The Changing Face of Long-Term Care: Yesterday, Today and Tomorrow

1. The Changing Face of Long-Term Care:Yesterday, Today and Tomorrow Michael P. Starkowski Commissioner, DSS January 9, 2009

2. Overview of The Department of Social Services

3. State of Connecticut Appropriations (General Fund)SFY 2009 $17.1 Billion(Legend Amounts in Millions)

4. Core Programs Based on Appropriated SFY 2009 Funds

5. SFY 2009 DSS Appropriation for Core Programs

6. DSS Health Care Appropriations SFY 2009

7. Medicaid Services by Category SFY 2009

8. Long Term Care by Category SFY 2009

9. Total Population that Received Health Care Services from DSS in November, 2008TOTAL – 579,472 *Includes waiver and state-funded **Includes CADAP, Refugee, breast and Cervical, etc.

10. Medicaid Nursing Home Expenditure Comparison *numbers in yellow represent costs minus user fee impact SFY 09 Based on Original Appropriation

11. Medicaid Nursing Home ClientComparison *Average Medicaid Nursing home clients 7/08-12/08

12. Licensed Nursing Home Beds

13. Homecare Client Comparison

14. CON and Rate Setting- Int. Rate Requests • Census Issue - 91.4% occupancy as of December • SFY 2008 • 16 facilities • Annual impact $4.6 million- requested $11.2 million • SFY 2009 • 27 facilities received rate relief to date*, $7.9 mil. – requested $19.8 • Approximately 15 pending to date, $6.7 mil. requested • * 10 of the 14 facilities are former Haven, $3.6 mil. relief, $9.0 requested

15. CON and Rate Setting- Rec./Bankruptcies • Receiverships – • Haven 3 facilities (Danielson, Norwich, Waterford-closed, Windham)-transition to Colonial Health 2/09 • Marathon 6 facilities (Prospect, Torrington, Norwalk, West Haven, Waterbury, New Haven) • Crescent Manor • Bankruptcies – • Affinity Healthcare 4 facilities (Alexandria, Blair, Douglas, Ellis Manor)

16. Nursing Facility Closures • Facility Closures SFY # Facilities # Beds Avg. Size 2002 3 267 89 2003 4 324 81 2004 5 498 100 2005 3 487 162 2006 1 59 59 2007 2 180 90 2008 0 0 0 2009 ytd 2 190 95 20 2,005

17. Nursing Facility Closures • 2007 Closures • Darien Health Center 120 • Oakcliff, Waterbury 60 • 2008 0 • 2009YTD • New Coleman Park 100 • Haven –Waterford 90 • Within 30 days of the filing of a Letter of Intent for facility closure, DSS must hold a Public Hearing at the nursing home (PA 07-209).

18. Assisted Living Services In the CT Home Care Program For Elders • To qualify for Assisted Living services, applicant must meet functional and financial eligibility requirements for the Home care Program either State funded or Medicaid Waiver • Program pays for services only, not room and board • Assisted Living is available in 4 different settings • State Funded Congregates • HUD Facilities • Private Assisted Living Facilities • Demonstration Affordable Assisted Living facilities • Costs range from an average of $1171 per month, per client to $1842 per month

19. Assisted Living Settings • State Funded Congregate • 17 sites throughout the state • 80 participating clients • HUD facilities • 4 participating-Immanuel House in Hartford, Juniper Hill Village in Storrs, Tower One/Tower East in New Haven and Welles Country Village in Talcottville • 150 participating clients

20. Assisted Living Settings • Private Assisted Living pilot • 33 facilities are participating • Pilot serves 75 clients that is the maximum allowed by statute • Waiting list of103 clients that appear to meet eligibility requirements • Wait exceeds 1 year • Assisted living Demonstration Projects • 4 sites- Hartford, Glastonbury, Middletown and Seymour • 199 participants

21. Money Follows the Person Rebalancing Demonstration

22. Goals of Demonstration • Reduce reliance on institutional care • Increase effectiveness and efficiency of the long term care system

23. What is ‘Money Follows the Person’? • Individuals participating in Medicaid have a choice about where they live and receive long-term care services.

24. Two Programmatic Components • Design and implementation of a transition initiative moving people from institutions to communities and supporting them with community services for 365 days; • Design and implementation of infrastructure change initiatives supporting the State’s capacity to develop high quality care in the community.

25. Rebalancing in ConnecticutKey Focus Areas for MFP • Assure pathway back to community for those institutionalized; • Address ‘critical pathways’ to institutions; • Address HCBS gaps, capacity, quality and housing in community. $ HCBS $$ Institutional Care 25

26. MFP Outcomes • Transition 700 people to the community • Eligibility: • Institutionalized for 6 months; and, • Eligible for Medicaid in the community; and, • Eligible for one of the community service packages.

27. Transitions by Target Population as Approved in Operating Protocol

28. Housing Options • Qualified Residences • Assisted Living • Apartment • Group home with fewer than 4 unrelated persons • Family home

29. MFP OutcomesDecrease hospital discharges to nursing facilities among those requiring care after discharge.

30. MFP Outcomes Increase probability of returning to community within first 6 months of admission to institution. • Note: Estimating 100 persons transitioned per year under this initiative

31. MFP Outcomes Increase percentage of persons receiving long term care services in the community relative to the number of persons in institutions. • HCBS State Plan Option • Waiver for persons with Mental Illness; • State plan supports and services;

32. Status of Contract Staff • 28 transition coordinators are working at a local level within Area Agencies on Aging and Independent Living Centers. • 20 of the transition coordinators are working with MFP applicants; • 8 are working with applicants not eligible for MFP • 5 housing coordinators are identifying housing • Housing Coordinators are located at FSW, Inc, HOME, Inc, and Housing Education Resource Center.

33. Status Update on Applications • Program announced on December 4. • 330 applications have been received representing 106 nursing facilities; • 300 applicants have been pre-screened for eligibility; • 289 applicants are eligible based on pre-screen; • Expressed desire to return to the community • Eligible for Medicaid/Community Service Package • Institutionalized for at least 6 months • 87 (30%) of the applicants are over the age of 65.

34. Transition Process DSS Completes eligibility Pre-screen: • Institutionalized 6 months • Medicaid eligible DSS refers pre- screened applicants to Transition Coordinators; Establish first meeting Initial MFP application Received (330) Informed Consent and Application for Services Completed at First Meeting; Referred to appropriate waiver manager; If housing needed, contact housing coordinator Eligibility for target waiver determined; If eligible, care plan developed Discharge Date Established; Housing in place; Transition to community

35. Status on Information Technology • Eligibility Management System and Interchange modifications in place to track all MFP participants; • This allows us to produce reports and analyze all service utilization expenditures for MFP participants; • This also allows us to monitor reinstitutionalization including hospitalization.

36. Status MFP Quality Management • Emergency Back up Support System • 24/7 emergency line staffed by case manager; • Model developed to address personal care emergencies in all areas of the state; • Implementation initiated week of December 29.

37. Status MFP Quality Management • Web based database is completed and in final testing. The web based system gives us the ability to track and report: • Variables indicating transition progress or delays for MFP participants; • All critical incidents and abuse for MFP participants served by DMHAS, DDS, and DSS; • Emergency back up staff utilization.

38. Status MFP Quality Management • UCONN Center on Aging is under contract as external evaluator; • Collect and analyze data related to: • Quality of Life • Assistive Technology • Gaps in long term care system

39. Status MFP Quality Management • Data from Interchange, the web based system, and UCONN will be analyzed on a regular basis; • First area of focus is workforce reliability; • Quarterly reports will be submitted to the Commissioner recommending systems improvement based on data.

40. Improving Workforce Reliability • As we increase demand for community services, the supply of direct community workforce must increase. • Workforce Development Workgroup established in December 2008; • Membership includes: UCONN Center on Aging, Commission on Aging, DSS Aging Services, DSS Bureau of Rehabilitation, DSS Alternate Care Unit, Ombudsman, DMHAS, DDS, providers, and consumers. • Align resources through coordination with: • Medicaid Infrastructure Grant, Office for Workforce Competitiveness, The Connecticut Employment Training Commission, Department of Labor, etc.

41. Additional Workgroups addressing MFP Focus Areas • Transition Workgroup: Review/revise nursing home resident outreach and identification methodology to assure that we meet the goal of 700 transitions by December 2011; • Members include DSS Aging Services, DSS Regional Office, Connecticut Community Care, Inc, AAAs, NAMI, DMHAS, DDS. • Hospital Discharge Planning Workgroup: Create plan to increase number of persons discharged to community after hospitalization rather than to an institution; • Outreach to hospitals • Members include DSS Aging Services, DMHAS, DDS, Ombudsman, Alzheimer’s Assoc, Acquired Brain Injury Association, Hospital Discharge Planners, Connecticut Community Care Inc, Area Agencies on Aging • Housing Workgroup: Design and implement MFP strategic housing plan • Department of Economic and Community Development, HUD, Corporation for Independent Living, New Samaritan, DSS Housing Unit, HOME, Inc, HERC, FSW