A Presentation to the Achieving Olmstead Implementation in California meeting Leslie Hendrickson Hendrickson Development September 29, 2010

Policy Arctic Zone Policy freezes in waning months of an administration. Governor is fund raising for new library to store papers. Legislators busy running for reelection. Key staff leave for lucrative lobbying jobs. Printing costs go up because of resume copying. Secretaries begin shredding documents. Campaign workers fantasize about possible state jobs.

What to Do from Advocate’s Point of View Good time to plan and organize. Need to have coherent strategy and asks for next administration. Coherent strategy contains clear tasks, alternatives, timelines, and implementation ideas. Not enough to have asks, must also show how to meet asks.

Where Asks Come From? What is Olmstead in 2011? What has been achieved? What needs to be achieved? How to bridge the gap from what is to what should be?

Community Choices Project Overview Community Choices Five-year project funded by CMS. Focused on improving access to long term services and supports to allow individuals with disabilities and older adults to stay in their homes and communities. The Community Choices website is:

: Home and Community Based Long ‐ Term Care Report Big report, 300 pages, not beach reading. 1,300 hits on it since November 2009 not counting hard copies. Two authors, but in reality is group effort. Reviewed all California long-term living programs. Emphasis on finance. Suggested both incremental and broader changes.

Recommendations Time to implement General Short-term (12 months) Medium-term (12 – 24 months) Longer-term (24 months or longer) Category Access/delivery system State-level organization Financing

General Recommendations

If you know where you are going it is easier to get there Establish a philosophy and legislative intent for all long- term services and supports. Currently only described for specific programs No overall statement of intent for the “system” Develop a strategic plan for long-term services and supports. Populations addressed Timetables, responsibilities and measureable goals

New Department Create a Department of Long-Term Services and Supports. Little Hoover Commission recommendation. Possible components. In Home Supportive Services Multipurpose Senior Services Program Assisted Living Waiver Program Other HCBS waivers Substance abuse and mental health programs Housing component Eligibility and level-of-care determination Nursing home, residential, and RCFE licensing

Everybody has a dual diagnosis. Need to stop slicing and dicing by diagnosis. Who is responsible for 64-year old person with intellectual disability, Alzheimer's, and a mental health issue? Inefficient policy to think of these as separate programs. Same persons served by different programs Movement of persons through programs is masked by data systems and organizational boxes that do not record or describe relations among programs. Oregon example. Think of it as a long-term living population that use medical, behavioral, long-term services as need changes.

Functional Equivalent Informal organizations now span departments Can build formal organizations that span Departments. Management databases spanning programs. Examples of Washington and Oregon Collect data on all persons regardless of program: Acuities ADLs, IADLs, medical conditions, ID and MH Establish service levels Record and monitor services and costs Programs are managed as one program even though they span Departments.

Diversion and Transition

Diversion Diversion is about improving hospital discharge planning. Work with hospitals to provide preadmission screening/options counseling for individuals who: Seek admission to a nursing home Discharged from a hospital with health & supportive service needs Provided by single entry points, ADRCs, community organizations. Priority groups: Medi-Cal beneficiaries Likely spend down within 3 or 6 months

Current Diversion Efforts Medical Case Management Program. Hospital-to-Home (H2H) Project. Operations begin in Helps person leave hospital well. To be implemented in four ADRCs. Four week intervention, low-cost, low- intensity model. Test of Coleman Transitions model. Coach is employee of ADRC. Serves all persons regardless of payor source. Prevents readmission to hospital. CalCareNet. Nursing Facility AH waiver.

Transition Transition is about improving nursing home discharge planning. Establish a statewide nursing facility case management function to support residents relocating to community. Expand Money Follows the Person project. Provide funds to help Independent Living Centers, MSSP sites, Area Agencies on Aging, other non-profits and counties to expand transition programs. Takes years to build an effective infrastructure. Pennsylvania program is now 11 years old.

Current Transition Efforts Money Follows the Person Encouraging report to July 15, 2010 Olmstead Advisory Committee. 216 transitioned, 341 in pipeline. Now 15 MFP lead provider agencies serving 44 counties. The 12 “seasoned’ providers have 20 full and 4 part time workers, the three new agencies have 1 worker each and the Developmental Centers have 11. Have approval to fund 34 positions to help 100 persons transition from Lanterman on 2011, then rest of approximately 300 persons in 2012 and 2013.

Expanding Transition Efforts Heart of Olmstead implementation is transition ask. Based on PA, NJ and TX efforts, reasonable California goal is transitioning 2,000 a year from NFs. Number transitioned is a function of labor input. Average transition worker helps aged persons per year. Average transition worker helps 9-10 persons with disabilities per year. Number of workers needed depends on spilt between aged and persons with disabilities. E.g. if 80% and 20% would need about 115 FTE transition workers, given vacations and sick leave say 135 workers + or – to get to 2,000.

Work With Nursing Homes Need cooperation of homes with transition efforts. Help nursing home by transitioning residents nursing home does not want. Homes might need help to do subacute or change business model. E.g. Nebraska grants to convert to assisted living. Need implementation of new MDS Section Q on discharge planning. Help homes improve discharge planning and develop referrals to local contact agencies. Q requirements came with no additional funding. Carrot and stick is more effective than only the stick.

Understanding Budget Analysts Budget analysts are always working on the budget and there is never a good time to talk with them. If you wish to talk with a budget analyst do not use words. Budget analysts do not write memos. They do fiscal impacts. Talking about your good program wastes time. Unspoken rules you might encounter The answer is always No. If given estimates by program, before you begin work, add 10% to their costs, cut their savings estimate 10%. Nothing is cost effective.

The Engine Need to manage the programs as though they are one program. Savings from reducing use of expensive services are put back into funding alternatives from expensive services. Successful states, Texas, Pennsylvania, Oregon, Washington have figured out how to do this. Transition programs are cost effective. Waiver programs can be cost effective and should be expanded. Transfer savings from individuals who transition from nursing facilities to HCBS programs

Cost effectiveness Question should be under what conditions are alternatives to institutions cost effective. Alternative programs have substantial cost avoidance impact on nursing facility budget. IHSS probably has primary impact. Waivers are probably cost effective if you look at a “break even” analysis. Cost differences are so large that waivers would be cost effective if only a small number would have been in the institution. Nursing home transition programs are very cost effective, e.g. $200m. in savings in Pennsylvania.

Access

Streamline Access to HCBS Create single entry points for older adults and adults with physical and mental disabilities. Scope of programs and activities Possible entities Regional Centers are single point of entries. San Diego close ADRCs – Now seven covering ten counties. State now focusing on ADRC expansion since AoA MSSP sites Area Agencies on Aging Need to co-locate financial eligibility workers in SEPs/ADRCs e.g. Riverside.

Help Individuals in Nursing Facilities Keep a Home Increase the home maintenance allowance. Allows individuals admitted to a nursing home to retain income to maintain their home. Must expect to return home within 180 days. Current allowance is $209 a month, unchanged since July Options: Up to actual monthly cost of home, Exempt up to 100% FPL; Percentage of the SSI/SSP payment; Total SSI/SSP payment.

Keep a Home… Maintain the SSI/SSP eligibility status for short-term nursing home admissions. California is “1634” state meaning Social Security Administration does SSI eligibility. Need to be sure individuals in a nursing home for less than 90 days receive their full SSI/SSP payment to maintain their home.

Services in Residential Settings Offers options for people who need access to services for unscheduled needs, oversight and supervision. Program options: Change current law to allow IHSS payments in RCFEs Expand assisted living waiver statewide. Currently has 1,000 waiver participants, 70 providers in 4 counties. Had 186 participants in 2006 Add assisted living services and adult foster homes to all other waivers, why restrict to one waiver. Add behavioral health services to all waivers.

Expedite Financial Eligibility Allow case managers to presume financial eligibility and enroll applicants in an HCBS waiver to avoid nursing facility admission. “Fast track” the eligibility process. Co-locate financial eligibility workers with single entry points/ADRCs.