Enhanced Nursing Home TransitionEnhanced Nursing Home Transition

NHT Collaborative Partners

Regional Meetings

August 2006

2

GoalsGoals

Provide a context for discussing change in Pennsylvania’s Long Term Living system

Provide key information for state staff to support Enhanced Nursing Home Transition

3

Drivers of LTL System ChangeDrivers of LTL System Change

PA, Nation and the World are aging.

Federal policy is promoting community living for people of all ages and disabilities--Americans with Disabilities Act, Olmstead Decision, New Freedom Initiative.

Consumers of LTL services want to remain in their homes and communities.

4

Drivers of LTL System ChangeDrivers of LTL System Change

Advocates are pushing for Home and Community-Based Care—ADAPT, AARP and others.

Consumer Direction is sweeping the states.

States are seeking ways to help people of all income levels find affordable options for both private pay and publicly supported services.

5

National PolicyNational Policy

For the first time ever, the Centers for Medicare & Medicaid Services (CMS) and the Administration on Aging (AOA) are partnering…

and they are urging the states to do more to help people live in their homes and communities.

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Dr. Mark McClellan, Administrator Dr. Mark McClellan, Administrator Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services

“We are about to enter a new era of personal control, of New Freedom, in the Medicaid program. With a concerted effort, every state can rebalance its Medicaid program. With the tools we have now, it is time to end the institutional bias….”

7

Josefina Carbonell, Josefina Carbonell, Assistant Secretary for AgingAssistant Secretary for Aging

“This is an exciting time to be involved in long-term care. It is clear we are witnessing a fundamental change in federal policy that is guided by the New Freedom Initiative and directed at giving people more control over their care, as well as providing more support for community living.”

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States are either Leading or States are either Leading or Following…but most are MovingFollowing…but most are Moving

Listening to older adults and people with disabilities.

Balancing public dollars spent on long term care (living).

Informing people about their options.

Emphasizing the “critical pathways” to a nursing home admission.

Assertively reaching out to people in nursing homes to help them return home.

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People in Nursing Homes Need People in Nursing Homes Need Information about LTL OptionsInformation about LTL Options

Crucial for consumers, their families

People enter a nursing home for many reasons; many can leave.

Without information and help, many people in nursing homes cannot make an informed decision about where to receive services outside of an institution.

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Myth: Most People in Nursing Myth: Most People in Nursing Homes Need to be ThereHomes Need to be There

Those who resist change say: “People in nursing homes today are too frail to live in the community. Only a few of them can really leave.”

Fact: For every person in a nursing home who needs assistance with 3 or more activities of daily living, there are 1.83 people living in the community who have the same level of disability.

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Improving Access to LTC OptionsImproving Access to LTC Options States are looking at best methods to avoid unwanted

institutionalization– Managed Care (Arizona, Texas, New York)– Various Nursing Home Transition programs

Nursing Home Transition programs

– Large statewide programs (WA, NJ, Oregon)

– State employees (NJ, WA)

– Contracted organizations (CO)

– Small programs for most challenging (SC, CT)

– Locally based organizations (Centers for Independent

Living, Area Agencies on Aging)

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Culture Change: Philosophy of Culture Change: Philosophy of Person-Centered Planning and ChoicePerson-Centered Planning and Choice

For Nursing Home Transition to work, all long-term living stakeholders have to see it as possible and desirable that consumers can choose and direct their services.

Need to confront ageism and institutional bias.

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SummarySummary

Federal policy and consumer activism are fueling historic, fundamental change in long-term living

States are developing various models for making community living a real option

Nursing home transition is a crucial component to balancing the LTL system

Not Easy, Not Fast, Worth it, Possible

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The Pennsylvania PictureThe Pennsylvania Picture

Three Imperatives to Balance the Long Term Living System in PA

– Demographic trends

– Consumer choice

– Fiscal challenge

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Demographic TrendsDemographic Trends85+ Population in PA85+ Population in PA

Fastest-growing segment in the U.S., 9% increase since July, 2003Medicaid long-term living utilization is consistent with demographic trends

Source: Penn State Data Center and PA Department of Public Welfare

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Jul-99

Jul-00

Jul-01

Jul-02

Jul-03

Jul-04

Jul-05

Jul-06

Jul-07

Jul-08

Jul-09

Jul-10

Jul-11

Jul-12

Jul-13

Jul-14

Jul-15

Jul-16

Jul-17

Jul-18

Jul-19

Jul-20

Total 85+ Population Total LTC Demand

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Consumer ChoiceConsumer ChoiceThe vast majority of people with

disabilities want to live independently and with dignity, free from the restrictions of institutional settings.

Nine out of ten older adults prefer to “age in place” in their homes and communities.

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The Elderly and Persons with Physical Disabilities Use the Greatest Share of Medicaid Resources

Disabled$4.3 billion

33%

Children & Families$3.2 billion

24%

Chronically Ill Adults$1.0 billion 8%

Elderly$4.7 billion

35%

Fiscal ChallengeFiscal Challenge

Elderly

$4.7 billion

35%

Disabled$4.3

billion 33%

Children & Families$3.2 billion

24%

Chronically Ill Adults$1.0 billion 8%

Source: PA Department of Public Welfare

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Long-Term Living SpendingLong-Term Living SpendingIncreasing investment in long-term living services to serve Elderly and

Persons with Physical Disabilities

Source: PA Department of Public Welfare

$0.0

$500.0

$1,000.0

$1,500.0

$2,000.0

$2,500.0

$3,000.0

$3,500.0

$4,000.0

2002-2003 2003-2004 2004-2005 2005-2006 2006-2007

Mill

ion

s of

Dol

lars

Nursing Home PDA Services OSP Services

$2,632.6$2,844.7

$3,122.5

$3,393.5

$3,623.5

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Nationwide Comparison of LTC users in NF versus HCBSNationwide Comparison of LTC users in NF versus HCBS

Nationwide trends show sustained commitment is necessary to rebalancingNationwide trends show sustained commitment is necessary to rebalancing

Sources: Thomson Medstat and Kaiser Family Foundation, 2002

74%

86%

65%

25%

70%

43%

26%

14%

35%

75%

30%

57%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

National PA MN OR VT WA

State

% o

f C

on

sum

ers

% NF % HCBS

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Pennsylvania’s ProgressPennsylvania’s Progress

17,964 21,832 27,524 30,394 34,694

78,50680,402

81,05181,441

81,807

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

2002/2003 2003/2004 2004/2005 2005/2006 2006/2007

Total HCBS Users Total NF Users

Share of HCBS waiver users have increased since 2002-2003

Source: PA Department of Public Welfare

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Long Term Living CouncilLong Term Living Council

In November of 2005, Governor Rendell established the Long Term Living Council aimed at:

– Accelerating reforms of the Commonwealth Long Term Living System, building on successful initiatives implemented to-date

– Positioning the Commonwealth to meet future demand for services while addressing the short-term and long term fiscal challenge this will entail

– Improving coordination across state departments in support of LTL reform agenda.

Council Members include Cabinet Secretaries from Aging, DPW, Budget, and Policy; Director of the Office of Health Care Reform and Deputy Chief of Staff

 

Michael Nardone named as Executive Director; cross-agency staff teams formed to support work of the Council

Subset of Governor Rendell’s Health Care Reform CabinetSubset of Governor Rendell’s Health Care Reform Cabinet

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Rendell Long-Term Living Reform AgendaRendell Long-Term Living Reform Agenda

To achieve this goal, the LTL Council will work to: • Enhance and expand efforts to assist nursing home residents

who wish to leave a facility-based care setting, and can safely return to their home or community

• Ensure that the supply of nursing home beds appropriately meets the need for such care, while providing opportunities for facilities to expand their continuum of care

• Ensure consistency in the application of eligibility criteria for long-term living services, while removing barriers to receiving home and community-based waiver services

• Maximize available waiver resources to serve as many consumers as possible, while ensuring provision of high-quality care and services

Governor Rendell’s vision is to offer consumers choice as to where they receive long-term living services, ensuring high-quality care in the

most clinically-appropriate, most cost-effective environment

Enhanced Nursing Home Enhanced Nursing Home TransitionTransition

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Enhanced Nursing Home TransitionEnhanced Nursing Home Transition Focus on new admissions

MDS Data

LTL Counseling

Strengthened collaborations

Active engagement of AAAs and DPW NHT partners

Incentives for agencies to achieve successful transitions

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Focus on New AdmissionsFocus on New AdmissionsNHT program has demonstrated that

the loss of housing and community supports is major barrier to successful transition

Need to inform and educate consumers, families and caregivers before resources and supports disappear

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MDS DataMDS DataCollected by nursing homes on all

new admissions to develop plan of care

06-07 rate agreement requires data to be submitted within 7 days of completion

MDS data will be used to focus NHT efforts on new admissions

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LTL CounselingLTL Counseling Provide information and guidance to

consumers in need of LTL services

Ensure that all options are explained fully

Enable consumers to make informed choices about where and how they receive LTL services.

Ensure that scheduled discharges occur as planned

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Strengthened CollaborationsStrengthened Collaborations Opportunity to strengthen and

expand existing collaborations– Clearly define roles and

responsibilities– Increase and improve inter-agency

communication– Include additional community partners

to support NHT, e.g. housing agencies, faith based organizations, community service organizations, other county agencies

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Long Term Living Counselor•Provide information and guidance to consumers•Ensure that all options are explained fully•Enable consumers to make informed choices about where and how they receive LTL services

AAA NHT Responsible for transition services and supports to over 60 consumers; actively works with each consumer to complete a successful transition

OSP Agency NHTResponsible for transition services and supportsto under 60 consumers; actively works with each consumer to complete a successful transition

Local CollaborationShares knowledge, expertise, and resources to support successful transition; case conferencingaround difficult transitions; other activatesdepending on local arrangements

Coordination between LTLand NHT activities

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Active Engagement of All PartnersActive Engagement of All Partners

AAAs will conduct LTL Counseling

AAA will be responsible for over 60 transitions

DPW NHT partners will be responsible for under 60 transitions

Collaborative partners will share experience, expertise and resources to support successful transitions

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Unified Data TrackingUnified Data Tracking

Module has been created in OMNIA to collect LTL Counseling and transition data

All agencies will use the same system

Real time data collection to allow ready access to critical information

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Technical AssistanceTechnical Assistance

Roll-out Meetings Monthly Regional TA Calls NHT Conference in October Regional Housing TA Meetings State Staff:

– PDA – Tim Hoskins, (717) 783-6207

– DPW – Kim Kramer, (717) 787-8097

– GOHCR – Lynne Miles, (717) 346-9992

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Summary of Enhanced NHTSummary of Enhanced NHT

Identification of NH Admissions through MDS Data

Early LTL counseling

Active engagement of AAA and DPW NHT agencies in transition activities

Strengthened collaborations

Incentives for successful outcomes

Nursing Home Transition

Incentive Plan

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The Commonwealth is proposing to invest in AAAs and DPW NHT agencies through the incentive program

Agencies will have the opportunity to earn additional dollars in incentive payments through this incentive pool

Two part system rewards performance and provides support for agency restructuring

Proposed Incentive PlanProposed Incentive Plan

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Incentive Plan PrinciplesIncentive Plan Principles•It is meaningful for agencies large and small;

•It will result in necessary restructuring;

•It strengthens partnerships;

•It balances these needs with existing agency capacity; and 

•It will not require a recurring expenditure for success.

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Restructuring Incentive

– Goal is to reward agencies for meeting transition goals

– Incentives are based on agencies performing specific functions and to restructure operations to support Enhanced NHT

– One-time, non recurring expenditure

Incentive Plan ComponentsIncentive Plan Components

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Goal Based Incentives

– Each agency has been given specific transition goals

– Incentive funds will be earned based on successful attainment of goals

Incentive Plan ComponentsIncentive Plan Components

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AAA Total Incentive ExamplesAAA Total Incentive Examples

Tier County Total Goal

Restructuring 2nd Quarter

4th Quarter Total Possible

6 Allegheny 188 $60,000 $15,000 $45,000 $120,000

5 Delaware 107 $50,000 $15,000 $35,000 $100,000

4 Lehigh 75 $40,000 $15,000 $25,000 $80,000

3 Cameron Elk McKean

52 $35,000 $15,000 $20,000 $70,000

2 Beaver 34 $25,000 $15,000 $10,000 $50,000

1 Jefferson 10 $20,000 $15,000 $5,000 $40,000

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BHCBS Partners Total Incentive ExamplesBHCBS Partners Total Incentive Examples

Tier County Total Goal

Restructuring 2nd Quarter

4th Quarter Total Possible

1 CIL of Central PA

10 $15,000 $5,000 $10,000 $30,000

2 VFI 30 $20,000 $10,000 $10,000 $40,000

3 CRI 66 $25,000 $30,000 $10,000 $65,000

4 Liberty 125 $25,000 $50,000 $20,000 $95,000