Money Follows the Person in Delaware

1. Money Follows the Person in Delaware

2. Presentation Overview • Background on the Money Follows the Person Study • Impetus • Lewin’s team • Overview of the Federal Money Follows the Person Framework • Case study examples of Money Follows the Person approaches taken in OR, TX, VT and WI • How Money Follows the Person could look in Delaware

3. Impetus for the Study • Senate Resolution 26, passed by the State Senate June 30, 2004 • Directs the Governor’s Commission on Community-Based Alternatives for Individuals with Disabilities to create a Subcommittee to undertake “all necessary steps to fund, facilitate and complete a study on the feasibility of implementing the Money Follows the Person initiative in the State of Delaware.” • The Lewin Group was hired in February 2005 to complete the study.

4. Our Team for the Project • Lewin Staff • Roger Auerbach • Amy Sander • Catherine Tsien • Brandon Maughn • Technical Advisory – Joel Menges and Lisa Alecxih • Delaware MFP Steering Committee Members

5. Money Follows the Person Study Overview • Section I Introduction • Section II Synthesis of the “Money Follows the Person” framework • Section III Background about Delaware’s LTC environment, including: • Access to LTC services in Delaware • LTC services available in Delaware • LTC financing mechanisms in Delaware • Delaware’s LTC quality assurance and improvement activities • Section IV Case Studies • Section V Cost Models for possible MFP initiative in Delaware • Section VI Analysis and Recommendations • Section VII Conclusion

6. Methodology for the Study • The Lewin Group conducted both qualitative and quantitative research in developing this report. • A Lewin team visited Delaware and met with a variety of DHSS staff, including representatives from DSAAPD, DDDS, DSAMH, DMMA, and CMHS. • Lewin conducted focus groups with Medicaid providers, advocates and consumers. • Lewin reviewed Delaware’s Medicaid policy and provider manuals and the State’s CMS 372 waiver reports.

7. What is Money Follows the Person? • The Centers for Medicare and Medicaid Services (CMS) says: “Money Follows the Person” refers to a system of flexible financing for long-term services and supports that enables available funds to move with the individual to the most appropriate and preferred setting as the individual’s needs and preferences change. It is a market-based approach that gives individuals more choice over the location and type of services they receive. A system in which money follows the person is also one that can incorporate the philosophy of self-direction and individual control in state policies and programs.” (Letter to State Medicaid Directors, 8/17/04)

8. Federal Money Follows the Person Initiative • A Medicaid initiative that is part of the CMS Real Choice Systems Change program and the President’s New Freedom Initiative • Since 2003, $8.5 million in Money Follows the Person and other LTC system rebalancing grants • 16 states have been awarded Money Follows the Person or other LTC system rebalancing grants • The 2006 federal budget bill authorizes a $1.75 billion five-year Money Follows the Person demonstration beginning January 2009

9. Coherent Systems Management Access Comprehensive information, simplified eligibility, and single access points Person Philosophy of self-direction and individual control in legislation, policies, and practices Community Life Financing A seamless funding system supporting individual choice Services Responsive supports across settings and provider types Quality Improvement Comprehensive systems that assure quality of life and services Money Follows the Person Federal Framework Lewin used the Federal Framework to evaluate Delaware’s LTC system.

10. Explanation of Framework • Access processes • Financing and Home and Community-Based Services (HCBS) • Services supporting Home and Community-Based Living • Medicaid (State Plan and Waivers) • State General Fund Quality improvement strategies for HCBS

11. Money Follows the Person in Delaware • Long term care services are provided through several divisions: DSAAPD, DDDS, DSAMH, DMMA, and CMHS. • Other Delaware departments also provide services that are not paid for by Medicaid, but support individuals with disabilities lives in the community • The Delaware State Housing Authority, the Department of Labor, and the Department of Transportation all provide needed supports to individuals with disabilities

12. Delaware Spends 71% of its LTC funds on Institutional Care U.S. and Delaware Medicaid Long Term Care Spending, FY 2004

13. But the proportion spent on HCBS is increasing The percentage of spending on HCBS has risen from 27.2 percent in 1999 to 29.0 percent in 2004. Delaware Medicaid Long Term Care Expenditures, FY 1999 - 2004

14. Access • Level of care requirements are the same for institutional care and the waivers for equivalent populations • There are multiple ways that individuals with disabilities learn about the services available and apply for services • Lewin recommendation: • Delaware should create a central, trusted entity for the dissemination of information about LTC services which allows immediate access to information about choice of services and settings

15. Services Key Delaware Medicaid LTC Services • Delaware also pays for other services, not paid by Medicaid: • Transportation • Housing • Employment Services • Assistive Technology

16. Financing • The financing of services in Delaware is budgeted for each division within DHSS, including DSAMH, DMMA, DDDS, and DSAAPD • Two Recommendations: • Delaware could consider a new budgeting strategy for LTC • Delaware should consolidate management of LTC

17. Quality • Delaware is engaged in a variety of state-level and federal quality assurance efforts, but they are not part of a larger quality improvement plan. • Recommendation: • Delaware should refine its quality assurance efforts. For example, create a process for collecting feedback from individuals about the quality of services provided and reporting that data; review and potentially enhance incident reporting procedures; develop systems for rewarding or penalizing providers based on their quality of care

18. Money Follows the Person in Other States • Oregon • created a consolidated budget to allow money to easily transfer between care settings • Texas • transfers funds from institutional to HCBS budget when a person transitions • Vermont • allows the Medicaid agency to use savings from the nursing home budget to enhance home and community-based services • Wisconsin • created an entitlement to LTC services in the setting of an enrollee’s choice & uses a comprehensive approach to outreach Case study states in the report were selected by Commission staff for in-depth study.

19. Oregon’s consolidated budget and administration • In 1981, Oregon consolidated its LTC budget, allowing allows program managers to monitor LTC expenditures as it expanded HCBS to meet individual desire to live at home. • At the same time, Oregon consolidated the State administration of LTC services for adults and persons with physical disabilities through one division, Senior and Disabled Services (MR/DD added in 2001). • Oregon also has a robust single entry point system, which informs individuals about community-care choices available to persons with a range of incomes. • In FY 2004, Oregon spent 70.5 percent on HCBS compared to 29.5 percent for institutional care.

20. Texas transfers funds for community care • In September 2003, CMS awarded Texas grant of $730,422 to fund Money Follows the Person efforts • The Texas State Legislature approved Rider 37 (Sept. 2001), allowing the Texas Department of Human Services to transfer funds from the nursing facilities budget to the HCBS budget when eligible individuals transferred from a nursing facility to community care. • The limitation of the program is that it cannot be used for preventing unnecessary institutionalization (diversion); a person participating in the program must be a nursing facility resident who wants to return to the community.

21. Vermont uses savings to enhance HCBS • In 1996, Vermont State legislators passed legislation that allowed expansion of community LTC programs, but only to the extent that nursing facility costs decreased. • Each year, Vermont’s Department of Aging and Independent Living projects future expenditures for nursing facility services and savings can be allocated to supplement HCBS services. • The State has seen a steady increase in the proportion of Medicaid LTC spending on HCBS (almost 58% in 2004). • Newly approved Section 1115 waiver -- the Vermont Long Term Care Plan – will allow the state to operate LTC under a global budget .

22. Wisconsin allows real choice • The Family Care program integrates federal, state, and local funding to provide Medicaid LTC benefits in a capitated environment. • Family Care serves adults with physical and developmental disabilities as well as older adults. • Participating counties have a single entry point Resource Center (RC) and, for a subset of counties, a Care Management Organization (CMO). • Family Care participants must meet the nursing home or ICF/MR level of care criteria.

23. Methodology for MFP Cost Modeling • Focused on older adults and individuals with physical disabilities as well as individuals with mental retardation/developmental disabilities. • In order to model Money Follows the Person program changes, Lewin first estimated baseline data: • Current enrollment in institutions and waivers • Costs for the home and community based services • Costs for nursing facilities and ICFs/MR • Annual trends for those expenditures • These were used to predict future expenditures.

24. Methodology (continued) • Lewin examined five states with Money Follows the Person programs or demonstrations to determine the percentage of eligible individuals who participated • Lewin modeled the effect of transitions from institutions (cost savings) along with the costs of serving those individuals in the community (new costs) • Lewin developed “High” and “Low” models

25. Modeling Results • Delaware could save between 7-12% over estimated baseline costs over a 10 year period by adopting a Money Follows the Person program • Delaware could save between $63-104 million in state Medicaid funds over the same 10 year period • Funds could be re-invested in serving more people, providing more services, increasing provider reimbursement or in other ways

26. Contact Information Roger Auerbach and Amy Sander The Lewin Group 3130 Fairview Park Drive, Suite 800 Falls Church, VA 22042 (703) 269-5500 roger.auerbach@lewin.com amy.sander@lewin.com