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California Community Transitions

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

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  1. California Community Transitions A Money Follows the Person Rebalancing Demonstration

  2. Introductions

  3. 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

  4. 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

  5. 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)

  6. 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

  7. 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)

  8. 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)

  9. 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

  10. 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

  11. 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

  12. Target Populations ― 2,000 Total • Elders • Persons who have: • Physical disability • Mental illness • Developmental disability • Dual diagnoses of chronic medical and mental illness

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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)

  18. Independent Living ResourceContra 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

  19. 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

  20. 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. Transition Teams (Links to existing HCBS)

  21. Health Care Services 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) Housing Transportation 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)

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. Discharge 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

  29. Scheduled Unscheduled Emergency Department Visits Waiver/State Plan Requirements Demonstration Requirements Leave of Absence

  30. Demonstration Ends–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

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

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