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Nursing Facility Level of Care Initiative: An Update

Nursing Facility Level of Care Initiative: An Update. Minnesota Department of Human Services Continuing Care Administration Aging and Disabilities Odyssey Duluth, MN June 17, 2013. Presenters. Douglas Silverman MN DHS, Aging and Adult Services Division Program Administrator

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Nursing Facility Level of Care Initiative: An Update

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  1. Nursing Facility Level of Care Initiative: An Update Minnesota Department of Human Services Continuing Care Administration Aging and Disabilities Odyssey Duluth, MN June 17, 2013

  2. Presenters • Douglas Silverman • MN DHS, Aging and Adult Services Division • Program Administrator • Policy Integration Unit • Jolene Kohn • MN DHS, Aging and Adult Services Division • State Programs Coordinator • Policy Integration Unit

  3. Outline • Background • NF LOC Criteria • Estimated impact • Implementation work plan • Available supports for individuals

  4. Background • Nursing Facility Level of Care (NF LOC) changes • Essential Community Supports (ECS) • Enacted in the 2009 Legislative session • Part of a larger strategy aimed at sustainable long term care • Ensure availability for those with greatest need

  5. NF LOC Delay • Due to Federal Legislation (ACA) • States signed Maintenance of Effort (MOE) agreements • Delayed implementation • 2014 for adults • 2019 for people under age 21

  6. Nursing Facility Level of Care Legislation • Current NF LOC criteria are relatively low compared to other states • Legislation strengthens NF LOC criteria to direct people with lower care needs to other supports, including new program under ECS • Meet increasing demand for services • Improves equity and access statewide

  7. Nursing Facility Level of Care Legislation • For Medicaid payment for NF services • Eligibility for certain long-term care waivers (EW, CADI, BI-NF) • State-funded Alternative Care (AC) • Doesn’t affect other payor criteria (Medicare, e.g.) • Criteria is found at Minnesota Statutes, section 144.0724, subdivision 11 • Effective January 1, 2014 for ages 21 and older

  8. Nursing Facility Level of Care Legislation • Applies to all new applicants 21+ with an eligibility start date on or after 1/1/14 • Applies to current HCBS participants at their next reassessment on or after 1/1/14 • Person was previously opened to EW, AC, CADI or BI-NF, and eligibility span overlaps with 1/1/14. • Transition for current HCBS participants will occur over 12 months as reassessments are completed.

  9. NF LOC Criteria • Reasonable operationalization of current criteria, decision-making by LTCC staff • A person must demonstrate at least one of the following: 1. Need for assistance with ADLs 2. Need for ongoing clinical monitoring 3. Significant cognitive, memory, or behavioral needs 4. Risk of institutionalization

  10. NF LOC Criteria: ADLs • Activities of Daily Living: Bathing, dressing, grooming, walking, toileting, positioning, transfer, eating. • An individual meets LOC criteria based on ADL if they: • Need assistance in 4 or more ADLs, OR • Need assistance with toileting, or transferring, or positioning that can’t be scheduled. • Assistance = dependency as defined for case mix classification

  11. NF LOC Criteria: Clinical Monitoring • Clinical monitoring meets the description and requirements used for case mix classification • Clinical monitoring must be needed at least once every 24 hours

  12. NF LOC Criteria: Cognitive-Behavioral • This criteria reflects needs that are assessed in several ways: • Mental Status Exam (memory) • Self-preservation (capacity to respond to changes in the environment) • Need for staff response to “behavior” • Orientation

  13. NF LOC Criteria: Institutional Risk • The individual lives alone (or will alive alone) AND • Has had a fall resulting in a fracture within the last 12 months OR • Has vision or hearing impairment that affects ability to maintain community life OR • Is at risk of maltreatment by others or at risk of self-neglect

  14. NF LOC Determination • NF level of care can be determined by a face-to-face LTCC assessment (MnCHOICES) • Telephone screening as part of PAS for NF admission • The criteria based on institutional risk must be determined in a face-to-face assessment

  15. NF LOC and Nursing Facilities • LOC determined at admission via PAS • LOC must be re-established at the first MDS quarterly that occurs after admission for continuing MA eligibility for payment of NF services • RUGs categories, MDS and LOC: all categories except PA1 and PA2 contain information that establishes LOC • PA1, PA2: complete LTCC

  16. Nursing Facilities • For MA payment for NFs, must meet criteria at both: • Admission into facility • 90 days after admission into facility • Admissions on or after 10/1/13 may be affected if criteria not met at MDS quarterly • Admissions prior to 10/1/13 are NOT affected by revised LOC

  17. Nursing Facilities • For private pay, PAS must be completed regardless of payor source for all admissions • Private pay will be reevaluated using last MDS quarterly assessment before MA eligibility start date • NF staff will need to be aware of and begin timely discharge planning for all residents not likely to qualify at 90 days

  18. Home and Community Based Programs • May affect access to public programs that require NF LOC: • EW • CADI • BI • AC • Rolling assessments for current participants, not all on 1/1/14

  19. Estimated Impact – HCBS Sample • Based on 2011 analysis of all individuals in EW, AC, CADI, BI-NF in the programs July, 2011 • Total numbers of enrollees evaluated • EW – 23,000 • AC – 3,100 • CADI – 16,960 • BI – 987

  20. Estimated Impact - EW • EW: 3,068 (13%) would not meet revised criteria • Of those, 2,822 (92%) live in own home or apartment • Of the 3,068, 337 (11%) were receiving CL or 24-hr CL

  21. Estimated Impact – AC, CADI, BI • AC: 268 (8.5%) would not meet modified criteria • All AC lived in own home or apt • CADI: 501 participants would not meet modified NF LOC criteria • BI: All participants remained eligible

  22. Estimated Impact - NF • May affect MA payment for NF services for lowest two RUG categories • PA1 • PA2 • About 1.5% of all NF admissions fall into one of these groups • 986 people out of 68,547 admission assessmentsthat occurred 4/1/12 - 3/31/13 • These individuals can still be assessed to meet LOC with LTCC assessment

  23. Available Supports • 93% of EW sample participants would remain eligible for MA basic health care • State Plan services • PCA • 7% will lose eligibility for MA (SIS) • Essential Community Supports: strategy to provide support to the “transition” group who lose program eligibility due to revised LOC (must be on a program 1-1-14)

  24. Available Supports • AC: 268 individuals will not meet modified NF LOC criteria • 100% are eligible for Essential Community Supports • CADI: 501 participants will not meet modified NF LOC criteria • 100% remain eligible for MA State plan, PCA • Essential Community Supports: strategy to provide support to the “transition” group who lose program eligibility due to revised LOC (must be on a program 1-1-14)

  25. Lead Agency Notification • Notifications • For HCBS, notice to lead agencies that includes individuals, who based on their last assessment in MMIS, may not meet revised criteria at their next reassessment

  26. Essential Community Supports • New program will provide specific services • People who do not meet NF LOC criteria • Based on analysis of needs and services of original sample group that did not meet revised criteria • What services were they most likely to be receiving? • Address emerging needs

  27. Essential Community Supports • To be run like AC with allocations to counties • $400/month budget • Must live in own home or apartment • Case management - $600/year for transition group

  28. Essential Community Supports • Must live in own apartment or single family home • Cannot be provided in • Board and lodge • Non-certified boarding care • Corporate/family foster care

  29. Essential Community Supports- New Program for Seniors • “Legacy” group • Not eligible for MA • Age 65 or older • Meets Alternative Care financial criteria • Have been assessed to need and can benefit from services available under ECS • Does NOT meet LOC criteria

  30. Essential Community Supports- Transition Group • Transition group: 12 month group • Must have been on waiver on 1-1-14 and immediately prior to eligibility for ECS (i.e. still on the program at reassessment) • Loses eligibility at reassessment due to changes in LOC criteria • Any age • Continue to be financially eligible for MA or AC • Can benefit from ECS services available • One-time case management benefit

  31. Essential Community Supports • Service coordination • Homemaker • Chore • Caregiver training and education • PERS • Home-delivered meals • Service definitions identical to AC/EW • New service: Community Living Assistance

  32. Essential Community Supports • Service Coordination • Reimbursement up to $600 in a service year • Performed by case manager, case aide employed by or under contract with the lead agency • For the transition group only, $600 for service coordination is outside of $400 per month budget

  33. Essential Community Supports Service Definitions • Homemaker may include: • Meal preparation • Routine household tasks • Assistance with arranging transportation • Companionship • Informal emotional support • Social stimulation • Monitoring the safety and well being of the client

  34. Essential Community SupportsService Definitions • Chore Services • Support or assist individual or primary caregiver to maintain home • Heavy household chores • Moving or removal of heavy items • Shoveling snow and lawn maintenance • Customary service charges • Extermination and pest control

  35. Essential Community Supports Service Definitions • Caregiver Training and Education • Family and informal caregiverswho provide direct services • Parent • Spouse • Adult child • Other relative • Not paid, not employed by provider

  36. Caregiver Training and Education • Caregiver training: Instruction about • Treatment regimens • Disease management • Nutrition • Personal/physical care • Behavior management • Family dynamics • Caregiver roles • Use of equipment

  37. Caregiver Training and Education • Caregiver Education includes: • Coaching • Guidance • Instructions • Directly related to providing care to the person receiving services • Must be documented in support plan

  38. Essential Community Supports Service Definitions • Personal Emergency Response Device or System (PERS) • Summon help in an emergency without dialing the telephone • Press an alert or panic button worn on a pendant or bracelet in event of fall or other emergency

  39. Strategies to Support NF LOC • Streamline Preadmission Screening (PAS) • Senior Linkage Line will conduct PAS • October 1, 2013 • Return to Community • MDS Section Q • Face-to-face assessments for <65

  40. Strategies to Support NF LOC • Relocation Services Coordination • Care Coordination in MCOs • Moving Home Minnesota • ECS • MA State Plan, PCA • NF discharge planning

  41. What Doesn’t Change • Appeal rights for individuals • Lead agency notification requirements • Provider discharge requirements • Provider notification requirements • Other eligibility criteria for HCBS • Other criteria for NF payment (MA LTC eligibility, claims edits, e.g.) • Health plan requirements for provider authorization and billing

  42. Implementation Plan • External stakeholder workgroup • Internal workgroups • Referral protocols • Training • Communications: bulletins, legislative notices to recipients, e.g. • Systems improvements • Evaluation

  43. Evaluation • Contractors will evaluate these initiatives: • NF Level of Care • Essential Community Supports • Return to Community Initiative • PCA and Home Care Reform • DHS Evaluation of NF LOC as required by legislature

  44. Training • The following groups will be trained on NF LOC changes and ECS program: • Lead Agencies • Financial Workers • Area Agencies on Aging • Title III Nutrition Service Providers • Provider Network • Other stakeholders

  45. Training Opportunities • Roadshows: First Contact/PAS/NF LOC (NF and Lead Agency Staff) • St Cloud – 8/7/13 • Brainerd – 8/8/13 • Arrowhead – 8/12/13 • Mankato – 8/13/13 • Rochester – 8/14/13 • Marshall – 8/19/13 • Fergus Falls – 8/20/13 • Crookston – 8/21/13

  46. Training Opportunities • Conferences (Providers) • Care Providers Billing Institute – 7/17/13 • Aging Services Billing “University” – 8/15/13 • Care Providers Convention – 11/18-20/13 • Videoconferences (Lead Agency Staff) • 10/24/13 • 11/14/13 • 12/12/13 • More to be added!

  47. Legislative Resources • NF LOC Legislation • Criteria: MN Statutes 144.0724, subd. 11 • Essential Community Supports • Minnesota Session Laws • Chapter 108, Article 7, Section 13 • MN Statutes 256B.0922 (later in summer)

  48. Contact Information • Email: dhs.nfloc@state.mn.us • Doug Silverman • Douglas.Silverman@state.mn.us • Jolene Kohn • Jolene.Kohn@state.mn.us • Website: http://www.dhs.state.mn.us

  49. Thank You!

  50. Questions?

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