South Carolina Department of Health and Human Services Money Follows the Person Grant Blue Ribbon Panel

1. South Carolina Department of Health and Human ServicesMoney Follows the PersonGrant Blue Ribbon Panel July 31, 2007

2. Agenda Welcome and Introductions Background of Money Follows the Person Grant Current status of LTC services in SC Grant commitments Roles and responsibilities of committee Next steps Next meeting date

3. Background The Deficit Reduction Act of 2005 provided authority for Money Follows the Person Rebalancing Demonstration grants to states. Prior to this, there were MFP efforts under President Bush’s New Freedom Initiatives. The purpose of the grants is to help states rebalance expenditures between institutional and community based services. Additionally, the federal government provides an enhanced match for one year for long term care services for persons transitioned from nursing homes to community settings.

4. Background, continued South Carolina applied and was one of 17 states approved for a grant that was award in January 2007. South Carolina was also the only southeastern state to receive the grant in the initial round. We received $5,768,496 for the 5 year grant period. The target population in our grant is the elderly and physically disabled population. For persons transitioned under the grant, our state’s match from the federal government will increase from approximately 70% to 85%. The federal requirement of the grant is that a person be in a nursing home six months before being eligible for transitioning with the enhanced match.

5. Background, continued Two major components of the grant – rebalancing and transitioning . One is planning and the other is actual transition of nursing facility residents to the community.

6. Overview of Long Term Care A Continuum of Care

7. Projections Persons age 50 and older in the US is projected to rise from 27.3% to 35% Persons age 65 and older is projected to rise from 12.4% to 16.3%

8. A Look at South CarolinaPersons 50+ Year 2002: Total population of 4,130,933 Year 2020: Total population of 5,052,030 22.3 % change in population U.S. Census Bureau, Populations Estimates for the U.S. Regions, Divisions, and States, March 2000.U.S. Census Bureau, Populations Estimates for the U.S. Regions, Divisions, and States, March 2000.

9. So, Here’s the Reality People are living longer Medicaid will continue to be the nation’s major source of financing for long-term care services covering services for both elderly and non-elderly persons in institutional and community-based settings Over 10 million Americans will need long-term care services and supports to assist them in life’s daily activities

10. Who We Serve Daily CLTC provides services to a number of people The Community Choice Waiver serves over 11,500 people The HIV/AIDS waiver serves over 1,000 people The Ventilator Dependent waiver serves over 30 Over 550 medically fragile children receive personal care services and/or private duty nursing

11. Profile of CLTC Clients Most (71%) are female Over half are African American More than 4 in 10 are widowed Almost 7 in 10 have less than a high school education

12. Profile Continued Almost 6 in 10 are incontinent of bowel and/or bladder In 1997 less than 50% of clients had problems with bowel and bladder Over 8 in 10 need hands on help every day to bathe, dress, and/or toilet One in every three uses a wheelchair

13. Client Age Profile More than 50 people are over 100 years old Almost 900 are at least 90 years old One in four are younger disabled persons under the age of 60 Over 400 qualify for the HASCI waiver Almost 600 qualify for the MR/RD waiver

14. Community Choices Clients Every client is frail and qualifies for Medicaid nursing home placement Every client chooses to receive care at home instead of a nursing home

15. Choices CLTC allows people to make their own choices: in where they live, in what services they get, and in who will provide those services The Community Choices waiver gives even more options – consumers control their own budgets and decide when they receive and how much they pay for services

16. CLTC ServicesMost Needed and Highly Utilized Case Management Personal Care Adult Day Health Care Meals Diapers Under Pads

17. Other Services Nursing (only in HIV and Vent Waivers) Companion Pest Control Personal Emergency Response System Respite Environmental Modification Adult Day Health Care Nursing

18. CLTC National Recognitions CLTC Client fund – money raised by CLTC staff to assist clients with basic necessities such as medication and electricity Best Practice for Case Management System software Best Practice for Care Call service documentation and billing system Implementation of a Consumer Directed Waiver for elderly disabled clients CLTC has gained a national reputation for being innovative with resources. Other states come to South Carolina for advice and technical assistance to enhance their programs.

20. Institutional Care Nursing Facilities A Necessary Reality

21. What is a Nursing Facility? Provides room, meals, recreational activities, assistance with daily living and protective 24 hour care Trained professionals on staff: Social Services, RNs, LPNs, CNAs, physical and occupational therapists, speech-language pathologists, medical director, etc. Generally, residents have physical or mental impairments which keep them from living independently

22. Resident Profile Widowed/divorced, female Memory loss (Dementia) Most recently hospitalized Cognitive impairment and mental disorder Requires assistance with at least 3.75 ADLs Takes about 6.7 prescribed medications 3 to 5 medical diagnoses

23. OversightFederal Level CMS under certain circumstances may also conduct unannounced surveys All surveys conducted by DHEC are subject to review by CMS

24. Medicaid Criteria for Placement Must meet skilled or intermediate level of care Must meet financial eligibility criteria

25. OversightState Level DHEC is the licensing and survey authority for nursing facilities Survey includes a case mix stratified sample of residents and measures quality of care Surveys are unannounced and conducted every 12 to 15 months

26. Little Known Facts As of June 30, 2007 Total NFs: 193 (Both Licensed & Certified) 88.6% NF Occupancy Rate (2003) Total NF beds: 19,457 (June 30, 2007) 71.5% covered by Medicaid (2003) 13.3% covered by Medicare (2003) 15.1% covered by “other” pay source (2003) Source: AARP, Across the States: Profiles of Long-Term Care, 2004.Source: AARP, Across the States: Profiles of Long-Term Care, 2004.

27. Total Number of NF Beds Certified and Licensed Source: SC DHEC, Listing of Certified/Licensed Facilities in South Carolina, June 2005Source: SC DHEC, Listing of Certified/Licensed Facilities in South Carolina, June 2005

28. Reimbursement SC Medicaid certified NFs submit cost reports to determine daily rate Information is reviewed by the Bureau of Long Term Care Reimbursement Each NF has a different rate The average daily rate is $135.92 (Effective October 1, 2006)

29. Sfy Ending June 30thYear to Date NF Medicaid Budgeted $ Budgeted Amount: $441,000,000 Year to date actual: $433,783,765 Percent of Budgeted Amount Spent: 98.40%

30. Expenditures

31. RECIPIENTS

32. PATIENT DAYS

33. Quality in Nursing Facilitieswww.Medicare.gov/NHCompare Web site the public can use to compare nursing homes Available info: no.of beds in the NF, survey results, deficiencies, complaints, quality measures, etc.

34. Comparative Data Between Nursing Facilities and Community Long Term Care

38. Other Long Term Care Services In the Bureau of Long Term Care

39. Optional State Supplementation OSS is an entitlement that subsidizes the resident’s income, allowing for a room and board payment of $1056.

40. OSS Facilities and Recipients 390 is the current number of facilities enrolled with DHHS to participate in the OSS program Facilities range in size from 3 beds to 169 beds Average Number of OSS recipients – 4200

41. Profile of OSS residents Have no alternative living arrangements and may otherwise be homeless 58% are female Most have a mental illness, developmental disability, or meet NF (intermediate) level of care Many have “aged in place” and their conditions have become more acute

42. OSS Rate Established annually by the General Assembly Last rate increase was 1999 Current OSS rate - $1003.00 (Or for a 30 day month - $33.43 compared to an average daily rate of $122.11 for nursing home care or compare with the $40.00 a day for Adult Day Health Care) OSS appropriation has increased from $15m to $19.5m from 1997 to 2007

43. Average monthly cost to operate a participating CRCF $1,424 per resident The short fall between CRCF cost and the maximum OSS providers are allowed to charge is $421.00 per month per resident

44. OSS residents Most placements made by DDSN, DMH and DSS/APS Many residents are intermediate level of care and the only currently available alternative placement is nursing home

45. Integrated Personal Care IPC services are funded by using a portion of OSS funds to provide a Medicaid payment to qualifying OSS facilities when the resident meets IPC level of care. IPC was developed as a way of providing additional care and improving quality.

46. IPC Program benefits Care planning and weekly oversight of residents by licensed nurses. Increased training requirements and increased availability of nurses to conduct training. Facilities must be ADA compliant

47. IPC Current Status 50 facilities enrolled in OSS participate in IPC 676 Residents receiving OSS participate in the IPC program

48. Hospice Program All inclusive program that assists both patient and family when the patient has been certified terminally ill.

49. Hospice Program Nursing Services Medical social services Physician Services Counseling Services Short Term Inpatient Services Medical appliances and supplies Aide Services Home Maker Services Therapy Services Prior Authorized Services not related to the terminal illness

50. Eligibility Criteria Certified terminally ill by personal physician Medical condition or prognosis if life expectancy is six months or less Benefit periods of 90, 90, 30 days with unlimited renewal of benefit periods

51. Hospice Program Funding Rates are set by CMS Issued each October and adjusted by the MSA standards Standard state match rate

52. 2004 Data – SC Hospice Patients and Days of Care by Payor Source

53. Home Health Services provided by a licensed and certified agency to eligible beneficiaries who are affected by illness or disability at their place of residence, based on a physician’s order.

54. Home Health Services Skilled Nursing Services Home Health Aide Supplies Medical Social Services (Pending) Physical Therapy Occupational Therapy Speech Therapy Telemedicine (to be added in FY07-08)

55. Home Health Reimbursement Rates are established by the lesser of Medicare cost, charges, or limits Cost Settlements are determined based on the lesser of these limits

56. Home Health Expenditures 2005

57. Program of All-inclusive Care for the Elderly (PACE) Program Profile: All-inclusive care capitated state plan program Only federal/state program utilizing Medicare and Medicaid funding Required to be cost-effective at less than the cost of nursing facility care Cares for individuals age 55 or older that choose to enter the program and who meet nursing facility level of care

58. Why PACE is needed PACE is a choice in the continuum of long term care PACE is a less costly managed care alternative to nursing facility placement

59. Why PACE is needed: (Continued) PACE participants typically have more intense needs than those in the Community Choices waiver The Community Choices waiver does not offer the extent of care needed for some individuals to remain in the community

60. PACE – Palmetto Senior Care (PSC) PSC has been an approved PACE provider since 1988 and serves up to 400 participants in Richland and Lexington counties Operates 5 day centers to provide and coordinate services on-site, at home, in a hospital or nursing facility Palmetto SeniorCare has been identified as serving one of the most frail populations in the nation and has made some of the most successful outcomes

61. PACE – The Oaks Expected to begin operation early in 2008 in Orangeburg county The Oaks is a faith-based non-profit continuing care retirement community The Oaks received a $ .5m grant for rural PACE expansion

62. DHHS Commitments Made to CMS as Part of the MFP Grant This State accepted the Money Follows the Person Rebalancing Demonstration Grant award including all terms and conditions. This acceptance committed us to: Ensure collaboration with the following entities: nursing facilities, advocacy groups, major State agencies, and providers of in-home services. Seek necessary legislative changes needed to rebalance South Carolina’s long term care system.

63. Commitments, continued Identify and coordinate housing options. Transition an estimated 192 individuals during the five year demonstration. Offer the following new services during the grant period: demonstration services to include adult foster care and transitional nursing; a supplemental service for one-time equipment and home adaptations. Consider modifications to existing waiver and/or state plan services to sustain this population in the community.

64. Commitments, continued Consider the use of temporary, time-limited NF certification in cases where a client assessment indicates the potential for transition. Conduct outreach activities Hire a full time Grant Project Coordinator Assure information will be available for all reports as specified by CMS. Modify the case management system as necessary.

65. Roles and Responsibilities of the Committee The major goal of this task force will be to address ways to identify and enhance the state’s long term care budget. (Page 52) The Blue Ribbon Task Force will make recommendations regarding necessary action required to give SCDHHS budget authority to manage all long term care funds within a global line item. (Page 52)

66. Roles and Responsibilities, continued The Task Force will be charged with determining what legislative changes are needed, refining additional services, identifying further gaps and making decisions among viable options. (Page 53) This group will also make public presentations to get further buy-in from the public and stakeholders. (Page 53)

67. Roles and Responsibilities, continued With Blue Ribbon Task Force input, the State will evaluate the following rebalancing options that may include the following: (Page64) Utilization of a global funding line for nursing facility care, PACE and the three 1915(c) waivers operated by SCDHHS, including necessary approvals; Increases in levels of current services and development and implementation of additional services as needs are identified for the Community Choices waiver; and Continued work with the State Housing Authority to increase funding for home modifications.

68. Roles and Responsibilities, continued Blue Ribbon Task Force is to assist with the following activities during the implementation phase: (Page66) Service Delivery Rebalancing Strategy Continued Improvements Infrastructure Changes Sustainability

69. Roles and Responsibilities, continued The Blue Ribbon Task Force will be charged with evaluating all barriers that prevent the flexible use of funds. Additionally, the Task Force will make advisory recommendations to SCDHHS to address identified barriers. (Page 74) The Task Force will also work collaboratively with industry representatives to evaluate the possibility of establishing pay for performance standards that will provide reimbursement for quality care through the development of measurements for positive outcomes. (Page74) 

70. Roles and Responsibilities, continued This task force will have as a major agenda item ways to rebalance the state’s long term care budget. (Page81)  This Task Force will also be charged with ensuring that all interested parties are fully aware of the progress of the grant application. (Page 81)

71. Next Steps/Other issues

72. Next Meeting