Community College (Bristol) certificate program

– Self-directed care model; incorporates disabled workers

– Cross-Secretariat strategy• Direct care typology; core curricula; education-to-career path;

certification(s)

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Money Follows the Person

Rebalancing Grant

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MFP Planning Grant

• Money Follows the Person Demonstration– Three-month, $200,000 planning grant in collaboration with

UMass led by OOM• In preparation for 5 year demonstration

• Requires MA to:– Draft the Operational Protocol– Assure involvement, collaboration and guidance from

stakeholders– Conduct a thorough analysis of MA’s readiness to participate– Identify budgetary impact– Determine if a Demonstration is sustainable– Determine need for legislative, regulatory, or administrative

changes necessary to remove barriers to rebalancing

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What is Money Follows the Person?• MFP Rebalancing Demonstration funded by CMS to provide

assistance to states to rebalance their long-term care systems by:– increasing the use of home and community-based services (HCBS)

– decreasing the use of institutional care

– eliminating barriers that restrict flexible use of Medicaid funds

– ensuring quality assurance and quality improvement

• Helps Medicaid enrollees transition from institutions to the community

• 29 states and DC currently have MFP programs

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MFP Operational Protocol Elements

• Organization and Administration– Systems readiness assessment / gap analysis; grant administrative structure

• Benchmarks (2 mandatory; 3 additional)

• Participant Recruitment and Enrollment

• Informed Consent and Guardianship

• Outreach/Marketing/Education

• Stakeholder Involvement

• Benefits and Services

• Consumer Supports

• Self-Direction

• Quality

• Housing

• Continuity of Care Post-Demonstration

• Evaluation11

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Who can receive MFP services?• “Eligible individuals”

– Medicaid enrollees who have lived in a “qualified institution” (inpatient facility,) for not less than 90 consecutive days

– Who, “but for the provision of HCBS long-term care services … would continue to require the level of care provided in an inpatient facility…

– Excludes individuals 21-64 in IMDs (Institutions for Mental Disorders: Worcester, Taunton, Fuller)

• Who must move to a “qualified residence” in the community– Home / apartment owned / leased by individual or family– Community-based residential setting of no more than 4 unrelated

people

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How does the MFP Match Work?

• Historic Federal Match for MA: 50%

• MFP enhanced match includes:– 75% for most HCBS for a one-year period (365 days) for

each individual transitioned from an institution• Rate could be higher if implemented during an enhanced FMAP

period

– 50% for certain HCBS only available in the 365 days post-transition

– 75% - 90% for IT and external quality reviews

– Up to 100% available for certain administrative costs

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MFP Services• Qualified Home & Community Based Services

– HCBS that can be covered under Medicaid (state plan or waiver) and must continue to be provided to the individual once the Demonstration program has ended (after 365 days)

• Demonstration services – Additional HCBS that can be covered under Medicaid and are

not required to continue after an individual’s one-year transition period

• Supplemental services – One-time / limited duration services to ensure successful

community transition, such as housing access & supports, including security and utility deposits & basic furnishings; environmental, home & vehicle modifications; other

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Additional MFP Features

• Preference for transitioning multiple population groups

• Opportunities to develop transition support, care coordination, & self-direction models

• Expectations regarding providing housing assistance, needed HCBS service development, & support for ADRC structures

• Considerable data collection & evaluation15

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What have other states done with their MFP resources?

• Demonstration Services– TX developed cognitive/adaptive support service for people with brain injuries

& mental illness– GA developed transition case management that supported individuals for one

year after leaving the facility– D.C. developed enhanced primary care coordination (EPCC) to provide

intensive care coordination between PCPs, nursing staff and specialty care providers

– AK and HI offer telehealth services to collect and transmit clinical information

• Supplemental Services– OH provides transition coordination, community transition services,

communication aids and service animals. This service package includes housing navigation and coordination of benefits, as well as purchase of items such as a bed, towels and utensils.

– D.C. developed community integration support which provides community inclusion and integration opportunities such as memberships to gyms or public organizations.

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States have also used MFPDemos to implement broader reforms

• Several states developed comprehensive educational materials, outreach and training curricula

• CT and other states developed IT infrastructure to support Demonstration management

• Some states developed services in response to housing shortage barriers

– IN provides incentives to developers to build new units for MFP participants

– WA and MD pay for or subsidize rent until the MFP participant qualifies for a Section 8 housing voucher

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A Model for MAQUALIFIED INDIVIDUALS / INSTITUTIONS

Hospitals

Nursing Facilities

RehabilitationHospitals

Intermediate Care Facilities

Public Health Hospitals

IMDs (age limits)

DEMONSTRATION SERVICES

Transition Svcs

Qualified HCBS- Existing State Plan & Waiver Services (DDS, ABI, TBI, & Frail Elder)

Demo HCBS Svcs

Other Community Supplemental Svcs

QUALIFIEDRESIDENCES

Individual’s or Family’s Home

Individual’s leased apartment

Community Residential Setting (Max 4 individuals)

•ADMINISTRATIVE SUPPORT

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The MA Fiscal Environment Sets the Stage for MFP Options

• MassHealth’s SFY11 budget has a projected shortfall

• Phase out of enhanced FMAP in FY12 removes$1.2B from FY12 state revenue projections compared to FY11

• MassHealth enrollment continues to exceed projections – higher costs

MassHealth Projected Growth FY08 - FY11

0

500,000

1,000,000

1,500,000

FY2008 FY2009 FY2010 FY2011(Projected)

State Fiscal Year

Mem

bers

(Sna

psho

t)

$0

$5,000

$10,000

Enrollment (snapshot) Expenditues ($M)

$ M

illio

ns

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MFP Planning is taking place within certain limits and uncertainties

• Rebalancing must take place without assuming expansion funds

• Existing & planned disability & elder long-term care commitments must be supported

• Other MassHealth changes & ACA developments need to be anticipated (e.g.: MCO complex care; <65 duals)

• Out-year opportunities will rely on population & revenue forecasting

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Looking at Current Transition in MA:

Process & Settings• Settings: Hospitals; NFs; ICFs/MR; IMDs

• Process:– Client Identification (In-reach)

• Entities: State agencies (DDS; DMH), ASAPs, ILCs, NFs

– Options / Transition Counseling, Assessment, Clinical Eligibility

• State agencies; UMass; NFs (discharge planning); ADRCs: ASAPs (CSSM), ILCs (not clinical)

– Transition Service Provision; Prior Authorization• DDS contracts; UMass

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Looking at Transition in MA

• Given potential new resources,– What are the priorities?

– What are the right services?

– Who are the providers?

– Where are there opportunities for integrated strategies?

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MFP IT Tools for Transition

• Current resources– 1-800-AGE-INFO

– MADIL

– PCA & Homecare Registries

– Housing Registry

• Planned resources– MDS 3.0 / Section Q Info

• Needed improvements / other capacity?

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Thinking about MFP Housing Support

• Current Capacities– Housing registry– Provider / agency-based housing locators / support – Bond development funds– Some modification capacity– Limited support for first / last

• Extensive needs documented in STG Housing Report

• New developments– Memorandum w/ DHCD / PHAs; Set-aside vouchers (~200 just in to 3 PHAs;

250 more requested for people leaving institutions)– Diverse strategies under MFP

• Priorities for grant?

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HCBS Opportunities in MFP

• Some HCBS development priorities identified through the Olmstead Plan– Cueing / monitoring support for brain injured, developmentally

disabled, & people with mental illness– Medication management options– Peer Support – Respite– Self-direction / individual budgets

• Challenges– Building cross-disability support– Identifying mechanisms for creating / managing access

• Priorities for MFP?

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MFP Timeline• October 2010

– Begin CMS TA– Hold Olmstead Meeting– Begin MFP Workgroups

• November 2010– Continue MFP Workgroups– Complete Population & Budget Analyses

• December 2010– Complete Operational Protocol

• January 2010– Re-convene Olmstead Group– Submit OPD

• July 2011– Start Demo

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MFP Information Available Online

• Additional MFP information will be available on the Community First website located at:

www.mass.gov/hhs/communityfirst