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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

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California community transitions l.jpg

California Community Transitions

A Money Follows the Person Rebalancing Demonstration

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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

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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

Project Team

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CCT Demonstration Care Projects Unit

  • 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)

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Authority Care Projects Unit

  • 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

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Purpose Care Projects Unit

  • “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)

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Purpose Care Projects Unit(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)

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Goals Care Projects Unit

  • 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

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Principles Care Projects Unit

  • 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

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Eligibility Care Projects Unit

  • 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

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Target Populations Care Projects Unit― 2,000 Total

  • Elders

  • Persons who have:

    • Physical disability

    • Mental illness

    • Developmental disability

    • Dual diagnoses of chronic medical and mental illness

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Partnerships Care Projects Unit

  • 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

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Initial Lead Organizations Care Projects Unit

  • 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

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Home Health Care Care Projects UnitManagement, 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

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

  • 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

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Independent Living Resource Care Projects UnitContra 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

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Training Care Projects Unit

  • 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

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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


Medi-Cal Eligibility


Transition Teams (Links to existing HCBS)

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Health Care Services transition teams comprised of representatives from various organizations with a variety of expertise

Plan of Treatment (POT)

Nursing Care Services

Nutrition Services

Allied Health/Other Therapies

Durable Medical Equipment and Supplies

Supportive Services

Personal Attendants

Personal Emergency Response System (PERS)



Social Services

Peer Support/Mentoring

Recreation/Cultural Connections

Environmental Services

Home & Vehicle Adaptation

Assistive Technology

Household Set-up

Education/Training Services

Independent Living Skills

Caregiver Training

Financial Services

Medi-Cal Codes

SSI/SSP payments

Other Services

Demonstration Services

Supplemental Services

Comprehensive Service Plan(Putting the pieces together)

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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

Connecting Residents with Services

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Demonstration Vision resident’s proposed service plan

  • 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

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Preference Interview resident’s proposed service plan

  • 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

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California Pathways Results resident’s proposed service plan

  • 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

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Quality of Life Survey resident’s proposed service plan

  • 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

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Quality of Life Survey (con’d) resident’s proposed service plan

  • 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

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Discharge Plan resident’s proposed service plan

  • 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

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Scheduled resident’s proposed service plan


Emergency Department Visits

Waiver/State Plan Requirements

Demonstration Requirements

Leave of Absence

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Demonstration Ends resident’s proposed service plan–What next?

  • 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

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Questions resident’s proposed service plan

Reach any member of the project team at (916) 440-7535 or [email protected]