New Jersey Balancing Incentive Program. Application for the State of New Jersey

Transcription

1 New Jersey Balancing Incentive Program Application for the State of New Jersey New Jersey Department of Human Services December 2012

2 State of New Jersey Balancing Incentive Program Table of Contents Cover Letter... 2 Project Abstract and Profile... 4 Preliminary Work Plan... 5 Application Narrative... 9 A. Understanding of Balancing Incentive Program Objectives... 9 B. Current System s Strengths and Challenges C. No Wrong Door/Single Entry Point Agency Partners and Roles D. No Wrong Door/Single Entry Point Person Flow E. No Wrong Door/Single Entry Point Data Flow F. Potential Automation of Initial Assessment G. Potential Automation of Core Standardized Assessment (CSA) H. Incorporation of CSA in Eligibility Determination Process I. Staff Qualifications and Training J. Locations of Single Entry Point Agencies K. Outreach and Advertising L. Funding Plan M. Challenges N. No Wrong Door/Single Entry Point s Effect on Rebalancing O. Other Balancing Incentives P. Technical Assistance Proposed Budget Acronyms/Abbreviations Letters of Endorsement

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5 Project Abstract and Profile In early October 2012, New Jersey received approval from the Centers of Medicare & Medicaid Services (CMS) for a new Medicaid Section 1115 (a) five-year demonstration: the Comprehensive Medicaid Waiver (CMW). New Jersey now has begun a statewide health reform effort that will increase existing managed care programs to include managed long term services and supports (MLTSS) and expand home and community based services (HCBS) to certain populations. It is within the framework of the CMW that the Department of Human Services (DHS) proposes to leverage the Balancing Incentive Program (BIP) to expand access to non-institutionally based long term services and supports (LTSS) in a managed care environment. The DHS Division of Aging Services, Disability Services, Developmental Disabilities, Medical Assistance and Health Services (Medicaid) and Mental Health and Addiction Services will work collaboratively on providing services to individuals in the most appropriate, least restrictive settings. New Jersey has a 20-plus year commitment to creating a LTSS system that emphasizes HCBS and relies less on institutionalization. The approval of the CMW elevates this obligation creating the opportunity for a coordinated, departmental mission. The State proposes to harness the collective strength of the DHS, as the single state Medicaid agency, with its community partners to meet the structural requirements mandated under the BIP and CMW demonstration: Expand New Jersey s Aging and Disability Resource Connection (ADRC) network beyond its current target population of older adults and people with disabilities to serve as the No Wrong Door/Single Entry Point (NWD/SEP) for the full array of Medicaid and non- Medicaid LTSS, including individuals under the auspices of the Divisions of Developmental Disabilities and Mental Health and Addiction Services. Access will be broadened through the website, the toll-free number and in a variety of physical locations. Develop and implement core standardized assessment tools to determine HCBS eligibility for populations included and excluded from managed LTSS. This would be similar to the NJ Choice tool used for older adults and people with disabilities and required under the CMW. The methods may differ across populations, but they all will have the capacity to determine a beneficiary s LTSS needs and develop an appropriate service plan. Ensure that conflict-free care management is employed uniformly to assist residents in gaining access to LTSS regardless of the funding source. Under the CMW, the state will establish a process for conflict free coordination by maintaining responsibility for the level of care determination. Care coordination will be provided by the respective managed care networks and the Program of All-Inclusive Care for the Elderly organizations and is responsible for monitoring the Plan of Care and assuring a beneficiary s health and safety. Behavioral Health Administrators will be assigned to integrate behavioral health care, physical health care and managed LTSS with the care coordinators. As a result of CMS approval of the CMW, New Jersey can continue to move forward with reforms to deliver smarter, more effective services with a focus on transitioning from institutionalized settings to HCBS. New Jersey s BIP application, with its proposed budget of about $108 million over a 2 ½ year period, further enhances the State s commitment to balancing services towards the home and in the community. 4

6 Preliminary Work Plan Issues in the application are included in this preliminary work plan. A more detailed work plan will be forthcoming upon the application s approval. General NWD/SEP Structure Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* Lead Person Status of Task Deliverables All individuals receive standardized information and experience the same eligibility determination and enrollment processes. Establish interdivisional Public Awareness and Education workgroup 2 months Establish major activities, time frames, and budget Develop standardized informational materials that ADRCs and partners provide to individuals Present draft materials to DHS MLTSS Steering Committee and Consumers for feedback and input. Train and certify personnel to conduct screenings and assessments for MLTSS for Awareness Campaign 5 months Informational materials 6 months Consumer and provider input to ensure materials are informative and consumer friendly 18 months A statewide network of ADRC, State and MCO personnel trained and certified to conduct level 1 and 2 screenings & assessments for MLTSS A single eligibility coordinator, case management system, or otherwise coordinated process guides the individual through the entire functional and financial eligibility determination process. Functional and financial assessment data or results are accessible to NWD/SEP staff so that eligibility determination and access to services can occur in a timely fashion. (The timing below corresponds to a system with an automated Level I screen, an automated Level II assessment and an automated case management system. NWD/SEP systems based on paper processes should require less time.) Design an integrated MLTSS client flow system (initial overview) that includes: older adults, and persons with physical, developmental, and mental health;/additions. 0 months (submit with Work Plan) Description of the system Design system (final detailed design) 6 months Detailed technical specifications of system Develop Level 1 screenings and Level 2 assessments and options counseling DoAS/DDS 5 months o Modify electronic Level 1 Screening Tool to include screening questions for DDD and DMHAS DDD o Develop a Level 1 Screening Tool or modify ADRC Level 1 Screening tool for DD population o Identify State database for automating Level 1 Screen DMHAS o Develop Level 1 Screening Tool or modify ADRC Level 1 Screening tool for DD 8 months 10 months 8 months 10 months Level 1 screening tools for each of the target populations will share common domains. Level 2 Core Standardized Assessment Tools will also include the core domains. 5

7 Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* population o Identify State database for automating Level 1 Screen NWD/SEP Implement and test system o o o DOAS/DDS test and implement modified Level 1 screen DDD test and implement modified Level 1 screen DMHAS test and implement modified Level 1 screen System goes live o DOAS/DDS o DDD o DMHAS System updates 8 months 18 months 18 months 18 months 24 months 24 months Semiannual Review Lead Person Status of Task Deliverables Validation of the Level 1 screening tools ADRCs will serve as the NWD/SEP for the expanded target populations. DD/MHA Description of successes and challenges State has a network of NWD/SEPs and an Operating Agency; the Medicaid Agency is the Oversight Agency. DoAS serves as the Operating Agency for the ADRC network The Area Agencies on Aging (AAA) serve as the lead county agency for the ADRC/NWD/SEPs Develop and implement a Memorandum of Understanding (MOU) across agencies including those agencies that serve the DD/MHA populations. Train all ADRC partners on the eligibility determination and enrollment processes for MLTSS, including eligibility process for MHAS and DD services. 0 months (submit with Work Plan) 0 months (submit with Work Plan) Division of Aging Services Attached are the names and contact information for the 21 AAAs /ADRCs 6 months All 21 AAA/ADRC Signed MOUs 15 months A training module will be developed to educate the current ADRC partners on the eligibility processes for the expanded target populations DD/MHAS. The training curriculum will be available through classroom and webinar formats NWD/SEPs have access points where individuals can inquire about community LTSS and receive comprehensive information, eligibility determinations, community LTSS program options counseling, and enrollment assistance. Identify service shed coverage of all NWD/SEPs 0 months NJ s ADRC are statewide, effective 5/12. Ensure NWD/SEPs are accessible to older adults and individuals with disabilities Develop Options Counseling Curriculum for ADRC screeners and assessors. Curriculum will include sections for expanded target populations served by the divisions of Mental Health 0 months NJ s AAAs/ADRCs must have a physical location that is handicapped accessible or staff that can travel to the persons residential setting. 4 months Training and certification curriculum for Level 1 and Level 2 screeners/assessors 6

8 Website Number Advertising CSA/CDS Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* & Addiction Services and Developmental Disabilities Conduct Options Counseling training and certification for ADRC partners, MCOs, PACE, OCCO, and other designated agencies. Lead Person Status of Task Deliverables 8 months All ADRC Level 1 screeners and Level 2 Assessors will have successfully completed training and certified as meeting the State s performance standards. The NWD/SEP system includes an informative community LTSS website; Website lists number for NWD/SEP system. Expand the ADRC On-Line Resource Center to include services and programs for DDD and DMHAS in the resource directory and learning library 8 months NJ ADRC Website will serve as the comprehensive database for MLTSS Single number where individuals can receive information about community LTSS options in the State, request additional information, and schedule appointments at local NWD/SEPs for assessments. DDS statewide toll-free number for individuals/caregivers seeking information for all disability populations will be expanded to include older adults. Reconfigure all Senior numbers, including the direct links to the 21 county AAAs to connect to DDS tollfree number Train State and county ADRC staff members on the broad array of MLTSS (including public & private) options, conducting the Level I screen for MLTSS and linking the caller to appropriate point of entry across all 4 months 8 months Single toll-free number for all populations seeking MLTSS. 9 months Training curriculum developed, core of trained State/local individuals certified to conduct training sessions for target populations. State advertises the NWD/SEP system to help establish it as the go to system for community LTSS Develop advertising plan 8 months Advertising plan Implement advertising plan 12 months Materials associated with advertising plan will be distributed through the ADRC NWD/SEP network A CSA, which supports the purposes of determining eligibility, identifying support needs and informing service planning, is used across the State and across a given population. The assessment is completed in person, with the assistance of a qualified professional. The CSA must capture the CDS (required domains and topics). Develop questions for the Level I screen o DOAS/DDS o DDD o MHAS 0 months 18 months 18 months Level I screening for Aging and physically disabled is completed Level 1 screenings for expanded populations are developed and automated or the ADRC Level 1 Screen is modified for the expanded target populations. 7

9 Conflict-Free Case Management Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* Fill out CDS crosswalk (see Appendix H) to determine if your State s current assessments include required domains and topics o o o DOAS/DDS DDD DMHAS Incorporate additional domains and topics if necessary (stakeholder involvement is highly recommended) DoAS/DDS included stakeholder input in the development of NJ Choice DDD/DMAS Train staff members at NWD/SEPs to coordinate the CSA o DOAS/DDS for MCOs, PACE, AAAs, OCCO o DDD o DMHAS Identify qualified personnel to conduct the CSA Continual updates 0 months (submit with Work Plan) 0 months 12 months 12 months 0 months Lead Person Status of Task Deliverables Completed crosswalk(s) NJ Choice includes all of the required domains DDD has a single CSA tool for determining LOC DMHAS has a single CSA tool for determining LOC 6 monts Final Level II assessment(s); notes from meetings involving stakeholder input 6 months 18 months 12 months Training materials and certification process for Level 2 assessment process is completed 12 months List of entities contracted to conduct the various components of the CSA Semiannual after Description of success 12 months and challenges States must establish conflict of interest standards for the Level I screen the Level II assessment and plan of care processes. An individual s plan of care must be created independently from the availability of funding to provide services. Describe current case management system, including conflict-free policies and areas of potential conflict Establish protocol for removing conflict of interest 6 months (submit with Work Plan) Under the Comprehensive Medicaid Waiver, the State will establish policies and protocols to ensure conflict-free care management. 9 months Protocol; if conflict cannot be removed entirely, explain why and describe mitigation strategies 8

10 Application Narrative A. Understanding of Balancing Incentive Program Objectives Overview New Jersey is significantly reforming its long-term care system with the transformation of the state Medicaid program through the federal government s approval of a five-year Medicaid Section 1115 (a) research and demonstration waiver known as the New Jersey Comprehensive Medicaid Waiver (CMW). Among other key components, this historic step includes the move to managed care for long-term services and supports; increased flexibility so that seniors and individuals with physical disabilities at risk of nursing home placement can choose the home and community-based services (HCBS) they need and live where they prefer; expanded support services for people with intellectual and developmental disabilities; and enhanced access to community-based mental health and addiction services. It is within the context of the move to a managed care system under the CMW with its integrated primary, acute, behavioral health and long-term services that New Jersey reiterates its commitment to making structural reforms and ensuring consumers and their caregivers have access to a no wrong door/single point of entry (NWD/SPE) to non-institutional long-term services and supports (LTSS), a core standardized assessment (CSA), and conflict-free care/case management. On July 1, 2012, the Governor realigned senior services from the Department of Health and Senior Services (DHSS) to the Department of Human Services (DHS), the single state agency for Medicaid. The realignment established a single point of access no wrong door for seniors, people with disabilities and their caregivers, regardless of Medicaid eligibility in the framework of state government. Within the DHS structure, the state s long-term services and supports systems are managed by the Divisions of Aging Services (DoAS), Developmental Disabilities (DDD), Disability Services (DDS) and Mental Health and Addiction Services (DMHAS). Administrative and fiscal oversight is delegated by DHS to its Division of Medical Assistance and Health Services (DMAHS). Over the past 25 years, New Jersey has created a LTSS system to enable people of all ages with disabilities and illnesses to have alternatives to institutions with (HCBS). In the past 10 years, New Jersey has used legislation, executive orders and budget initiatives to advance balancing of long-term care expenditures away from a historical reliance on institutions. In 1996, the consolidation of senior services in the DHSS by a Governor s Reorganization Plan was the state s first step to consolidating services for older adults and allowing for the expansion of HCBS for this population. Through Medicaid HCBS waivers, the implementation of Aging and Disability Resource Centers, and nursing home transitions/money Follows the Person (MFP), the DoAS served as a catalyst for promoting home and community-based services that resulted in the percentage of funding spent on nursing homes dropping from 92.7 percent in 1997 to 74 percent in 2010 and the number of people served in nursing homes decreasing from almost 32,000 in 1997 to 27,000 in

11 ADRC and Balancing Long-Term Care A strong partnership formed among the DHS divisions dating back to 2003 when New Jersey was awarded the original Aging and Disability Resource Center (ADRC) grant from the U.S. Administration on Aging. New Jersey s ADRC was the first joint venture partnering the two state agencies responsible for aging and disabilities to create a NWD/SEP system. The ADRC, which began as a pilot project in two counties, now operates statewide with the 21 Area Agencies on Aging (AAA) serving as the county lead agencies in partnership with the county welfare agencies (CWA), County Offices for Disabilities, Centers for Independent Living, hospitals, and other nonprofit agencies in the aging and disability services networks. Other federal grants supporting New Jersey s balancing efforts included two Nursing Home Diversion Modernization Grants, a Real Choice Systems Change Grant for Community Living, a Systems Transformation Grant and the Veterans Directed HCBS Program. In , building upon a successful nursing home transition program and the creation of a NWD/SEP system for seniors and younger adults with physical disabilities, a series of Governor s Executive Orders called for the implementation of a global budgeting process and a fast track Medicaid eligibility option for LTSS. Supported by AARP, the SFY 2006 budget included a provision to reallocate funds from its nursing home budget to HCBS. In 2006, New Jersey enacted the Independence, Dignity and Choice in Long-Term Care Act. The Act directed balancing of the long-term care budget to support expanded HCBS options for older adults and persons with physical disabilities who meet nursing facility level of care. Since 2007, additional opportunities for balancing were realized through New Jersey's participation in the MFP demonstration initiative. The MFP partnership which includes DoAS, DMAHS, DDD and DDS is based on a common vision: (1) consumer friendly access to information and assistance; (2) streamlined eligibility processes for state and federal programs; (3) person-centered planning/self-directed control over service plans; (4) continued expansion of affordable and cost-effective options for receiving HCBS, and (5) continuous quality improvement. Division of Developmental Disabilities (DDD) Since 1990, the DDD decreased the number of people served in its seven (ICF-MR) Developmental Centers by 53 percent or 2,721 people from 5,110 to 2,389 (Sept. 30, 2012). Beginning in 1999, DDD increased the number of people served in the community by 89 percent from 23,174 to 43,841; and home and community based waiver participants increased by 56 percent from 6,635 to 10,375. DDD s blueprint for these efforts is showcased in its strategic plan New and Expanded Options for Individuals with Developmental Disabilities and their Families. While adopting a philosophy of person-centered planning, DDD provided more options for self-direction through a series of budget initiatives that increased state resources for HCBS. Administrative practice changes were accompanied by the creation of a more efficient, automated infrastructure for claiming federal match for state-funded services. The 10

12 Governor and the Legislature supported these efforts, facilitating the reinvestment of new revenues to further expand home and community based services. Balancing will be furthered by the upcoming closures of two developmental centers. In addition to transitioning over 500 consumers to community residences, the closures will generate state savings that will be reinvested in community services and supports. Division of Mental Health and Addiction Services (DMHAS) In 2006, the DMHAS initiated its recovery-oriented community service model. This initiative resulted in an additional $80 million in state funding and a dramatic expansion of community services that will continue through at least SFY2014. Between SFY2006 and 2009, these state funds were responsible for 938 new community placements. Since the Olmstead Settlement Agreement was signed in 2009, the DMHAS developed 734 housing options for individuals diagnosed with a mental illness, expanding such options for its consumers in all 21 counties. While the DMHAS has created a vast array of evidence-based practices to support individuals in the community, it still is exploring and piloting innovative programs. The regional state psychiatric hospitals have been redesigned within this communitybased context. All such hospitals now have admission units that provide active treatment and return individuals to the community without requiring longer-term hospitalization. Each hospital now features a treatment mall, thereby increasing the availability of active treatment for individuals in the state psychiatric hospitals. They offer an array of programming choices whereby individuals in conjunction with their treatment team can select areas of interest based on their treatment goals, strengths and areas for improvement. Olmstead efforts, in conjunction with increased active treatment in the state psychiatric hospitals, have resulted in a census reduction in the state psychiatric hospitals. Specifically, the hospital census on July 1, 2006 was 2,111 and on August 31, 2012 it was 1,450 excluding the state forensic hospital. This decrease marks a 32 percent reduction (661 less individuals) in the state hospital census. It enabled the closure of a state psychiatric hospital in June 2012 and the reinvestment of some of the savings from the hospital closure in the expansion of community-based services. Included are outpatient treatment, supportive housing, supported employment and the development of diversion programs. A diversion program offers treatment, stabilization, referral and linkage services for individuals with behavioral health needs who are high utilizers of the emergency department and emergency psychiatric screening service. While there is still a need in New Jersey for long-term care provided in the state psychiatric system, the decline in hospital census (both current and anticipated) allows for a redistribution of resources. This reallocation will advance community integration for mental health consumers while generating budgetary cost savings. Commitment to Balancing Incentive Program Goals The CMW is designed to advance the state's balancing efforts away from institutionallybased expenditures to less costly HCBS. The Balancing Incentive Program (BIP) will further support this goal. Indeed, the CMW is committed to the goals of the BIP and its requirements of a NWD/SEP system, conflict-free case management services and core 11

13 standardized assessment instruments. A number of elements are already in place, starting with the recent state realignment of consolidating all divisions responsible for LTSS into the DHS. With the exception of the DDD, New Jersey is moving away from fee-for-service toward managed LTSS. The move to managed LTSS will integrate acute, primary, behavioral and long-term care. It is driven by the state's desire to see improved health outcomes, appropriate care in the appropriate setting, coordination of services and the ability to create increased opportunities for individuals in need of LTSS to remain at home. Managed LTSS will provide an opportunity to benefit from the financial incentives offered in the BIP to the advantage of the citizens of New Jersey. The DDD currently operates a cost-reimbursement model, which will shortly begin transition to a fee-for-service system, thus standardizing services across the State and resulting in greater consumer flexibility when choosing service providers. B. Current System s Strength and Challenges In 2010, New Jersey spent more than $3.5 billion on long-term care services for seniors and individuals with physical disabilities under existing long-term services and supports (LTSS) 74 percent for institutional care while only 26 percent was for home and community based services (HCBS). The goal of the state s current Medicaid reform proposal is to move into a managed long-term services and supports (LTSS) delivery system to assist beneficiaries with nursing level of care needs to navigate a complex network of health and social support providers, reduce duplication and cost-shifting in the LTSS system and assist the state in better controlling and predicting long-term care expenditures. New Jersey s biggest strength in advancing the structural changes required under the BIP application is found in the approval of its 1115(a) demonstration the New Jersey Comprehensive Medicaid Waiver (CMW). Yet the state s greatest challenge in moving to a managed LTSS system under the CMW is to measure improved health outcomes. New Jersey will move to managed LTSS by amending its existing managed care organization (MCO) contracts to require management of all long-term care services, including HCBS and nursing home care for seniors and individuals with physical disabilities who meet NF level of care. Under the 1115(a) demonstration, New Jersey will terminate its 1915(j) SPA and its 1915(c) waivers for the Traumatic Brain Injury (TBI), Aids Community Care Alternatives Program (ACCAP), Community Resources for Persons with Disabilities (CRPD) and the Global Options for Long-Term Care (GO) programs. Although these separate waivers will end, the same service options will continue but will no longer be restricted to a specific target population. Once the state determines that the MCOs are ready, these entities will assume full risk for all LTSS, including NF placements. In addition, New Jersey will continue the Program of All- Inclusive Care for the Elderly (PACE). PACE is outside of managed LTSS, but it is still an option for seniors and others in designated zip code areas. 12

14 The current systems strengths and challenges with regard to the state s LTSS information and referral, eligibility determination and case management processes are as follows: LTSS Information and Referral Processes New Jersey s ADRC serves as the No Wrong Door/Single Entry Point (NWD/SEP) for older adults, younger persons with physical disabilities and long-term chronic illnesses and their caregivers in need of LTSS, providing access to information and a full range of public (federal/state/county) and non-profit community-based alternatives. With its ADRC fully operational and statewide, New Jersey has a pathway by which individuals enter the LTSS system and have access to programs and services through a statewide toll-free number, a website, and county-based locations. Through these entry points, consumers and their caregivers may receive a level 1 screening to determine if they are at risk of NF placement and may be referred for a Level 2 comprehensive clinical assessment and financial eligibility determination for Medicaid and other federally or state funded programs. A challenge for New Jersey s ADRC will be to expand its knowledge and customer base to assist the populations served by the Divisions of Developmental Disabilities (DDD) and Mental Health and Addiction Services (DMHAS). Under the CMW, New Jersey plans to use the ADRC partnership as the NWD/SEP for consumers to access managed LTSS regardless of age, disability or income. In concert with New Jersey s move to managed LTSS under the Comprehensive Medicaid Waiver, the BIP will enable the DHS to build upon its current ADRC model. Specifically, the Division of Disability Services (DDS) will assume responsibility at the DHS for managing the community LTSS number to provide the widest access to the NWD/SEP system. This number will connect individuals directly to the countybased ADRCs where they can receive information about community LTSS options. LTSS Eligibility Determination Processes Since 1996, New Jersey s eligibility system has been administered by two separate departments. The Department of Human Services (DHS), as the single state agency for Medicaid, was responsible for financial eligibility, while the Department of Health and Senior Services (DHSS) managed the clinical eligibility side. In July 2012, under legislative authority, aging services under DHSS were transferred to the DHS, thereby creating a single department responsible for both Medicaid clinical and financial eligibility determinations. This transition allows DHS to effectively coordinate these processes at the state and county levels, resulting in the streamlining and implementing of policies and regulations to more efficiently expand long term services and supports across the lifespan. Currently the 21 county welfare agencies (CWAs) are designated as the state s agent for determining financial eligibility for Medicaid programs. Within the context of state policies and regulations, each CWA operates under its own county governance, which results in inconsistencies for consumers when applying for Medicaid programs. Individuals who qualify financially for the Divisions of Aging Services (DoAS) and 13

15 Disability Services'(DDS) 1915 (c) HCBS Waivers are referred to the state (DoAS Office of Community Choice Options) or to its designated agents for a comprehensive clinical assessment and eligibility determination. Unnecessary delays result because financial and clinical eligibility systems are separate. Traditionally, individuals first go to the CWA office to apply for Medicaid programs, which starts the financial eligibility process. If approved for LTSS, individuals are then referred to the DoAS Office of Community Choice Options (OCCO) for a comprehensive functional assessment and clinical eligibility determination. Between the two processes, consumers could wait weeks before final eligibility is determined. With its new tools and processes, the ADRC client pathway was designed to streamline and coordinate financial and clinical eligibility. A computerized Level 1 screen enables ADRC specialists to identify individuals who are potentially clinically and financially eligible for LTSS; conduct an initial options counseling session on the full range of HCBS; and, if interested in LTSS, refer individuals simultaneously to the CWA for financial eligibility and to the OCCO for a Level 2 comprehensive functional assessment and clinical eligibility determination. The ADRC model also created a second process for financial eligibility: Fast Track. It is an expedited eligibility process that allows consumers, who appear eligible for Medicaid, to be authorized to receive State Plan Services for up to 90 days while they complete the full Medicaid application and determination process. Because Federal Financial Participation (FFP) is not available for services delivered to applicants deemed ineligible for Medicaid, the state assumes the cost of services if the applicant is not approved. At the basis of the ADRC client pathway and included to be used under the Comprehensive Medicaid Waiver (CMW) is the NJ Choice Suite. It contains a level 1 screening tool to evaluate a person s care needs for HCBS and potential financial eligibility for state and federally funded programs and a level 2 core standardized assessment tool. Together they provide New Jersey with a validated instrument to ensure that consumers needs for HCBS are addressed in a consistent manner, regardless of their income and point of entry. LTSS Conflict Free Case Management Processes Under the current 1915 (c) waivers, the Department of Human Services (DHS) subscribes to a conflict-free case management strategy. The department has established clear delineations between determining clinical eligibility; developing and authorizing plans of care; establishing service caps; and overseeing quality assurance management. The MCOs and PACE organizations will have the authority and flexibility to manage their members health and social LTSS needs, yet must ensure that they have established clear separation between: Case management from direct service provision; Eligibility determination from direct service provision; and Individuals performing evaluations, assessments, and plans of care cannot be: 14

16 o Related by blood or marriage to the individual or any of the individual s paid caregivers; o Financially responsible for the individual, and o Empowered to make financial or health-related decisions on behalf of the individual. For those individuals enrolled at the time of the managed LTSS implementation, the state will establish timelines for the initial contact, care assessment, plan of care, individual service agreement, and authorization and implementation of services. The state will ensure that the MCO and PACE case managers have successfully completed the training and certification required by the state before these entities will be considered "ready" for managing LTSS members. For individuals already enrolled in an MCO or PACE and who may benefit from LTSS, the MCO or PACE will be responsible for conducting the Level 2 comprehensive functional assessments and forwarding the completed assessment to OCCO for review and clinical eligibility determination. It is the state that retains sole authority for approving/denying clinical eligibility. The MCOs and PACE organizations are responsible for automating their assessment tool. However, the tool must contain all the data elements and algorithm found in the NJ Choice assessment tool. Preadmission Screening and Resident Review (PASRR) regulation requires states to screen all individuals entering a Medicaid certified nursing facility regardless of payer source for the presence of serious mental Illness or intellectual disablities and/or a related condition. A Medicaid-certified Nursing Facility (NF) may include facilities that are certified by both Medicaid and Medicare, or the Medicaid-certified distinct part of a larger institution. The level I PASRR screening tool must be completed for all NF applicants prior to NF admission in accordance with Federal Regulations 42 CFR The minimum credentials for a professional completing the level I PASRR screening tool is a Registered Nurse or Certified Social Worker. To ensure preadmission screening is done prior to NF admission, it will be necessary for hospitals to initiate completion of the PASRR screening in their discharge planning process. Hospital discharge planners must complete a level I screening tool (LTC 26) for all individuals regardless of payment source who are being referred to a NF from the hospital. NF staff will complete the level I screening tool for NF admissions from the community. If the Level I PASRR screening tool indicates that the NF applicant screened positive for mental illness, a PASRR Level II Psychiatric Evaluation must be done and sent to the Division of Mental Health and Addiction Services (DMHAS) for a determination on whether the individuals mental health care needs can be meet in a NF. If the Level I PASRR screening tool indicates that the NF applicant screened positive for intellectual/developmental disability and/or related condition, a referral is made to the 15

17 Division of Developmental Disabilities (DDD) to conduct a PASRR level II ID/DD and/or related condition determination on whether the individuals ID/DD and/or related condition needs can be meet in a NF. MCOs and PACE providers must develop and implement a person-centered written plan of care and individual service agreement in compliance with Medicaid regulations. The MCOs and PACE providers are expected to promote HCBS in order to prevent or delay institutionalization whenever possible. An update to the plan of care must occur at least annually. Each MCO and PACE organization will be required to develop and provide to the state an annual case management plan how it will implement and monitor the case management contract and policy requirements established by the state. The state s oversight process will be more intensive during the first one to two years of managed LTSS operations so that steps can be taken to resolve issues and program improvement can be rapidly carried out. C. NWD/SEP Agency Partners and Roles In 2003, the NWD/SEP concept for New Jersey was developed and implemented as the centerpiece of its ADRC model through federal grant funding. Today, the ADRC serves as the single point of access in all 21 counties for older adults 60 years and older, adults 18 years and older with physical disabilities, and their caregivers, regardless of income. The ADRC is a partnership between the Department of Human Services (DHS) as the single state Medicaid agency and the State Unit on Aging, the 21 county-based Area Agencies on Aging (AAAs), the 21 county welfare agencies (CWAs), the 16 county offices on disability services, the 12 non-profit Centers for Independent Living (CILs) and other nonprofit agencies in the aging and disability services networks. The ADRC provides consumers with improved access to community programs such as meals-onwheels, personal care, housekeeping, specialized transportation, assisted living and nursing home care. It also connects seniors and adults with disabilities with work and volunteer opportunities, insurance programs, health promotion and disease prevention programs, housing, crisis intervention, and other home and community programs. The Division of Disability Services (DDS) Office of Information and Assistance serves as the statewide entry point for individuals with disabilities and their caregivers to educate them about disability issues, community resources, and link them to either state or private service providers. In concert with New Jersey s move to managed LTSS under the Comprehensive Medicaid Waiver, the BIPP will enable the DHS to build upon its current ADRC model. Specifically, DDS will assume responsibility at the DHS for managing the community LTSS number to provide the widest access to the NWD/SEP system. This number will connect individuals directly to the countybased ADRCs where they can receive information about community LTSS options. Through the ADRC physical locations and virtual portals, consumers have easy access to information on the full array of home and community-based services (HCBS). The ADRC provides the consumer with a level 1 screen whereby he or she can be evaluated 16

18 for long term services and supports (LTSS) and, if appropriate, can be referred for a Level 2 comprehensive functional assessment. The ADRC enables the consumer to begin applying for state and federal programs and services and can link the consumer to programs based on their care needs and financial situation. Consumers and their caregivers can access information through a toll-free statewide number, the ADRC website or a visit to county-based offices. The ADRC website contains thousands of national, state and local resources, several new search options, and other consumer-friendly tools including Google translation and mapping features. The site is Section 508 compliant for improved access to individuals with vision impairments. The state ADRC team focused largely on seven goals in the development of its NWD/SEP: (1) Access; (2) Assessment and Options Counseling; (3) Money Follows the Person; (4) Transition Care Models; (5) IT Support; (6) Financing Opportunities, and (7) Quality Management. The ADRC as the NWD/SEP serves as the focal point for continued LTSS infrastructure, process and delivery development. The ADRC s statewide presence is the foundation for New Jersey s plan to use and expand this NWD/SEP network for consumers, including individuals served by the Divisions of Developmental Disabilities and Mental Health and Addiction Services, to access LTSS under the Comprehensive Medicaid Waiver. With collaborative partnerships comprised of the aging and disability entities at the state and county levels, New Jersey will ensure that AAAs as fully functioning ADRCs. In 2006, the ADRC was included in the legislation known as the Independence, Dignity and Choice in Long-Term Care Act. The Act charged the state with expanding the Medicaid long-term care system by offering a larger array of HCBS. It fostered greater consumer choice that would facilitate maximum flexibility between HCBS and nursing home care (in line with the goals of the BIP). Traditionally, services for older adults have been administered separately from those for persons with disabilities although these groups share many of the same needs and face many similar barriers to care. While the ADRC has already changed access to LTSS, the shift to managed LTSS under the Comprehensive Medicaid Waiver (CMW) will further expand the populations served through this NWD/SEP. Under managed LTSS, the ADRCs will work closely with the managed care organizations (MCOs) and Program of All-Intensive Care for the Elderly (PACE) organizations, and serve as the NWD/SEP for all consumers to learn about their long-term care options. Under the CMW, the ADRC role will be expanded to focus on outreach and educational activities to individuals potentially Medicaid eligible; assist individuals to gather the required documents for the Medicaid application process; track status of an application; and arrange short-term services until LTSS can be put in place. At this time, the ADRCs are performing certain functions that may be transitioned to other partners. The following examples are representative of such potential changes: 17

19 The DDS also creates and uses a resource guide that is updated regularly. Meanwhile the ADRCs use a separate guide that identifies county resources. The BIP will designate the DDS as the lead to assume on-going responsibility for integrating all available DHS resource directories and guides into a single database. The Comprehensive Medicaid Waiver enables the Division of Mental Health and Addiction Services (DMHAS) to contract with an Administrative Services Organization (ASO) to manage behavioral health services (inclusive of Medicaid, state and block grant funded services) across the continuum of inpatient to ambulatory treatment and services. One of the ASO s functions will be to provide information concerning services available, assess an individual s need for treatment and refer individuals to the least restrictive, most integrated services. In instances where an individual is seeking managed LTSS services for his or her primary care needs, the individual will be referred to the MCO for primary care services. Through the data exchange between the ASO and MCOs and by examining utilization patterns, it may be possible to identify consumers at risk of LTSS earlier and provide targeted interventions to lessen nursing home placement. D.NWD/SEP Person Flow ADRC Person Flow Built upon an algorithm, the ADRC client pathway is designed to assist professionals with the decision-making process for accessing information; determining clinical and financial eligibility for state, Medicaid, and Older Americans Act funded programs; counseling individuals on home and community-based services (HCBS) regardless of their income and linking them to appropriate public/private community services and programs. New Jersey s unique ADRC client pathway was a collaborative effort between the Divisions of Aging Services (DoAS), Disability Services (DDS) and Medical Assistance and Health Services (DMAHS) to serve as the NWD/SEP for older adults, younger adults with physical disabilities and their caregivers. Currently in each county, the AAA serves as the lead agency for the ADRC partnership as detailed in Section C of this document. Under the BIP initiative, the DDD and Division of Mental Health and Addiction Services (DMHAS) in partnership with the DoAS will expand the client pathway to include their populations in the ADRC model. DHS will establish an interdivisional work group to: Identify key access points where the new target populations can receive Level 1 screenings, Level 2 functional assessments, options counseling, and referrals to public and community-based LTSS; Based on the person flow identified above, integrate the screening and referral process into the ADRC client pathway; Identify and develop additional screening criteria to be added to the ADRC Level 1 screening tool for the new target populations; 18

20 Expand the ADRCNJ Online Resource website to include state and community-resources for these populations; Develop and implement training curriculum for the ADRC partners on the special needs and community resources for these populations, and Transfer the DoAS toll-free number to the DDS that now serves as the statewide toll-free number for families and persons with disabilities across the lifespan. Level 1 Screen and Level 2 Core Standardized Assessment At the basis of the ADRC client pathway and included to be used under the Comprehensive Medicaid Waiver (CMW) is the NJ Choice Suite. It contains a level 1 screening tool to evaluate a person s care needs for HCBS and potential financial eligibility for state and federally funded programs and a level 2 core standardized assessment tool. Together they provide New Jersey with a validated instrument to ensure that consumers needs for HCBS are addressed in a consistent manner, regardless of their income and point of entry. The suite includes the minimum data elements for intake; a level 1 screen for community services designed as a telephone survey and used by the ADRC Specialists to assess a caller s potential LTSS needs; and the level 2 core standardized assessment tool to determine the person s functional needs and clinical eligibility for LTSS. The Level 1 screen and Level 2 tools identify these five level of care needs: (1) information and Assistance; (2) homemaker; (3) intermittent personal care; (4) home care, and (5) nursing home level of care. Based upon the outcome of the level 1 screen, consumers may be referred to the state, ADRC or Program for All Inclusive Care for the Elderly (PACE) assessors who are responsible for conducting home visits and the NJ Choice assessment. The assessors review the outcomes; counsel consumers and their caregivers on appropriate home and community-based services; and connect them to their locally-based care management agencies or other appropriate service providers. Medicaid Financial Fast Track Eligibility Determination The ADRC s client pathway also includes an expedited financial eligibility determination as part of its NWD/SEP system called Fast Track Eligibility. It is a process that allows consumers, who appear to have a high probability of being eligible for Medicaid, to be authorized to receive State Plan Services for up to 90 days while they complete the full Medicaid application and undergo the determination process. Because Federal Financial Participation (FFP) is not available for services delivered to applicants deemed ineligible for Medicaid, the state assumes the cost of services if the applicant is not approved. Under the NJ-Choice Core Standardized Assessment tool mentioned above, the Level 1 Screen for Community Services triggers the Fast Track: if a consumer s screening results indicate a high probability of being eligible for Medicaid long-term care benefits, the outcome is forwarded to the ADRC or the DoAS assessor for a comprehensive functional assessment. Once the assessment is scored, the results are uploaded to a central database whereby the DoAS reviews the assessment and approves or denies 19

21 nursing facility level of care. Names of individuals who meet clinical eligibility are checked against two internal databases -- the Medicare Part D Low Income Subsidy (LIS) and Pharmaceutical Assistance to the Aged and Disabled (PAAD) databases. Within two business days, the state is able to forward the financial information to the ADRC to review and approve or deny Medicaid benefits under Fast Track. If the person is approved for Fast Track, a temporary Medicaid number is assigned and State Plan services and care management are authorized for up to 90 days. Within 30 days, the person must schedule an appointment with the County Welfare Agency (CWA) to complete the full Medicaid application process or risk being terminated from Fast Track. The DHS is monitoring progress and working with the CWA directors and eligibility supervisors to address the issues and concerns. Feedback indicates that a major contributor to the low number of participants being approved is because the databases must show that the federal financial requirements are met, ensuring that there is adequate documentation for the five-year look back period. Fast Track can t proceed without proof that the person s current income/assets fall within the financial guidelines at the time of the application. The ADRC current person flow is based upon the schematic detailed on the following page and will be modified to include the expanded target populations and reflect the move to managed care under the CMW. 20

22 The ADRC Eligibility Process Schematic ASSISTANCE SOUGHT Contact is made by or on behalf of a person seeking Medicaid eligibility. Contact can be made by the individual or family, the local hospital, the local nursing facility or the local assisted living facility. ELIGIBILITY 2 part eligibility for Medicaid Waivers, clinical and financial. Eligibility Process begins with the financial eligibility or the clinical eligibility or both concurrently. Consumer indicates they are not on SSI and is receiving Social Security and/or other retirement payments (pension, IRA, etc. Referral is made to the local CWA for financial eligibility and to the Regional OCCO for clinical eligibility. Consumer indicates they are SSI eligible, no referral to the CWA is needed, the clinical eligibility can be done since financial eligibility is established by being on SSI. Consumer is determined eligible for Community Medicaid/NJCARE but is not seeking NF care, not referred for clinical eligibility or waiver services. PROCESS ENDS Financial Eligibility Determined by the local County Welfare Agency/Board of Social Services (CWA/BSS) Consumer is determined eligible for Community Medicaid/NJCARE and is seeking NF care or waiver enrollment. CP-2 form is issued to OCCO indicating the consumer has met the financial eligibility for institutional care. Clinical Eligibility Determined by the Regional Office of Community Choice Options (OCCO) Offices located in Newark, Edison and Hammonton State staff determines Nursing Facility Level of Care (NFLOC) eligibility for NF, hospital or AL or community consumers Clinical review or Pre- Admission Screen (PAS) is performed, using the NJCHOICE tool for clinical eligibility determination Clinical eligibility for NF LOC is met; consumer is provided information on program options pending financial eligibility determination In Atlantic, Gloucester and Warren Counties, clinical eligibility is determined by the County Assessor located in the County Office on Aging. The PAS is reviewed by state staff in OCCO who authorizes the determination of Nursing Facility Level of Care (NFLOC) eligibility for community only in these counties, OCCO for all others. Clinical eligibility for NF LOC is not met; consumer is referred to local county agencies for other, non-medicaid services. PROCESS ENDS Financial and clinical eligibility is established. If consumer is wants and is willing to accept two waiver services they are referred to a local care management site for enrollment into the GO waiver or approved for NF placement. 21

23 Behavioral Health Standardized Assessment The MCO, in collaboration with the Administrative Service Organization/Managed Behavioral Health Organization (ASO/MBHO), under the Comprehensive Medicaid Waiver (CMW), will establish a level 1 screening process for identification and management of the top five percent (in terms of medical costs and medical or psychosocial risk factors) of individuals with co-morbid medical and behavioral health (BH) conditions. The MCO will participate in the necessary co-management of these cases, which may be done through MCO care management staff or through provider initiatives. The MCO will establish a process for dissemination and implementation of Evidence-Based Practices (EBP) for BH conditions commonly treated in primary care settings, protocols to monitor primary care provider adherence to these EBPs and financial incentives for BH-physical health (PH) coordination activities in the primary care setting (i.e., submitting the BH screening tool to the MCO, developing care coordination capacity within a primary care practice for enrollees with chronic diseases and BH comorbidities, or co-location of BH and PH specialists). The adult MBHO will be required to develop and/or implement a level 2 uniform clinical and medical necessity criteria. Combining screening and assessment results with claims and other utilization data, the adult MBHO will develop a predictive model and a systematic approach to risk stratification to identify high risk BH consumers for participation in intensive care management services, which may include behavioral health home services. The adult MBHO must have the ability to meet the care coordination needs of individuals across a number of specialized programs targeted to specific consumers, including the welfare to work substance abuse initiative (SAI) and behavioral health initiative (BHI).The SAI and BHI are specialty care management programs that go beyond traditional utilization and care management by incorporating return to work goals into consumer treatment plans. Each MCO will be required to implement a standardized protocol to identify common BH risks in primary care settings, provide necessary education and brief intervention in order to facilitate referrals of individuals who screen positive to an appropriately credentialed and qualified BH provider. This includes but is not limited to selecting appropriate screening tools and establishing provider requirements to follow the established screening and referral protocols, including the Screening, Brief Intervention and Referral to Treatment (SBIRT) protocol. The MCO will collaborate with the ASO/MBHO and DMAHS to create a list of approved screening tools that are efficient to use and meet generally accepted standards for reliability (consistency of results) and two measures of validity: sensitivity (accuracy in identifying a problem) and specificity (accuracy in identifying individuals without a problem). E. NWD/SEP Data Flow New Jersey has embarked on a major redesign of its Medicaid management information system (MMIS). Once the MMIS is fully implemented, it will dramatically streamline the Medicaid eligibility business process, eliminate redundancies for both state and county 22

24 personnel, and provide real-time access to client data, status, and service utilization. The two major initiatives are the procurement for a new MMIS and a client eligibility system known as the Consolidated Assistance Support System (CASS). Medicaid Financial Eligibility System CASS will be the foundation for the NWD/SEP financial data flow. CASS will replace multiple obsolete applications within the Divisions of Family Development and Medical Assistance and Health Services. It will provide a full integrated system to: standardize financial eligibility and benefit calculations; provide real-time access to information and services; enable case management access to the applicant s information across multiple programs (including waiver programs for aging, disability, developmental, and mental health and addiction services); and data sharing. The GO Live target date for implementation is October Prior to CASS, DHS has created a work-around for eligibility for managed LTSS. ADRCNJ Website for LTSS In May 2012, the state announced it had established an ADRC in all 21 New Jersey counties. A new ADRC website was launched that includes an interface with the SAMS provider database (soon to include 4,000 aging and disability network providers); a library with thousands of national, state and local resources; multiple search options; and other consumer-friendly tools including Google translation and mapping features. The site is also Section 508 compliant for improved access to individuals with vision impairments. A workgroup comprised of representatives from the NJ Divisions of Aging Services (DoAS), Disability Services (DDS) and Developmental Disabilities (DD), and the Area Agencies on Aging (AAAs) worked for several months to develop the site along with Harmony and their website development partner, AGIS. The ADRC site offers a number of unique features as follows for consumers and aging and disability services workers that are not available on the other websites: Gives access to a database of national resources created and maintained by the AGIS Network; Provides read-only access to the SAMS database information posted on the ADRC website for agencies without SAMS; Has its information refreshed on a schedule set the by DoAS, and Ability to electronically request regular content updates and verification from providers. Intake, Level 1 Screen, and Level 2 Core Standardized Assessment In 2008, the DoAS bought an integrated client-tracking system from Harmony Information Systems, Inc. known as the Social Assistance Management System (SAMS). As of January 2012, over 1,000 associate users of the 21 AAAs and over 600 additional users of their contracted agencies were trained. As a web-based, client-tracking system, SAMS can support multiple departments, divisions and programs. The SAMS integrated 23

25 data system provides intake, consumer profiles, screen for home and community-based services (HCBS), functional assessment, case management, service planning and authorization, service utilization, and the federal reports required by New Jersey under the Older Americans Act. Data Flow for Behavioral Health Management Organizations The Administrative Service Organization/Managed Behavioral Health Organization (ASO/MBHO) will establish and maintain an MIS that allows the MBHO and its subcontractors to collect, analyze, integrate and report data on service utilization, service costs, claim disputes, appeals and clinical and financial outcomes. As relevant, the MIS must also meet Federal block grant reporting requirements. The ASO/MBHO also will establish and maintain electronic interfaces to: Send and receive information to and from the Divisions of Medical Assistance and Health Services (DMAHS), Mental Health and Addiction Services (DMHAS) including but not limited to eligibility data and timely, accurate encounter data submissions that meet all state and Federal requirements; Receive encounter data and information from subcontractors and providers after assumption of responsibility for claims administration; Send behavioral (BH) claims (as relevant) and physical health (PH) risk screening results to the appropriate MCO; Receive pharmacy claims, medical claims and BH risk screening results from the MCOs; Send and receive data and information to and from other agencies, as required (i.e., other child serving agencies to administer cross system collaboration and measure outcomes under the Children s System of Care); Adopt electronic health records (EHR) in use by the Children s System of Care, and Adhere to state and federal guidelines regarding the privacy and security of protected health information and confidentiality of client records. F. Automation of Initial Level 1 Screen Assessment Under the ADRC initiative, a work group researched, evaluated and selected an assessment suite developed by the University of Michigan (Michigan). The suite was tested in the two ADRC pilot counties, modified to meet New Jersey s regulations for nursing facility (NF) level of care and implemented statewide as the NJ Choice assessment suite. The suite, which was based upon the InterRAI MDS-HC assessment, is a nationally and internationally validated assessment tool. The suite includes: (1) minimum data elements for information and assistance (I&A) intake; (2) the Level 1 screen - screen for community services, a set of 20 clinical and 10 financial questions that ADRC specialists ask consumers over the phone to assess their potential need for long-term care support services, and (3) the Level 2 comprehensive clinical/functional assessment known as NJ Choice. 24

26 Michigan wrote an algorithm for the Level 1 screen that predicts the care needs of persons seeking long term care assistance. The algorithm is imbedded in the telephone screening instrument used by NJ ADRC screening professionals and predicts five "levels of care" that roughly correspond with the following care modalities: 1. Information and referral: the person needs assistance in securing information but does not need any formal (paid) services; 2. Homemaker: In order to help maintain his or her home, the person needs nonpersonal assistance, such as meals, housecleaning, transportation, etc.; 3. Intermittent personal care: the person can be cared for in a home or community based setting and requires minimal personal care (less than daily care or daily care for a single task, e.g., bathing.): 4. Home care: the person can be cared for in a home or community based setting but requires intensive skilled nursing care or therapy services (three or more times a week), minimal skilled nursing care or therapy services (one to two times a week), or intensive personal care services (daily assistance for multiple tasks.), and 5. Nursing Facility Level of Care: the person has extensive medical and personal care needs that require ongoing 24 hour care. The algorithm does not consider the informal care available to the individual, the person s ability to pay for services needed, the person s preferences for (or refusal of) specific care modalities, the specific formal care options available locally, or concerns about the ability of services to ensure the person s health and safety. The Division of Aging Services (DoAS) worked with the Harmony Information Systems, Inc. development team to computerize the intake and Level 1 screening tool into the SAMS application. The tool was tested in the ADRC pilot counties and is now operational in all 21 ADRCs. The state established a performance standard whereby those consumers who score from level three to five are offered the opportunity to have an assessor come to their home to conduct a clinical assessment and counsel them on the full range of HCBS. The ADRC computerized screening tool has proven to be an effective indicator of a consumer s need for home and community based services. When clinically assessed, 94 percent of those individuals who scored at level three or above on the screening tool were clinically determined appropriate for LTSS. Not only is the tool effective in targeting the appropriate individuals for home visits and assessments, but it is also an important means to help allocate state and county resources more efficiently and cost-effectively. G. Potential Automation of a Core Standardized Assessment During the past year Harmony Information Systems, Inc. worked with the Division of Aging Services (DoAS) to migrate the NJ Choice clinical assessment tool from a standalone database administered by DoAS to the Social Assistance Management System 25

27 (SAMS) database supported by Harmony. At this time, the modification is in the testing phase with a go live target date of June 30, By including the NJ Choice clinical assessment tool in SAMS, the DoAS and ADRC assessors will be able to use a single database to gain access to client demographic information, outcomes of level 1 screens and Level 2 comprehensive clinical assessments; and to track referrals to programs such as Medicaid services, Older Americans Act and state funded programs, and other home and community-based services for all expanded target populations. H. Incorporation of a Core Standardized Assessment (CSA) in the Eligibility Determination Process As background, the Division of Aging Services (DoAS) contracted with the University of Michigan (Michigan) to support use and interpretation of data from the interrai Minimum Data Set for Home Care version 2.0, known as the MDS-HC, for policy and program administration purposes. The DoAS asked Michigan to analyze MDS-HC records from persons applying either for home and community based services (HCBS) or nursing facility (NF) services under Medicaid. The New Jersey version of the MDS-HC is comprised of all the items in the standard interrai instrument as well as additional items identified by New Jersey. Thus, the New Jersey MDS-HC records are fully capable of producing a variety of standardized measures on an individual or population basis. These include: clinical assessment protocols (CAPs) to identify persons at risk for a variety of problems; scales to measure the individual s status in key domains such as cognition, functional capacity, pain, and depression; and measures of acuity/resource use that utilize the RUG-III/HC system. Michigan analyzed the outcomes of NF level of care (NF LOC) determination decisions. Prior to the UM analysis, DoAS staff had developed a scoring logic, or an algorithm, to interpret state NF LOC regulations (NJAC8:85-2.1). At that time, the NF LOC decision was a judgment by the individual assessor, informed by DoAS training on the particular MDS-HC items used in the decision logic. The goal of the analysis was to use the data from 19,093 Pre-Admission Screenings conducted by the DoAS assessors and develop the logic in the software used by OCCO assessors to enable implementation of evidence-based, objective NF LOC determination criteria. UM was asked to profile the characteristics of persons who would be deemed NF LOC eligible using the OCCO algorithm and to compare the outcomes of the algorithm logic with OCCO assessor judgments to see how accurately the two processes corresponded. Based on the dialogue with DoAS staff, Michigan then developed a flow chart to illustrate the interplay of the MDS-HC items with the scoring logic used in the NF LOC criteria. Upon approval of the flow chart, Michigan then programmed it as an algorithm and applied it to the MDS-HC records described above. 26

28 Michigan also created a profile of all NF LOC applicants from the New Jersey MDS-HC data. The profile was also applied to two sub-groups of interest: persons who had been judged by DoAS staff as NF LOC eligible and persons who had been judged as not NF LOC eligible. The profile s purpose was to enable a side-by-side comparison of key characteristics of each sub-group, including Activities of Daily Living (ADL) function, cognitive performance, acuity level, and health/mental health status. Due to the large size of the two sub-groups, almost any difference would be statistically significant. Therefore, the subsequent analysis utilizing data from this profile focused on substantial differences, defined as a +/- 5 percent variation between the two groups. Lastly, Michigan undertook a special analysis to identify the applicant characteristics that would best explain the underlying logic by which DoAS was deciding whether persons met the NF LOC criteria. In this analysis, Automatic Interactions Detections (AID), a statistical procedure, was used to create a classification system based on characteristics of persons in the sample that were related to their LOC eligibility. Thus, the AID classification system attempted to mimic the DoAS decisions. Findings One of the key advantages for New Jersey in adopting the MDS-HC is that it is a standardized assessment instrument with a strong research base. As a result, the research base can and should be used to inform policy. Based on the Michigan analysis, New Jersey NF LOC algorithm was amended to incorporate established scales with demonstrated reliability and validity without compromising the existing NJ LOC regulations. Finally the NJ Choice database was programmed based on the validated algorithm. Although discussions continue with Division of Developmental Disabilities, for the near term the Division will continue to use the ID/DD clinical assessment tool developed by the New Jersey Institute of Technology. As part of the transition to fee-for-service, various components of this tool will be merged into a single assessment that will determine both eligibility and the functional limitations relevant to service planning. I. Staff Qualifications and Training In preparation for the implementation of the Comprehensive Medicaid Waiver (CMW), the Department of Human Services (DHS) created an interdivisional workgroup on case management to develop guiding principles, staff qualifications and training, requirements, frequency of outreach, and case weights and caseload. In regards to care management and clinical assessors qualifications, the following criteria were established: Licensed or Certified Social Worker, NJSA 45:1-15 OR Licensed, Registered Nurse, NJSA 45: 11-26, OR Graduate from an accredited college or university with a Bachelor s degree, or higher, in a health related or behavioral science field, with 1,600 hours (46 weeks working 35 hours per week) of paid work or internship experience (non-volunteer) with the elderly or physically disabled in an institutional or community setting. 27

29 J. Location of SEP Agencies With 8.8 million residents, New Jersey ranked as the 11 th most populous state in the 2010 Census. New Jersey is also the fifth smallest state in terms of land area. These factors combined give New Jersey its ranking as the most densely populated U.S. state with 1,195 persons per square mile. The 21 county-based Area Agencies on Aging (AAAs) serve as the lead organizations and are responsible for establishing the ADRC partnership. The partners must minimally include the following: county government officials and social service heads, the 21 county welfare agencies (CWAs), the 16 offices on disability services, the 12 Centers for Independent Living, State Health Insurance Assistance Program (SHIP) coordinators, state and county veteran services offices, hospital systems, senior centers/nutrition sites, home care agencies and other access points. New Jersey s decision to modify the national branded ADRC name from Center to Connection reflects the state s approach to the ADRC that New Jersey s ADRC is not limited to a specific site, but rather is accessed through the coordinated network of the county s ADRC partners. Every AAA office serves as a site where consumers can come to the center for information, screening, options counseling and linkages to appropriate community-based services. As required by the State Unit of Aging policies, the AAA s offices must be located in an area that is accessible for walk-ins, by car, and if possible by mass transportation. Consumers can also get assistance through the ADRC partners offices such as the county welfare agencies, senior centers/nutrition sites, and county offices for the disabled, and Centers for Independent Living. K. Outreach and Advertising Key to the future success of the NWD/SEP system under the BIP will be the ability for New Jersey to publicize and promote the ADRC as its NWD/SEP. It is through increased awareness of the ADRC as the visible, trusted and consumer-friendly connection to long term services and supports (LTSS) that will help drive the balancing of the state s public long-term care expenditures. While traditionally services for older adults have been administered separately from those for people with disabilities, the ADRC changed this paradigm in New Jersey beginning in 2003 by serving persons with physical disabilities an outcome that will be further expanded with the move to managed LTSS under the Comprehensive Medicaid Waiver (CMW). Indeed, the ADRC is expected to become the NWD/SEP for all consumers to access managed LTSS, including seniors as well as people with disabilities and people who need access to community based mental health and addiction services. 28

30 With increased awareness and visibility of the ADRC, New Jersey will develop and implement new strategies that align with the BIP and its requirements. The state s strategy will ensure that the ADRC reaches hard-to-serve and underserved target populations, that it is culturally and linguistically competent, increases the community s knowledge of public and private pay LTSS and empowers consumers to make informed decisions. New Jersey will primarily use these methods to advance the ADRC as the NWD/SEP: In-House Communications As all of the state s LTSS are housed in the Department of Human Services (DHS), the department s public relations efforts can be directed at advancing the ADRC as the NWD/SEP through its regular channels. For example, the ADRC can be promoted as the NWD/SEP for the entire department and also publicized separately by the Divisions of Aging Services (DoAS), Developmental Disabilities (DDD), Disability Services (DDS), Medical Assistance and Health Services (DMAHS), and Mental Health and Addiction Services (MHAS). The in-house Communications Team is responsible for the department s publicity efforts, including printed materials, social marketing, website and public service announcements. Education and Training With the rollout of managed LTSS, the state will give presentations and trainings to interested parties, ranging from state legislators to managed care organizations (MCOs), Program of All-Inclusive Care for the Elderly (PACE) programs and providers regarding the changes and then periodic updates as necessary. If the ADRC is to serve as the NWD/SEP for consumers to access managed LTSS, the ADRC partners need to be trained so that individuals receive accurate and timely information on LTSS regardless of their first point of entry into the system. A key element in the state s outreach plan under the BIP is to train and certify community professionals on ADRC options counseling standards and the NJ Choice assessment tool. Resource materials must be developed for usage by the ADRC partners so that the same messages are provided on managed LTSS regardless of the entry point. An options counseling manual, training curriculum and certification process with written materials for state staff, the MCOs, PACE programs and long-term care industry providers will reinforce the NWD/SEP. Linkages to Stakeholders The state will also rely on the strength of its strong relationships with stakeholder groups to promote the ADRC as the NWD/SEP for New Jersey under the BIP. In the development of the application for the CMW, the state had conducted an extensive process for public input and held special meetings of the DMAHS Medical Assistance Advisory Council (MAAC) and the Managed Long Term Services and Supports (MLTSS) Steering Committee. Furthermore, the final recommendations of the MLTSS Steering Committee dated June 25, 2012 called for the establishment of the ADRC as the NWD/SEP for managed LTSS. 29

31 Interested stakeholders groups and advocates include but are not limited to the New Jersey Hospital Association, Health Care Association of NJ, Managed Care Organizations, Legal Services of New Jersey, New Jersey Association of Mental Health and Addiction Agencies, National Alliance on Mental Illness, ARC of NJ, Alliance for the Betterment of Citizens with Disabilities, NJ Association of Community Providers and the AARP. These groups need to be kept engaged and used as a platform to reach their audiences on the ADRC as the NWD/SEP. L. Funding Plan The transformation of New Jersey s Medicaid program into a managed care system for LTSS under the five-year Medicaid Section 1115(a) demonstration presents a new funding opportunity for supporting the development of the NWD/SEP system as required under the BIP. For New Jersey, the additional funding will be derived from increased Federal Financial Participation (FFP). New Jersey s ADRC, which was been underway since 2003, has evolved into the NWD/SEP statewide for aging residents and individuals with disabilities to get information or referrals, submit applications and receive certain services. Historically, services for older adults have been administered separately from those for people with disabilities. The ADRC, however, has changed this traditional path and the shift to managed LTSS in the Comprehensive Medicaid Waiver (CMW) will further define it. At the core of each ADRC remains the local county-based AAA whose role has expanded since their original creation under the Older Americans Act in A mainstay of the work at the 21 AAAs/ADRCs now and in the future entails outreach and educational activities to ensure individuals know about the array of LTSS available to delay or eliminate the need for institutional care financed under Medicaid. As a result, the Department of Human Services (DHS) plans to apply for Medicaid administrative federal match funding for the ADRC functions of NWD/SEP. The AAAs/ADRCs are performing the functions that are necessary for the efficient and effective administration of Medicaid and are entitled to receive FFP from the federal government for the associated administrative costs. Furthermore, the CMW seeks FFP for approved AAA/ADRC activities and functions that assist consumers seeking managed LTSS. A plan will need to be created to identify the specific functions and costs the AAAs/ADRCs will assume, including the qualifications of those performing the function and the data to be collected as documentation. To support New Jersey s move to managed LTSS under the CMW, the AAAs/ADRCs will be expanded to serve as the NWD/SEP for the full array of Medicaid and non-medicaid LTSS beyond its current target population of aging residents and individuals with disabilities. And the DHS will rely on the AAA/ADRC network to assist individuals in accessing LTSS, including individuals served by its Divisions of Developmental Disabilities and Mental Health and Addiction Services. 30

32 As a NWD/SEP, the AAA/ADRC partnership will assist consumers with accessing LTSS, including these responsibilities: Gives access to a database of national resources created and maintained by the AGIS Network; Conducting screening for potential eligibility; Providing initial and ongoing options counseling on full range of long term services and supports including MLTSS;Helping consumers in completing the Medicaid application; Tracking the status of clinical and financial determination, and Ensuring that information is available to consumers via internet in understandable/accessible format. In order to receive Medicaid administrative match for AAA/ADRC functions, the DHS must develop a cost allocation for each county. There must also be a formalized memorandum of understanding between the DHS and the AAA/ADRC partnerships. The AAAs/ADRCs are slated to play a pivotal role in the implementation of the managed LTSS under the CMW. The NWD/SEP is instrumental to the success of New Jersey s efforts in balancing long-term care expenditures away from a reliance on institutional care as required under the BIP. M. Challenges New Jersey is on the verge of reforming its Medicaid long-term care system as a result of federal government approval of the Comprehensive Medicaid Waiver (CMW). Among 31

33 other reforms, the Waiver includes the move to managed care for long-term services and supports (LTSS), increased flexibility so that seniors at risk of nursing facility (NF) placement can choose the home and community-based services (HCBS) they need and live where they prefer as well as expanded support services for people with intellectual and developmental disabilities and enhanced access to community-based mental health and addiction services. Other states experiences suggest that managed long-term care in a capitated framework can significantly impact cost and shift care to HCBS. All the CMW s components will support an increase in New Jersey s community LTSS spending. The move to managed LTSS, however, offers New Jersey s greatest opportunity to drive balancing of its long-term care expenditures by providing access to more services, delaying or eliminating the need for care in a facility and focusing on preventive and inhome care. Yet it presents some systemic challenges due to a new payment system, service delivery system, and quality oversight process and outcome measures. Additionally, these systemic challenges for New Jersey need to be set against other nationally recognized barriers to community living, including the availability of a stable workforce of home care providers and direct care workers in the long-term care field and accessible, affordable housing. Under managed LTSS, New Jersey s long term care industry will move from a fee for service (FFS) payment system to a managed care environment. Managed care organization (MCO) providers and Program of All-Inclusive Care for the Elderly (PACE) programs include HCBS, NFs, specialty nursing facilities, assisted living facilities, longterm care pharmacies an industry that currently serves about 40,000 Medicaid-eligible beneficiaries with chronic or disabling conditions of which approximately 27,000 are in nursing homes. Between July through October 2011, New Jersey s aged, blind and disabled populations and dual eligible individuals were required to move into managed care, but this change didn t include LTSS. Under the CMW, New Jersey will add NFs and HCBS to managed care contracts for Medicaid-eligible individuals who meet a nursing home level of care. In New Jersey s managed LTSS delivery system, there are three types of managed entities to administer HCBS and facility-based long term care: the MCO, for administering acute, behavioral and managed LTSS; the Dually Eligible Special Needs Plans (D-SNP) for those eligible for Medicare and Medicaid, with the former as the primary payer; and PACE, which currently operates from four licensed facilities in New Jersey. PACE facilities receive a blended capitated rate to provide for physical health and at-home services and assume the risk for hospital and nursing home care if and when those services are necessary Each of the aforementioned delivery systems will be responsible for coordinating LTSS for the 40,000 Medicaid eligible beneficiaries. They will need to provide a menu of service options across beneficiary groups or care settings, coordinate providers and 32

34 community based services and supports, and enhance the ability of their beneficiaries to live as independently as possible in the community. New under managed LTSS, the state is exploring opportunities with the nursing home industry to implement policies and programs to ease the effects of transition and diversion of individuals from NFs. Concurrently, the MCOs will be required to develop and implement a NF diversion plan, which will help individuals most at risk for NF placement; and a nursing home to community transition plan, to safely transition NF residents into the community. The CMW, furthermore, impacts behavioral health (BH) services funded by the Division of Mental Health and Addiction Services (DMHAS). It integrates behavioral health and primary care, supports community alternatives to institutional placement, braids federal and state funding streams, provides opportunities for rate balancing, increases the focus on the Work First NJ Substance Abuse Initiative and consumers with developmental disabilities, and implements a managed care behavioral health system (ASO/no-risk into MBHO/risk-based). Implementation of the CMW provides for integrated care for consumers with co-occurring substance abuse and mental health issues as well as for consumers with BH and physical health (PH) concerns. It offers an opportunity for rate balancing, increased federal financial participation, as well as to expand services for consumers with substance abuse dependence in accordance with parity requirements. Meanwhile there is an opportunity for reinvestment of some savings as a result of an increase in reimbursement for HCBS as opposed to acute care services. Ultimately the new system will result in better access, enhanced quality and improved outcomes for consumers of BH services. Some of the innovations of the new BH system will include: uniform screening and level of care determination, tiered-care management, the creation of division-funded behavioral health homes, consumers with developmental disabilities and consumers in the WorkFirst NJ-Substance Abuse Initiative (WFNJ-SAI). Some of the specific populations/initiatives are described below. BH Homes The DMHAS, in coordination with the Division of Medical Assistance and Health Services, is developing a Medicaid State Plan Amendment for BH Homes. This initiative will enable greater coordination of BH and PH care for individuals with serious mental illness and a substance use disorder and one other chronic physical health condition, or co-occurring mental health and substance abuse disorders. Health Home services include bidirectional behavioral health and primary care screening, identification, services and/or referrals and linkage for consumers. Consumers with Developmental Disabilities Individuals with Intellectual/ Developmental Disabilities and Mental Illness and Substance Use Disorders will receive BH Services through the BH ASO. Currently the BH benefits for this population are carved into the Medicaid managed care plan. The ASO will manage the BH Services (hospital stays and the services of licensed BH health care 33

35 professionals who are identified in the State Plan) and BH State Plan Rehabilitation Services for this population. DMHAS, DDD, DMAHS are planning to develop a specialized or preferred provider network to treat individuals with I/DD and MI. The need for improved BH-PH coordination must be balanced with the need to introduce managed care technologies that go beyond basic utilization review of higher levels of care to incorporate care management protocols for the populations with Serious Mental Illness (SMI) or serious emotional disturbance (SED). In addition, many individuals who are not currently eligible for Medicaid receive critical BH services through state-only funds, federal block grant dollars or other resources. Some of these individuals will become eligible for Medicaid under health care reform measures in Under the CMW, however, the state plans to braid non-medicaid funding streams with Medicaid funds to develop a more integrated system of care with an eye toward meeting the BH needs of the Medicaid expansion population in These initiatives occur within the context of a recent merger of the Divisions of Mental Health Services (DMHS) and Division of Addiction Services (DAS) to support the integration of care. They include reviewing rate structures to improve consistency and competitiveness of reimbursement rates across funding streams with the overall goal of adequate access to appropriate services. This merger also provides an opportunity to build a combined system that provides best practice treatments for individuals with cooccurring mental illness and substance use disorders. The management of SMI and SED populations, the use of medication to enhance treatment of substance use disorders, integration of mental health and substance use disorder services and braided funding requires specialized expertise, tools and protocols inconsistently found within most medical plans. Introducing managed care technologies through contracting with an ASO or an MBHO has been associated with improved access, better monitoring of quality outcomes, and an improved distribution of services across the entire care continuum. Examples include both full risk and non-risk arrangements. In FY2010, over 40,000 child/adolescent consumers with SED and multi-system involvement access BH care through New Jersey s Children s System of Care (CSOC) administered by an ASO contractor with claims payment continuing to be administered through the state s fee-for-service MMIS. In place since 2002, this program has made substantial progress in expanding access and improving outcomes while managing costs. Under the CSOC, utilization has shifted to more HCBS and allocation of resources has been better matched to level of need. In addition, coordination of care across child serving systems including education, child welfare and juvenile justice has been a priority under the CSOC. Given that over 50 percent of youth with SED are also involved with child welfare services, specialized BH expertise to maintain this connection is vital. Furthermore, the implementation of managed LTSS will require the state to submit to the Centers for Medicare and Medicaid Services (CMS) an integrated Quality Improvement (QI) strategy which builds upon existing managed care quality requirements. Meanwhile the MCOs and PACE programs will be required to establish methods for discovery, remediation and systems improvement and per the state s prescribed timeframes, 34

36 regularly report on outcomes associated with continuous QIs. The state will provide oversight of this process and submit its QI strategy to CMS for approval before implementation of the managed LTSS program. Then the state will annually provide information to CMS regarding its QI activities. The state also needs to establish the baseline and ongoing long-term care data appropriate for managing programmatic trends under managed LTSS. These systems will be in place to record the requisite data elements before implementation and then quarterly and annually throughout the demonstration of the Comprehensive Medicaid Waiver. Such baseline data ranges from collecting and submitting to CMS the number of persons actively receiving home and community based services versus those receiving nursing home care to the unduplicated numbers of persons receiving home and community based services and nursing home services during a 12-month period, and the number of persons transitioned from nursing homes to home and community based services during a 12-month period. N. NWD/SEP s Effect on Balancing The ADRC initiative is a catalyst for balancing long-term care in New Jersey. The Division of Aging Services (DoAS) Medicaid 1915(c) Waiver, known as Global Options for Long-Term Care (GO) with a focus on community residents and consumer direction has been integral in the ADRC model. Consumers are informed about appropriate longterm care options and based on their eligibility criteria, they are counseled on appropriate home and community based services (HCBS). The ADRC s achievements are significant to date. As previously mentioned New Jersey signed into law the Independence, Dignity and Choice in Long-Term Care Act (Act) in 2006 to create a process to reallocate Medicaid long-term care expenditures for older adults and persons with physical disabilities and develop a more appropriate funding balance between nursing home care and other HCBS. The state is now charged in balancing its Medicaid long-term care system to include more HCBS and greater consumer choice, and ensure that money follows the person, allowing maximum flexibility between nursing homes and HCBS settings. The Act specifically required the commissioners of the former Department of Health and Senior Services and DHS, together with the State Treasurer, to create budgetary processes for expanding HCBS within the existing budget allocation. According to the Act, for the State fiscal years 2008 through 2013, funds equal to the amount of the reduction in the projected growth of Medicaid expenditures for nursing home care (state dollars only), plus the percentage anticipated for programs and persons that would be eligible to receive federal matching dollars, need to be reallocated to HCBS. The state engaged Mercer Government Human Resources Consulting (Mercer), a part of Mercer Health & Benefits LLC, to create a budget balancing model to track the DoAS and DDS waivers, Adult Day Health Services (MD), Personal Care Assistance (PCA) and nursing facility (NF) expenditures, and project future long term care expenditure as was detailed in the Act. 35

37 The purpose of the model is two-fold: 1. To estimate the state and federal budgets for waivers and direct care costs that fall under the responsibility of DoAS and DDS, and 2. To quantify the impact of the Act by estimating the cost savings of the balancing efforts made by the state by redirecting Medicaid clients from NFs to HCBS. Based on the tenets of the Act, the first and most important graph in the model illustrates the reduction in the projected growth of Medicaid expenditures from moving or diverting clients from a nursing home into HCBS. For the purposes of the model, July 1, 2007 (State Fiscal Year 2008) is the date cited in the Act that the state had to begin measuring cost savings. Balancing the state s long-term care budget can also be estimated by determining what would have been spent if the Act had not been passed. The budget projection model calculates historical and projected savings as a result of balancing efforts. In the chart below, the Act Induced lines represent the total cost of nursing facility and HCBS services respectively after the passage of the Act. The non-legislative lines represent what might have happened had the Act not been passed. The nursing facility savings are derived by calculating the difference between the NF costs had the Act not passed (non-legislative) and the nursing home costs due to the Act. The difference between the Act Induced HCBS costs and non-legislative HCBS costs are then subtracted from the nursing facility savings to arrive at projected net savings due to balancing. As a result, the reduction in the projected growth of Medicaid expenditures (state and federal dollars) for long term services and supports (LTSS) for the state due to its balancing efforts can be seen in the graph on the next page: 36

38 State/Federal Balancing Calculation $200,000,000 $180,000,000 $160,000,000 $140,000,000 $120,000,000 $100,000,000 $80,000,000 Act Passed $60,000,000 $40,000,000 GO Launched $20,000,000 $- Apr-12 Jan-12 Oct-11 Jul-11 Apr-11 Jan-11 Oct-10 Jul-10 Apr-10 Jan-10 Oct-09 Jul-09 Apr-09 Jan-09 Oct-08 Jul-08 Apr-08 Jan-08 Oct-07 Jul-07 Apr-07 Jan-07 Oct-06 Jul-06 Apr-06 Jan-06 Oct-05 Act Induced HCBS Act Induced NF Non-Legislative HCBS Non-Legislative NF Based on the Global Budget Projection model, the Act s impact has been positive on the state s fiscal situation if one considers the potential costs of long-term care without any balancing activities. Looking at historical and projected savings resulting from balancing activities, in federal and state dollars combined, New Jersey saved a total of $99,003,741 in 2010; in 2011 $68,728,929 is the projected savings and for 2013 the projected savings is $111,011,789. At this point in time the state s public HCBS expenditures are increasing minimally as a percentage of the total long-term care Medicaid expenditures. The Global Budget Projection model shows definite cost containment of $442,721,077 (combined federal and state funds) over five years ( ). Another way to measure the effectiveness of the state s balancing efforts according to the Act is to calculate the percentage of total spending among the different long term care services. If balancing efforts are working, then the percentage of nursing home spending should decrease over time with a corresponding increase in HCBS spending, including waiver, Adult Day Health Services (MD) and Personal Care Attendant Services (PCA). Again based on the Act, data from SFY2007 was used as the baseline, while data from SFY2009 was used to measure change. As additional counties migrate to the ADRC model, the balancing projections will change as well. Addressing the imbalance in New Jersey s long-term care budget which currently favors nursing home care remains a large part of the solution in the context of the State s long-term care reform agenda. Although cost containment will be compounded by 37

39 the aging of the baby boom generation, New Jersey is moving steadily and purposefully in the right direction. Table I shows the count of people, by county, served through the GO Waiver in each calendar year since It is clear that the GO Waiver is expanding throughout the state. By providing less-costly HCBS to its members, the GO Waiver helps to keep the cost of the state s overall long-term care program down. The growth in this program is one of the major drivers of the state s recent success in balancing the long-term care program. *Decrease due to an Adult Foster Care provider agency withdrawing from Medicaid. All GO participants were relocated to assisted living facilities adjacent to Cumberland County. I GO Waiver recipients by county, County Change in recipients 2007 to 2010 Percentage change 2007 to 2010 Atlantic % Bergen % Burlington % Camden , % Cape May % Cumberland (10)* -2% Essex % Gloucester % Hudson , % Hunterdon % Mercer % Middlesex % Monmouth 1,140 1,141 1,106 1, % Morris % Ocean 995 1,077 1,033 1, % Passaic % Salem % Somerset % Sussex % Union % Warren % Total 10,789 11,324 11,257 13,573 2,784 21% In SFY 2007, 45 percent of member months for clients receiving long-term care services were classified as nursing facility based on the model s algorithm, while 13 percent were 38

40 classified as long-term care waiver. In SFY 2009, however, the percentage of members classified as nursing facility had decreased to 43 percent, while the percentage of members classified as waiver had increased to 14 percent. This continued into SFY 2010, as the percentage of members classified as nursing facility had decreased even further to 41 percent, while the percentage of members classified as waiver had continued to increase to 15 percent. This trend is indicative of more clients being directed to and opting for home- and community-based settings for their care. As discussed earlier, the nursing facility, MD and PCA populations are determined based on claim activity. As a result, the SFY 2010 numbers may change as more claims come in. This data includes claims paid through January There has been a strong effort on the part of the state to provide waiver services to the new long-term care members. While all HCBS services have seen growth (as exhibited in Table I), the waiver programs have shown continued and substantial growth since their inception. From SFY 2009 to SFY 2010, the waiver membership grew by over 15 percent. As the data in Table II below indicates, there was a lower but still significant growth of 6.7 percent when all HCBS related member months are combined. Table II Long-term care classification by SFY Service SFY 2007 SFY 2009 SFY 2010 Nursing Facility 369, , ,877 Medical Day Care 121, , ,732 Personal Care Assistant 220, , ,145 Waiver Services 104, , ,069 Total 815, , ,823 One item that may have influenced the slow (or negative) growth of nursing facilities is that there was no rebasing done for the nursing facility rates in SFY 2009 or SFY Additionally, in SFY 2010 inflation was not applied to the nursing facility rates. While these factors directly impact the overall costs, utilization of nursing facilities also fell. The change in utilization is the main driver of the cost decrease. Table III Long-term care spending by member classification and SFY Service SFY 2007 SFY 2009* SFY 2010* Nursing Facility $1,733,000,000 $1,872,000,000 $1,805,000,000 Medical Day Care $209,000,000 $255,000,000 $253,000,000 Personal Care Assistant $256,000,000 $268,000,000 $279,000,000 Waiver Services $162,000,000 $205,000,000 $257,000,000 Total $2,360,000,000 $2,600,000,000 $2,594,000,000 *Note that there was no rebasing of the nursing facility rates in SFY 2009 or SFY

41 At this time, the most complete data available to support the budget projection model is for the two original ADRC pilot counties, Atlantic and Warren. These two counties have showed marked improvement in HCBS penetration. In Atlantic County, nursing home (NF) costs decreased from 79 to 73 percent, while HCBS waiver costs increased from 9 to 13 percent as seen in the following graph. Alantic County LTC Cost Dist 90.00% 80.00% 70.00% 60.00% Percentage of Cost 50.00% 40.00% 30.00% NF MD PCA WV 20.00% 10.00% 0.00% State Fiscal Year 40

42 In Warren County, the change was even more pronounced, as nursing home (NF) costs decreased from 91 to 83 percent. In addition, Waiver costs, including the Global Options (GO) waiver, increased from 4 to 11 percent. Warren County LTC Cost Dist % 90.00% 80.00% 70.00% Percentage of Cost 60.00% 50.00% 40.00% NF MD PCA WV 30.00% 20.00% 10.00% 0.00% State Fiscal Year The Global Options (GO) Medicaid waiver budget has thus far supported the increase in waiver members and the model is currently constructed to take recent enrollment changes into account without regard for factors such as enrollment caps. As the state moves forward with the Comprehensive Medicaid Waiver, the basis for these projections will change. O. Other Balancing Initiatives The BIP will be another resource in New Jersey s tool kit to support balancing long term services and supports (LTSS). Balancing is a goal to which New Jersey has been working towards for over 25 years to enable people of all ages to live outside of institutions through the administration of services and activities in the most integrated settings. New Jersey is committed to balancing on all levels as evidenced by its past and present activities. The move to managed LTSS through the Comprehensive Medicaid Waiver (CMW) supports seniors and peoples with disabilities desire to work and live in their communities for as long as possible. Major components include the expansion of home and community based services (HCBS) to any qualifying Medicaid-eligible enrollee and a removal of the current Medicaid bias towards institutional care. This reform to New Jersey s Medicaid system should prove to be among the most important pieces of the state s balancing efforts and critical to the state achieving its objectives as defined under the BIP. 41

43 But the Department of Human Services (DHS) has been dedicated since the 1990s to increasing LTSS and moving away from institutional care as required by the Supreme Court s 1999 Olmstead decision. This core value is exemplified in the administrative and fiscal oversight provided by the Division of Medical Assistance and Health Services (DMAHS). It is also evident in the balancing progress exemplified by its sister Divisions of Developmental Disabilities (DDD), Disability Services and Mental Health and Addiction Services (DMHAS) and the Division of Aging Services (DoAS), which until July 1, 2012 was in the Department of Health. As the single state agency for Medicaid, the DHS had historically worked collaboratively with its sister state agency the Department of Health and Senior Services to administer many programs and services to the aging population. With the restructuring as part of the State Fiscal Year 2013 budget, all federal- and state-funded services and supports for seniors are now coordinated in the DHS. The benefits for this move were very much highlighted during the discussions and design of the Comprehensive Medicaid Waiver (CMW). This move to managed long-term care will reduce duplication of services, streamline a complex network of health and social support providers, and prevent unnecessary placement in nursing homes all activities in support of accelerated balancing. Division of Developmental Disabilities (DDD) Since 1990, the DDD decreased the number of people served in its seven (ICF-MR) Developmental Centers by 53 percent or 2,721 people from 5,110 to 2,389 (Sept. 30, 2012). Beginning in 1999, DDD increased the number of people served in the community by 89 percent from 23,174 to 43,841; and home and community based waiver participants increased by 56 percent from 6,635 to 10,375. DDD s blueprint for these efforts was put forth in its strategic plan New and Expanded Options for Individuals with Developmental Disabilities and their Families. While adopting a philosophy of person-centered planning, DDD provided more options for self-direction through a series of budget initiatives that increased state resources for HCBS. Administrative practice changes were accompanied by the creation of a more efficient, automated infrastructure for claiming federal match for state-funded services. The Governor and the Legislature supported these efforts, facilitating the reinvestment of new revenues to further expand home and community based services. Balancing will be furthered by the upcoming closures of two developmental centers. In addition to transitioning over 500 consumers to community residences, the closures will generate state savings that will be reinvested in community services and supports. Division of Mental Health and Addiction Services (DMHAS) In 2006, the DMHAS initiated its recovery-oriented, community service model. This new direction resulted in an additional $80 million in state funding and a dramatic expansion of community services that began then and is planned to continue through at least SFY2014. Between SFY2006 and 2009, these funds were responsible for 938 new community placements. Since the Olmstead settlement agreement was signed in 2009, the DMHAS has developed 734 housing options for individuals diagnosed with a mental illness, expanding housing options for mental health consumers in all 21 counties. The 42

44 DMAHS has implemented an array of evidence-based practices to support individuals in the community and continues to explore and pilot innovative programs. In addition, the regional state psychiatric hospitals were redesigned within this community-based context. All hospitals have admission units that provide treatment and return individuals to the community without requiring longer-term hospitalization. Each of the hospitals have developed treatment malls, whereby increasing the availability of active treatment for individuals in the state psychiatric hospitals. Treatment malls offer programming choices and individuals in conjunction with their treatment team can select areas of interest based on their treatment goals, strengths and areas for improvement. The census at the regional state psychiatric hospitals was reduced by 661 (32 percent) from the July 2006 census of 2,111. As a result of its compliance with the Olmstead Settlement Agreement, DMHAS was able to further decrease its census by June 30, 2012 and allowed for the responsible closure of the Senator G.W. Hagedorn State Psychiatric Hospital (Hagedorn). Some of the savings resulting from Hagedorn s closure has been reinvested to expand community services such as supportive housing, outpatient services, supportive employment and the development of diversion programs offering treatment, stabilization, referral and linkage services for individuals with BH needs who are high utilizers of the ED and Emergency Psychiatric Screening services. During FY 2010, there were approximately 60,000 Medicaid adult consumers and 40,000 Medicaid child/adolescent consumers who accessed Behavioral Health (BH) care through the fee-for-service (FFS) system. BH care for adult consumers and children s services under FFS was fragmented and largely unmanaged, with an over reliance on institutional rather than HCBS. These same individuals receive their medical care through one of four managed care organizations (MCOs), with very limited or no formal protocols for coordination between the medical and BH delivery systems. Under this scenario, the risk is greater that BH needs go unidentified and that consumers receive suboptimal BH care in primary care settings. Untreated or suboptimal treatment of BH conditions has long been associated with lower adherence to prescribed medical treatment, higher medical costs, and poorer health outcomes. In particular, adults with mental disorders have a twofold to fourfold elevated risk of premature mortality 1 largely due to poorer primary health status, not accidents or suicides. There is growing evidence as to the effectiveness of interventions to address the need for BH-PH coordination. Given that for Medicaid s highest cost adult beneficiaries, approximately two-thirds have a mental illness and one-fifth has both a mental illness and substance use disorder, the opportunity for improved clinical and financial outcomes through improved BH-PH coordination is strong. While there is still a need in New Jersey for long-term care provided in the state psychiatric system, the decline in the hospital census, both current and anticipated, 1 Steven S. Sharfstein, M.D., Editorial, American Journal of Psychiatry, (November 2011). 43

45 allows for a redistribution of resources that will advance community integration for mental health consumers while generating budgetary cost savings. Independence, Dignity and Choice in Long-Term Care Act Meanwhile the Independence, Dignity and Choice in Long-Term Care Act (Act), which was signed into law in 2006, called for a process to reallocate Medicaid long-term care expenditures and develop a more appropriate funding balance between nursing home care and other HCBS. The trajectory of balancing New Jersey s long-term care system is moving in the right direction as is seen in the Global Budget Projection model produced by Mercer Government Human Services Consulting. It is important note that the following captured long-term care expenditures pertain to services provided through the former Division of Aging and Community Services (now the Division of Aging Services) and the Division of Disability Services: From State Fiscal Year 2009 to 2010, enrollment in nursing homes decreased while participation in home and community-based services (HCBS) increased. With the increasing proportion of individuals utilizing HCBS, the cost of long-term care per-member-per-month (PMPM) is decreasing. In SFY 2010, nursing facility expenditures accounted for 70 percent of total longterm care expenditures, down 3 percent from SFY As part of the Act, the Medicaid Long-Term Care Funding Advisory Council has been meeting regularly since then to provide input on this process to rebalance the allocation of funds for the expansion of home and community based services. Their recommendations have helped shape policy direction and service delivery on the path to long-term care funding equity. There are 12 public members and three ex-officio designees from the Departments of Human Services, Health and Treasury. And with the advent of managed LTSS under the Medicaid Comprehensive Waiver, the Council has been tapped to solicit specific input for consideration during the program s development and implementation. The reconfigured Managed Long Term Services and Supports Steering Committee is comprised of the Council s membership, managed care organizations and consumers all who have a New Jersey stake in balancing LTS. Besides the new Global Budget Projection model, the DoAS implemented a new data system, consumer assessment instrument and quality management system in support of balancing. Because there was no state funding attached to the Act, the Division of Aging and Community Services and its partners at the DHS worked to secure all possible federal funding opportunities offered by the Centers for Medicare & Medicaid Services and the U.S. Administration on Aging. They include the ADRC grants, the Veterans Directed Home and Community Based Services Program, the Nursing Home Diversion Modernization Grants to the Real Choice Systems Change Grants for Community Living, and the Sustainable Systems Grant. Money Follows the Person Rebalancing Demonstration New Jersey has participated in the Money Follows the Person (MFP) Rebalancing Demonstration since 2007 when it was awarded a grant of approximately $14 million and 44

46 in May 2012 received a supplemental grant award in the amount of about $18 million for a total of $32 million. It represents a collaboration of four divisions in the Department of Human Services Aging Services, Disability Services, Developmental Disabilities and Medical Assistance and Health Services plus the Office of the Ombudsman for the Institutionalized Elderly. MFP is assisting the state in setting a process for moving longterm institutional residents into the community. To date, New Jersey has transitioned 527 individuals: 199 from developmental centers and 328 from nursing homes. The savings to New Jersey as a result of the MFP enhanced match funding is being used to support initiatives critical to the transition process and therefore essential to advance New Jersey s balancing efforts. Such initiatives include the following: Gives access to a database of national resources created by the AGIS Network; Workforce development efforts to Direct Support Professionals in long-term care settings; Capital costs (acquisition and/or rehabilitation) for new development of fourperson group homes to serve individuals leaving developmental centers; Maintenance of an MFP Outreach and Marketing campaign coordinated by the Office of the Ombudsman for the Institutionalized Elderly; Improvements in long-term care quality systems through oversight activities, and Development and distribution of materials for public information on home and community based service options. P. Technical Assistance New Jersey plans to take advantage of the technical assistance (TA) afforded by the BIP in accordance with Section of the Patient Protection and Affordable Care Act from the Centers for Medicare & Medicaid Services (CMS). During this period and beyond, New Jersey will also be operating a statewide reform effort that will expand existing managed care programs to include managed long term services and supports (LTSS) and expand home and community based services (HCBS) to some populations. Through the federal government s approval of the Comprehensive Medicaid Waiver, the state is be better positioned to serve more individuals with HCBS and meet the BIP s conditions. It is within the context of the BIP coupled with New Jersey s move to managed LTSS that the state would best benefit from TA. With regards to the BIP s structural changes, data collection and reporting requirements, New Jersey will use CMS TA to ensure that the state meets the program s mandate. It is in New Jersey s best interest to benefit from the nation s best practices and lessons learned in terms of increasing access to non-institutionally based LTSS. First, it will be important to receive guidance on developing the state s work plan for the BIP prior to implementation. 45

47 Attachment B DEPARTMENT OF HEALTH & HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES BALANCING INCENTIVE PAYMENTS PROGRAM (Balancing Incentive Program) APPLICANT FUNDING ESTIMATES LONG TERM SERVICES AND SUPPORTS State Agency Name Quarter Ended Year of Service (1-4) Home Health Services Home and Community PACE Personal Care Services Targeted Case Management Private Duty Nursing - EPSDT Medical Day Care Personal Care IADLs Personal Care Health-Related Personal Care Adult Companion Personal Care PERS Pers. Care Assistive Technology Habilitation Day Habilitation Behavioral Habilitation Prevocational Hab. Supported Employment Hab. Educational Services Respite Care Day Treatment / Partial Hosp. Psychosocial Rehabilitation Clinic Services Other HCBS Services Health Homes CFC LTSS Money Follows the Person* Total Service Expenditures NJ State FMAP Rate 50.00% DHS Extra Balancing Incentive Program Portion (2 or 5 %) 2.00% FFY FFY 2015 Regular FEDERAL Portion INSTRUCTIONS: PLEASE COMPLETE ONLY THE NON-SHADED CELLS - BLUE CELLS WILL AUTO-CALCULATE. Projected LTSS Spending Regular STATE Portion Amount Funded By Balancing Incentive Program (4 year total) Year 1 FFY 2012 Year 2 FFY 2013 (4/1/13-9/30/13) Year 3 FFY 2014 Year 4 FFY 2015 (A) (B) (C (D) (E) (F) (G) (H) Total $ 96,403,485 $ 48,201,742 $ 48,201,742 $ 1,928,070 $ - $ 16,959,904 $ 37,650,986 $ 41,792,595 Total $ 2,977,289,369 $ 1,488,644,684 $ 1,488,644,684 $ 59,545,787 $ - $ 523,783,359 $ 1,162,799,057 $ 1,290,706,953 Total $ 35,055,977 $ 17,527,989 $ 17,527,989 $ 701,120 $ - $ 6,167,267 $ 13,691,332 $ 15,197,378 Total $ 1,306,368,828 $ 653,184,414 $ 653,184,414 $ 26,127,377 $ - $ 229,824,571 $ 510,210,548 $ 566,333,708 Total $ 76,069,037 $ 38,034,519 $ 38,034,519 $ 1,521,381 $ - $ 13,382,541 $ 29,709,240 $ 32,977,257 Total $ 151,563,196 $ 75,781,598 $ 75,781,598 $ 3,031,264 $ - $ 26,663,945 $ 59,193,958 $ 65,705,293 Total $ 781,768,510 $ 390,884,255 $ 390,884,255 $ 15,635,370 $ - $ 137,533,604 $ 305,324,600 $ 338,910,306 Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Service 1 $ - $ - $ - $ - $ - $ - $ - $ - Service 2 $ - $ - $ - $ - $ - $ - $ - $ - Service 3 $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ - $ - $ - $ - $ - $ - $ - $ - Total $ 81,391,542 $ 40,695,771 $ 40,695,771 $ - $ 13,129,409 $ 33,322,196 $ 34,939,937 TOTALS* $ 5,505,909,944 $ 2,752,954,972 $ 2,752,954,972 $ 108,490,368 $ - $ 967,444,598 $ 2,151,901,918 $ 2,386,563,428 *MFP does not receive enhanced FMAP through BIP, but the expenditures do count towards the state's target spending of 50% or 25%. *Total for Federal and State share for MFP reflect regular state share; does not calculate MFP enhanced FMAP. 46

48 Abbreviation/ Acronym Act AAA ADL ADRC AID ASO BH BHI BHO CAP CASS CSOC CWA DoAS DCF DD DDD DHS DHSS DMAHS EHR FFP FFS GO HCBS MCO I&A I/DD Term Independence, Dignity and Choice in Long Term Care Act Area Agencies on Aging Activity of Daily Living Aging and Disability Resource Centers Automatic Interactions Detections Administrative Services Organization Behavioral Health Behavioral Health Initiative Behavioral Health Organization Clinical Assessment Protocol Consolidated Assistance Support System Children s System of Care County Welfare Agencies Division of Aging Services Department of Children and Families Developmentally Disabled Division of Developmental Disabilities Department of Human Services Department of Health and Senior Services Division of Medical Assistance and Health Services Electronic Health Records Federal Financial Participation Fee for Service Global Options for Long-term Care Home and Community Based Services Managed Care Organization Information and Assistance Intellectual and Developmental Disabilities InterRai MDS-HC InteRai Minimum Data Set for Home Care Version 2.0 ICF/MR Intermediate Care Facility for Persons with Mental Retardation 47

49 LOC LTC LTSS MAAC MAC MBHO MDC MFP Michigan MMIS NF PAAD PACE PASRR PCA PCP PH POC QA QM RAI RN SBIRT SED SFY SHIP SMI SPA SPH SAI TA WFNJ-SAI Level of Care Long term Care Long term services and supports Medical Assistance Advisory Council Medicaid Advisory Council Managed Behavioral Health Organization Medical Day Care Money Follows the Person University of Michigan Medicaid Management Information System Nursing Facility Prescription Assistance for the Aged and Disabled Program of All-Inclusive Care for the Elderly Preadmission Screening and Resident Review Personal Care Assistance Primary Care Provider Physical Health Plan of Care Quality Assurance Quality Management Request for Additional Information Registered Nurse Screening, Brief Intervention and Referral to Treatment Serious Emotional Disturbance State Fiscal Year State Health Insurance Assistance Program Serious Mental Illness State Plan Amendment State Psychiatric Hospital Substance Abuse Initiative Technical Assistance WorkFirst NJ-Substance Abuse Initiative 48

50 Letters of Endorsement Copies of the following letters of endorsement for New Jersey s application by the New Jersey Department of Human Services are included in this section: AARP Home Care Association of NJ Mental Health Association in New Jersey New Jersey Association of Centers for Independent Living New Jersey Council on Developmental Disabilities New Jersey Foundation for Aging New Jersey Hospital Association New Jersey Medical Assistance Advisory Council 49

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