No Wrong Door System forAll Payers and All Populations

Joseph Lugo, Center for Integrated Programs

U.S. Administration for Community Living

November 19, 2015

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3

1) How to keep from sinking

2) How to keep from bumping into other ships

3) Why are we out here in the first place

C.S. Lewis

Long TermServices & SupportsPublic

This Is About Changing the Interface Between Public and LTSS

5

NWD System Organizations

Long TermServices & SupportsPublic

This Is About Changing the Interface Between Public and LTSS

Where do I start? How do I get there? How do I plan before I go? How much does it cost? How do I pay? How do I customize for my situation?

Community Scan – Potential Buyers

No Wrong

Door System

Foundations

Private

Insurance Employer

Assistance

Programs

Employer

Insurance

Plans

Medicare

FFS/MAP/SNPOAA

Medicaid

VA Medical

Center

Transportation

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A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers

List of 26 Indicators Across 5 Domains in a State Scorecard on LTSS

1) Affordability and Access2) Choice of Setting and Provider3) Quality of Life and Quality of

Care4) Support for Family Caregivers5) Effective Transitions

VAMC

SWAAA

NCAAA

WCAAA

ECAAA

AAASC AAASC

Connecticut’s Single Contractor Model –

Veteran Health Administration

@Be The Table

End Up Menu

Silo Thinking leads to Silo Funding

Franklin Hiram King – 1889 Wisconsin

“It’s difficult for

organizations to be

efficient and

responsiveness when

functions, information

and supporting

systems are duplicated

across product silos.”

Rusty Wiley

Americas Banking Lead

IBM Business Consulting Services

Agency

1

Division Division

Unit Unit

Agency

2

Division Division

Unit Unit

Agency

3

Division Division

Unit Unit

Dep't. Dep't. Dep't. Dep't. Dep't. Dep't.

Bureau Bureau Bureau Bureau Bureau Bureau

Citizen

The way we traditionally think of government

Governing by Network, Goldsmith (2004)

Silos in the Delivery of Public and Private Services

• The rise in the use of private firms and nonprofits to do government’s work;

• Efforts to “join up” governments horizontally and vertically to streamline processes from the perspective of the customer-citizen;

• Technological breakthroughs that dramatically reduce the costs of partnering; and

• Increased citizen demands for more choices in public services.

In 2004, the Brookings Institute in collaboration with the Innovations in American Government at the John F. Kennedy School of Government identified four influential trends that are altering the shape

of the public sector in Governing by Network: The New Shape of the Public Sector.

Governing by Network:

The New Shape of the Public Sector

Now Posted to CMS Website

“Federal matching funds under Medicaid are available for the cost of administrative activities that directly support efforts to identify and enroll potential eligibles into Medicaid and that directly support the provision of medical services covered under the state Medicaid plan. To the extent that NWD/ADRC employees perform administrative activities that are in support of the state Medicaid plan, federal reimbursement may be available.” 16

Wisconsin - $70M Budget forADRC and Related Activities

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State Governance and Administration

Public Outreach and Coordination with

Key Referral Sources

Person Centered Counseling

Streamlined Eligibility to Public

LTSS Programs

NWD System

Functions

Defining Characteristics of No Wrong Door System Seamless system from consumer perspective

High level of visibility and trust

Proactive intervention into LTSS pathways

Integration of aging and disability service systems

Formal partnerships across aging, disability and Medicaid

All income levels served

Coordination and transformation of existing access functions across multiple organizations serving all populations and all payers 20

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Vision Really Needed?

Administration for Community Living, Centers for Medicare & Medicaid Services, Veterans Health Administration

No Wrong Door System State Activty

American Samoa

Guam

N. Mariana Islands

Puerto Rico

Virgin Islands

DC

HI

MD

DE

NJ

CT

RI

MA

NH

VT

ME

MT

ID

CO

WY

NV

CA

NM

AZ

MN

KS

TX

IA

IL

WI

TN

INOH

MI

ALMS

AR

LA

GA

WV

PA

OR

SD

ND

MO

OK

NE

NY

SC

NC

KY

FL

VAAK

WA

Indicates NWD System Implementation States (13)

Indicates NWD System Planning Grant States (25)

Indicates States & Territories Balancing Incentive Program (18)

*States participating in either BIP and/or NWD Implementation (35)

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1) How to keep from sinking

2) How to keep from bumping into other ships

3) Why are we out here in the first place

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Let’s Admit Bumping Into Other ShipsIs Hard

Overlapping CustomersElderly adults needing LTSS

Physical:2,400,000

I/DD orother

cognitive:550,000

Mentalhealth:270,000

Source: Author’s analysis of data from the 2012 National Health Interview Survey

Birth/infancy

onset4%

Childhoodonset

4%Adultonset41%

Elderlyonset51%

Medical Model

Determines needs and service plan

Oversees provision of services

May seek participant input

Establishes goals and outcomes

Program parameters and standards limit flexibility

Solves problems

Assesses quality of services and supports

The Traditional

System Case Manager

Social Model

Works with participant to determine needs and service plan

Assists participant with overseeing provision of services

Participant involvement is critical

Participant is responsible for goals and outcomes

High flexibility of services and supports

Advises participant on problem solving strategies

Participant assesses quality of services and supports

The Participant-

Directed Services

Counselor

Different Perspectives on Roles of

Support System

The Traditional

System Case Manager

The Person Centered Option

Counselor

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Consequences Bumping Into Each Unifying Voice - Who Benefits When Conflict Arises?

Favorite System Change EffortsCreating Change on Multiple Fronts

System Workforce Individual

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Creating Change on Multiple Fronts

Workforce

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9

38

52

27

79

88

96

61

0 20 40 60 80 100

Worksoutsidethehome

Leisure/socialac vi es

Getsoutwithfriends/family

Communityac vi es

Percent

Par cipa onamongadultsneedingLTSS

NeedsLTSS

Nodisability

(ages 18–64)

Having a Prepared Workforce Sensitive toCommunity Engagement

Source: Author’s analysis of data from the 2011 National Health Interview Survey

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No Wrong Door Person Centered

Counseling Functions

– Pilot the Person Centered Training

– After Pilot/Evaluation the content/text will be made available in public domain

– Goal - see it on numerous platforms (e.g., Community Colleges, Training System) 1) Introduction to NWD System

2) Introduction to Person Centered Counseling

– In Person Training – Person Centered Planning

3) Who We Serve (All Populations)

4) Long Term Services and Supports

5) Protection and Advocacy33

What is Happening Right Now?

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1) How to keep from sinking

2) How to keep from bumping into other ships

3) Why are we out here in the first place

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The LTSS Puzzle

70% of Americans who reach age 65

Will need some form of LTSS for an average of 3 years.

Source: JCHS tabulations of US Census Bureau, 2012 American Community Survey2014 Housing America’s Older Adults/ Meeting the Needs of an Aging PopulationJoint Center for Housing Studies of Harvard University

Data Indicates that the Chances of Becoming Medicaid Eligible Increases with Longer NF Stays

Source: The Lewin Group analysis of CMS CCW 2007 Timeline File enhanced with MAX data.39

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We Need LeadersShow The Way – Risks?

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Tom Nerney