Enhanced Nursing Home Transition

1. Enhanced Nursing Home Transition NHT Collaborative Partners Regional Meetings August 2006

2. Goals • Provide a context for discussing change in Pennsylvania’s Long Term Living system • Provide key information for state staff to support Enhanced Nursing Home Transition

3. Drivers of LTL System Change • PA, Nation and the World are aging. • Federal policy is promoting community living for people of all ages and disabilities--Americans with Disabilities Act, Olmstead Decision, New Freedom Initiative. • Consumers of LTL services want to remain in their homes and communities.

4. Drivers of LTL System Change • Advocates are pushing for Home and Community-Based Care—ADAPT, AARP and others. • Consumer Direction is sweeping the states. • States are seeking ways to help people of all income levels find affordable options for both private pay and publicly supported services.

5. National Policy For the first time ever, the Centers for Medicare & Medicaid Services (CMS) and the Administration on Aging (AOA) are partnering… and they are urging the states to do more to help people live in their homes and communities.

6. Dr. Mark McClellan, Administrator Centers for Medicare & Medicaid Services “We are about to enter a new era of personal control, of New Freedom, in the Medicaid program. With a concerted effort, every state can rebalance its Medicaid program. With the tools we have now, it is time to end the institutional bias….”

7. Josefina Carbonell, Assistant Secretary for Aging “This is an exciting time to be involved in long-term care. It is clear we are witnessing a fundamental change in federal policy that is guided by the New Freedom Initiative and directed at giving people more control over their care, as well as providing more support for community living.”

8. States are either Leading or Following…but most are Moving • Listening to older adults and people with disabilities. • Balancing public dollars spent on long term care (living). • Informing people about their options. • Emphasizing the “critical pathways” to a nursing home admission. • Assertively reaching out to people in nursing homes to help them return home.

9. People in Nursing Homes Need Information about LTL Options • Crucial for consumers, their families • People enter a nursing home for many reasons; many can leave. • Without information and help, many people in nursing homes cannot make an informed decision about where to receive services outside of an institution.

10. Myth: Most People in Nursing Homes Need to be There • Those who resist change say: “People in nursing homes today are too frail to live in the community. Only a few of them can really leave.” • Fact: For every person in a nursing home who needs assistance with 3 or more activities of daily living, there are 1.83 people living in the community who have the same level of disability.

11. Improving Access to LTC Options • States are looking at best methods to avoid unwanted institutionalization • Managed Care (Arizona, Texas, New York) • Various Nursing Home Transition programs • Nursing Home Transition programs • Large statewide programs (WA, NJ, Oregon) • State employees (NJ, WA) • Contracted organizations (CO) • Small programs for most challenging (SC, CT) • Locally based organizations (Centers for Independent Living, Area Agencies on Aging)

12. Culture Change: Philosophy of Person-Centered Planning and Choice • For Nursing Home Transition to work, all long-term living stakeholders have to see it as possible and desirable that consumers can choose and direct their services. • Need to confront ageism and institutional bias.

13. Summary • Federal policy and consumer activism are fueling historic, fundamental change in long-term living • States are developing various models for making community living a real option • Nursing home transition is a crucial component to balancing the LTL system • Not Easy, Not Fast, Worth it, Possible

14. The Pennsylvania Picture • Three Imperatives to Balance the Long Term Living System in PA • Demographic trends • Consumer choice • Fiscal challenge

15. Demographic Trends85+ Population in PA Fastest-growing segment in the U.S., 9% increase since July, 2003Medicaid long-term living utilization is consistent with demographic trends Source: Penn State Data Center and PA Department of Public Welfare

16. Consumer Choice • The vast majority of people with disabilities want to live independently and with dignity, free from the restrictions of institutional settings. • Nine out of ten older adults prefer to “age in place” in their homes and communities.

17. Fiscal Challenge The Elderly and Persons with Physical Disabilities Use the Greatest Share of Medicaid Resources Chronically Ill Adults $1.0 billion 8% Elderly $4.7 billion 35% Elderly $4.7 billion 35% Children & Families $3.2 billion 24% Disabled $4.3 billion 33% Disabled $4.3 billion 33% Children & Families $3.2 billion 24% Chronically Ill Adults $1.0 billion 8% Source: PA Department of Public Welfare

18. Long-Term Living Spending Increasing investment in long-term living services to serve Elderly and Persons with Physical Disabilities Source: PA Department of Public Welfare

19. % HCBS % NF 100% 90% 86% 80% 74% 75% 70% 70% 65% 57% 60% % of Consumers 50% 43% 40% 35% 30% 30% 26% 25% 20% 14% 10% 0% National PA MN OR VT WA State Nationwide Comparison of LTC users in NF versus HCBS Nationwide trends show sustained commitment is necessary to rebalancing Sources: Thomson Medstat and Kaiser Family Foundation, 2002

20. Pennsylvania’s Progress Share of HCBS waiver users have increased since 2002-2003 Source: PA Department of Public Welfare

21. Long Term Living Council Subset of Governor Rendell’s Health Care Reform Cabinet • In November of 2005, Governor Rendell established the Long Term Living Council aimed at: • Accelerating reforms of the Commonwealth Long Term Living System, building on successful initiatives implemented to-date • Positioning the Commonwealth to meet future demand for services while addressing the short-term and long term fiscal challenge this will entail • Improving coordination across state departments in support of LTL reform agenda. • Council Members include Cabinet Secretaries from Aging, DPW, Budget, and Policy; Director of the Office of Health Care Reform and Deputy Chief of Staff • Michael Nardone named as Executive Director; cross-agency staff teams formed to support work of the Council

22. Rendell Long-Term Living Reform Agenda Governor Rendell’s vision is to offer consumers choice as to where they receive long-term living services, ensuring high-quality care in the most clinically-appropriate, most cost-effective environment To achieve this goal, the LTL Council will work to: • Enhance and expand efforts to assist nursing home residents who wish to leave a facility-based care setting, and can safely return to their home or community • Ensure that the supply of nursing home beds appropriately meets the need for such care, while providing opportunities for facilities to expand their continuum of care • Ensure consistency in the application of eligibility criteria for long-term living services, while removing barriers to receiving home and community-based waiver services • Maximize available waiver resources to serve as many consumers as possible, while ensuring provision of high-quality care and services

23. Enhanced Nursing Home Transition

24. Enhanced Nursing Home Transition • Focus on new admissions • MDS Data • LTL Counseling • Strengthened collaborations • Active engagement of AAAs and DPW NHT partners • Incentives for agencies to achieve successful transitions

25. Focus on New Admissions • NHT program has demonstrated that the loss of housing and community supports is major barrier to successful transition • Need to inform and educate consumers, families and caregivers before resources and supports disappear

26. MDS Data • Collected by nursing homes on all new admissions to develop plan of care • 06-07 rate agreement requires data to be submitted within 7 days of completion • MDS data will be used to focus NHT efforts on new admissions

27. LTL Counseling • Provide information and guidance to consumers in need of LTL services • Ensure that all options are explained fully • Enable consumers to make informed choices about where and how they receive LTL services. • Ensure that scheduled discharges occur as planned

28. Strengthened Collaborations • Opportunity to strengthen and expand existing collaborations • Clearly define roles and responsibilities • Increase and improve inter-agency communication • Include additional community partners to support NHT, e.g. housing agencies, faith based organizations, community service organizations, other county agencies

29. Coordination between LTL and NHT activities AAA NHT Responsible for transition services and supports to over 60 consumers; actively works with each consumer to complete a successful transition • Long Term Living Counselor • Provide information and guidance to consumers • Ensure that all options are explained fully • Enable consumers to make informed choices about where and how they receive LTL services Local Collaboration Shares knowledge, expertise, and resources to support successful transition; case conferencing around difficult transitions; other activates depending on local arrangements OSP Agency NHT Responsible for transition services and supports to under 60 consumers; actively works with each consumer to complete a successful transition

30. Active Engagement of All Partners • AAAs will conduct LTL Counseling • AAA will be responsible for over 60 transitions • DPW NHT partners will be responsible for under 60 transitions • Collaborative partners will share experience, expertise and resources to support successful transitions

31. Unified Data Tracking • Module has been created in OMNIA to collect LTL Counseling and transition data • All agencies will use the same system • Real time data collection to allow ready access to critical information

32. Technical Assistance • Roll-out Meetings • Monthly Regional TA Calls • NHT Conference in October • Regional Housing TA Meetings • State Staff: • PDA – Tim Hoskins, (717) 783-6207 • DPW – Kim Kramer, (717) 787-8097 • GOHCR – Lynne Miles, (717) 346-9992

33. Summary of Enhanced NHT • Identification of NH Admissions through MDS Data • Early LTL counseling • Active engagement of AAA and DPW NHT agencies in transition activities • Strengthened collaborations • Incentives for successful outcomes

34. Nursing Home Transition Incentive Plan

35. Proposed Incentive Plan • The Commonwealth is proposing to invest in AAAs and DPW NHT agencies through the incentive program • Agencies will have the opportunity to earn additional dollars in incentive payments through this incentive pool • Two part system rewards performance and provides support for agency restructuring

36. Incentive Plan Principles • It is meaningful for agencies large and small; • It will result in necessary restructuring; • It strengthens partnerships; • It balances these needs with existing agency capacity; and  • It will not require a recurring expenditure for success.

37. Incentive Plan Components • Restructuring Incentive • Goal is to reward agencies for meeting transition goals • Incentives are based on agencies performing specific functions and to restructure operations to support Enhanced NHT • One-time, non recurring expenditure

38. Incentive Plan Components • Goal Based Incentives • Each agency has been given specific transition goals • Incentive funds will be earned based on successful attainment of goals

39. AAA Total Incentive Examples

40. BHCBS Partners Total Incentive Examples DRAFT