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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

California Community Transitions

A Money Follows the Person Rebalancing Demonstration

dhcs long term care division
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
project team
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
cct demonstration
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)
  • 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
  • “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)

purpose continued
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)
  • 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
  • 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
  • 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
target populations 2 000 total
Target Populations ― 2,000 Total
  • Elders
  • Persons who have:
    • Physical disability
    • Mental illness
    • Developmental disability
    • Dual diagnoses of chronic medical and mental illness
  • 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
initial lead organizations
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
home health care management inc butte glenn and tehama counties
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
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
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)
independent living resource contra costa and solano counties
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
  • 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
transition teams links to existing hcbs
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)
comprehensive service plan putting the pieces together
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)



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)
connecting residents with services
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
demonstration vision
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
preference interview
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
california pathways results
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
quality of life survey
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
quality of life survey con d
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
discharge plan
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
leave of absence


Emergency Department Visits

Waiver/State Plan Requirements

Demonstration Requirements

Leave of Absence
demonstration ends what next
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

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