Public Health Practice Grand Rounds

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1 Services for Older Adults: A Changing Landscape for In-Home Care January 15, 2014 Public Health Practice Grand Rounds presented by the Mid-Atlantic Public Health Training Center Maryland Department of Health and Mental Hygiene

2 Services for Older Adults: A Changing Landscape for In-Home Care Mayor Of Baltimore - Stephanie Rawlings-Blake Office of Aging and CARE Services Baltimore City Health Department Health Commissioner Dr. Oxiris Barbot Arnold Eppel, Director - Office of Aging and CARE Services

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5 Programs that currently provide Long Term Services Support (LTSS) Department of Health and Mental Hygiene (Medicaid) Home and Community Based Waivers Medical Assistance Personal Care Program (MAPC) PACE (Program of All-Inclusive Care for the Elderly) Maryland Department of Aging Senior Care Veteran-Directed Home and Community Based Services Caregiver services Maryland Department of Disabilities Attendant Care Program Maryland Department of Human Resources In Home-Aide Services Project Home

6 Why home and community based living?

7 What trends are we seeing locally Nursing Homes & Assisted Living Nursing Homes are utilizing a higher percentage of their beds for short rehabilitation (reimbursement rates for rehab is greater) 3 Baltimore City Nursing Homes have closed in the last 2 years (Genesis Hamilton, JH Bayview, Ravenwood) total beds Assisted Livings sites have increased 20% from 315 to 378 (new sites in 2013)

8 Chronic Disease Self Management Programs (CDSMP) in the community setting Area Agencies on Aging (AAA) have worked with the CDSMP and DSMP-Diabetes, Stanford University model. The purpose is to help those persons to self manage their chronic disease. The Chronic Disease Self-Management Program is a workshop given two and a half hours, once a week, for six weeks, in community settings such as senior centers, churches, libraries and hospitals. People with different chronic health problems attend together. Workshops are facilitated by two trained leaders, one or both of whom are non-health professionals with chronic diseases themselves. Outreach to find resources from schools of nursing to assist in this effort are key to long term sustainability.

9 CMS Innovation Grants Various models are being implemented nationally to create best practices. The purpose is to assist prior patients in the community setting with Coaches (e.g. Coleman Model) and define for these patients the community resources that are currently and locally available to them. Helping prior patients to prevent unnecessarily reentry to a hospital inpatient setting. Compliance with physician orders, follow up regarding rehab, coordinating physician appointments and medication compliance. Understanding the physician orders are the focus including follow up. This includes defining the patients short term and long term goals. Models to assist the caregiver and new ideas for innovation

10 Medicare Enhancements including Preventive Services now covered under - ACA Annualized Wellness Plan Part B prevention services are now covered at 100% beginning 2011 (Some exceptions apply) Closing the donut hole for Part D by 2020 Medicare Waiver: focus on preventive care and keeping people out of hospitals as Maryland works toward care coordination

11 Understanding Hospice, by educating underserved populations to decrease utilization disparities A focus is to help families understand what Hospice is and what Hospice can do for the patient. Educating underserved populations and or others regarding the barriers toward hospice services. Preference by families for aggressive care, lack of knowledge, lack of providers diverse staffing, religion, giving up hope, and mistrust of the health care system. Concentrating on Communities who have limited access based on resources available. Understanding the difference between Hospice and Palliative care; where the goals of helping the patient with a serious illness feel better are primary. 95% of all Hospice services are rendered in the home.

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13 Current Reform Efforts Community options Waiver / Merger of (Living at Home -ages & Waiver for Older Adults ages 50+) CW Community First Choice (created by section 2401 of the Patient Protection and ACA) CFC Balancing Incentive Program Maryland Access Point (MAP)/ ADRC Money Follows the Individual (apply for waiver regardless of budgetary caps)

14 Reformed Medicaid Long Term Services Support (LTSS) Home and Community Options Waiver* Merger of Older Adults Waiver (OAW) and the Living At Home Waiver (LAH) 1915C Waivers Community First Choice (CFC)* Medical Assistance Personal Care Program (MAPC will now require an AERS/ interrai assessment and a Support Planning Assistant) The redesign of two* of the three programs above will provide better health, safety and additional quality of life for home based services to be rendered. MAPC will now require an Adult Evaluation Review Service (AERS) assessment. This will help in the delivery of tailored services, that are now defined. Specific assistance with ADL s, along with a support planner will be provided to the individual. The plan of care will include a strong emphasis on personal choice.

15 New Service Structure These two 1915(c) waiver programs will be merged into a single waiver Reduces duplicate applications Offers a full menu of services to waiver participants Simplifies administration CFC services currently offered under the LAH and OAW programs will no longer be offered as waiver services but offered through CFC Maximize the enhanced Federal match Resolves inconsistent rates and policies across programs 15

16 New Service Structure for MAPC MAPC will remain in effect for individuals who does not meet an institutional level of care MAPC will be revised to mimic the CFC program Move from a per diem rate to 15 minute payment units Offer Supports Planning and Self-direction options MAPC participants will be phased in between January and April 2014 Individual participants will select and meet with a supports planner, determine their desired level of self-direction, develop a new Plan Of Service (POS) with an individual budget and hourly personal assistance services, and then enroll by April 1st MAPC case rate will be effective for people remaining in MAPC until April 1st 16

17 Adult Evaluation Review Services (AERS) interrai assessment tool has now been implemented in Maryland and is a comprehensive assessment tool that is required by CMS. Core set of assessment items that are important in all care settings. These common items have identical definitions, observation time frames, and scoring. RUGS (Resource Utilization Group) 1-7 a scoring based on physical, behavioral, cognitive, rehab, (ADLs and IADL), special care, extensive services, clinical complexities The interrai assessment tool will now be utilized for MAPC, CFC, Home and Community Based Options Waiver. Senior Care (State Grant for 60% median income 65+ at risk), Assisted Living subsidy, Congregate housing and Adult Medical Day Care are on the horizon.

18 Current Service Structure Personal Assistance Services Case Management/Nurse Case Monitoring Consumer Training Personal Emergency Back-up Systems Transition Services Home Delivered Meals Assistive Technology Accessibility Adaptations Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus MAPC LAH WOA 18

19 Personal Assistance Services Case Management/Supports Planning Nurse Monitoring Personal Emergency Back-up Systems Transition Services Consumer Training Home Delivered Meals 1 Assistive Technology 1 New Service Structure Accessibility Adaptations 1 Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus 1. Items that sub *CFC Services will be available to all waiver participants MAPC CFC Waiver

20 Rebalancing Principles Improved access to home and community-based services (HCBS). Eliminate barriers to receiving HCBS. Coordinating services and increase collaboration between agencies. Enhance person-centered focus. Shift focus from institutional settings to HCBS. Shift spending. Increase self-direction options. Take advantage of opportunities presented through the Affordable Care Act.

21 Projected State Enrollment in Each Program Waiver Participants Receiving CFC services 3,857 CFC-Only Population 5,061 MAPC Population

22 Maryland Legislation establishing Adult Disability Resource Centers Maryland Senate Bill 83 passed in 2013 Human Services Article, Section (D) Purpose was to define ADRC and establishes Maryland Department of Aging (MDOA) as lead agency Defines options counseling Identifies statutory partners 22

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24 Accessing MAP Statewide Toll Free Phone Number Anticipated statewide number in early 2014 Baltimore City is now using CARE (2273) Website 3.0 procurement underway 10,500 listings Working with Brain Injury Assoc. of MD.,Alzheimer s Association, and others In-Person 20 MAP sites statewide CIL staff co-located (Center for Independent Living) The Image Center (serving Baltimore City and County)

25 Adult Disability Resource Centers (ADRC) Maryland Access Point (MAP) Designed to integrate Aging and Disability services Single point of entry for information, telephone screening, support, and services. Support for caregivers and the families who are looking for answers. Options Counseling The website includes local and private resources

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28 Options Counseling and Money Follows the Person Options Counselors assist those persons living in institutional care to consider transition of long term care back into the community. Section Q of the MDS 3.0 (Min data set) requires all patients to be part of goal setting. AERS re-assessment is required for all patients who want to transition to the community. Centers for Independent Living (CILS), Area Agencies on Aging (AAA), ADRC s will help in the plan, alongside the nursing home discharge summary to help organize the transition. Money Follows the Person approved by CMS and developed to allow persons to transfer their Medicaid reimbursable care services (primarily provided in the past at the institutional setting) back to the community setting as part of the state rebalancing of long term care systems.

29 MFP Participation MFP Participants generally receive their services through an existing waiver program. Additional services are available to MFP participants on top of waiver services: Housing Assistance Behavioral Health Specialist Flex Funds Peer Mentoring

30 Emphasis on Advance Directives: Providing the consumer what they want 60% of people say that making sure their family is not burdened by tough decisions is "extremely important" but 56% have not communicated their end-of-life wishes (Source: Survey by California HealthCare Foundation, 2012) 70% of people say they prefer to die at home, but 70% die in a hospital or nursing home. (Source: Centers for Disease Control, 2005) 80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care, but only 7% report having had this conversation with doctor (Source: Survey by California HealthCare Foundation, 2012)

31 Emphasis on Advance Directives: Providing the consumers what they want 82% of people say it's important to put their wishes in writing, but only 23% have actually done it (Source: Survey by California HealthCare Foundation, 2012) 34% of Marylanders report having an advance directive, but African-Americans are significantly less likely to have one, thus identifying a new minority health disparity (Source: Johns Hopkins Bloomberg School of Public Health study, 2010)

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