Future of Home- & Community- Based Services in Maine

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Future of Home- & Community- Based Services in Maine

Diana Scully, Director, Office of Elder ServicesMaine Department of Health & Human Services

20th Annual Maine Geriatric ConferenceBar Harbor, Maine

June 11, 2010

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Many Tables & Charts in Presentation are from:

Chartbook—Older Adults & Adults with Disabilities:

Population & Service Use Trends in Maine (2010)

Published by University of Southern Maine Muskie School of Public Service

Funded by Department of Health & Human Services Offices of Elder Services & MaineCare Services

www.maine.gov/dhhs/oes/publications.htm

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What I Will Talk about Today

• Facts about long-term care (LTC)

• Home- & community-based services (HCBS) quality improvement process

• Drivers of LTC reform

• Vision for future

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Facts: Needs Assessment• OES asked Muskie School to conduct LTC

needs assessment.

• Gathered demographic trends & info about use of services over time.

• Includes MaineCare & state-funded programs for elders & adults with physical disabilities.

• Must understand entire LTC system in order to make informed decisions about any part.

• See Chartbook…

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Facts: Aging Demographics

• Maine has one of oldest populations in US.

• 1st in median age (42 years).

• Age 65+ as % of Maine’s population:• 2008 15%; Maine ranked 4th in US• 2015 18+%• 2020 21+%; Maine expected to rank 2nd after Florida

• 65-74 year-olds = Maine's fastest growing age group: 104,000 in 2008 & 184,000 by 2020.

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Projected Changes in Maine's Age Profile 2008 - 2020

220

169

152

184

220

179

104

69

28

232

149 164

173 185

224

184

89

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0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+Age Groups

2008 2015 2020

Number of Persons(in thousands)

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Facts: People Receiving Services

Age of people in different settings:

• Residents of LTC facilities = average age 81+.

• People receiving home care services are younger than residents of facilities.

• Home Care—people receiving state-funded services (average age 77) are older than people receiving MaineCare services.

• People with physical disabilities receiving home care services under 2 MaineCare programs are youngest…but not that young (average age 50+/-).

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Average Age of Maine Long-Term Care Users by Setting (SFY

2008) 81.6 81.2

63.2

48.8

68.1

52.6

77.4

Nursing Facility

(All Payers)(N=6,208)

Residential Care Facility (All Payers) (N = 3,988)

Elderly & Adults w/ Disabilities

Waiver(N=1,066)

Physically Disabled Waiver(N=163)

Private Duty Nursing

(N=1,549)

Consumer Directed State

Plan(N=366)

Home Based Care

(4 levels)(N=812)

MaineCare

Age in Years

All Payers State-Funded

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Single people receiving services at home:

• Varies widely by program.

• Nearly 2/3 of people receiving MaineCare Personal Care Services live alone.

• More than half of people receiving state-funded home care services live alone.

• Smaller % of people served under MaineCare home-based programs live alone.

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Maine LTC Service Users Who Live Alone, by Program (SFY 2008)

21%28%

63%

39%

55%

Elderly & Adults w/ Disabilities Waiver

(N=1,066)

Physically Disabled Waiver(N=163)

Private Duty Nursing(N=1,549)

Consumer Directed State Plan(N=366)

Home Based Care(4 levels)(N=812)

Percent of LTC service users who lived alone

MaineCare State-Funded

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Diagnoses of Maine LTC Users:

• Hypertension is most common diagnosis in all settings.

• Depression is common in all settings.

• Dementia is common in LTC facilities & much less common at home.

• Arthritis is more common in home care settings.

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Diagnoses of Maine LTC Users,by Setting (SFY 2008)

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MaineCare LTC users, by setting:

• Between 2000 & 2008, MaineCare LTC users grew by 2.1% (from 11,941 to 12,190).

• Residential care facilities increased their share of LTC users by 9 percentage points.

• Nursing facilities’ share of LTC users fell by 6 points.

• Home care’s share of LTC users fell by 5 points.

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Average Monthly # of MaineCare LTC Usersby Setting (2000, 2006, 2008)

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Facts: LTC Expenditures• MaineCare expenditures growing for facility-

based care, but not for HCBS.

• 2000: 82% spent for facilities & 18% for HCBS

• 2008: 87% spent for facilities & 12% for HCBS

• 2000: 5% of total expenditures were for state-funded home care; in 2008 only 3%.

• Good News!!! 124th Maine Legislature approved addition of $1 million extra proposed by Baldacci Administration for home-based services.

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Annual MaineCare LTC Expenditures by Setting (2000, 2006, 2008)

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Annual LTC Expenditures by Setting— MaineCare

& State-funded: 2000, 2006, 2008

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What I Will Talk about Next


• Home- & community-based services (HCBS) quality improvement (QI) process



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QI Process• LEAN = improvement process that looks at

“current state” & desired “future state” & how to get from here to there.

• 4 bills before 124th Legislature resulted in DHHS LEAN process for HCBS: • LD 400 (Sen. Craven)• LD 1059 (Sen. Sullivan)• LDs 1078 and 1364 (Rep. Peterson)

• Since summer 2009, DHHS staff & many others have devoted many hours to process.

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QI Process

• 2 LEAN groups: 18-member Core Team & 17-member Direct Care Worker Task Force.

• 18 organizations represented.

• 15 objectives & 100+ actions identified to implement LEAN recommendations.

• 2 LEAN reports: Direct Care Worker report to DHHS and DHHS LEAN report to Legislature.

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QI Recommendations

• Goal: 50% of all LTC expenditures should be for HCBS.

• Combine multiple programs into fewer.

• Create greater equity across programs.

• Design all programs to include both agency-provided services & self-directed services.

• Develop single self-directed model across programs with budget authority.

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QI Recommendations

• Maximize flexibility in care plans & delivery of services.

• Improve awareness of options among consumers & providers, especially during discharge planning process.

• Provide livable compensation for direct care workers.

• Require consistency in rate-setting approaches & cost components across programs.

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QI Implementation

• DHHS leaders have carefully considered QI recommendations.

• Work is underway to improve self-directed options to better allow consumers & families to direct & manage their own care.

• Other changes will provide for greater flexibility for program participants.

• Our intention: rulemaking in play by October.

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QI Implementation

• Changes in HCBS must take into account National Health Care Reform & Maine’s managed care initiative.

• Before any major restructuring, more input from people receiving services is needed.

• DHHS will reconvene Direct Care Worker Task Force to perform tasks required by LD 1364 (enacted version of Rep. Peterson’s bill) on policies, training & compensation for “direct support aides”.

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What I Will Talk about Next


• Home- & community-based services (HCBS) quality improvement (QI) process



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Drivers of LTC Reform #1 Mainers are old & getting older.

#2 Older Mainers would rather be in their own homes than go to LTC facilities.

#3 Home care services cost less than LTC facility services.

#4 Maine’s LTC system lacks balance.

#5 LTC facilities are aging; financial implications are huge.

# 6 National Health Care Reform will play a role.

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Drivers of LTC Reform#1 Mainers are getting older. Watch out for

Boomers!

#2 Older Mainers would rather be at home than go to LTC facilities.

• Recent AARP survey confirms this.

• In early 2010, 401 Maine residents were asked where they’d prefer to receive LTC.

• Responses: 79% at home, 7% at home of family member/friend, 9% residential care/assisted living, 2% nursing home.

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Mainers’ LTC Setting Preference (2010 AARP Survey)

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Drivers of LTC Reform#3 Home care services cost less than LTC

facility services. Average MaineCare costs (per member per month):

• $4,229 nursing facilities (NFs)

• $2,045 residential care

• $1,833 NF-eligible people under “waiver”

• $541 Private Duty Nursing

• $483 Personal Care Assistance

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Drivers of LTC Reform#4 Maine’s LTC system lacks balance. Uneven

distribution of beds across Maine counties (per 1,000 persons age 65+ in SFY 2008):

• Nursing facility beds range from 49 in Aroostook to 16 in Waldo.

• Residential care beds range from 36 in Androscoggin to 3 in Sagadahoc.

• Total beds range from 71 in Aroostook to 28 in Sagadahoc.

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Drivers of LTC Reform#4 Maine’s LTC system lacks balance. Home

care declined (SFY2000 - SFY 2008):

• MaineCare users of home care services dropped from 38% to 32% of total MaineCare LTC users.

• MaineCare expenditures for home care dropped from 18% to 12% of total MaineCare LTC expenditures.

• State-funded expenditures for home care dropped from 5% to 3% of total MaineCare & state-funded LTC expenditures.

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Drivers of LTC Reform#5 LTC facilities are aging; financial implications

are huge.

• 47 nursing facilities with 2,498 beds (36% of total beds) are in need of renovation or replacement.

• 40 residential care facilities with 1,257 beds (41% of total beds) are in need of renovation or replacement.

• These #s are based on estimates by DHHS Division of Licensing & Certification.

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Drivers of LTC Reform#5 LTC facilities are aging; financial implications

are huge. Total costs could exceed $233 million:

• Cost of replacing nursing facility beds is $109,000-$130,000 per bed. Replacing 457 beds = estimated $50-$59 million.

• Cost of replacing residential care beds is $80,000-$95,000 per bed. Replacing 530 beds = estimated $42-$50 million.

• Substantial rehabilitation costs run $70,000-$80,000 per bed. If cost were only $50,000, estimated cost of renovating all 2,677 nursing facility & residential care beds in need of rehab = $133+ million.

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Drivers of LTC Reform#6 National Health Care Reform will play a role:

• Patient Protection & Affordable Care Act creates new opportunities for states to balance their Medicaid LTC system by expanding access to HCBS, including:

HCBS State Plan option expansion.

Community First Choice option.

State Balancing Incentive Program.

CLASS Program (voluntary insurance).

• See publication #8079 at Kaiser Family Foundation website at www.kff.org.

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What I Will Talk about Finally


• Home- & community-based services (HCBS) quality improvement process



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Vision for Future: Projection Model

• Lewin Group, with assistance of Muskie, developed projection model for Maine.

• Tool helps us plan for LTC services.

• Model uses 4 factors:

Changes in population, by age & by county.

County-specific use rates for each service.

Changes in nursing facility use rates by MaineCare members & other payers.

# of residential care beds.

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Vision for Future: Projection Model

• Can vary assumptions and plug them into model to get:

Statewide & county-specific estimates of use for each year between 2009 & 2015.

Expenditures by multiplying estimated # of users by cost per person in base year.

• Model does not tell us what to do. Model = tool to help us make decisions.

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Vision of Future: Year 2020 • HCBS will represent more than 50% of all LTC

expenditures.

• More people receiving home care services will direct their own personal care services & have flexibility.

• There will be much more support for family caregivers, including more adult day services.

• There will be greater access to evidence-based programs by people with LTC needs.

• There will be more affordable housing with services for Maine’s elders.

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Vision of Future: Year 2020 • There will be several smaller, homelike places

for people who need nursing facility-level of care (e.g. Green House).

• There will be greater access to specialized services & facilities for people with dementia.

• Most people will no longer believe that nursing home is inevitable for old people when they can no longer take care of themselves.

• Direct care workers will receive livable wages & benefits that recognize the great value of their work.

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Vision of Future: Year 2020 • How can we get there?

Take advantage of opportunities presented by Health Care Reform.

Do not replace every aging LTC bed.

Shift economics of LTC through statewide managed care or local PACE programs.

Provide greater support to families to help care for their loved ones.

Make sure people know all possible options.

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Questions ?

Contact Diana Scully: [email protected] 207 / 287-9200

Documents

Future of Home- & Community- Based Services in Maine