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Ohio’s Unified Long-term Care Budget Building a Cost-Effective, Consumer Friendly Long-term Services & Supports System Purpose To develop a comprehensive, flexible and transparent process for effective and efficient budgeting and service delivery that:

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ohio s unified long term care budget

Ohio’s Unified Long-term Care Budget

Building a Cost-Effective, Consumer Friendly Long-term Services & Supports System

  • To develop a comprehensive, flexible and transparent process for effective and efficient budgeting and service delivery that:
    • Encompasses both facility-based and home- and community-based long-term services and supports
    • Is based on consumer choice and differing levels of service need
    • Includes a seamless array of service delivery options
    • Features a consolidated policymaking and budget authority to simplify decision making and maximize the state’s flexibility

Ohio Department of Aging

desired outcomes consumers
Desired Outcomes - Consumers
  • Consumers will be satisfied with the services they receive and experience a higher quality of life.
  • Ohioans will be encouraged to plan ahead for future service and support needs, as well as be better prepared to make informed decisions about their options.

Ohio Department of Aging

desired outcomes system
Desired Outcomes - System
  • A transparent budget for policymakers.
  • A cost-effective system that links disparate services across agencies and jurisdictions.
  • Consistency in provider rate-setting.
  • Accurate expenditure forecasts.

Ohio Department of Aging


Promoting Flexible Funding

to Support Long Term Living

Presentation courtesy ofSusan C. Reinhard, DirectorAARP Public Policy Institute

key concepts
Balancing LTC = Achieving more “parity” in funding community and institutional options so consumers have more “real choice”.

Set of Balancing Strategies, including increasing community capacity, informing people of options, funding/budgeting, nurse delegation and workforce, etc.

Key Concepts

Ohio Department of Aging

  • Money Follows the Person = financing for services and supports moves with the person to the most appropriate and preferred setting.
    • Global budgeting
    • Texas MFP
    • Deficit Reduction Omnibus Reconciliation Act
  • Rebalancing (Balancing) = reduced reliance on institutional options, increased community options.

Ohio Department of Aging

key building blocks

Coherent Systems Management


Comprehensive information, simplified eligibility, and single access points


Philosophy of self-direction and individual control in legislation, policies, and practices




A seamless funding system supporting individual choice


Responsive supports across settings and provider types

Quality Improvement

Comprehensive systems that assure quality of life and services

Key Building Blocks

Ohio Department of Aging

budget strategies
Money Follows the Person (MFP)

Planned Parity

Global Budget (Pooled Financing; Unified Budget)

Budget Strategies

Ohio Department of Aging

mfp strategy
Money Follows the Person = financing for services and supports moves with the person to the most appropriate and preferred setting

Commonly starts from nursing home to HCBS--State example is Texas

Useful when long HCBS waiting lists and low occupancy in nursing homes

MFP Strategy

Ohio Department of Aging

planned parity strategy
Can be separate LTC budgets (nursing home, HCBS); mandates reductions in nursing home budget and transfer of those savings to fund HCBS

Aggressive policy and program actions required (universal screening, level of care criteria, pre-admission processes, etc.)

Examples--Maine, Vermont in 1990s

Planned Parity Strategy

Ohio Department of Aging

vermont act 160
Vermont Act 160
  • Shifted funds from nursing home to the HCBS appropriation
  • Goal 60-40% institution/community
  • Strategies: NF moratorium, expand residential alternatives, one time investments
  • Five percent drop in NF supply

Ohio Department of Aging

act 160
Act 160
  • “The reductions required … shall be redirected in FY 1997 to fund home and community-based services. For fiscal year 1998 and thereafter, the reductions required ... shall be redirected … to fund both home and community-based services and any programs designed to reduce the number of nursing home beds.
  • Any general funds redirected but not spent during any fiscal year shall be transferred to the long-term care special administration fund...”

Department of Aging and IndependentLiving Services

Ohio Department of Aging

vermont 1115 waiver
Vermont 1115 Waiver
  • Provide maximum choice of services and settings
  • Eliminate institutional bias
  • Promote early intervention
  • Break link between 1915 (c) waivers and NF level of care

Ohio Department of Aging

global budget
Global Budget
  • Consolidating all of the components of long term care spending into a single state agency budget
    • Funding can follow the person as they move between services
  • Placing the nursing facility, HCBS and state-funded personal care programs and budgets into a single division

Ohio Department of Aging

global budgeting
Global Budgeting
  • Global Budgeting provides a budget appropriation format that allows LTC dollars to be used in the most cost-effective manner

Ohio Department of Aging

global budget17
Global Budget
  • Set a total LTC spending budget based on
    • projected LTC needs and preferences
    • planned policy and program initiatives
  • Provide full administrative freedom to manage costs within the spending limit to respond quickly to consumer preferences

Ohio Department of Aging

washington a pioneer
Washington: A Pioneer
  • Legislature set forth philosophy
  • ….establish a balanced range of health, social and supportive services that deliver long term care services to chronically, functionally disabled persons of all ages and to ensure that services are provided in the most independent living situation consistent with individual needs” (Revised Code of Washington (RCW) §74.39.005) and “to the extent of available funding, the department shall expand cost effective options for home and community services for consumers” (RCW, 74.39A.030).

Ohio Department of Aging

new jersey strategy
New Jersey Strategy
  • Budget and Policy Consolidation at state level for older adults
  • Create more choices for HCBS services
  • Help consumers find choices easily through single entry point (NJ EASE) and Community Choice Counseling (nursing home transition)

Ohio Department of Aging


Patrick Flood, VT DAILS

Ohio Department of Aging

washington success ltc spending trends
Washington Success: LTC Spending Trends

Based on data from the Washington Aging and Disability Services Administration

Ohio Department of Aging

wa shifting spending balance
WA: Shifting spending balance

Ohio Department of Aging

new jersey success
New Jersey Success
  • 3,500 fewer Medicaid beneficiaries in nursing homes
  • 10.4 % reduction in census, surpasses almost all states in recent years

Ohio Department of Aging

Ohio Department of Aging

Source: NJDHSS, Sept 15, 2004 Trenton, NJ

indicators of success in colorado
Indicators of Success in Colorado
  • Reduced the rate of growth in LTC spending
  • Saved 17% over projected LTC budget in 1994
  • Served 21% fewer in nursing facilities than projected
    • (Lewin Group study)
  • In 1996, began serving more clients in HCBS than in nursing facilities (cross-over point)
    • Milne, 2005

Ohio Department of Aging

indicators of success in colorado26
Indicators of Success in Colorado
  • Spent 51.1% of LTC budget on HCBS in 2001
  • Ranked 5th in US
    • Profiles of LTC-2002, AARP
  • Spent 32.7% of Elderly/Disabled LTC budget on HCBS
  • Ranked 8th in US in 2003
    • Milne, 2005

Ohio Department of Aging

critical elements to support transformation
Critical Elements to Support Transformation
  • Vision, Mission
  • Leadership and Partnerships
  • Access to multiple financing sources (Medicaid HCBS & state plan, OAA, state general revenues)
  • Streamlined financial and functional eligibility
  • Comprehensive/single entry point
  • Strong quality management system, including information systems

Ohio Department of Aging


The Changing Face of Long-Term Care: Ohio’s Experience 1993-2005 Presentation courtesy ofRobert Applebaum Scripps Gerontology CenterMiami University

ohio fast facts
Ohio Fast Facts…
  • The population in Ohio who are most likely to need long-term care (those over age 85) has increased by 55,000 (38%) over the last 12 years (1993-2005).
  • Despite the population increase the number of nursing home beds in service has been reduced from a high of 99,000 in 1997 to about 94,000 in 2005.
  • By 2050, there will be one million Ohioans over age 85.
  • By 2020, Ohio will have more than 220,000 older people with severe disabilities, almost 26% more than 2005.
  • The number of residential care facility beds has increased from 8,700 in 1993 to about 43,000 in 2005.

Ohio Department of Aging

estimated proportion of ohio s population with severe disability in different settings
Estimated Proportion of Ohio's Population with Severe Disability in Different Settings

Ohio Department of Aging

ohio medicaid 2005
Ohio Medicaid 2005
  • Ohio spent $11.5 billion on Medicaid.
  • Medicaid was 24% of Ohio’s annual budget.
  • 42% of Ohio’s total Medicaid budget was spent on long-term care.
  • Ohio spent $2.6 billion on Medicaid nursing homes (ranks 9th) $1 billion on Medicaid ICF/MR facilities (ranks 5th).
  • Ohio spent $950 million on Home and Community Based Care Waivers (ranks 26th).
  • Ohio ranked 47th in home care/nursing home expenditure ratio.

Ohio Department of Aging


























Home Care

MR Waiver

Mental Health

ICF/MR Public

ICF/MR Private

ABD Community

Average Annual Cost per Person FY 2005, Includes Medicaid Card Costs

Ohio Department of Aging

short term stay
Short-Term Stay…

More than 56% of all those admitted to nursing homes:

  • are no longer residents after 3 months
  • almost 7 in 10 are no longer residents after 6 months
  • by year end only one out of every 6 still there

Ohio Department of Aging

proportion of total medicaid nursing home residents still living in a facility
Proportion of Total & Medicaid Nursing Home Residents Still Living in a Facility

Ohio Department of Aging

demographics of residents in ohio s certified nursing facilities june 2004
Demographics of Residents in Ohio’s Certified Nursing Facilities: June 2004 (%)

Ohio Department of Aging

passport usage

Ohio Department of Aging


Distribution of Ohio’s Medicaid LTC Utilization by Setting: 1993-2005

Ohio Department of Aging


Number of Older Persons* Using Nursing Facilities or PASSPORT Services

* Per 1,000 persons over age 60 in the population

Ohio Department of Aging

the process
The Process
  • The Governor will appoint a workgroup.
  • Legislative leadership will appoint four members of the General Assembly.
  • The plan is to be completed by June 1, 2008, and must be submitted to the Joint Committee on Medicaid Technology and Reform.
  • Seven subcommittees, building on existing efforts, will assist the workgroup.

Ohio Department of Aging

decision roadmap
Decision Roadmap
  • Who will be served by the long-term services and supports budget?
  • What does “long-term services and supports” include?

Ohio Department of Aging

front door subcommittee
“Front Door” Subcommittee
  • What will be the design of the “front door” to long-term services and supports?

Ohio Department of Aging

care management subcommittee
Care Management Subcommittee
  • What is the role of care management?
  • Who benefits from care management?
  • How will we interface with Medicare Special Needs Plans?

Ohio Department of Aging

quality subcommittee
Quality Subcommittee
  • How will we incorporate the CMS “quality framework” into all aspects of long-term services and supports, including nursing facilities?

Ohio Department of Aging

unmet needs subcommittee
“Unmet Needs” Subcommittee
  • What unmet needs currently exist and what additional long-term services and supports should Ohio offer?

Ohio Department of Aging

consumer direction subcommittee
Consumer Direction Subcommittee
  • How will we incorporate the key principles of consumer direction into the system?

Ohio Department of Aging

it systems subcommittee
IT Systems Subcommittee
  • How will existing and planned IT systems be modified to accommodate a unified budget?

Ohio Department of Aging

budgeting subcommittee
Budgeting Subcommittee
  • How will the budget be built and what model will be used?

Ohio Department of Aging

ohio department of aging
Ohio Department of Aging