Recommendations for Olmstead Implementation in California

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

2. 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.

3. 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.

4. 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?

5. :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.

6. 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

7. General Recommendations

8. 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

9. State-level Organization

10. 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

11. 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.

12. 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.

13. Diversion and Transition

14. 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

15. Current Diversion Efforts • Medical Case Management Program. • Hospital-to-Home (H2H) Project. Operations begin in 2011. 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.

16. 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.

17. 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.

18. 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 22-23 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.

19. 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.

20. Financing

21. 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.

22. 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

23. 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.

24. Access

25. 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.

26. 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 1989. • Options: Up to actual monthly cost of home, Exempt up to 100% FPL; Percentage of the SSI/SSP payment; Total SSI/SSP payment.

27. 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.

28. 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.

29. 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.