California Community Transitions

A Money Follows the Person Rebalancing Demonstration

Introductions

DHCS Long-Term Care Division

• Committed to offering people a choice of where they receive long-term care services and supports:– In a facility– In the community

• Focused on developing and implementing programs that provide Medi-Cal beneficiaries with LTC services in the community

Project Team

• Betsi Howard, Project Director and Chief, Long-Term Care Projects Unit

• Mary Sayles, RN, MSN• Cecilia Wolff, AGPA• Tuyet Hoang, RA II• Paula Acosta, Technical Advisor

CCT Demonstration

• Funding: Over $130 million

• Timeline: 1/1/2007 - 9/30/2011

• Operational Protocol– 11/30/2007 - First submitted to CMS– Revised twice per CMS input– 6/30/2008 – Approved by CMS subject

to special terms and conditions (received 8/12/08)

Authority

• Section 6071 of the Deficit Reduction Act of 2005

• CMS solicitation, Money Follows the Person Rebalancing Demonstration CFDA 93.791

• CMS policy statements• Existing HCBS waivers and

1115 Demonstration• State Plan• Operational Protocol

Purpose

• “Balancing”* means:– Serving a greater number of people with

long-term care needs in their homes or in more home-like settings in their communities than in inpatient facilities (freestanding NF or DP/NF, acute or ICF/DD)

– Shifting more resources toward home and community-based services to ‘balance’ Medi-Cal long-term services and supports spending between facility services and HCBS

*Steve Gold’s Information Bulletin #254 (7/08)

Purpose (continued)

• Support Medi-Cal beneficiaries’ choices of living arrangement

• Receive increased federal funding for providing HCBS to eligible beneficiaries– 75 FF/25 GF (QHCBS and demo)

Goals

• Improve existing and establish new procedures that:– Support the diversity of LTC consumers and their

formal and informal support networks– Are proactive and supply adequate information for

informed decision-making

• Establish system changes that build linkages between the state’s Administration and unique range of local Medi-Cal and non-Medi-Cal HCBS providers and supportive community agencies

Principles• California Community Transitions is

grounded in a partnership between the state, counties, health care facilities, home and community-based service organizations and consumers

• Individuals who reside in nursing facilities and other health facilities have the right to self-determination, access to home and community-based services, independence and choice

Eligibility

• Demonstration Participants:– Must have lived continuously in an inpatient

facility (freestanding NF or DP/NF, acute or ICF/DD) for six months or longer

– Must be a Medi-Cal beneficiary for at least 30 days

– Would continue to require the “level of care” provided in a health care facility

Target Populations ― 2,000 Total

• Elders

• Persons who have:– Physical disability– Mental illness– Developmental disability– Dual diagnoses of chronic medical and mental

illness

Partnerships

• 23-Member Advisory Committee

• California Health & Human Services and Business, Transportation & Housing Agencies

• Other State Departments

• Olmstead Advisory Committee

• Community-Based Organizations

• Other Interested Persons

Initial Lead Organizations

• Four lead organizations are poised and ready to begin the transition process:

– Home Health Care Management, Inc., Chico– Westside Center for Independent Living,

northwestern LA County– Independence at Home™, a division of SCAN

Health Plan, southern LA County– Independent Living Resource, Contra Costa

County

Home Health CareManagement, Inc.Butte, Glenn, and Tehama Counties

• Licensed, Medicare-certified home health agency

• Operates as a private/for-profit corporation

• Employs experienced RNs and mastered-prepared social workers as transition coordinators to work with experts from local community agencies

• Organized as a private, not-for-profit 501(c)(3)

• Participated in the DOR pilot project to design and implement a model for transition services

• Has actively worked with 45 skilled nursing facilities in the LA area

• Experienced in guiding individuals through the social services system

• Organized as a private, non-profit 501(c)(3) organization

• Participated in California Pathways by providing transitional care management and assessments

• Operates one of the largest Multi-Purpose Senior Service Programs (MSSP)

Independent Living Resource Contra Costa and Solano Counties

• Operates as a private, not-for profit 501(c)(3)

• Recently reorganized the ILR board of directors

• Has established relationships with discharge planning teams in a dozen subacute facilities and successfully transitioned consumers

Training

• The lead organizations have participated in training: – Medi-Cal waivers and State Plan services– Project eligibility, standards and legal issues– HIPAA and Mandated Reporting– Administration and use of the Preference

Interview Tool and the Quality of Life Survey

Transition Teams (Links to existing HCBS)

• Lead organizations will establish one or more regional transition teams comprised of representatives from various organizations with a variety of expertise

• Transition Coordinator• Area Agency on Aging• Regional Center• Independent Living Ctr.• Home Health Agency• IHSS• Medi-Cal Eligibility• Etc.

Comprehensive Service Plan(Putting the pieces together)

Health Care Services• Plan of Treatment (POT)• Nursing Care Services• Nutrition Services• Allied Health/Other Therapies• Durable Medical Equipment and

SuppliesSupportive Services• Personal Attendants• Personal Emergency Response

System (PERS)• Housing• TransportationSocial Services• Peer Support/Mentoring• Recreation/Cultural Connections

Environmental Services• Home & Vehicle Adaptation• Assistive Technology• Household Set-upEducation/Training Services• Independent Living Skills• Caregiver TrainingFinancial Services• Medi-Cal Codes• SSI/SSP paymentsOther Services• Demonstration Services• Supplemental Services

Connecting Residents with Services

• Transition Coordinator confers with Project Nurse regarding resident’s proposed service plan

• Project Nurse assists with assessment of participants’ needs and provides the Transition Coordinator with a list of available waiver and/or State Plan service options

Demonstration Vision• Teams conduct preference interviews and identify

residents who are interested in transitioning• Team members

– Inform potential participants about the demonstration– Ensure potential participants meet eligibility

• Participant, transition coordinator and team members work together to design a comprehensive service plan

• Transition coordinator works with the project nurse to enroll participants into appropriate waivers

• Teams ensure all services are in place prior to discharge

Preference Interview

• Under the “California Pathways: MFP” Grant, DHCS contracted with UCLA and USC to develop a comprehensive Preference Interview Tool and Protocol to determine NF residents’ choices about transitioning to community living

• Grant period spanned September 2003 through September 2007

• Grant award was $750,000 with additional funding from the Department of Rehabilitation

California Pathways Results• Analyzed 13 existing assessment tools: all measured

functional capacity—not resident preference

• Developed and field-tested a screening instrument to ascertain residents’ personal choice for returning to living their communities

• Tried interventions to assist nursing facility residents relocate to community living arrangements

• Provided DHCS with a summary report.

• Published research findings in the Journal of the American Geriatrics Society

Quality of Life Survey

• Required of all MFP grantees

• Team members will survey each participant 3 times:– Baseline – About 2 weeks before discharge– First follow-up – About 11 months after

discharge– Second follow-up – About 24 months after

discharge

Quality of Life Survey (con’d)

• Designed by Mathematica Policy Research, Inc., with input from states, to measure QoL in:– Living situation– Choice and control– Access to personal care– Respect/dignity– Community integration/inclusion– Overall life satisfaction– Health status

• Transition team members follow participants for two months to ensure HCBS continue to meet participants’ medical and service needs

• By month three, lead organizations relinquish responsibility to waiver service managers

Discharge Plan

Leave of Absence

• Scheduled

• Unscheduled

• Emergency Department Visits

• Waiver/State Plan Requirements

• Demonstration Requirements

• Twelve months from date of discharge

• Participants will continue receiving waiver and/or State Plan services, as long as care and service needs remain the same and Medi-Cal eligibility is maintained

• A Quality of Life survey will be conducted at 12 and 24 months after discharge per CMS requirements

Demonstration Ends–What next?

Questions

Reach any member of the project team at (916) 440-7535 or CCT_OLTC@dhcs.ca.gov