11

Long-term CareLong-term Care Vermont’s Approach Vermont’s Approach

Individual Supports UnitIndividual Supports UnitDivision of Disability and Aging ServicesDivision of Disability and Aging Services

Department of Disabilities, Aging & Department of Disabilities, Aging & Independent LivingIndependent Living

22

National Medicaid National Medicaid CongressCongress  • Historical ProspectiveHistorical Prospective

Senator Jim Leddy , Chair, Health and Senator Jim Leddy , Chair, Health and Welfare Committee, (D) Vermont Welfare Committee, (D) Vermont Senate, South Burlington, VermontSenate, South Burlington, Vermont

•   Choices for Care OverviewChoices for Care Overview Lorraine Wargo, Director, Individual Lorraine Wargo, Director, Individual Supports UnitSupports Unit

33

AgendaAgenda

• HistoryHistory

• OverviewOverview

• ImplementationImplementation

• DataData

• TrendsTrends

• Next StepsNext Steps

• QuestionsQuestions

4

History

Legislative Action Act 160 Other Initiatives

5

Overview

“Vermont’s 1st in the Nation 1115 Medicaid Waiver offers equal choice among all long-term settings – nursing home, home-based services, or enhanced residential care”.

Goals Provide choice and equal access to long-

term care services and supports. Serve more people. Create a balanced system of long-term

care by increasing the capacity of the home and community-based system, while maintaining the right number of quality nursing facility beds.

Manage the costs of long-term care. Prepare for future population growth.

7

Overview Each individual’s needs are evaluated based on a

clinical assessment and determined to be “highest”, “high”, or moderate needs.

Highest needs individuals are enrolled once Medicaid financial criteria have been determined.

High needs individuals are enrolled when funds are available, and financial criteria has been determined. Enrollment consideration is given to individuals with special circumstances.

Moderate needs services are designed to be preventative in nature; services are adult day, homemaker, case management.

3 levels of need – “highest”, “high” and “moderate”.

8

•

HISTORY

“Never Say Never”

“A Team Effort”

9

Eligibility

Vermont resident 65 years of age or older OR 18 or

older with a physical disability Meet financial criteria for Vermont

Long-term Care Medicaid Meet specific clinical criteria

10

Options

Home-Based Enhanced Residential Care Nursing Home

11

Home-Based

Case Management Personal Care Adult Day Respite Companionship Assistive Devices and Home

Modifications Personal Emergency Response Systems

12

Enhanced Residential Care

Personal Care Meals Medication Management Nursing Overview Activities 24-hour Supervision Laundry/Housekeeping

13

Nursing Home

Personal Care Meals/Nutritional Services 24-hour Skilled Nursing Rehab and Therapy Activities 24-hour Supervision Social Services Laundry/Housekeeping

14

Implementation Approval received from Centers for Medicare & Medicaid

Services (CMS) June 2005.

July-August 2005 hired 12 regionally-based Long-Term Care Clinical Coordinators; these staff determine clinical eligibility, provide technical assistance to providers; provide options education for consumers; conduct utilization reviews; and facilitate waiver teams.

CMS conducted successful readiness review on site in September; approved implementation for October 1, 2005.

Medicaid regulations approved effective October 7, 2005.

October 1, 2005 – 3,447 participants were transferred from the old program to the new Choices for Care Program.

15

Implementation Since October 1, Long-Term Care Clinical Coordinators have

determined clinical eligibility for over 2,100 individuals seeking or receiving Choices for Care Services.

Providers received initial training through Vermont Interactive Television sessions; waiver team meetings; and individual contacts.

Billing and reporting processes were designed and implemented with Electronic Data Systems (EDS).

Waiver recipients received notification of enrollment via individual letters; case managers from local providers and state staff provided technical assistance to individuals with questions and concerns.

Long Term Care Ombudsman contract was negotiated and implemented, expanding services to home-based recipients.

16

Implementation Nursing Homes

Initial concerns regarding payments for admissions.

Hospital discharge planners concerned that nursing homes wouldn’t admit individuals.

DAIL staff met with nursing home administrators and hospital discharge planners; issued clarifying memorandum.

New procedures regarding “patient share” added some confusion and required additional clarification with providers.

17

Implementation

Home-Based Services Some role confusion between DAIL’s new Long-Term

Care Clinical Coordinators and community provider case managers.

Ongoing waiver team meetings, VIT sessions, provider meetings and support from DAIL staff have assisted with clarifying roles & expectations.

Billing issues developed as a result of unintended consequences of new procedures (e.g. patient share)

Weekly meetings with EDS, Department for Children & Families (DCF) and Office of Vermont Health Access (OVHA) have resolved many of these issues.

18

Implementation

Enhanced Residential Care Homes Overall smoother transition to Choices for Care. Initial data indicate higher use of ERC homes. New billing procedures created some confusion and

delays in payment. Weekly meetings as noted previously with EDS,

DCF, & OVHA have resolved many of the issues.

19

Implementation Adult Day Providers

Negotiations during regulatory process resulted in changes to financial eligibility for moderate needs group not intended during program design.

As a result, individuals previously expected to be eligible, were not, creating confusion for providers & consumers.

Implemented exception to the rule allowing those Vermonters to qualify and reinstate adult day services.

New billing procedures presented significant issues for adult day providers.

Weekly meetings, teleconferences, meetings with adult day providers, etc., have resulted in resolution or planned resolution of many of these issues.

20

Implementation Volume of data into the new database system created

delays in data entry.

Initially, the volume of applications from all settings resulted in delays in processing clinical applications.

Revisions to Choices for Care Regulations will be required to adjust the financial eligibility section for “moderate needs” individuals.

Financial eligibility issues continue to be a work in progress.

Previous wait list decreased from 260 to current CFC high needs wait list of 55.

21

Consumer and Surrogate Directed Care:Actual Costs and Avoided Costs, July 2005-April 2006

$8,952,068.23

$2,981,409.06

$9,692,929.05

$3,719,531.69

$0.00

$2,000,000.00

$4,000,000.00

$6,000,000.00

$8,000,000.00

$10,000,000.00

$12,000,000.00

$14,000,000.00

$16,000,000.00

$18,000,000.00

$20,000,000.00

Personal Care Respite/Companion Care

Avoided Costs (Compared to Agency Services)

Actual Costs

Waiver In-Home Services by Type, July 2005-April 2006

417,182

771,730

65,781

367,54335%

65%

18%

82%

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

Home Health AgencyPersonal Care

Consumer/SurrogateDirected Personal Care

Home Health AgencyRespite/Companion

Consumer/SurrogateDirected

Respite/Companion

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%hours (#)

hours (% of service type)

Choices for Care: Total Number of Enrolled Participants October 2005 - May 2006

2286 2279 2250 2216 2211 2214 2198 2150

988 991 1012 1037 1059 1070 1082 1090

0 84 157 260 338 368 412 441173

183 191197

202 210 206 214

0

500

1000

1500

2000

2500

3000

3500

4000

4500

Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06

Nursing Facility Home and Community Based (Highest and High Needs)

Home and Community Based (Moderate Needs) Enhanced Residential Care

Choices for Care Applications Received by Month, by Service ProgramOctober, 2005 - April, 2006

2228 14 13 19 10 5

11

196

11894 89

68 76

66

127

103

94127

88 9378

136

69

48

68

45 28 24

0

100

200

300

400

500

600

Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06

Num

ber o

f App

licat

ions

Rec

eive

d

Moderate NeedsNursing FacilityHCBSERCundetermined

Consumers Pending Long Term Care Medicaid Eligibility Per Department of Children & Families

33%37%

3%27%

No Application on File Applications GrantedApplications Denied Applications Pending

Choices for Care: High Needs Waiting Lists by Countyas of 5/1/06(Total = 55)

1 2 2

25

1

6

0 0 24

1 1

6

31

0

5

10

15

20

25

30

Nu

mb

er o

f A

pp

lican

ts

Choices for Care: Average Monthly Costs of Approved Plans of CareOctober, 2005 - May, 2006

$1,794

$3,655

$1,780

$3,629

$1,773

$3,614

$1,772

$3,629

$1,766

$3,598

$1,746

$3,595

$1,748

$3,553

$1,748

$3,536

$-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

ERC HCBS (highest and high needs)

10/1/2005 11/1/2005 12/1/2005 1/1/2006 2/1/2006 3/1/2006 4/1/2006 5/1/2006

Goals Provide choice and equal access to long-

term care services and supports. Serve more people. Create a balanced system of long-term

care by increasing the capacity of the home and community-based system, while maintaining the right number of quality nursing facility beds.

Manage the costs of long-term care. Prepare for future population growth.

30

Early Trends

Decrease in nursing home admissions.

More individuals receiving services. Decreased Waiting list. Increase in home–based and

Enhanced. Residential Care admissions.

Decreasing cost in Plans of Care.

31

Next Steps

Flexible Choices Paying Spouses Programs for All-inclusive Care for

the Elderly (PACE) Health and Long-Term Care

Integration Project

33

Thank You!