Driving the Future 2011

DESIGN OF A MEDICAID LONG TERM CARE SYSTEM IN OHIOIN OHIO

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Agency Mission & VisionAgency Mission & VisionMissionThe Area Agency on Aging provides older adults and their caregivers l t h ilong-term care choices, consumer protection and education so they can achieve the highest possible quality of life.q y

VisionThe Area Agency on Aging will be the preferred long term carethe preferred long-term care management organization for older adults across all care settings.

Western Reserve Area Agency on Aging ● 10A

Agency Mission & VisionAgency Mission & Vision

Mission

The mission of the Western Reserve Area Agency on Aging is to empower and support older adults to maintain wellness, independence and dignity.

Western Reserve Area Agency on Aging Western Reserve Area Agency on Aging –– 10A10A

Western Reserve Area Agency on Aging ● 10A

Agency Mission & VisionAgency Mission & VisionVision of the Western Reserve Area Agency onVision of the Western Reserve Area Agency on

Aging is to be the Leader in....

Creating a caring and compassionate community that fully understands the needs of older adults and embraces advocacy to ensure these needs are met.

● Educating individuals to ensure individual choice in the way these needs are to be satisfied.

● Developing a highly accessible system of home and community based services for older adults.

● Developing an enhanced provider network through innovative partnerships and collaborations to provide a range of quality community based services.Ad i f i ll f d d i bl● Advocating for an optimally funded, equitable distribution of state, federal and other funds to fully meet the needs of older adults.

Our HistoryOur History• Leader in the long-term care industry for

more than 35 years.

Old A i A t f 1965• Older Americans Act of 1965

• National Aging Network

– U.S. Administration on Aging– State Units on Aging– Area Agencies on Aging

What We DoWhat We Do• Core Business

Long-term care focused on providing impaired older adults home and community-based options to permanentnursing facility placement.

• Specialtyp y

Managed care in home and community-based settings for older adultswith functional impairmentswith functional impairments.

• Niche Market Segment

Medicaid-eligible frail older adultsMedicaid-eligible frail older adults.

The Way Forward- IntroductionThe Way Forward Introduction Ohio’s $8 billion budgetary challenges are unprecedented, there

remains opportunity because we offer the public policy solution to remains opportunity because we offer the public policy solution to Ohio’s Medicaid long term care problem: “consumer choice.”

Home is where the heart is, and a consumer-driven home and community based care system holds the key to saving Ohio community based care system holds the key to saving Ohio taxpayers $billions.

According to the Ohio Business Roundtable, if Ohio’s annualized Medicaid spending per member moved to the national average the Medicaid spending per member moved to the national average, the State would realize nearly $1 billion in savings a year. Additionally, if Ohio moved to the first quartile of states, Ohio’s savings would be $2 billion annually.$ y

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The Changing Face of MedicareThe Changing Face of Medicare Medicare Reform targets the dual eligibles,

h h i b h M di d M di idthose who receive both Medicare and Medicaid. According to a 2010 study by AARP, 8.1 million

d l li ibl t di ti t dual eligibles represent disproportionate spending in both programs In Medicaid they comprise 18 percent of the In Medicaid, they comprise 18 percent of the

Medicaid population but represent 46 percent of Medicaid expenditures.

In Medicare, they comprise 16 percent of the population but account for 27 percent of all expenditures. expenditures.

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The Changing Face of MedicareThe Changing Face of Medicare Specifically, Medicare reform is aimed at reducing

id bl h i l d i i d h i avoidable hospital readmissions around 5 chronic diseases Heart Disease Stroke Diabetes Cancer Chronic Obstructive Pulmonary Disease (COPD).

Medicare’s focus on dual eligible and beneficiaries with Medicare s focus on dual eligible and beneficiaries with these chronic diseases is particularly relevant to us, as 85% of our PASSPORT and Assisted Living members are d l li ibl d l ll ( %) h f dual eligibles and nearly all (92%) have one or more of these infirmities.

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The Changing Face of MedicaidThe Changing Face of Medicaid Medicaid is two programs: medical insurance

d l f h i di and long term care for the indigent Medicaid accounted for 30% of the State of

Ohi ’ di i Ohio’s spending in 2010

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The Changing Face of MedicaidThe Changing Face of Medicaid Ohio spends $4.7 billion in Medicaid annually for long-term care.

Long-term care costs for older Ohioans account for 42 percent of the state’s total Medicaid expenditures.

Ohio spends approximately 75 percent of long-term care Medicaid funds on institutional care and about 25 percent on home and community-based services community-based services.

Ohio’s severely disabled older population is expected to double from 175 000 to 350 000 by 2035from 175,000 to 350,000 by 2035.

Citation: Scripps Gerontology 2009 Citation: Scripps Gerontology 2009

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The Changing Face of MedicaidThe Changing Face of Medicaid

Th h b th M di id R f C i i There have been three Medicaid Reform Commissions appointed by Ohio’s last two Governors, dating back to 2003.

While there has been much discussion, there has been limited action.

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The Changing Face of MedicaidThe Changing Face of Medicaid

M di id f i Ohi d t b i 1. Medicaid reform in Ohio needs to begin first by making long term care (as

d t i l i h ) th opposed to simply nursing home) the entitlement in any venue, thus promoting

h i i tti consumer choice in care settings. 2. The existing nursing home population

should be care managed by Area Agencies on Aging in order to expedite transition to more appropriate, less expensive, and more desirable care settings. 13

The Changing Face of MedicaidThe Changing Face of Medicaid

Th M di id i h b d l 3. The Medicaid nursing home bed supply needs to be “right-sized.” Limiting bed supply will immediately eliminate the need to supply will immediately eliminate the need to backfill beds with other populations.

4. We need to expand options in the middle of 4. We need to expand options in the middle of the care continuum to include Foster Care Facilities for consumers unable to live at home but that do not require permanent nursing home placement.

5. We need to better integrate Medicare services with long term care. 14

The Changing Face of MedicaidThe Changing Face of Medicaid Integration of medical and long term care could

be accomplished by quickly implementing the following recommendations from the Unified L T C S t W k R t f Long Term Care System Workgroup Report of 2010: Allow Medicaid Managed Care beneficiaries the choice Allow Medicaid Managed Care beneficiaries the choice

to maintain their benefits when they enroll in PASSPORT.

Expand access to information, assistance/referral and Long-term Care Consultations through AAA’s Aging and Disability Resource Centers. and Disability Resource Centers.

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The Changing Face of MedicaidThe Changing Face of Medicaid

D l A A A i L t C Deploy Area Agency on Aging Long-term Care Registered Nurse Consultants in hospitals, to transition patients to home and community based care settings.

Develop Area Agency on Aging/health care partnerships and implement evidence-based health coaching programscoaching programs.

Deploy Area Agency on Aging Long-term Care Registered Nurse Consultants in large Medicaid physician practices to support patient access to available community-based programs and support.

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The Changing Face of MedicaidThe Changing Face of Medicaid

I l ti th i l h t th l Implementing these simple changes to the long term care system will address the three key public policy issues confronting Ohio’s Medicaid long policy issues confronting Ohio s Medicaid long term care system; Defining consumer choice in long term care, g g , Building the middle of the care setting continuum Integrating medical and long term care services

Moving aggressively, we will improve consumer outcomes and satisfaction and according to the Ohi i d bl Ohi Ohio Business Roundtable save Ohio taxpayers up to $2 billion each year.

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Our Progress-Our ProgressChoice in Long Term Care

W h “ d th dl ” f i tit ti l We have “moved the needle” from institutional based Medicaid long term care to home and community based optionscommunity based options

We have successfully advocated for legislation to make consumer choice a reality in Medicaid to make consumer choice a reality in Medicaid long term care

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Our ProgressOur Progress“Moving the Needle”

Si th i ti f Since the inception of PASSPORT in 1992, the rate of people receiving nursing facility people receiving nursing facility care compared to in-home care has decreased from more than 90% to 58%

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Our ProgressOur ProgressHome First Legislation

H Fi t H Bill 66 i 2005 ll d ld d lt Home First- House Bill 66 in 2005 allowed older adult residents in a Medicaid nursing home bed to bypass waiting lists utilizing Medicaid nursing home long term care funding to move to PASSPORT

Home First Expansion- House Bill 398 in 2010 passed both houses without a dissenting vote virtually both houses without a dissenting vote, virtually eliminating waiting lists for the 60+ population by allowing older adults at “imminent risk” of nursing h l b lhome placement to bypass waiting lists

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Transition to next speakerTransition to next speaker…

Defining Consumer Choice inDefining Consumer Choice inLong Term Care helps…C Consumers: Access to long-term services & supports Aging Disability Resource Centers (ADRC)

Available alternatives Waivers: PASSPORT & Assisted Living Utilizing Care Management Person-Centered Approach

Ratio NF/HCBS from 90%/10% at inception to 58%/42% today58%/42% today

Defining Consumer Choice in L T C h lLong Term Care helps…

H l h C S Health Care System Control costs via AAA Network care

management PASSPORT Waiver services 1/3 annual

cost of NF care Reduces Medicare institutional

expenditure

Aging Disability Resource Centers Aging Disability Resource Centers (ADRC)

Single Points of entry into Long Term Services and Single Points of entry into Long Term Services and & Supports System

Resource Centers Aging and Disability Centers/Networkg g y / Front Door to Services and Supports

All provide seamless access into formal network of community services and supports

Aging Disability Resource Centers Aging Disability Resource Centers (ADRC)

C t di t d ll b t Cooperate, coordinate and collaborate with multiple partners: Healthcare institutions & organizations Healthcare institutions & organizations Community service organizations County officesy

Identify most likely consumer pathways to access information, awareness & assistance

From medical care to rehab to in-home h lhelp

ADRC Consumer ExperienceADRC Consumer Experience

Assistance for all adults older and disabled irrespective of income

Information, referral/assistance local resourcesInformation, referral/assistance local resources In-home assessment Benefits access options counseling Benefits access, options counseling Evidence Based Programs access e.g.:

F ll P ti Falls Prevention Chronic Disease Self Management Diabetes Self Management Diabetes Self Management

Range of Options for Long Term Care Range of Options for Long Term Care Services and Supports

Institutional Nursing facilities

Community Based Long Term Care Waivers: over 60 PASSPORT; Assisted Living Self-directed care options

Person Centered ApproachPerson Centered Approach

Learned from Disability CommunityLearned from Disability Community Actions required: focused listening focused listening, creative thinking and alliance building alliance building

Realization a person’s ‘buy-in’ is central to their success in living with their chronic their success in living with their chronic condition

Central to defining real consumer choice in Central to defining real consumer choice in LTC

Next iteration: Person-DirectedNext iteration: Person Directed

P di d h l Person-directed concepts help create a more :

t ff ti cost effective responsive LTC system

A h d LTC t dd A changed LTC system addresses: societal,

fi l d fiscal and market concerns

Integrating Medical and Long Term CareIntegrating Medical and Long Term Care

Formal relationships AAA Network:l Hospitals

Insurances

Transition Services MDS Q: AAA Community Living Specialists Between service settings: Discharges between institutional settings Discharges from institutional settings to

communitycommunity

Integrating Medical and Long Term CareIntegrating Medical and Long Term Care Incentives ACA change re-admission reimbursement ACA change re-admission reimbursement Over 65 yrs. National average re-admit 30% Discharge planning added as Safe Practice #11 g p g

National Quality Forums Solutions: Best combination: Medical + Community

Partnered Interventions Re-Engineered Discharge Planning (RED) Re-Engineered Discharge Planning (RED) Transitions Coach (Coleman Model) Better Outcomes for Older Adults through Safe g

Transitions (BOOST)

Role of NursingRole of Nursing

S tti it f d iSettings community focused nursing: Assigned to hospitals, nursing facilities Follow consumer in-home assessment Follow consumer in-home assessment Physician practices Law offices

Care ManagementCare Management Transition Specialists Coach not determinerCoach not determiner

Skill Set in the CommunitySkill Set in the Community Strong comprehensive assessment

Wholistic listening Wholistic listening Active person-centered chronic care approach Engage consumer/care giver then educateEngage consumer/care giver then educate Validate learning & understanding Consumer & care giver

Interdisciplinary with person as ‘driver’ The plan belongs to the person, their goals

Let the person teach you. Together discover their pathway to optimized well beingtheir pathway to optimized well being.

Remember:Remember:“Fall seven times, stand up eight.”

Japanese proverb