Oregon’sLong Term Care System

Jim McConnell, DirectorMultnomah County Aging & Disability Services

503-988-3441August 2002

2

Multnomah County Aging and Disability Services

County-based Area Agency on Aging State contract to administer

Medicaid Long Term Care Eligibility and Case management (Oregon Law ORS 410)

Medicaid provider payments stay with the State

3

Older Americans Act $2,387,074

USDA 350,000

Medicaid (Title XIX) block grant 27,923,727

Oregon Project Independence 1,246,418

Multnomah County General Fund

4,569,075

General Fund-other cities 613,541

Contributions/Fees 399,911

Total $37,489,746.

Multnomah County Funding Sources (FY 2002-03)

4

AAA LTC SystemAAA LTC System

Referrals

• people needing help

• relatives, friends

• human services agencies;

• hospitals

• health care;

• gatekeepers;

• police

24 hour HELPLINE

Access points

•Eligibility determination (Food Stamps,Financial, LTC, Health Plan, Vets)

•Case Management

•Senior center/meals

•Info & assist., outreach

• PAS/Relocation

•Protective investigations

•Insurance/ housing assist,

•Enrollment in managed care health plans.

Community Services: Transportation, day care, legal, respite, guardian, meals

In-Home Services: Home/ personal care, chores, live-in, medical equipment, meals

Housing Options: ACH, ALF, RCF, NH,other

Caregiver support

Other Community Resources:MH, DD, Voc ReH.,Employment

5

Aging & Disability Services - Values

Be customer driven Involve people in the decisions that

affect them Promote client independence and choice Use client and public resources with the

utmost effectiveness Act with personal and professional

integrity

6

ADS – June 2002

Clients Medicaid 27,518

N.Facility 1,340

Adult Foster care

1,479

RCF 531

ALF 338

7

ADS – June 2002 (contd.)

After Hours 449

Spec.Living 38

In-home 3,944

Food Stamps only

2,191

Health 26,933

8

ADS – June 2002 (contd.)

Public Guardian(new)

33

Transportation 437

Protective 245

Financial Assistance

19,270

SSI Liaison 893

9

How the Oregon system evolved

10

Senior Advocates Wanted integration of services i.e.

Senior centers, meal sites, Medicaid case managers, etc.

Health services were not included. State developed a test model –

FIG waiver. Legislature passed new law in

1981.

11

Two State Initiatives Long term care – designed to

promote alternatives to nursing homes/client independence

Oregon health plan (OHP) – designed to mainstream health care for low income persons

OHP original plan was to be a public/private plan for all Oregonians

12

Oregon Long Term Care

1981 legislative mandate: “…a growing elderly population demands services be provided in a coordinated manner…; That the elderly and disabled citizens of Oregon will receive the necessary care and services at the least cost and in the least confining situation…it is appropriate that savings in nursing home…allocations…be reallocated to alternative care services…”

13

LTC System Development

1974-80 state initiatives to control LTC spending e.g.

- Oregon Project Independence (OPI) 1975.

- FIG waiver 1978. - Pre-admission screening. 1980 governor’s

commission/coalition - draft legislation.

14

LTC Development (contd.)

1981 Legislation (SB955) - Philosophy

* Independence, Choice, Dignity* Savings from Nursing Homes to

go to CBC- Single State Agency\Combined Funding- Local/AAA administration of LTC- Advisory Committees at State and Local level

15

LTC Development (contd.)

1984 - Enhanced Single Entry (Financial

and Food Stamps added) - Use of Single Client

Assessment Statewide (360) - ADLs

1985-89 All regulation of Homes transferred to SDSD

15

16

LTC Development (contd.)

1990 Disability Transfer to SDSD

1999-2002 Planning for Integration of Health and LTC?

17

Nursing Facility/Community-Based Care

0

500

1000

1500

2000

2500

3000

1992 1993 1994 1995 1996 1997 1998 1999

CBC

NF

18

Total Dollars $801.8 Million

27.7%

1.5%

46.5% 24.2%

Nursing Facilities $373.2

Substitute Homes $194.0

Oregon Project Independence $12.3

In-Home Care $222.3

Total Cases 36,026

18.7%

25.5%

10.3%

45.5%

Nursing Facilities 6,741

Substitute Homes 9,177

Oregon Project Independence 3,717

In-Home Care 16,391

19

Oregon Health Plan development

1994 Oregon Health Plan - managed care - AAA choice counseling Managed Care/Capitation Contracts with

HMOs/PCCM/Fee for service

20

OHP development (contd.) Benefits Limitations-Health Care

Commission Medicaid Waiver – 1115 Dual Eligibles – mandatory with

exceptions Statewide – if plans are available All ages

21

Multnomah Co.OHP Enrollees – June 2002

Elderly – 7792 Persons with disabilities –

13,106 Spending - $12 million Receiving benefits – 3.74% 5 Plans (incl. PACE) – 86%

22

AAA Developments

Transfer of State staff to AAA Eligibility Workers became Case

Managers Co-location in Senior Centers Enhanced Outreach (Gatekeeper) and

Information and Referral Extensive Development of Alternative

Living: 600 Adult Foster Care Homes Specialized Adult Foster Care Homes Services in congregate living

23

AAA Developments (contd.)

Assisted Living Facilities Enhanced Protective Service Investigations

& Interventions (funded by Medicaid) Participation in PACE (400 Medicaid clients) Enhanced advocacy by seniors for Medicaid

services at local and state level Enhanced case management quality with

Multi-Disciplinary Teams.

24

AAA Developments (contd.)

Increased Title XIX Medicaid Funds available by using local government funds for match

Local AAAs/HMOs consortium Enhanced transportation system Employment Initiative – 1998 Veterans Initiative - 2000

25

Key Elements in LTC

Single State Agency Single Local Agency/coordinated

funding Easy Access at local level Case Management continuum (I&R

to Protective to Guardianship)

26

Key Elements

Empowered Case Manager Assessment Care Planning Eligibility Service Broker Authorize payments

State/Local Partnership in: Policy Development Quality Review Planning

27

Key Elements

Expansive Federal Waiver. Community-Based/Social Model

Preference. Broad Continuum of

services/options. Provider Network. Cooperating Partners i.e. Health,

Housing, Mental Health, Law Enforcement, Transportation, etc.

28

Key Elements

Liberal Nurse Delegation Act Values - Independence, Choice,

Dignity, Least Intensive Intervention

Standard Statewide Assessment Statewide Service Priority List

29

CASE MANAGER FUNCTIONS

Determines eligibility Develops, implements, and

monitors holistic care plan Coordinates medical care, as

necessary, with primary care practitioner and/or ENC

Locates and prior-approves all LTC and community based services

30

CASE MANAGER FUNCTIONS

Provides advocacy and linkages to various other services

Uses MDT for consultation Provides choice counseling Processes fee-for-service prior

authorization requests

31

Use of Medical Professionals

Pre-admission screening clients at risk of entering nursing

facility Branch Nursing Consultation

teamed with case manager Quality Assurance RNs

random site visits

32

Medical Professionals (Contd.)

Liaison with ENCC at HMOs Multi-Disciplinary Teams

consultation on complex cases Private Duty Nursing

in home care, training, supervision

33

Multnomah County in Partnership with Local Business (2002)

36 Nursing Facilities 600 Adult Foster Care Homes 2,100 Housekeepers & Live-In

Attendants 30 Contract Registered Nurses 3 Housekeeping Agencies 37 Residential Care Facilities 14 Assisted Living Facilities 4 Managed Care Plans

34

ADS and Health system Eligibility/enrollment/dis-enrollment Options-Managed Care(4)

/FFS/PACE/SHMO Case Manager/ENCC liaison Joint Case Manager tracking demo: Diabetes High Risk Joint discharge planning

35

What have we learned? Case Management is our core mission. Empower the CM/client to make all

systems work for the client – including Health, Housing, Mental Health, etc.

Integration with one specialty. e.g. Health, means dis-integration with others.

All business plans have limitations e.g.

36

Fully integrated/fully capitated PACE-style model-costs controlled. Efficient, flexible Gov.$$, cost-

savings in Medicare stay in the community, high quality,intense service mix

In Portland, people have become patients – and live in the system

Client gives up some choices Health-based model

Oregon’sLong Term Care System