The Role of Aging Service Technologies in LTC Reform: Early Medicaid Initiatives

1. The Role of Aging Service Technologies in LTC Reform:Early Medicaid Initiatives Majd Alwan, Ph.D., DirectorCenter for Aging Services Technologies (CAST)Medicaid CongressJune 6, 2008

2. What is CAST? Government Agencies Providers ofAging Services University Researchers Tech Industry Partners CAST Associations A national coalition of more than 400 organizations working together to improve the aging experience through technology

3. Why We’re Here • CAST Mission • Help older adultsmaximizetheirindependence • Supportprofessional and familycaregivers’needs • Improvequalityof care and quality of life • Reduceour nation’s health carecosts • Increaseaging services providers’efficiency

4. HOME CARE Healthy, Independent Living 100% Community Clinic Chronic Disease Management Doctor’s Office RESIDENTIAL CARE ACUTE CARE Assisted Living QUALITYof LIFE Specialty Clinic Skilled Nursing Facility Community Hospital ICU 0% $1 $10 $100 $1,000 $10,000 COST of CARE/DAY “Shift Left” through Technology

5. Categories of Aging Services Technologies Safety in the Environment Physical & Mental Health/ Wellbeing Social Connectedness to others EHRs & Point of Care/ Point of Service

6. Three-month study on the impact of monitoring technology on care Billable interventions Hospital days 75% cost savings  Cost-Effectiveness Proof Transferred more time away from paperwork and towards direct care and reduced workloads.

7. New York State Medicaid Home Telehealth New York State Enacts Medicaid Reimbursement for Home Telehealth in 2007[Senate Bill S.2108-C, Chapter 58 of the Laws of New York (budget bill)] • State 18-month new Medicaid Waiver pilot that will evaluate cost effectiveness and assess permanent rate • The bill is a result of collaborative effort between Visiting Nurse Services of NY (VNSNY) the NY Home Care Association, and the NY legislature and executive branch • Only providers who have existing telehealth programs are eligible to participate.

8. New York State Medicaid Home Telehealth 3-Tier Monthly Reimbursement (rates set by DOH on 2/1/08) • Tier 1: $270/month/patient – FDA approved Class 2 Device Capable of interoperability with Point of Care (POC) Software • Tier 2: $310/month/patient - Interconnected with POC software • Tier 3: (rate to be developed) - Interconnected with EMR and statewide health information network • Installation Fee: Providers can bill for a "one time" installation fee of $50 for each Telehealth user.

9. New York State Medicaid Home Telehealth Precursors to Reform: • Several home health agencies throughout NYS, including VNSNY, had begun to pilot Telehealth • Funded mostly through private grants or self-funded • Facilitated by NYS Telehealth grants that had been offered to HHAs since 2003 • Visiting Nurse Services of NY (VNSNY) ran a 500 patient pilot that demonstrated reduced hospitalization and ER visits and shared the results with the State • VNSNY shared with the State its Telehealth Evaluation tool for Risk & Placement Criteria which help identify those patients who would benefit most from Telehealth in the home.

10. New York State Medicaid Home Telehealth The rates cover: • Monitoring patient vital signs • Patient education • Medication management • Equipment maintenance • Review of patient trends and/or changes in patient condition and identifying changes necessitating intervention.

11. New York State Medicaid Home Telehealth Patient criteria for the program: • Patients who have conditions or clinical circumstances which require frequent monitoring; and • Patients for whom Telehealth can appropriately reduce the need for an unscheduled nursing visits, in-office visit or acute or LTC facility admission (regulatory definitions to be resolved). • Not limited to patients with specific diagnoses; specific conditions are listed as examples of targeted patients, these include: CHF, COPD, wound care, polypharmacy, mental/behavioral problems, technology-dependent care etc.

12. California Initiatives in Medicaid Waiver Programs I. Electronic Care Assessment & Management: web-based, with medication tracking II. Virtual Multi-Disciplinary Care Team (“Virtual MDT”): • Riverside County Office on Aging partnering with other local government partners including the Community Health Agency, Dept. of Mental Health and Dept. of Public Social Services (adult protective services) • Population is isolated older adults (including Medicaid enrollees) with multiple and complex health and social issues, as well as victims of elder abuse & neglect • Video-conferencing technology in clients’ homes, satellite office or congregate setting that is convenient for the older adult enable senior to participate in the MDT meeting and promote more frequent use of MDTs • The technology respects the social dynamic of presence more than phone conferencing and email

13. Pennsylvania Initiatives in Medicaid Waiver Programs Medicaid 60+ “PDA Waiver” Reimbursement for Home Telehealth & Telemonitoring • Reimbursements began Sept. 1, 2007 • Covers range of telecare services provided by home health, DME providers, pharmacies or hospitals via AAA contract for specified older adults: • Health Status Measuring & Monitoring: $10/day • Activity & Sensor Monitoring: $200/install $79.95/mo. • Medication Dispensing & Monitoring: $50/mo. • Personal Emergency Response Systems: $30/mo. • New Medicaid aging waiver to begin July 2008, with telecare language pending CMS approval

14. Pennsylvania Initiatives in Medicaid Waiver Programs Medicaid 60+ “PDA Waiver” Reimbursement for Home Telehealth & Telemonitoring Requirements: • Medical need for the services (Dr.’s order) and evidence that services are not covered under Medicare, State Plan or other third party resources • Participants must: • Meet nursing facility clinically eligible (NFCE) determination • Meet at least three of the following needs criteria: • Three (3) or more hospitalizations in the past year • Frequent, recurrent, repeated or regular use of the emergency room • Poor adherence with physician orders or medications • Formal or informal support systems are limited or absent • Documented history of falls within the last six months that resulted in an injury that required medical or emergent care • Lives alone or is at home alone for extended periods of time or care access challenges (for example, RN shortage, rural access issues, etc.) • Be cognitively able to operate equipment if needed or have caregiver • Be in a residence that allow the use of the technology

15. Pennsylvania Initiatives in Medicaid Waiver Programs Virtual Care Management Pilot • PA Department of Aging and rural AAA covering a four county area through Medicaid Waiver program planning to pilot “Virtual care management” to older adults at senior centers/ affordable senior housing communities (co-located) using high-quality hands free video conferencing technology • One care manager can serve older adults in several locations, and/or triage to specialized provider via video conference (mental and behavioral health, legal aid) • Provides capacity for “walk-in” AAA services at senior centers and increased utilization of center programs • HUD Neighborhood Networks funding available for video-conference technology installation costs and monthly fee at affordable senior housing communities

16. Opportunities to Utilize AST’s in Medicaid LTC • Existing State LTC Reform Efforts • 5-year CMS “Money Follows the Person” ($FP) Grants to 30 states and D.C. are demonstrating how to support persons who transition from SNF to home setting with LTC services & supports • Aging Service Technologies have great potential to be important tools for states to use to achieve $FP goals • Connecticut, Delaware, Georgia, Iowa, Kentucky, Nebraska, New Hampshire, New York, North Dakota, Oregon, Pennsylvania, Virginia, and Washington identified technology in their menu of services to demonstrate with this population • HCBS Medicaid Waiver (AAAs) • Pilot use of technology to serve existing HCBS waiver population like in PA • Important to be able to demonstrate cost savings to meet cost neutrality rules • Pursue dedicated Medicaid Reimbursement for Telehealth/ Aging Services Technologies • Pilots and objective evaluation data are key to reform.

17. Questions? Majd Alwan, Ph.D. Director, CAST malwan@agingtech.org (202) 508-9463 www.agingtech.org