Recommendations for Olmstead Implementation

in California

A Presentation to the Achieving Olmstead Implementation in California meeting

Leslie HendricksonHendrickson Development

September 29, 2010

Policy Arctic ZonePolicy 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.

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.

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?

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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.

RecommendationsTime to implement

General Short-term (12 months) Medium-term (12 – 24 months)Longer-term (24 months or longer)

CategoryAccess/delivery systemState-level organizationFinancing

General

Recommendations

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 programsNo overall statement of intent for the “system”

Develop a strategic plan for long-term services and supports.Populations addressedTimetables, responsibilities and measureable goals

State-level Organization

New Department Create a Department of Long-Term Services and Supports.Little Hoover Commission recommendation.Possible components.

In Home Supportive ServicesMultipurpose Senior Services ProgramAssisted Living Waiver ProgramOther HCBS waiversSubstance abuse and mental health programsHousing componentEligibility and level-of-care determinationNursing home, residential, and RCFE licensing

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 programsMovement 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.

Functional EquivalentInformal organizations now span departmentsCan build formal organizations that span Departments.Management databases spanning programs.

Examples of Washington and OregonCollect data on all persons regardless of program:

Acuities ADLs, IADLs, medical conditions, ID and MHEstablish service levelsRecord and monitor services and costs

Programs are managed as one program even though they span Departments.

Diversion and

Transition

DiversionDiversion is about improving hospital discharge planning.Work with hospitals to provide preadmission

screening/options counseling for individuals who:Seek admission to a nursing homeDischarged from a hospital with health & supportive service

needsProvided by single entry points, ADRCs, community

organizations.Priority groups:

Medi-Cal beneficiariesLikely spend down within 3 or 6 months

Current Diversion EffortsMedical 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.

TransitionTransition 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.

Current Transition EffortsMoney 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.

Expanding Transition EffortsHeart 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.

Work With Nursing HomesNeed 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.

Financing

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.

The EngineNeed 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

Cost effectivenessQuestion 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.

Access

Streamline Access to HCBSCreate single entry points for older adults and adults with

physical and mental disabilities.Scope of programs and activitiesPossible entities

Regional Centers are single point of entries. San Diego close ADRCs – Now seven covering ten counties. State now

focusing on ADRC expansion since AoAMSSP sitesArea Agencies on Aging

Need to co-locate financial eligibility workers in SEPs/ADRCs e.g. Riverside.

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.

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.

Services in Residential SettingsOffers options for people who need access to services for

unscheduled needs, oversight and supervision.Program options:

Change current law to allow IHSS payments in RCFEsExpand 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.

Expedite Financial EligibilityAllow 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.