1 State Initiatives in Nursing Facility Transitions Susan C. Reinhard Co-Director Rutgers Center for State Health Policy Michigan’s LTC Conference Detroit, Michigan March 23-24, 2006

2 Goals Highlight key developments in Nursing Facility Transition across the country. Offer state examples Share Michigan State Policy in Practice brief

3 Information about LTC options Crucial for consumers, their families and the professionals who counsel them –Once people enter a nursing facility and give up their community supports, it is hard to leave. Without information, people cannot make an informed decision about where to receive services. States are looking at the best ways to provide information

4 Improving Access to LTC Nursing Home Transition programs –Large statewide programs (WA, NJ, Oregon) –State employees (NJ, WA) –Smaller programs for most challenging situations (SC, CT, MA) –Locally based organizations (Centers for Independent Living, Area Agencies on Aging) Hospital Diversion Programs –Indiana (see Rutgers brief)

5 CMS Nursing Facility Transition Grants 12 Demonstration Grants funded –$160,000 - $175,000 in 1998; thereafter $500, NFT grants funded (to 27 states) in 2001 and 2002 –23 grants to state programs; 10 grants to Independent Living partnerships (6 states received grants to both) –State programs got up to $800,000; ILCs got up to $450, states total funded in some way

6 Washington: A Pioneer State funded chore services since 1970s 1980s budget crises lead to greater reliance on Medicaid LTC benefit 1983 Medicaid Waiver Program 1989 Medicaid Personal Care Program 1993 legislature approves relocation of 750 nursing home clients to HCBS budget reduces NH caseload by 1,600 clients

7 Legislative direction… Nurse delegation legislation and ongoing changes Global budget provides significant management flexibility Caseload Forecasting Council projects NH & HCBS trends NH caseload is falling while HCBS absorbs growth in service demand

8 Washington’s Aging and Disability Services Administration (ADSA) Manages all state-supported long- term support services for older adults and people with physical disabilities. Administers long-term support services through regional offices and 13 AAAs. –ADSAs and AAAs use common database.

9 ADSA Regional Offices Staffed by state-employed nurses and social workers. Conducts initial assessment for Medicaid- funded services, functional eligibility determination, care plan development. Provides on-going case management and reassessment for consumers in nursing facilities, adult family homes, and assisted living settings.

10 Area Agencies on Aging Help consumers identify, understand, and access available resources through information and referrals. Provide case management and reassessments for consumers living at home.

11 Comprehensive Assessment Reporting Evaluation (CARE) Single automated system used by both ADSA regional offices and AAAs to: –Assess functional, health, cognitive and behavior status. –Determine long-term care eligibility. –Develop plan of care. –Determine maximum number of authorized service level.

12 Care Plan Development Completion of assessment generates report of programs the consumer is eligible for. –Assessor describes programs to consumer. Most HCBS are provided using consumer direction.

13 Authorized Service Level Determination CARE system authorizes number of in- home hours consumer can receive each month. –Maximum 420 hours/month. Standardized service limits. –Based on consumer’s clinical and functional characteristics. Payment levels established for services in adult home or assisted living facility.

14 Medicaid Financial Eligibility Determination Initiated at the same time as functional eligibility determination. Quick determination (internal goal of 15 days): –Presumptive eligibility for an individual being discharged from hospital. –Avoid delays that dictate whether consumer remains in the community or enters a nursing facility.

15 Washington’s Nursing Home Relocation Assign case managers (social workers and nurses) to each nursing facility (one for 2-3 NHs) Priority clients: new admits (within 7 days), 180 day conversions & others expressing interest Provide assistive technology and individualized community support services Use civil penalty fund and nursing facility discharge allowance Promote NH capacity reduction and bed conversion strategies WA Aging and Disability Services Administration

16 Nursing Home Transition Services Case managers contact residents within 7 days of NH admission to discuss preferences, care needs and supports available in the community. Comprehensive assessment completed when consumer is ready to work with case manager who develops transition plan with consumer.

17 Washington Nursing Home Transition Grant Strengthen capacity of independent living centers, providers, and contractors to provide support and technical assistance on independent living and consumer-directed services. Expand access to accessible, affordable housing for people transitioning from nursing homes. Improve provision of assistive technology services necessary to live in the community.

18 Washington: NF caseload trends Figures for July each year

19 Washington: HCBS trends Figures for July each year

20 Washington LTC Spending trends (millions Based on data from the Washington Aging and Disability Services Administration

21 WA: Shifting spending balance

22 WA: Elders and Adults

23 New Jersey’s Three-Pronged Strategy for Systems Change Consolidation at state level Create more choices for HCBS services Help consumers find choices New Jersey’s Three-Pronged Strategy for Systems Change Consolidation at state level Create more choices for HCBS services Help consumers find choices

24 Help Consumers Find Choices NJ EASE (New Jersey Easy Access Single Entry) –Resource Center –Information, assistance, care management Community Choice Counseling –nursing home transition program

25 Community Choice Counseling New Jersey has one of the the largest Nursing Home Transition Programs in the country. Program uses nurses and social workers to assist people to leave the nursing home.

26 Foundations of the Community Choice Counseling A 1988 state law and its implementing regulations provided the opportunity to create the Community Choice Counseling program a decade later. Nursing Home Pre-admission Screening law in 1988 (P.L. 1988, Chapter 97)

27Foundations All persons who will become eligible for Medicaid within six months following NH admission must be assessed or Medicaid will not pay. Provides the legal framework for the state to claim a federal match for the salaries of staff performing PAS for almost all people entering a NH for a projected long stay.

28 In 2004, did a total of 33,746 PAS assessments (26,686 “initial” and 7,060 “reassessments”) to determine Medicaid eligibility for LTC services 80% of Hospital PAS assessments done within 24 hours. Rest are done within 72 hours (the policy) Pre-Admission Screening Program: PAS

29Foundations Track I are unlikely candidates for nursing home alternatives. Track III are those who are diverted from nursing home residence through community placement. Track II is the targeted group who cannot be immediately diverted from nursing homes, but might be able to return to HCBS.

30Foundations Track II was the target group for the 1998 Community Choice Counseling pilot and the initial roll-out of this program because the state employed nurses already had a legal mandate to periodically assess and counsel these nursing home residents. Important factor in overcoming NH resistance.

31Foundations Started with 2 state nurses in Ramped up to 73 professional staff now--mainly nurses. Transition fund--state dollars, now Medicaid waiver. Three CMS grants, starting in Currently refining work with younger persons with disabilities.

32 CCC Practices State staff members cross-trained to do PAS, options counseling, and transition support. –61 registered nurses; 12 social workers. –Assigned specific hospitals and nursing homes.

33 CCC: The Present 2002 pilot with Independent Living Centers “Round Tables” to address the broad and complex needs of consumer who needs substantial assistance to find housing, social services and other community connections for sustained community residence. –Involves Community Choice counselor, consumer, NH discharge planner, and others.

34 CCC Results and Future Goals As of September 23, 2005, 5,583 individuals have been discharged from nursing homes to less costly alternative living arrangements since March 1998 In SFY05, 503 individuals transitioned from nursing homes to home and community- based services In SFY06, goal is to discharge 500 individuals through Community Choice Counseling

35 Divisions of Aging and Community Services (DHSS) and Division of Disability Services (DHS), with the ILCs, have worked together to transition younger disabled adults from nursing homes into the community –In SFY04, 83 younger disabled adults were transitioned –In SFY05, 196 younger disabled adults were transitioned Nursing Facility Transitions Grant

36 NF Actual Recipients vs. Recipients Without Reductions

37 Source: NJDHSS, Sept 15, 2004 Trenton, NJ

38 Community Choice Counseling Evaluation (Howell White et al) Focus both on the Former Nursing Home Residents’ and the Counselors’ Perspectives Quality of Life for Former Nursing Home Residents in terms of –Current living situation –Use of services –Health care service use –Social support network

39 Key Findings Key Findings High satisfaction with their return to the community Most return home Most are alive and remained in the community for the full year Returning to a NH or being deceased seems to be related to frailty and significant adverse health incidents

40 Status at One Year After Discharge N=1344

41 Federal grant of almost $800,000 over 3 years Among first 12 states to get ADRC funding Department of Health and Senior Services is lead agency with Department of Human Services as partner Redesign aging and disability service systems: multiple entry points that are coordinated and standardized Extends to persons 18 years and older with physical disabilities Major component HCBS/CMS Quality Model & Consumer Satisfaction NJ=A National Model through Aging & Disability Resource Center Grant (ADRC)

42 CCC Integration

43 Nursing Facility Transition Grant MI Choice Assessment Tool CCC Links to ADRC Initiative

44 Focus in Warren County ADRC pilot on conducting clinical needs assessments and counseling consumers on the broad range of home and community based services (HCBS) Activities include: –Testing MI-Choice: the selected clinical needs assessment tool –Streamlining and coordinating PAS and financial eligibility process –Coordinating and arranging HCBS with community agencies and Community Choice Counselors MI-CHOICE Clinical Assessment Tool

45 Minnesota—Long Term Care Consultation Preadmission screening was revised by the legislature in 2001 into a much broader program on long term care consultation. It now includes: –assessment of needs –assistance in identifying and recommending cost- effective home and community-based services –development of a community support plan –preliminary determination of eligibility for public program support –transition assistance for people who are currently institutionalized

46 Minnesota—Long Term Care Consultation Consultation is available to everyone, regardless of income or acuity levels –The statute includes a mandate to provide information and education to the general public regarding long term care consultation Service teams are organized at the county level and consist of at least one social worker and one public health nurse Consumers must be assessed within 10 days of the request or referral Consumers under age 65 must have a face-to- face assessment within 40 days of NF admission

47 Minnesota--Results Accelerated trend away from institutional services and toward community-based services

48 Minnesota—Data (Source: Minnesota Department of Human Services)

49 Indiana—Priority Diversion, Transition and Options Counseling Indiana has diverted over 1,300 consumers from nursing facility admissions to home and community-based services with its priority diversion program implemented in 2003 by AAAs working with hospital discharge planners. –These consumers are given a priority for spots in the HCBS waiver program, which otherwise has a waiting list, so that they can avoid losing housing and community supports

50 Indiana—Priority Diversion, Transition and Options Counseling Indiana personnel believe that the state would benefit by changing its preadmission screening process to emphasize long-term care options counseling in addition to determining level of care needs Also looking at restructuring case management payments for transitions because the current cap on eligible hours may lead to hiring more expensive formal care instead of trying to work out informal options.

51 Importance of Evaluation Can help build the case for NHT programs with policymakers Can provide information to improve the program Connecticut and Michigan are examples of this

52 Conceptual Model of Transition Relationships

53 Connecticut—Design & Evaluation Built evaluation into design of program Asked state how to measure costs of NF vs. HCBS –State involvement from the beginning, combined with an external evaluator for the program, meant that results were not questioned Involved stakeholders with knowledge and decision-making authority in the steering committee Results showed a savings of $96/day on average for each person transitioned.

54 Connecticut--Outcomes Governor requested to sustain program with funding for transition coordinators and more waiver slots. State changed its housing plan to set aside Section 8 vouchers for persons transitioning from institutions. State dedicated $500,000 in bond funds to be used for housing modifications for transitionees (rental or owner-occupied)

55 Michigan’s Nursing Home Transition Program One of the first group of states to receive NHT funding in Focus on resident’s choice to leave NH rather than ability. 41% of NH transitionees required no government-paid services after transition assistance. Costs for transitionees enrolled in Medicaid waiver or other service programs 60-76% less on average than costs to stay in NH.

56 Michigan’s Long-term Care Population 1.24 million of 10.1 million residents are 65 years old or older (12%). –40% have some type of disability. 40,365 nursing home residents in –67% paid by Medicaid, 15% by Medicare, 18% private. 10 th highest nursing home population in the US. –3.4% of residents 65 and older are in nursing homes. –US average: 4%.

57 Long-term Care Spending in Michigan Michigan’s total Medicaid budget in 2004: $8.2 billion. –$2.4 billion in total Medicaid spent on LTC. –$1.7 of $2.4 billion (71%) spent on nursing home care. Percentage of Michigan’s LTC budget going to nursing homes is decreasing. –75% in 2000 to 71% in –US average: 51.3%.

58 Improving LTC Access 1998: Nursing Home Transitions Demonstration Program Grant. 2001: Nursing Facility Transition grant ($770,000) and Real Choice Systems Change grant ($2.1 million). 2003: Money Follows the Person ($786,000). 2004: Cash and Counseling (RWJ). 2005: ADRC grant ($800,000).

59 Nursing Home Transition Program 2001: 2 pilot sites –Area Agency on Aging of Western Michigan (9 counties inc. Grand Rapids) –Detroit Area Agency on Aging As of April 2005, NHT program is statewide through MI Choice program. –22 waiver agents (AAAs and others) serving 14 regions.

60 Michigan Cost Data

61 Susan C. Reinhard Co-Director Rutgers Center for State Health Policy Director Community Living Exchange at Rutgers Technical Assistance for Real Systems Change