1. Long-Term Care Options Counseling at Your Service-Providing Decision Support to Meet Individual Long-term Care Needs!

2. Today’s Presentation
Learn the definition of long-term care options counseling as a service and how it’s being delivered through the Senior LinkAge Line®.
Understand the care transitions model and how it’s being implemented through the Senior LinkAge Line®.
Identify when to make a referral to the Senior LinkAge Line® for long-term care options counseling.

3. Celebrating at Home…
“Thanks Connie. We are so grateful for all of the help you have given our family. We are celebrating my dad’s 97th birthday on Sunday and are so happy to be doing it AT HOME!”

4. There are many reasons why the State needs Linkage Lines…
We are statewide
We have one brand
We can triage people into critical services

5. Policy and Financial Business Drivers
Increased Pressure on State Budget
Health and Human Services makes up 28% of state budget
The fastest growing portion goes to low income seniors in long-term care and children and adults with disabilities
Caregivers will have to be increasingly tapped to care for aging relatives (current estimates range from 75% to 90%)
There is a slow uptake on long-term care insurance even with LTC Partnership incentives
Coordination of programs doesn’t always happen (silos)

6. Federal Business Drivers
There are similar messages coming out of federal government
We need to Reduce Fiscal Pressure on Medicaid and Medicare
Increasing need to explain and manage health insurance options
CMS is placing a bigger emphasis on diversion and community living
CMS is starting new efforts focused on improving care transitions between hospitals, NHs and community

7. The Challenges of Funding Medicaid LTC Spending Will Continue
With the 2009 Legislative changes and unallotments, the rate of growth for LTC Medicaid services has slowed to about 4.8% per year. Please note, however that this rate of growth does not include cost of living increases for CC programs, except for Nursing Facilities (APS COLA)
However, this rate of growth will continue to exceed projected revenue increases in the general fund. These differences will have an escalating and compounding effects overtime.
The number of persons needing for services will continue to increase given the aging demographics and increase number of persons with disabilities. Recipients with Federal disability determinations have been increasing at rate of 5% per year. Meeting the requirement for a federal disability determination is a significant criterion to become eligible for Medical Assistance.
Higher Proportion of Persons with disabilities accessing LTC (from 32% to 46% of overall MA caseload)

8. Consumer Facts People have a hard time understanding the system
Most people want community connections, to contribute, to work and to live independently
Baby boomers present a big challenge. The majority have less than $50,000 in the bank
Government programs offer a safety net, but can’t afford large numbers who need long-term care

9. Consumer Facts
Information for consumers is often not accessible and too high of a literacy level
People who need help, don’t self identify
There are many “sources” of information and assistance but not all are neutral
Generation Xr’s and Millenials have high demands for technology and we are not prepared as they move into the role of caregiver

10. Minnesota Average Annual Care Costs in 2011
Source: 2011 Genworth Cost of Care LTC Survey
Annual
Monthly
Nursing Home Private Room
$76,796
$6,400
Nursing Home Semi-Private Room
$67,583
$5,632
Assisted Living Facility
$37,200
$3,100
Adult Day Health Care Facility
$17,050
$1,421
Home Health Aide (44 hours per week)
$58,916
$4,910
Homemaker Services (8 hours a day,
5 days a week)
$50,336
$4,195

11. Long-term Care Options Counseling Defined
Long-term care options counseling is an interactive decision-support process whereby consumers, family members and/or significant others are supported in their deliberations to determine appropriate long-term support choices in the context of the consumer’s needs, preferences, values, and individual circumstances.

12. Senior LinkAge Line® Expertise Includes:
The benefits provided by private options and how they intersect with public options (such as Medicare or Medicaid)
Public systems and assistance with applications
Other insurance benefits like Long-term Care Insurance and other financing options
Housing options and the appropriate time to consider a move
Caregiver supports
Understanding home and community service options

13. Qualifications for Senior LinkAge Line® Specialists
Staff have minimum of Bachelors Degree in Social Work or Nursing
18 hour Core Body of Knowledge training
15 CEUs annually
Monthly videoconferences/ILinc trainings
Monthly conference calls
Mandatory Certificate on Aging training from Boston University
Annual in-person training

14. Who are Senior LinkAge Line® Specialists?
Area Agencies on Aging
Manage seven contact centers
Many outreach staff/volunteers statewide
Single statewide number –consumers then routed to localized assistance
Objective, comprehensive, neutral information
Individualized assistance by phone, in-person or online
No fee or charge for assistance
Does not sell, endorse or promote any product or service

15. Contact Centers

16. The Senior LinkAge Line® serves people through four channels
Phone
In-person
Print
Web

17. Phone-Based Assistance

18. In-Person and Face to Face Assistance
Whitney Senior Center
Waseca Clinic

19. Print, At Outreach Sites

20. The Internet
Service of the MN Board on Aging on behalf of the State of Minnesota
Online at since 2003
It is the web-based means of finding provider information about health and human services endorsed by the state of Minnesota
Provides information for consumers based on “Special Topics” sections
Senior, Caregiver, Disability, Homeless, Health Care, Children and Families, Veterans

22. What’s in MinnesotaHelp.info?
Nearly 31,000 services (plus)
More than 11,000 providers
More than 23,000 sites
Over 148,731 unique visitors in CY2010

23. When should you call the Senior LinkAge Line®?
Hospital observation status issues
After admission to a long-term care facility
To assist with connection to county for long-term care consultation, if appropriate
Follow-up in the community is available after discharge
When a family caregiver needs help to continue providing care
Stressed caregiver or caregiver becomes ill
Consumers interested in volunteering opportunities

24. When should you call the Senior LinkAge Line®?
Consumers who need help to access publicly funded benefits
Consumers/families looking at financing options –
Long-term care insurance, reverse mortgages, annuities, LTC Partnership
And what happens if denied public programs
Medicare questions
Part D -- Supplemental Options
New to Medicare -- What’s covered?

25. This is what we’ll do….
Consumer receives evidence based risk screen (phone or in-person)
High Risk Consumers = Automatic referral to LTCC if consumer agrees and wants a face-to-face assessment
While waiting for an LTCC, the consumer is provided with a resource plan in the community
Moderate/Low Risk Consumers = Consumer receives a resource plan for implementation in the community
10 day follow-up phone call regardless of risk

27. Long-term Care Choices Navigator
Available via
Consumers, caregivers, providers and Senior LinkAge Line® staff
Produces individualized care plan based on consumer needs and preferences
Based on professional advice-national experts
Plan can be saved and accessed as needs change

28. Long-term Care Choices Navigator

31. Definition of Care Transitions-According to Federal Government
Care transitions are any transition between care settings, including hospital to home, hospital to nursing home, and nursing home to home.

32. Examples of when Senior LinkAge Line® assists with Care Transitions
When consumers are deciding if they want to remain in their home or move to a new location
When consumers want to return to the setting of their choice after a nursing home stay
When consumers are at risk of being placed in a nursing home and spending down to Medical Assistance while living in the community
When consumers have been recently discharged from a hospital stay or ER visit
Explain the background on TC, RTC, Section Q, etc.
Talk about the statutory authority and why the SLL has their role

33. What is the Return To Community Initiative?
Passed in 2009 and based on research conducted by the U of MN School of Public Health & the Indiana University Center for Aging Research
Utilizes the MinnesotaHelp Network™ which includes the LinkAge Lines (Senior, Disability and Veterans), the web site MinnesotaHelp.info®, and in-person assistance through staff and volunteers.
The MinnesotaHelp Network™ is Minnesota’s federally designated Aging and Disability Resource Centers (ADRCs). There are ADRCs in every state.

34. Resulted in Change to Statute 256.975 subd.7-
11) using risk management and support planning protocols, provide long-term care options counseling to current residents of nursing homes deemed appropriate for discharge by the commissioner. In order to meet this requirement, the commissioner shall provide designated Senior LinkAge Line contact centers with a list of nursing home residents appropriate for discharge planning via a secure Web portal. Senior LinkAge Line shall provide these residents, if they indicate a preference to receive long-term care options counseling, with initial assessment, review of risk factors, independent living support consultation, or referral to:
(i) long-term care consultation services under section 256B.0911;
(ii) designated care coordinators of contracted entities under section 256B.035 for persons who are enrolled in a managed care plan; or
(iii) the long-term care consultation team for those who are appropriate for relocation service coordination due to high-risk factors or psychological or physical disability.

35. Return to Community Goals
Effort to change the public’s mindset that nursing homes are best long-term residence for the elderly
The project targets people who have the potential to live successfully in the community
Respect people’s preferences for living and caregiving arrangements
Use public resources efficiently

36. Targeting Criteria Developed by Researchers
In working with the Centers on Aging at the U of M and Indiana University – researchers determined that a group of people were more likely to return home, but weren’t doing so.
They created a profile:
Prefer to return to the community and/or have a support person for community care,
Residents early in nursing home stays and still have community ties
Fit a community discharge profile -- health, functional, or personal characteristics indicating high probability of community discharge

37. Community Discharge Profile
Greater than 50% probability of community discharge
Each resident has unique combination of discharge characteristics
Characteristics predicting discharge that are included in model:
Female
No Mental Health/Alzheimer’s/Dementia Dx
Married or Lived Alone
No Serious Behavioral Problems
Younger
No Diabetes
Medicare Admission
No End Stage Disease or Cancer
Hip Fracture
Lower Cognitive Impairment
RUG Extensive
Lower ADL Dependence
RUG Rehabilitation
No Serious Incontinence

38. Findings of Follow-up Study by University of MN/Indiana U
Characteristics of nursing homes with a higher community discharge rate (adjusted for resident differences)
Higher percentage of Medicare residents and lower percentage Medicaid
More nursing hours per resident day
Higher facility occupancy rate
Higher percentage of residents preferring or having support for community discharge
Located in areas with more use of home and community-based services

39. Where are they after 1 year?
Annual Minnesota Nursing Home Admissions (38,309) July 1, 2007 through June 30, 2008
Admitted from where?
Where are they after 1 year?
All Admissions (38,309)
No Prior NH Use (27,875)
Acute Hospital (23,837)
Community (3,114)
Other (924)
Prior NH Use (10,434)
Acute Hospital (8,251)
Community (1,234)
Other (949)
Community Discharge (21,503)
In Nursing Home in One Year (4,844)
NH Transfer (1,410)
Hospitalization or Other (5,546)
Mortality
(5,006)

41. Residents Still in Nursing Home at 90 Days (8,765 Residents)
Return to Community and MDS Section Q
November 16, 2010
Residents Still in Nursing Home at 90 Days (8,765 Residents)
Targeted: 22% Prefer/Support & Fit Profile
(2115 Residents)
45% Prefer/Support Return to Community (3785 Residents)
25% Fit Discharge Profile (2941 Residents)
Care Providers Annual Convention and Expo 2010 41

42. Who do we help and how?
Based on the profile, the Board on Aging staff work with Depts. of Health and Human Services who produce a current list of consumer names based on nursing home Minimum Data Set (MDS) admission assessments:
Approximately 60 days after admission
Meets targeting profile
Desire to return to the community
Current nursing home resident
A rigorous service delivery model was created with the input of NH social workers and discharge planners and include follow-up protocols.

43. Step By Step with Nursing Homes
Community Living Specialist receives names from Minimum Data Set (MDS) profile list
Contacts nursing home designee
NH Social Worker or NH Discharge Planner
Current resident discharge status determined
Meeting arranged with resident and support person, if available
Resident interview completed at nursing home
Release of information obtained
Collaboration/Partnership between NH, resident, Community Living Specialist, support person

44. Follow-Up Protocol for Those Assisted by Community Living Specialist
Initial follow-up
In-home visit within 3 days after nursing home discharge
Continued follow-up by Community Living Specialist
14 days, 30 days and 60 days after nursing home discharge
Phone based follow-up continues by Senior LinkAge Line®
Quarterly for up to 5 years

45. Why is this Service Important?
It focuses on private pay individuals
Upstream planning is unique
Intensive follow-up services are available for people assisted out of the nursing home
Also available for those we don’t specifically assist
Trend data will be available for years to come

46. Evaluation Goals
All consumers - private or public pay - discharged from the nursing home will be contacted every 90 days for up to 5 years
Satisfaction levels living at home
Health and functional status-improve or decline?
What services are needed for someone to successfully remain at home?
Cost savings for state of MN
Delay spend down to Medical Assistance
Access to home and community-based services

47. Numbers So Far…
Over 600 consumers receiving follow-up phone calls in community
Public and private pay
97% of nursing homes have been touched by this initiative

48. Reasons People are Staying Long-term According to NHs
We track “barriers to leaving” for those (public and private pay) who aren’t leaving nursing home
58% Health status declined
43% Personal choice
17% Family refused
16% Caregiver exhaustion
7% Lack of housing

49. Lessons Learned Since April 2010…
Some residents have already been discharged by the time we make contact
Based on MDS discharge tracking form to Dept. of Health
Relationship building with nursing home discharge planners
Face to face meetings to explain initiative
Presentations to family and resident councils
Partnership and collaboration are key to helping the consumer and their family
Follow-up protocol in the community has been helpful for nursing homes

50. Senior LinkAge Line® Success Story
68 year old married female- retired elementary teacher
Aneursym at Target Field in June hydrocephalus, craniectomy and more
Resided in metro nursing facility from July 2010-February 2011
Now residing in assisted living in Rochester
Therapy at Mayo Clinic
Goal to return to St Paul with her husband
Extremely supportive family and siblings
“I couldn’t have done this without the help of the Senior LinkAge Line®!”

51. MDS 3.0- What is MDS?
Minimum Data Set (MDS) federally mandated assessments for people residing in a Medicare/Medicaid certified nursing facility
Conducted upon entry and quarterly thereafter at a minimum
Used to determine rates
A new MDS 3.0 was implemented October 1, 2010
This initiative positioned Minnesota well and prepared the nursing homes and Senior LinkAge Line® for this change

52. Who can be a Local Contact Agency?
Each state Medicaid agency is responsible for selecting and contracting with the organizations that it chooses to serve as LCAs. CMS lists several organizations that can potentially serve as LCAs, including Aging and Disability Resource Centers, Area Agencies on Aging, Centers for Independent Living, and others.

53. Who is the Local Contact Agency in Minnesota?

54. Senior LinkAge Line® MDS Section Q Protocol
Nursing home makes referral to the Senior LinkAge Line® at
Phone calls are triaged based on caller’s need
Designated staff at each Area Agency on Aging will assist nursing home and consumer
Phone-based assistance will be provided unless face to face is requested or required
Long-term care options counseling will be provided to consumers and families

55. Protocol Cont. Public Pay
Referrals are made to case worker or managed care coordinator for assistance over the phone or in-person
Private Pay
Consumers are assisted directly in a variety of ways
Over the phone or in-person

56. Senior LinkAge Line® MDS Section Q Protocol Cont.
Senior LinkAge Line® staff contacts consumer or family member within 1 business day
Reviews resources in the community (needs-based)
Creates support plan
Mailed to consumer/caregiver and nursing home discharge planner
Provides follow-up with nursing home to verify discharge status
Follow-up in the community for up to 5 years with consent

57. How do Return to Community and MDS Section Q interact with each other?
Nurses and SWs were already hired and available to provide in-person visits for Section Q referrals
Relationships were already established between Senior LinkAge Line® and MN nursing homes
The Return to Community initiative will continue to develop profile lists based on admission MDS assessments and revised to reflect MDS 3.0 changes

58. For Questions Elissa Schley, MinnesotaHelp Network™ Consultantor
Darci Buttke, Return to Community Coordinator or