1. Pennsylvanias Nursing Home Transition Program 2012 State Conference for Pennsylvania Nursing Home Transition Coordinators, Care Managers and Service Coordinators Hershey, PA December 7, 2012 Leslie Hendrickson

2. God first created the starry night

4. Then God created the earth

6. And 8,000 or several million years later, depending on which source document you use, God created Medicaid in 1965

8. Since then Congress has steadily simplified and made Medicaid more cost effective; so it now looks like this

10. Use of Terms From the standpoint of the elderly and persons with physical disabilities, Nursing Home Transition is the long-standing practice numerous states evolved of helping persons leave nursing homes and live somewhere else. Money Follows the Person is a variation of nursing home transition that began in 2005 and was designed by an anonymous committee in Washington, D.C.

11. Picture of a Nursing Home Transition Program

12. Transition Beginnings Numerous states had transition practices that grew in the 1990s. In the late 1980s and early 1990s these practices were sometimes referred to as relocation and the staff doing them were referred to as relo workers; More organized Nursing Home Transition programs began in the late in late 1990s. Over a decade ago, as a region, states in the northwest, Idaho, Nevada, Oregon and Washington were operating programs that resulted in persons leaving nursing homes; New Jersey in 1999. Texas, the largest program in the country, began in 2001.

13. In general, 183 Olmstead-related lawsuits substantially changed long-term living programs. The 1999 Olmstead Decision was soon followed by the first round of Federal funding for nursing home transition was during 2000-2003. Over 33 projects funded as part of Real Systems Change grants: 23 to state agencies and 10 to independent living centers (ILCs); In The Context Of Olmstead

14. The Center for Medicare and Medicaid Services (CMS) has continuously supported these efforts through grants and policy changes. For example early on, between 2000 and 2003, CMS wrote multiple State Medicaid Directors letters announcing polices that made it easier to operate transition programs. Continued Federal Support

15. The 2005 Deficit Reduction Act in Section 6071 provided $1.75 billion over 5 years through awards in 2011; The Affordable Care Act (ACA provides an additional $2.25 billion through Federal Fiscal years FFY) 2016 and Section 2403 contained funding for 30 programs, plus 13 additional programs were funded. MFP is in business until 2020. Any unused portion of a State grant award made in 2016 would be available to the State until 2020. Money Follows the Person (MFP) Begins

16. Cumulative Number of MFP Transitions 16 Source: Mathematica, Semiannual progress reports. End of month data The number of MFP transitions continues to grow

17. Level of Care Needs Among MFP Participants 17 MFP participants leaving nursing homes have a higher rate of low care needs than other groups Source: 2008 and 2009 linked MFP program participation data, Medicaid Analytical Extract data, and the nursing home minimum data set (MDS) from 28 MFP grantee states.

18. MFP Numbers About 25,000 people transitioned back into the community as of July 2012. CMS is expecting the number of transitions to approach 30,000 by January 2013. By 2016, States anticipate transitioning over 58,000 individuals.

19. Managed Care has come regarding NHT Integration of dual eligibles into accountable care organizations, managed care organizations (MCOs), or specialty managed care, e.g. behavioral health organization. Subject of considerable interest webinars, articles. One focus is on contract language.

21. State Contract Language is Important State contracts can require MCO plans to put on the equivalent of an NHT program, including capitating the plan for transition expenses. Will managed care plans be responsible for both nursing facility (NF) and Home and Community Based Services? Who do the plans contract with? CILs, ADRCs?

22. Reasons for NHT Durability Mix of good policy and good financials Good policy -provides a choice to persons and helps maintain dignity and independence. Good financials – long-run average costs in community can be lower. No lobby. No provider group. No association. Labor function – predictable activity levels Aging of the Population

23. Aging of the Pennsylvania Population The next data is from Catherine Tucker at Population Research Center at PSU www.pop.psu.edu/research/projects/PA-Projection-Final-Report.pdf

24. Erie Zoo Gives Aging Gorilla a bunny named Panda for a companion.

26. Year Number of Persons Aged 80 and older Population of Pennsylvania % Change in Persons aged 80 and Older since 2010 % Change in State Population since 2010 2010618,81812,744,758 2015660,61012,549,7386.75%-1.53% 2020699,15812,645,78312.98%-0.78% 2025783,71912,709,79126.65%-0.27% 2030940,14512,704,24451.93%-0.32%

27. Some States do Better Alaska Michigan Nevada New Jersey Pennsylvania Ohio, Texas, and Washington account for 40% of all nursing home transitions in July-December 2011.

28. Pennsylvania For Example

29. Pennsylvania Transitions

30. Why do Some States do Better? Long history Continuity of leadership Policy support from legislature or Gov.s office Take out all payor sources: private pay and Medicare Build data infrastructure Resource development Training and local support Better management of staff time -- predictable activity levels

31. Why is Pennsylvania Better? Much hard work by all concerned for ten years; Undergone continuous technology and policy changes; The integration of programs into the Office of Long-Term Living showed support at high levels for the program;

32. Why is Pennsylvania Better? #2 Office of Long-Term Living and verbal geography. Same state and local leadership for about a decade; Leadership is not a position; Followed policy of taking everyone out thus all Pennsylvanians were treated the same;

33. Why is Pennsylvania Better? #3 Considerable efforts were expended on: Building a health technology that captured program statistics; Developing training materials and toolboxes to help local agency staff; Developing communication patterns like routine training calls and talks with state staff, and Developing housing and related linkages.

34. Closing Comments The values of dignity, choice, and independence that have so infused nursing home transition work have had a substantive impact on other parts of society. For example in the architecture of hospital and nursing home patient rooms.

35. Architecture of Hospital and Nursing Home Patient Rooms All hospitals in New Jersey built in the last five years have the following architecture of patient rooms. Some nursing homes as well, Combination of dignity, choice, independence and safety.

36. Architecture - Privacy Each room has a large window, and The private room permits private conversations with the physicians and nurses as there is the possibility that patient conversations can be inhibited when third parties are present.

37. If you remove the second patient you can move the family in; The rooms are designed to engage the family in the care of the person. The rooms are built with fold out sofas that can be used as a bed and may have reclining chairs with big comfortable cushions, and They have refrigerators where food and drinks can be stored so family members can bring their own food to the room. Architecture -The Family

38. Architecture - Rooms and Technology The room has a computer that staff can use to input notes minimizing traffic in and out of the room while permitting timely data entering of patient information: The large television screens are also linked to the acute care centers electronic records so patient information such as x- rays can be shown on the screen, and The television set also doubles a screen where the patient can enter meal choices and food is prepared from the selections chosen by the patient.

39. Architecture - Minimize Health Risks A wash sink is built near the door, but the sink is automatic and has no faucet handles thus minimizing the transmission of bacteria and other organisms from hand to hand; The curtain surrounding the bed, which is frequently touched, is bacteria resistant; Beds and bathrooms are built on the same wall to minimize falls and there is often a grab bar on the wall from the bed to the bathroom, and The private room eliminates the risk of infection from having another person in the room.

40. For more information – Institutional Level of Care among Money Follows the Person Participants, Reports from the Field #10. Cambridge, MA: Mathematica Policy Research, October 2012, No. PP12-79, 12 Pages Available at Mathematica website, use MFP in Search Box

41. Managed LTSS Sources AARPs On the Verge report at: http://www.aarp.org/health/health-care- reform/info-02-2012/On-the-Verge-The-Transformation-of-Long-Term-Services- and-Supports-AARP-ppi-ltc.htmlhttp://www.aarp.org/health/health-care- reform/info-02-2012/On-the-Verge-The-Transformation-of-Long-Term-Services- and-Supports-AARP-ppi-ltc.html Center for Medicare and Medicaid Services informational bulletin: http://content.govdelivery.com/attachments/USCMS/2012/08/06/file_attachment s/147362/CIB-08-06-12.pdf http://content.govdelivery.com/attachments/USCMS/2012/08/06/file_attachment s/147362/CIB-08-06-12.pdf Scan Foundation January 2012 description of specific states. Go to publications page and see Flexible Accounting paper at: http://www.hendricksondevelopment.biz/ http://www.hendricksondevelopment.biz/ CHCS summaries of state managed LTSS approaches http://www.chcs.org/publications3960/publications_show.htm?doc_id=1261451

42. For more information CMS and Mathematica websites: http://www.cms.gov/CommunityServices/20_MFP.asp http://www.mathematica- mpr.com/health/moneyfollowsperson.asp http://www.mathematica- mpr.com/health/moneyfollowsperson.asp Olmstead lawsuits http://www.pascenter.org/olmstead/olmsteadcases.php Leslie Hendrickson leslie.c.hendrickson@gmail.com http://www.hendricksondevelopment.biz