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HomeMy WebLinkAboutMINUTES - 07242001 - D.3 TO: - BOARD OF SUPERVISORS bE L Contra FROM: WILLIAM B. WALKER M.D. - Health Services Director °` ^" ��` -',z Costa JOHN CULLEN, � tl" ",• CountyEmployment and Human Services Director °s>� nor ` DATE: July 23, 2001 - SUBJECT: Contra Costa County Long Term Care Integrated Pilot Project SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION: APPROVE, staff report on the overview of the work completed by the Contra Costa County Long Term Care Integrated Pilot Project (LTCIPP) Task Force APPROVE staff recommendations for a LTCIPP framework as outlined in the report. ACKNOWLEDGE that extensive input was provided from consumers and from the public to formulate this report. APPROVE the objectives for the FY 01102 final phase, as outlined in the report. BACKGROUND: On May 16, 2000, the Board of Supervisors directed staff from the Health Services Department, Employment and Human Services Department, and the County Administrator's Office to formulate a plan on how Long Term Care could be integrated into a single system easily accessible to consumers. The Board also directed staff to return in the summer of 2001with recommendations how to implement a Long Term Care Integration Project. Subsequently, an LTCIPP Task Force was formed consisting of staff, consumer advocates, union representatives and agency representatives from the private sector. The Task Force identified six issues that needed to be addressed for implementation of a Long Term Care Plan: • Consumer Input; • Scope of Services; • Access to Transportation; Supportive Housing • Service Delivery System; and • Resource Allocation and Finance Design. CONTINUED ON ATTACHMENT: X YES SIGNATURE: �D ------------------------------------- ------------------ ------------------------------------------- ----- �1-�--- --- -- - - - '-RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): ACTION OF BO /ON -f _APPROVE AS RECOMMENDED_� OT-I-IER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN J —UNANIMOUS(ABSENT ;�y--' ) AND ENTERED ON THE MINUTES OF THE T�/ BOARD OF SUPERVISORS ON THE DATE AYES: NOES: SHOWN. ABSENT: ABSTAIN: ATTESTED CONTACT: Julie Kelley 370-5055 JOHN RK O THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR CC: Health Services Administration Employment/Human Services Administration County Administrator BY PUTY BSard of Supervisors Page—2- Long Term Care Integration Pilot Project July 23, 2001 During the FY 00/01, six design.teams formed recommendations to the Task Force. Public meetings were also held by the Task Force to ensure broad consumer input in the development steps of the recommendations. Lastly, the Task Force reviewed recommendations between March and May 2001 in order to bring the report and its recommendations before the Board of Supervisors for approval. REQUEST TO SPEAR FORM rl (THREE (3) MINUTE LIMIT) Complete this form and place it in the box near the speakers' rostrum before addressing the Board. Name. Phone:0,�-5) Address: City:_ I am speaking for myself �� or organization: (name of organization) CHECK ONE: I wish to speak on Agenda Item # 3 Date: z/ LI My comments will be: general ✓ for against I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to consider: SPEAKERS r 1. Deposit the "Request to Speak" form (on the reverse side) in the box next to the speaker's microphone before your agenda item is to be considered. 2. You will be called on to make your presentation. Please speak into the microphone at the podium.- 3 . Begin by stating your name and address and whether you are speaking for yourself or as the representative of an organization. 4. Give the Clerk a copy of your presentation or support documentation if available before speaking. 5. Limit your presentation to three minutes. Avoid repeating comments made by previous speakers. (The Chair may limit length of presentations so all persons may be heard) . CAWING FOR THE -LONG-TERM A Itepoirt from The bong-Term Care Integration ,Pilot Project Tisk force June 2001 I> Caring for the Long-Term This report is being presented by the Long-Term Care Integration Pilot Project (LTCIPP) Task Force to John Cullen, Director of Contra Costa County Employment and Human Services (EIAS) and to Dr. William Walker, Director of Contra Costa Health Services (HS). The purpose of this report is three-fold: * To provide an overview of the work completed to date by the Contra Costa County Long-Term Care Integration Pilot Project (LTCIPP) Task Force, * To present our recommendations, to date, for a LTCIPP framework, and * To recommend the 2001-2002 objectives for our last and final year of planning. :• It is expected that the directors will present this report, along with their recommendations, to the Board of Supervisors. It is our hope, that after acceptance by the board, this report will serve as a LTCIPP Report to the community. To this end, preparations are going forward to develop a press release, news interviews, and other PR activities. This report is being presented in 1.2-point type. Copies are available in larger print upon request. Please call (925) 335-8808. • i 6/01 Caring for the Long-Term • MISSION, VISION AND VALUES for the . Long-Term Care Integ ation:Pilot Project (LT.CIPP) OUR MISSION is to provide a Seamless System of Long-Term Care with Consumer Choice for Contra Costa County residents. OUR VISION is to develop an integrated system of care for Contra Costa County seniors, adults with disabilities, and their families which will: • Bea culturally sensitive, consumer centered system • Provide a continuum of medical, social and supportive services in the least restrictive and most integrated and appropriate settings possible • Foster independence and sell'-reliance • Be consumer driven and responsive to consumers' needs, choices and preferences • Expand access to care • • Decrease fragmentation and duplication • Improve quality and cost effectiveness • Redirect long-term care funds into a consolidated pool to fund an expanded array of services. OUR VALUES INCLUDE: • Respect for consumer dignity, independence, choice and stability • Quality standards • Diversity and individuality • Confidentiality • Prevention, education and outreach • Development and sustainability of provider capacity • Hiring and retention of competent staff • Affordable and accessible transportation and housing as essential • components of quality of life • All inclusive long-term care services for everyone Adopted 12/00 i i 6/01 Caring for the Long-Term LTCIPP TASK FORCE MEMBERSHIP • Linda Anderson Julie Kelley—Executive Team Case Management, Division Manager Assistant for Program and Policy CCC EHS, Aging& Adult Services Bureau CCC HS Adminstration Joanne Bell Bill Liskamm Executive Director Paratransit Coordinator Independent Living Resource CC Transportation Authority Sandra Jordan Brackett Daisy LoWz Case Management Supervisor Owner/Operator Regional Center of the East Bay Board and Care Homes Joanne Bump Ilene Lubkin Nurse, West County Older Adults Clinic Professor Emeritis/ Retired Nurse CCC HS,Ambulatory Care Advisory Council on Aging Deborah Card Eldon Luce Public Health Manager Executive Director CCC HS, Public Health IHSS Public Authority Dorothy Clinton Hilda Newall Consumer Executive Director Kathleen (Kagev) Dorosz Bedford Center • Elder Abuse Prevention Georgette Redondo Michael Dugan Consumer Principal E.R. Riggall, M.D. Living for Seniors Alameda/ Contra Costa Medical Ednah Beth Friedman Association Conservatorship & LTC Program Manager Dana Simon CC HS, Mental Health Field Representative Dennis Greenberg SEIU Health Workers Union, Local 250 Benefits Specialist Doreen (Pam)Steneberg Independent Living Resource Consumer Advocate Helen Hall Jim Wiant Consumer Advocate, Caregiver Coordinated Care Management Arthur Hollister,M.D.—Executive Team Contra Costa Health Plan Caregiver STAFF: Advisory Council on Aging Ruth Goodin David Johnson Long-Term Care Coordinator Consumer Robert Sessler Attorney Director Sharon Johnson—Executive Team CCC EHS, Aging &Adult Services Bureau • Planner Connie Tolleson CCC EHS, Aging & Adult Services Bureau Long-Term Care Administrative Assistant iii 6/01 Caring for the Long-Terni • REPORT CONTENTS page A. Introduction: `What Is and Why Do"Long-Term Care Integration 1 B. The Planning Process 3 C. Recommendations for a Long-Term Care Integration Framework 6 1. LTCIPP Mission, Vision and Values 6 2. Incremental Phases 6 3. Eligibility 7 4. Organizational Model 9 • 5. Services to be Offered 12 6. Funding Pool 14 D. Goals and Objectives for Fiscal Year 2001—2002 16 E. Challenges and Opportunities 18 F. Long-Term Care Glossary 19 G. List of Supporting Documents 24 • Caring for the Long-Term • A. Introduction: "What Is & Why Do" Long-Term Care Integration? For many people the phrase"long-tern care"conjures visions of nursing homes and other types of institutionalization. In fact, our definition is much broader. In addition to institutional care, it includes a wide range of services provided within the home and the community to the elderly and adults with disabilities who need on-going care for a sustained period of time. These services could include medical care, rehabilitation, and assistance with activities of daily living and facilitation with navigating the health and social service delivery system. Long-term care expenditures represent a substantial share of total health care spending in the United States, and are an area of major concern for state and local policymakers. In California, long-tern care represents one of the largest costs and fastest growing components of the state MediCal budget. Four years ago, residents of Contra Costa County recognized the need for changes in the existing system of long-term care services. Various committees, work groups and a LTCIPP Task Force conducted consumer and provider interviews, service inventories and demographic and statistical analysis. All of our findings validated the need for long- term care reorganization. There were 123,974 The following driving forces were apparent::' residents aged 65+ in Contra Costa County in the a)A growing population of elderly and of adults with disabilities year 2000. By the year 2002, this number is b)A high number of residents in nursing;facilities inappropriately expected to grow by 90%. placed Contra Costa County had a 40% higher growth rate in c) Fragmentation and unnecessary duplication of services and the 1990s than the average administration growth rate in California, and a 62% higher growth d) Inefficient use of resources, consumer confusion and barriers to rate than the rest of the Bay appropriate care Area. Individuals with disabilities and/or chronic conditions typically need a combination of medical and non-medical supportive services to "I don't know what services maintain their functioning and independence. Currently, the acute care there are. I don't and long-term care service systems are defined and administered understand the forms. I separately by several different agencies in California. For example, could not find anyone to nursing home care and acute care services are regulated by the state help me. 1 just gave up." Consumer • ' Supporting Document 1: "Identifying the Need f v Change" from Report:A Seamless System with Consumer Choice,Contra Costa Long-Term Care Coordinating Committee, 1/99 1 6/01 I'I Caring for the Long-Terns Department of Health Services. Many home care and community-based services are administered through the state's Departments of Aging and of Social Services, respectively. There are different and sometimes conflicting eligibility rules, criteria and benefits for each of the various programs and services. For the consumer, there is no continuum of care, only.much confusion,frustration and fragmentation. The 1999 United States Supreme Court ruling Olmstead v. L.C. provided additional motivation to our work. This ruling requires that states provide community-based services for people with disabilities who are otherwise entitled to institutional services if the community placement: a) is appropriate, b) is desired by the individual and c) can reasonably be accommodated, taking into account the resources available. We are locally grappling with the implications of this :ruling through our LTCI planning process, as well as participating in state-wide discussions regarding Olmstead. In researching solutions to address these issues, the LTCIPP Task Force has utilized the California Long-Term Care Integration Pilot Project(AB 1040) as an effective roadmap toward a seamless system of long-term care for Contra Costa County seniors and adults with disabilities.' The concept of integration has generated much national' excitement and controversy in recent years and means different things to different people. The ultimate goal of A131040 is "long-term care integration" defined as a capitated system which includes: AB 1040 • Pooling MediCal (and other)funds into a consolidated funding pool, Enacted in 1995, this CA State legislation • Integration of financing and administration of medical, social'.and authorized the Long-Term supportive services, and Care Integration Pilot • Provision of a broad continuum of services while remaining cost Project. The statute neutral: ("Remaining cost neutral" means that the costs of this pilot directed the Department of Health Services work project will not exceed the direct and indirect costs that existing; with counties to develop programs would expect to incur had the integrated services not been integrated systems of care provided through this project.) for seniors and adults with disabilities. The AB 1040 legislation defines those eligible for services through long-term care integration as adults who are MediCal eligible. Additional populations could be added under a similar, but separate pilot project. Initially, we are developing this LTCIPP to serve only the MediCal population. Capitated managed long-term care requires risk, but it offers the potential for financial and programmatic creativity, and freedom from Supporting Document 2: Text of 1995 AB 1040 Legislation 2 6/01 Caring for the Long-Term • many state regulations. Cost-effective services can be offered and financial incentives can be created to ensure care is provided to consumers in the least restrictive environment possible. Integration also means the blending of services together so the system is seamless from the consumers' perspective. Full long-term care integration,operated under a capitated delivery system with Medical (and ideally Medicare funds), is difficult to achieve. The Task Force considers full long-term care integration as an end point on a continuum, with the starting point represented by the current level of fragmented care.The Task Force is recommending incremental phases, along the continuum, to make long-term care funding and services work more effectively. Perhaps our goal is better defined as an Integrated Adult and Aging System of Care. Medi-Cal (called Medicaid in all other states) is a federal /state cooperatively funded and state-operated program of health benefits to qualifying low-income persons. States determine program benefits, eligibility requirements, rates of payment for agencies and institutions that provide services, and methods of administering the program under broad federal guidelines. • • 3 6/01 I , III Caring for the Long-Term I B. The Planning Process II Four and one-half years ago, the Contra Costa Advisory Council on Aging began to explore alternatives to the existing system of long- term care services. In October 1996 a freestanding"ad-hoc" committee of ten community stakeholders was formed and included individuals representing seniors,as well as younger persons with disabilities. This committee, which had now expanded its purview beyond just the elderly population, adopted the specific purpose of initiating a long-term care planning strategy for Contra Costa County. An overview of the committee's findings and recommendations were presented in a 11999 report A Seamless System with Consumer Choice, to the directors of the Employment and Human Services and Health Services Departments. The directors submitted the report to the county Board of Supervisors, along with a request for the establishment of a LTCIPP Task Force. The Board approved the request and authorized the Empioyment and Human Services and Health Services directors to jointly submit,an application to the State for a LTCI Planning Grant. A $50,000 planning grant was awarded in July 1999 and was renewed for fiscal yearS2000— 2001 and 2001 — 2002. Each year the Employment and Human Services and Health Services Departments have confirmed their commitment to the planning process through their investment of additional monetary, in- kind and staffing resources. • The initial stages of the grant's formal planning process focused "Everybody came to the on the grass-roots building of community involvement through tabllee with ith p passion and education, dialogue and input. Before recommending a model for a full- e amus asm...place.ible continuum of integrated medical, social and supportive services, the learning took place...." Task Force Member Task Force members needed to increase their knowledge-base regarding LTCI concepts, models and issues. Various meetings,focus groups 3, workshops and in-service trainings were held to increase the community's understanding and knowledge of the vast array of long- term care integration components and subject matter. `I gained a broader Concurrently, six Design Teams were formed to further research respect for many people specific subjects and to bring related information and recommendations who I had presumed to to the Task Force. Each of these Design Teams (Consumer Input', Scope be too narrowly of Services,Transportation, Housing, Service Delivery and Resource focused." Allocation and Finance)met for a year fulfilling their stated purposes, Task Force Member goals and objectives.' In September 2000, an overview of the newly-acquired knowledge-base was shared at an LTCI Summit, "Who Cares For�the Long-Term?We Do", attended by over 100 community participants . 3 Supporting Document 3: Consumer Input Report, Consumer Input Design Team 7/00 4 Supporting Document 4: Design Teams:Purpose and Work Completed 4 6/01 I Caring for the Long-Term • The information shared can be found in the Who Cares? binder, which was distributed at the event. This compilation of information was the foundation for the LTCI framework, completed by the Task Force fiscal year 2000-2001. As a Task Force we have carefully listened to the individuals we want to serve as they have expressed their desires, needs and anxieties, and we have collectively soul-searched for the vision and values we want our LTCIPP to reflect. "The `grassroots'approach began with the commitment and vision of ten individuals who recognized that the currant system was broken—for consumers, as well as for providers of long-term care services. Through the dedication and leadership of these ten individuals their efforts have grown to include more than one hundred individuals in a formal planning process." A Contra Costa County Administrator • • 5 6/01 I II Caring for the Long-Term I C. Recommendations for a LTCI Framework Over the past year, the LTCIPP Task Force has carefully • reviewed and considered a myriad of approaches and strategies',to "It is positive to work with integrate acute and long-term care services for the elderly and disabled people who truly believe population in Contra Costa County. In doing so, we have developed a in consumer choice." "framework" around which our system can be constructed. To date, the Task Force Member Task Force has reached consensus regarding the following framework components. We are recommending these components as the foundation of our planning for fiscal year 2001 —2002,as we focus on decision- making and transitioning to LTCI development in fiscal year 2002— 2003. We recognize that these recommendations may change as we research and analyze new information. I The Recommended Framework Components Include: I I Recommendation#1 LTCIPP MISSION,VISION AND VALUES Input from over 150 community stakeholders assisted in the development of the Mission,Vision and Values that can be seen on paged ii of this report. I Recommendation#2 INCREMENTAL PHASES II The LTCIPP will be implemented in achievable, incremental phases, Phase I: Increased Coordination of Services: This phase focuses on strengthening and coordinating home 'We are establishing good and community-based services which are operated by the county's working relationships with Employment and Human Services and Health Service departments other agencies. We didn't and local community-based services. During this phase all of these even talk to each other programs will continue to operate under existing program regulations before. Program Manager and categorical and fee-for-service reimbursement systems. Coordination efforts will encompass services provided by both' public and private providers. This phase is currently in progress. Accomplishments to date can be seen in Supporting Documents.' I s Supporting Document 5:Accomplishments to Date 5101 6 6/01 Caring for the Long-Term • Phase II: Addition of Medical and Institutional Services: This phase, which will likely have various stages and pilots, "Cooperation is essential, would incorporate primary and acute medical care and skilled Each agency and service nursing care into the coordination model above. There will be a provider may have focus on the expansion of home and community-based services and different operating the achievement of MediCal expenditure;flexibility. Until some of systems and policies that the planning objectives for fiscal year 2001 —2002 are completed, it conflict with one another. is not possible to outline the specifics of this phase. Depending on Because of efficiency, an the distinct developments of this phase, a waiver may be required. A agency or service provider waiver is an agreement between the state and the Health Care may have to give up Financing Administration (HCFA) to permit states (or portions of certain goals so that the consumer receives states)to use MediCal funds in innovative ways to create a broader optimum services array of services which offer more benefit choices for consumers. Consumer Phase III: Capitated Managed Long Term Care: This phase will transition to a managed care system with a fully integrated and capitated continuum of primary and acute medical Until we include medical services and have care, skilled nursing care and home and community-based services. capitation 1 don't think that As a capitated system, the current categorical and fee-for-service we can have a truly reimbursement systems will be replaced with a reimbursement seamless system." system paying a fixed amount for each person enrolled, regardless of Task Force Member • the type or amount of service provided. Revenues to fund this system will be received on a per-capita basis from MediCal. Additional funding sources will be sought for integration and coordination with this system. Current program regulations will be broadened, allowing for a broader array of benefit choices for consumers. A waiver will be required. It is strongly recommended by the Task Force,that each phase be evaluated for congruency with the LTCIPP mission, vision and values. It is further recommended that before committing to move from one phase to another, a thorough evaluation be conducted to determine if the next phase will lead to increased quality of services for consumers and cost effectiveness and acceptable levels of risk for the governing body. Recommendation#3 ELIGIBLILITY "When this program is in All aged, blind or disabled MediCal adult(18 years +) residents place it should be • of Contra Costa County will be eligible for the LTCIPP. There were expanded to everyone." approximately 29,656 individuals who met the proposed eligibility Task Force Member 7 6/01 i Caring for the Long-Term requirements during the 1997 calendar year.6(In standing with our values, we will strive to eventually include all aged, blind or disabled • adults, regardless of their income. This inclusion will be evaluated in future years.) Initially, the Task Force considered a more limited eligibility criteria, which included: • aged, blind or disabled adults who were Medi-Cal eligible„ in need of LTC services for at least 3 or more months, and who were functionally or cognitively impaired (needing assistance,with at least two activities of daily living); • or nursing-facility certifiable. However, after careful consideration, it was agreed that inclusion of all aged, blind or disabled Medi-Cal eligible adults allowed for a more seamless, less fragmented continuum of care. Serving this larger population would allow for more prevention, education, and early intervention opportunities to improve outcomes and maintain wellness. In addition, it would provide administrative efficiencies and cost savings, leaving more funds for direct consumer services. The State Office of Long-Term Care agreed with this reasoning. During the next fiscal year, an important decision will need to be made regarding the issue of voluntary or mandatory enrollment of the eligible population into the LTCIPP. Fiscal analysis of the cost:;and benefits of both options and consumer input will be key elements of this discussion. `There is a cost to implementing managed care, both for the staffing and for the infrastructure costs. We need a critical mass of enrollees in order to be successful." Health Administrator "We can't force a person into a system. Everyone needs choice." Task Force Member 6 Supporting Document 6:Medical Data Analysis for 1997 8 6/01 Caring for the Long-Term • Recommendation#4 ORGANIZATIONAL MODEL The organizational chart below presents an overview of the organizational model of the Task Force's Vision of an Integrated Adult and Aging System of Care. This chart depicts the various relationships between the LTCI system components.' The vision provides the"framework"for the LTCIPP. Specifics for implementation, built upon this framework, will be addressed in the objectives for the next fiscal year. Following the chart you will find a listing of each of these components with a brief explanation. Independent GOVERNING BODY Ombudsman/ QA Administrative LTC AGENCY • All Medi-Cal Entry/Info Unit eligible Aged, • Screening Blind or • Enrollment Info only Disabled a. Initial Assessment linkage with: Referral to other programs as appropriate Care Medical Provider Coordination Network and PCP: Inter-disciplinary SERVICES: All Medical Primary and Acute Medical,Support and Social Services • 7 Supporting Document 7:A Vision of an Integrated Adult and Aging System of Care, Developed by the LTCIPP Task Force,Spring 2001 9 6/01 'I Curing for the Long-Term �I ♦ GOVERNING BODY • This body will hold ultimate responsibility for the LTCIPP. "We need to have a Y P Y governing body that we can As the"keeper"of the Mission, Vision and Values of the trust to respect the mission, system it will be responsible for: vision and values. Task Force Member • Fiscal liability • Policy setting • Contracting with an administrative long-term',care agency,the independent ombudsman and other services as necessary. ♦ ADMINISTRATIVE LONG-TERM CARE AGENCY This agency will be responsible for the operation of the "If we had a better LTCIPP. Its responsibilities will include:. coordinated system with less duplication, then we 0 Administration and oversight of the LTCIPP system could spend our savings for more direct services. Financial administration That would be wonderful." Administration of policy and procedures Task Force Member • Contract administration • Management Information Systems • Evaluation and quality assurance • Constituent relations �I ♦ ENTRY UNIT(of the Administrative LTC Agency) `It is essential that there The Entry Unit is the central access into the system. be a single point of Multiple points of entry, with diverse language, cultural entry, only one eligibility and communication capabilities will lead to this central form to complete and access, assuring a"no wrong door"entry process. This unit, services available at all staffed by health and social service professionals, will be times. In other words, responsible for screening, assessment, enrollment and the system must be as linking consumers with the appropriate care coordination easy as possible for teams and medical providers. This unit will also be capable those who will receive of directly providing care coordination in crisis situations. services.Task Force Member In addition, this unit will provide information and referrals to services outside of the LTCIPP. ♦ CARE COORDINATION Care Coordination, the "hub"of LTCI, is the important link that exists between the consumer and the myriad of available services. This collaborative process between a 10 6/01 Caring for the Long-Term • consumer and a care coordinator assesses consumer needs, develops a care plan, arranges for services and conducts necessary follow-up. Service options explored may involve risk management and will always involve choice for the consumer. Care Coordination will be provided by 1 wish 1 had someone interdisciplinary teams of social service and health to talk to about what professionals, with varying levels of decision-making, choices to make." based upon the consumers needs and preferences. Choices Consumer for consumers will always include a range of options for the consumer and may involve varying levels of risk. It has not yet been decided if the care coordination will be centralized with the administrative long-term care agency,or decentralized with the medical provider networks. Research is currently being conducted regarding this issue. ♦ MEDICAL PROVIDER NETWORKS Each LTCIPP consumer will be enrolled in a medical provider network. All medical and ancillary services • available to the consumer by MediCal will be provided through their chosen network. Ideally, consumers who are also MediCare eligible will choose to receive their MediCare services through.this network. Incentives are being explored to encourage the LTCIPP enrollees who are dual eligible(eligible for both MediCal and MediCare) to receive all medical services through their LTCIPP medical provider. This could result in medical cost savings, because of the LTCIPP's attention to prevention and early intervention. Medical provider networks will include CCHP,and other managed care providers, to be determined. ♦ INDEPENDENT OMBUDSMAN "We need on-going An agency, independent of the LTCIPP, will be monitoring, not just by responsible for dispute resolution, on behalf of the ourselves, but also by LTCIPP consumers, regarding benefits and services. a separate team." Task Force Member • it 6roi i Caring for the Long-Term I Recommendation#5 • SERVICES TO BE OFFERED The menu of services recommended by the Task Force to be provided by the LTCIPP is listed below. All services will be offered as part of the capitated managed care system. Although specific eligibility criteria for each service has not yet been determined, it will be mandated by HCFA that LTCIPP levels of services available to each individual must be equal to,or greater than, the services available to that individual under;the current system. A study of financial viability will be conducted and a prioritization of services to be provided will be completed, before a final recommendation of services will be agreed upon. Certain services recommended might require a waiver, a revision of the MediCal 'state plan, or a change in state regulation before MediCal funds can be used to pay for these expanded services.a It is possible that in the course.of planning, during this next year, new services will be added to this lust. ♦ CARE COORDINATION ♦ EDUCATION I ♦ IN-HOME SERVICES . Personal Care ....... 200 hours a => Protective Supervision month is not enough. Paramedical Care I wish that they could give Mr. P more Home Health Care hours. I am afraid => Nutrition / Food Services that he will have to go into a skilled nursing => Emergency Response Services facility. If he could � Caregivers Support/ Respite have more hours he g PPo P could stay at home." ♦ ADULT DAY SERVICES Provider => Adult Day Health Care => Adult Day Social Care ♦ RESIDENTIAL FACILITY LTC =* Skilled Nursing Facilities => Intermediate Care Facilities => Residential Care Facilities/Assisted Living ♦ HOSPICE 8 Supporting Document 8: Description of Recommended Services, LTCIPP Task Force 5/01 12 6/01 Caring for the Long-Term • ♦ HEALTH SERVICES => Primary Medical Care Acute Medical / Psychiatric Care => Alternative Health Practices =:> Mental Health Services => Pharmacy and Medication Services =::> Rehabilitation and Habilitation Services => Prevention and Wellness Services =:> Substance Abuse; Intervention ♦ SOCIAL REASSURANCE SERVICES ♦ TRANSPORTATION9 ♦ ACCESSIBILITY /MOBILITY PROVISIONS => Home modifications => Durable and Assistive Devices ♦ INTERVENTION Crisis Intervention • Abuse Intervention ♦ BENEFITS COUNSELING, ADVOCACY & LEGAL ASSISTANCE ♦ SPIRITUAL AND CULTURAL SUPPORT Although independent housing is not being recommended as a service to be provided by the "Unless we resolve the LTCIPP, it is recognized as a high priority need for the issues of transportation target population. The L,TCIPPTask Force will remain and housing, none of this a strong advocate for affordable and accessible housing planning will be worth a for all aged, blind or disabled residents of the county. darn!" We cannot address the issues of long-term care without Task Force Member addressing this need for housing.10 • 9 Supporting Document 9: Transportation Policy Statement,Transportation Design Team, 7/00 '0 Supporting Document 10:Philosophy of Housing, Housing Design Team 1/01 13 6/01 li SII Caring for the Long-Term �I Recommendation#6 FUNDING POOL Funds being recommended by the LTCIPP'Task There .. a Force for inclusion in the Integrated Funding Pool are change...fearofloosing listed below. These recommendations will not be dollars and control." Task Force Member finalized until a comprehensive fiscal analysis is completed. It is possible, that in the course of planning during this next year, some of the funding sources will be deleted from this list, while new funding sources may be added. • MEDI-CAL FUNDS currently expended for: "If we pool the funds we => Acute Medical Care/ Hospital Skilled Nursing can end the categorical, Care bureaucratic funding piMedical Care streams. We could put Primary our attention, and our => Ancillary Care money, toward the needs of people—not => Personal Care Services the needs of programs. " => In-Home Supportive Services (IHSS) Design Team Member => Multi-Purpose Senior Services Program (MSSP) .=> Adult Day Health Care => Home Health Care Hospice => Transportation => (Mental Health funds are being explored) • STATE FUNDS =:> IHSS Administration => IHSS Residual • COUNTY FUNDS => Currently supporting long-term care programs specifically for the aged, blind or disabled MediCal population (such as IHSS, MSSP) i 14 6/01 Caring for the Long-Term • Funds being recommended for Coordination with the LTCIPP Some funds, which currently provide services to the target population, will not able to be blended with the LTCI funding pool, by virtue of their mandate to serve a broader population than MediCal eligible persons who are aged, blind or disabled. For example,Title II113 funds of the Older Americans Act are to lie used for specified services for all persons over the age of 60, with an emphasis on the more frail, low-income population. Although these funds may not be integrated into the funding pool,the LTCIPP can coordinate closely with services provided by these funds, providing a"seamless" service for the "The consumers don't consumer of the LTCIPP. The consumer should not need to know that need to know what pot of the services are being provided by different funding sources. Funds money is paying for their being recommended for close coordination with LTCIPP include: services. The money => Title 11I13 of the Older Americans Act can come from different pots and the services => Older Californians Act can still be seamless." => Adult Protective Services Task Force Member. =* Ryan White AIDS Fund => Public Guardian => LPS Conservatorship a • "Begin a program NOW In addition, start-up funds are be sought by several counties of consumer choice in statewide, who are working with state legislators to draft legislation for home and community- innovative long-tem care programs. Private foundations and other based long-tern care avenues of funding are also being researched for pilot project funding. services to see where the major gaps are and begin finding solutions." Task Force Member • 15 6/01 i i Caring for the Long-Term. D. Goals and Objectives for Fiscal Year 2001 —2002 • The goals and objectives for 2001 —2002 are based upon the results of our prior years of planning. The prevailing focus of the first year of formal planning was the building of grass-roots community interest, support and understanding of long-term integration. This second year of planning focused on research and education in order to make informed decisions regarding the framework of long-term,care integration. This next year of planning will focus on specific issues identified by the Task Force as needing additional research and analysis, as well as determining the means of overcoming recognized barriers and challenges. The goals and objectives of fiscal year 2001 - 2002 are intended to guide us toward decision-making and transitioning to long-term care development in fiscal year 2002 4 2003. While much of the work completed to date has been conceptual in manner, the goals and objectives for fiscal year 2001 — 2002 are intended to provide the specificity necessary to engage state level resources required to initiate LTCI development phases. The document"LTC/Development Readiness" prepared by the California State Office of LTC will be used as a reference guide." w During fiscal year 2001 —2002 the Long-Term Care Integration planning efforts will: • Continue to Establish Better Coordination Between Existing: Services => Determine Financial Viability of LTCIPP => Identify service trends => Identify utilization trends => Estimate revenues for integrated funding pool • Establish Final Recommendation of Services for Inclusion in. LTCIPP, including: Eligibility for specific services "We must eliminate Coordination with non-MediCal services waiting lists and assure => Identification of service capacity, service gaps, and action Contra Costa residents steps to address identified needs that services will be 0 available to them when Address Consumer Choice options, including: they are needed. => Medical provider networks Consumer " Supporting Document 11:LTCI Development Readiness, prepared by the California State Office of LTC 16 6/01 Caring for the Long-Term • =* Home and community-based service providers => Voluntary vs. mandatory enrollment • Develop Expected Outcomes • Identify Appropriate Waivers • Create an Overall Description, with Details, of the LTCIPP including: => Identification of governance structure => Service delivery structure including entry into the system,. service authorization,and quality assurance => Staffing Vendor agreements and protocols ' Care coordination structure and protocols => Management information systems Funding sources to be blended Billing and fiscal oversight "We need to make surethat we include the • Determine Specific Phase-in Timeline and Workplan consumers in this process. u • Ensure On-going Stakeholder Involvement Task Force Member The activities which will achieve these goals and objectives will bring us from the planning stages to the development stages of long- term care integration. It is our vision that the next phase will be that of implementation. • 17 6/01 i Caring for the Long-Term E. Challenges and Opportunities The value of our grassroots planning process comes from `There is so much bringing insightful,creative, committed and diverse people together. expertise at the table, and Many of these people have never worked together before. They each everybody has this broad come from distinct perspectives. We have consumers of service's, base of knowledge that caregivers, service providers, administrators, advocates and planners of they bring". m public policy represented on the Task Force and the Design Teas. Task Force Member Collectively they generate creative questions, answers, ideas, and action plans. The difficulty of grassroots planning is the time that it takes for "How about a miracle? education, understanding and listening. Many meetings, workshops This kind of work is slow, and in-service trainings were hosted to increase the community's; unfortunately, and will understanding and knowledge of the vast array of long-term care' take time. It would be integration components and issues. We have grappled with definitions, nice if we could complete process, vision and values. It takes time and moves more slowly',than it all quickly, but..." we would like. When we do reach consensus however, it is with ' Task Force Member ownership by the entire group and the foundation of our planning efforts feels solid. Along with our successes and recommendations comes a host of questions, challenges, and barriers for us to address, including such al have learned to issues as: *gaps in service capacity; *work force issues/ standards Task Forcee Member become patient" and shortages; *labor/ union issues; *need for more recent utilization data to estimate costs/ risks; *need for technology systems/ software to integrate service components; •"turfism"and fear of change re: governance/ administration / service provision; *confidentiality issues; *need for waivers to expand service options (are there ones to meet our needs?); *system structure (where does care coordination belong? where does service authorization belong?); *rate setting risk; *budget; *inclusion of non-Medi-Cal dollars and consumers into the system; *mandatory vs. voluntary enrollment; *system phase-in/ minimal disruption for consumers; *reductions in reimbursements from HCFA; *consumer skepticism re: managed' care; and *the need for more funding for health care and home and community-based services. "I want to see our Despite these challenges we remain committed and optimistic. ideas implemented at The focus of this next year of planning is to overcome the hurdles and the end of our to build upon the foundation laid by the Task Force. We appreciate planning process. I your commitment to the process,and we look forward to continuing want people to be our work with you so that together we can create a seamless system of able to live how they long-term care, with choice,for seniors and persons with disabilities :in choose." Contra Costa County. Task Force Member 18 6/01 LONG-TERM CARE Glossary of Terms • (12/00) AB 1040 California State legislation enacted in 1995 to authorize the Long-Term Care Integration Pilot Project (LTCIPP). This statue directed the Department of Health Services to work with counties to develop integrated systems of care for seniors and adults with disabilities. ABD (Aged, Blind or Disabled): The MediCal subgroup specified in AB 1040 enabling legislation as the target population pool from which long-term care integration consumers will be drawn. Activities Of Daily Living (ADCs): A scale or index that measures an individual's ability in performing functions of daily living such as walking, bathing, getting out of the house, moving from bed to chair, dressing and eating. (see also Instrumental Activities of Daily Living - IADLs) Acute Care: Medical treatment rendered to individuals whose illnesses or health problems are of a short-term or episodic nature. Adult Day Health Care (ADHC): • A licensed daytime community-based program for functionally impaired adults, including personal care and supervision, that provides a variety of social and related support services along with medical, rehabilitation and health related support services in a protective setting. Adult Protective Services (APS): A public program which provides assistance to elderly and dependent adults who are victims of physical, emotional or financial harm or abuse. Area Agency on Aging (AAA): The agency which coordinates comprehensive planning and services for older persons, within a specific geographic area (such as a county). In Contra Costa County the AAA is a division of Employment and Human Services, Aging and Adult Services Bureau. Assessment: Collection of in-depth consumer information and a comprehensive appraisal of consumer functionality to aid in making evaluations about needed services. Capitation: A payment method whereby a managed care plan is paid a fixed amount for each person enrolled, regardless of the type or amount of service provided. Care Coordination (Management): • A collaborative process between a consumer and a care manager to assess, plan, implement, coordinate, monitor and evaluate options and environmental needs, using formal and informal available resources to promote quality services which meet the needs of the consumer. 19 i it Care Coordinator(Manager): A professional, typically a nurse or a social worker (they may often work together as a team)who works with a consumer in the care management process (as described above). • Case Management: Another term often used for "Care Management'. (The Scope of Service Design Team chose to use the term "Care Management; in response to a consumer's statement— "I am not a case and I do not need.to be managed".) Contra Costa Health Plan (CCHP): A division of Contra Costa Health Services, which is a state licensed, federally qualified, county-sponsored and operated HMO. Cooperative Care Management Unit (CCMU): Multi-disciplinary care management unit of Contra Costa Health Plan. Dual Eligible: A person who qualifies for both Medical and Medicare payment for health care.', Also referred to as Medi-Medi's. Durable Medical Equipment(DME); Medical and other equipment, including oxygen machines, wheelchairs, and dialysis equipment which is appropriate for use in the home. Fee-for-Service: Traditional method of paying providers a fee for each service after it has been delivered. Medical often requires service providers to submit Treatment Authorization Requests (TARs) to receive authorization (approval of payment) prior to service.delivery. Habilitation: Services designed to assist individuals in acquiring, retaining and improving the self- help, socialization and adaptive skills necessary to reside successfully in home and community-based settings. �I Health Care Financing Administration (HCFA): The federal agency that administers Medicaid (MediCal), Medicare and the State, Children's Health Insurance Program. Home-and Community-Based Services (HCBS): Services designed to help older people and disabled adults remain independent, in their own homes and in the community. Includes such services as In-home Support Services (IHSS), adult day health care, senior centers, transportation, congregate meal sites or delivered meals, visiting nurses or home health aides, adult day care, and homemaker services. Home Health Care: Health care services, authorized by a physician, provided to individuals and families in their homes by professional staff(nurses, physical therapists, occupational therapists, speech therapists, medical social workers, and home health aides) for the purpose of promoting, maintaining, or restoring health. 20 Hospice: Comprehensive care specifically designed for terminally ill persons, offering an individualized program of medical, nursing, social, psychological and spiritual support. • Provides pain management and symptom management plus psycho-social and spiritual services for individuals and their families. In-Home Supportive Services (IHSS): In-home Supportive Services provides homemaker and personal chore services to the elderly and disabled. Individuals must be SSI and Medicaid eligible. IHSS is a federal, state, and county funded program and is administered by the county. (Contra Costa County IHSS program serves approximately 4,000+ consumers at any given time.) IHSS Public Authority: The Contra Costa County IHSS Public.Authority is a public agency whose general purpose is to improve the IHSS program for IHSS consumers and workers. Public Authority services include: IHSS provider recruitment, screening and registry, provider and consumer training and related support services. Information and Assistance (I W (sometimes referred to as Information and Referral [I&R]) Provides information and assistance of appropriate resources and support in problem solving through comprehensive database screening. I&A also provides short-term help and assessment to enable persons to identify and gain access to resources appropriate to their needs. 1(800)510-2020 • Instrumental Activities of Daily Living IADLs : Additional functions of daily living such as shopping, cleaning, bill paying, and meal preparation. (See also Activities of Daily Living —ADLs) Intake: Initial screening and processing of paperwork to allow entry into a program. Unkanes: A care management program for individuals 18+ at risk of institutionalization, regardless of income. The program has funds to purchase home- and community bases services. (Contra Costa County's Linkages program serves apporoximately 100 individuals at any given time.) Long-Term Care Integaration Pilot Project(LTCIPP): The local county project working toward the development and implementation of an integrated system of long-term care with consumer choice. Lona-Term Care: The provision of assistance through services which are home-, community-, and institution-based (including health, social and support services), on an intermittent or continuous basis, over a sustained period of time. Managed Care: • In general, refers to efforts to coordinate, rationalize, and channel the use of services to achieve desired access, services, and outcomes, while controlling costs. • Risk-based managed care describes care from managed care organizations (MCOs) that provide or contract to provide health care in broad but specified areas 21. i of a defined population for a fixed prepaid price. The MCOs are at financial'risk to deliver the services within the fixed price, and they use various strategies to control costs. Medi-Cal (Medicaid): Medi-Cal (called Medicaid in all states other than California) is a federal / state cooperatively funded and state-operated program of health benefits to qualifying low income persons, established under Title XIX of the Social Services Act. States determine program benefits, eligibility requirements, rates of payment for agencies and institutions that provide services, and methods of administering the program under broad federal guidelines. Medicaid is operated in every state except Arizona, which has a comparable program. Medicare: A nationwide health insurance program for people 65+ and for people eligible for.social security disability payments for 2 years or more. Part A pays for hospital insurance, Part B for medial insurance. Consumers contribute to the costs.of Medicare through premiums, deductibles and copayments as specified under law. MSSP (Multi-Purpose Senior Services Program): Care Management program for SSI level seniors who are nursing facility eligible; The program has funds to pay for home- and community-based services. The cost to serve the consumer must be no more than 90% of skilled nursing facility costs. (Contra Costa County has an approximate caseload of 200 at any one time.) Multi-Disciplinary Team (MDT) or Inter-Disciplinary Team (IDT): A group of persons commonly including, but not limited to, one representative from each of the following disciplines: social worker, registered nurse, psychologist, physician, public guardian, who come together to plan for care and coordinate services for individuals. Nursing Facility (NF): A freestanding nursing home, hospital-based nursing facility, skilled nursing facility, or public institution whose primary function is to provide skilled nursing services for individuals who require the continuous availability of skilled nursing care provided by RNs (registered nurses) or LVNs (licensed vocational nurses)for the treatment of illness or injury. I Nursing Facility Eligible: Individuals meeting the standards and criteria outlined in Title XX, which refers to a level of impairment sufficient for nursing home placement. Olmstead: A1999 U.S. Supreme Court decision which states that people with disabilities and their families have the right to chose where they live and receive support services. The ruling upholds a key civil rights provision in the 1990 Americans with Disabilities Act (ADA), which maintains that individuals with disabilities must be offered services in the "most integrated setting" possible. The Supreme Court, in upholding the mandate, has reinforced the fundamental intent of the ADA, which is to prevent discrimination and promote the integration of people with disabilities into our communities. 22 Primary Care' Basic or general health and preventive care provided when a patient first seeks assistance from the medical care system. It is also defined as the entry point into the • health care system and is generally provided in a physician's office or health care clinic setting. Quality Assurance (QA): A process to ensure that the quality of care meets an expected threshold. It includes defining criteria for quality and standards for performance, assessing care to the standards, and corrective action when the standards are not met. Respite Care: Assistance (a few hours to several days) to relieve family members, or other caregivers, caring for an elderly or disabled person. Respite care may be provided by a volunteers, an institution, or an adult day care center. Care may be provided in-home or at a center. Service Authorization: Approval for payment of services. Social Adult Day Care: A licensed daytime community-based program for functionally impaired adults, including personal care and supervision, that provides a variety of social and related support services in a protective setting. Supplemental Security Insurance ( W • Federally-administered cash allowance for people over the age of 65 or with server and permanent disabilities whose incomes, after some disallowances, fall below a specified amount. Waiver (MediCal): Permits states or counties to use Medi-Cal funds in innovative ways. Long-term care waiver programs may be granted waiver authority under Section 2176 of the OMNIBUS Reconciliation Act of 1981. States may apply for waivers on behalf of individual counties. Woodwork Effect: The phenomenon where persons who have not previously used particular services become consumers due to improved service delivery. This phenomenon, if it occurs, may lead to increased numbers of consumers and greater demand for services. This glossary has excerpted definitions from various sources including The Heart of Long Term Care, Kane and Ladd(1998); RTZ Case Management Report(2000); Yolo County Older Adult Long-Term Care Report(1998); Contra Costa County Office on Aging Alphabet Soup Glossary(1999;) and the worm of the LTCIPP Design Teams. • 23 Caring for the Long-Term • SUPPORTING DOCUMENTS 1. Identifying the Need For Change from Report: A Seamless System with Consumer Choice, Contra Costa Long-Term Care Coordinating Committee, 1/99 2. Text of AB 1040 Legislation 3. Consumer Input Forum Report,Consumer Input Design Team,7/00 4. Design Teams: Purpose and Work Completed 5. Accomplishments to Date, 5/01 6. MediCal Data Analysis for FY 1997 • 7. A Vision of Integrated Adult and Aging System of Care, Developed by the LTCIPP Task Force, Spring '01 8. Description of Recommended Services, LTCIPP Task Force, 5/01 9. Transportation Policy Statement, Transportation Design Team,7/00 10. Philosophy of Housing, Housing Design Team 1/01 11. LTCI Readiness Development Readiness, prepared by the California State Officee of LTC • 24 bio 1 i ;;�:� � � ���Q� v__�=.-_. .- ---._.-____ a�a_��_-._- ---_ ---�-- -.� � _�.R�._. ___. _____ �. -m .--.----- _ .�. __. ,I :.�_.__ --__ - - -------�- -- -e. ��- i.__.�., �__._ _ _�_ - ,--- ____ �.� w�_____..______ _.._ . n_.�_ ------___.��..� __�. ;I __�. _a__ Supporting Document 1 • IDENTIFYING NEED FOR CHANGE Consumer and provider forums and interviews; inventories and research of existing services, procedures,and statistical analysis; and review of local and state-wide demographics all validated the need for change. Consensus was quickly achieved regarding the need for change due to the following driving forces: a A Growing Population of Elderly and of Adults w/Disabilities:* Due to the increasing size of CCC'S elderly and disabled population, the demand for long-term care will continue to grow. In 2000, CCC had 123,974 residents aged 65+ . By the year 202, this number is expected to grow by 90%. Contra Costa County had a 40% higher growth rate in the 1990s than the average growth rate in California, and a 62% higher growth rate than the Bay Area. b) A High Number of Residents in Nursing Facilities are Inappropriately Placed, due to such actors as: • General lack of knowledge regarding home and community-based services, • Many consumers cannot afford the cost of alternative living facilities and Medi-Cal will not pay for room and board except in a nursing facility setting„ • • The current service systems are difficult to navigate due to lack of coordination and fragmentation. 0 Fragmentation and Unnecessary Duplication: • Uncoordinated and redundant eligibility standards and requirements for programs set by a myriad of local, state, and federal agencies limit the ability of these programs to provide the most appropriate services to the target populations, • Many consumers who have no one to assist them find it impossible to negotiate this fragmented system which has duplication of screening, eligibility, assessment, case/care management functions, paperwork, documentation, and management information systems, • The eligibility requirements and application process to receive a meal at home differs from those to get a ride to a medical appointment; getting in-home supportive services differs from getting visits from a nurse. Such redundancy leads to frustration for consumers, the inability to provide a seamless continuum of services, unnecessary administrative work for service providers, and excessive financial costs for management. d)Gaps and Inefficiencies in the Curren.t Service Delivery System: • Lack of communication (and therefore coordination) between the medical, social and support systems utilized by the consumers, • Lack of accessible and affordable transportation and housing, • Inadequate personal finances, i i i i i • Insufficient communication about, and access to, services and support, • Limited access to in-home care and support services, proper assistive devices, medication • management, relief from isolation and loneliness, proper nutrition, and assistance with long- term care plans, • Isolation and loneliness among frail seniors and disabled adults is exacerbated by these service inefficiencies. Year 2000 Year 2010 Year 2020 i Total Population 971,262 1,096,253 1,212,788 Persons 65+ 123,974(12.7%) 166,375 (1.5.2%) 236,466(19.5%)i Persons 75+ 58,732(6%) 75,752 (6.9%) 1.01,524(8.3%) Person 85+ 15,759(1.6%) 24,446(2.2%) 30,435 (2.5%) State of California,Department of Finance, Official State Projections. 1993 i i i i i i i i i i i i i i i I I I I I I I I I I I " I I I I I ' I I I I I Supporting Document 2 'TEXT AB 1040 1995 (BATES) • APPENDIX 1 BILL NUMBER: AB 1040 CHAPTERED 10/16/95 CHAPTER 875 FILED WITH SECRETARY OF STATE OCTOBER 16, 1995 APPROVED BY GOVERNOR OCTOBER 13, 1995 PASSED THE ASSEMBLY SEPTEMBER 1.5, 1995 PASSED THE SENATE SEPTEMBER 14, 1.995 AMENDED IN SENATE SEPTEMBER 7, 1995 AMENDED IN SENATE AUGUST 24, 1995 AMENDED IN SENATE JULY 10, 199 AMENDED IN ASSEMBLY MAY 23. 1995 AMENDED IN ASSEMBLY APRIL 17, 1995 INTRODUCED BY Assemblv Member Bates FEBRUARY 23, 1995 An act to add Article 4.05 (commencing with Section 14139.05) to, • and to repeal Article 4.1 (commencing Nvith ;lection 14139.7)of, Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, relating to long-term care. LEGISLATIVE:COUNSEL'S DIGEST AB 1040, Bates. Long-term care. Existing law provides for various programs that provide long-term care services for elderly and disabled adults. This bill would require the State Department of Health Services to administer a pilot program, for the establishment of not more than 5 pilot project sites around the state. The bill would require each pilot project to develop an administrative action plan. Local project sites would be required to have a long-term care services agency that would be responsible for implementing the plan. The bill would require that the department set a capitated rate for payment unless the department determines one or more integrated programs cannot be capitated. Existing law enacted in Chapter 305 of the Statutes of 1995 provides for the establishment of a long=term care integration pilot program. • This bill would repeal that provision. 1 I I I I . I - II THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS: SECTION 1. Article 4.05 (commencing with Section 14139.05) is added to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to read: Article 4.05. Long-Term Care Integration Pilot Program 14139.05. The Legislature finds and declares that: (a) Long-term care services in California include an uncoordinated array of categorical programs offering medical,social, and other support services that are funded and administered by a variety of federal, state, and local agencies and are replete with gaps, duplication, and little or no emphasis on the specific concerns of individual consumers. (b) Although the need for a coordinated continuum of long-term care services has long been apparent, numerous obstacles prevent its development, including inflexible and inconsistent funding sources, economic incentives that encourage the placement of consumers in the highest levels of care, lack of coordination between aging, health, and social service agencies at both state and local levels, and inflexible state and federal regulations. (c) The office of the Legislative Analyst and others have pointed out that California's systems of service delivery in a number of areas are dysfunctional, due to the fragmentation of responsibility and- funding for interrelated services. Principles proposed by the Legislative Analyst to guide the restructuring of these systems include recognizing program linkages, coordinating service delivery mechanisms, removing barriers to innovation, and instilling financial incentives to promote prevention and coordination. I (d) It is both more efficient and more humane to restructure long-term care services so that duplicative and confusing eligibility criteria,assessments, intake forms,and service limitations -will not inhibit consumer satisfaction, impede improvements in consumer health status,and result in the ineffective use of resources. (e) There is a growing interest in community-directed systems of funding and organizing the broad array of health, support, and community living services needed by persons of all ages %with disabilities. (f) It is in the interest of those in need of long-term care services,and the state as a whole, to develop a long-term care system that provides dignity and maximum independence for the consumer,creates home and community based alternatives to unnecessary out-of-home placement,and is cost effective. 1413 9.1 . (a) It is the intent of the Legislature to establish the I I 2 • Long-Term Care Integration Pilot Program that will integrate the financing and administration of long-term care services in up to five pilot project sites in the state. Contingent upon a state approved administrative action plan,at least one site shall be in a rural or under served part of the state. (b) Itis further the intent of the Legislature to support, in each pilot project site, the development of a model integrated service delivery system that meets the needs of all beneficiaries, both those who live in their own homes and those who are in out-of-home placements, in a humane,appropriate, and cost-effective manner. 11139.11. The goals of this pilot program shall be to: (a) Provide a continuum of social and health services that foster independence and self-reliance, maintain individual dignity, and allow consumers of long-term care services to remain an integral part of their family and community life. (b) If out-of-home placement is necessary, to ensure that it is at the appropriate level of care, and to prevent unnecessary utilization of acute care hospitals. (c) If family caregivers are involved in the long-term care of an • individual, to support caregiving arrangements that maximize the family's ongoing relationship with, and care: for, that individual. (d) Deliver long-term care services in the least restrictive environment appropriate for the consumer. (e) Encourage as much self direction as possible by consumers, given their capability and interest, and involve them and their family members as partners in the development and implementation of the pilot project. (f) Identify performance outcomes that will be used to evaluate the appropriateness and quality of the services provided,as well as the efficacy and cost effectiveness of each pilot project, including, but not limited to, the use of acute and out-of-home care,consumer satisfaction,the health status of consumers,and the degree of independent living maintained among those served. (g)Test a variety of models intended to serve different geographic areas, with differing populations and service availability. (h)Achieve greater efficiencies through consolidated screening and reporting requirements. (i)Allow each pilot project site to use existing funding sources in a manner that it determines will meet local need and that is cost-effective. • 0) Allow the pilot project sites to determine other services that 3 i i i i i may be necessary to meet the needs of eligible beneficiaries. (k) Identify ways to expand funding options for the pilot program to include medicare and other funding sources. 14139.12. It is the intent of the Legislature that the costs of this pilot program to the General Fund will not exceed the direct and indirect costs that existing programs would expect to incur had the integrated services not been provided through this pilot program. If the Department of Finance determines,and informs the director in writing,.that the implementation of this pilot program will result in any additional costs to the state relative to the provision of long-term care services to eligible beneficiaries, the department may terminate the operation of all or any part of this pilot program. The state shall not be held liable for any additional costs incurred by a pilot project site. Any such determination made by the Department of Finance shall be available to any party upon request. 1413 9.13. (a) Any contract entered into pursuant to this article may be renewed if the long-term care services agency continues to meet the requirements of this article and the contract. Failure to meet these requirements shall be cause for nonrenewal of the contract. The department i may condition renewal on timely completion of, a mutually agreed upon plan i of corrections of any deficiencies. (b) The department may terminate or decline to renew a contract in whole or in part when the director determines that the action is necessary to protect the health of the beneficiaries or the funds appropriated to the Medi-Cal program. The administrative hearing requirements of Section 14123 do not apply to the nonrenewal or termination of a contract under this article. (c) In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this article is necessary. Therefore, contracts under this article shall be exempt from Chapter 2.(commencing with Section 10290)of Part 2 of Division 2 of the Public Contract Code.The contracts shall i not take effect unless they are approved by the Department of Finance. (d) The Commissioner of Corporations shall,at the director request, immediately grant an exemption from Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code for purposes of carrying out any contract entered into pursuant to this article. 14139.2. The department shall serve as the lead agency for the administration of this chapter.The department's responsibilities shall ' include, but are not limited to: (a) Development of criteria for the selection of pilot project sites. 4 i • (b) Selection of the pilot project sites to participate in the pilot program. (c) Providing, or arranging for, technical assistance to participating sites. (d) Development of specific performance outcome measures by which the program can be evaluated. (e) Development of standards for complying with reporting requirements specified in state law for the programs integrated within the pilot program implemented pursuant to this article. The standards developed pursuant to this subdivision shall apply in lieu of any existing reporting obligations for the programs. The existing individual reporting requirements for programs integrated within the pilot program shall be deemed to have been met through the reports required by this section. Existing requirements for reports to the Office of Statewide Health Planning and Development shall not be eliminated. (f) Seeking all federal waivers necessary for full implementation of the pilot program. (g) Setting a payment rate consistent with Section 14139.5. (h) Approval or disapproval of administrative action plans. 14139.21. The department may accept funding from federal agencies, • foundations or other nongovernmental sources and may contract with qualified consultants to assist with the provision of technical assistance, the development of data collection, reporting, and analysis systems, or any other purposes that further the goals of this demonstration program The department shall not accept funds from any entity that stands to gain financially from implementation of the pilot program. In contracting with consultants to assist with the pilot program, the department shall specify timelines and delivery dates so as to ensure the continued implementation of the pilot program. 14139.22. (a)The department shall convene a working group that shall include the Director of Health Services, the Director of Social Services, and the Director of Aging,or the program staff from each of those departments who have direct responsibility for the programs listed in subdivision(b) of Section 14139.32,and may include the Director of Mental Health and the Director of Rehabilitation, or program staff from those departments with direct responsibilities for programs that may be included as a service in any pilot project site, and representatives from each pilot project site upon its selection. (b) The department shall consult with the working group during the designing of the pilot program, in the selection of the pilot • 5 i i i I project sites, and in the monitoring of the program under this article, and i shall utilize the working group as a resource for problem-solving and a means of maintaining interdepartmental and intersite communication. (c) The working group shall strive to ensure that the pilot program under this article makes maximum use of home-based and community-based services, and throughout the continuum of care for each beneficiary, i encourages the use of the least restrictive environment in which the i beneficiary can receive appropriate care. 14139.23. Upon the implementation of the pilot program, responsibility ! for administering the programs integrated within the pilot program shall be transferred to the department,and shall be specified in an interagency agreement between participating departments. Prior requirements for any program integrated within this pilot program shall be deemed to have been i met through compliance with the requirements established by this article, by i the department for the pilot program by each county's approved plan, and i by the approved applicable federal waivers. 14139.24. The department shall seek all federal waivers necessary to i allow for federal financial participation in the pilot program implemented pursuant to this article. This article shall not be implemented unless and i until the director has executed a declaration that the approval of all necessary federal waivers has been obtained by the department. 14139.25. Notwithstanding any other provision of this article, costs to the General Fund shall not exceed the amount that would have been expended in the absence of the pilot program. 14139.3. (a) Pilot project sites may be comprised of a single I county, a multicounty unit, or a subcounty unit. i (b) Each selected site shall do all of the following: (1) Establish a consolidated long-term care services fund that shall accommodate state and federal fiscal and auditing requirements, shall be used solely for the purposes described in this article,and shall not be used i for any county pooled investment fund. (2) Identify a local entity,that may be either a governmental entity or a not-for-profit private agency, to administer the fund. The local entity may be one that already exists, or may be established for the express purpose of administering the fund. This agency shall be designated as the long-term care services agency and shall contract with the department to carry out this article. (3) Develop and provide to the department an administrative action plan that shall include, but is not limited to: i (A) A complete description of the covered scope of services and I i i i I 6 i • programs to be integrated. (B) A complete description of the proposed long-term care delivery system and how it will improve system efficiency and enhance service quality. (C) Demonstration of a willingness and commitment by the long-term care services agency to work with local community groups, providers, and consumers to obtain their input. (D) Proposed measurable performance outcomes that the pilot program is designed to achieve. (E) A description of the expected impact on current program services to Medi-Cal eligible beneficiaries and consumers of non-Medi-Cal services included in the integrated system. (F) Assurance of minimal disruption to current recipients of long-term care services during the phase-in of the pilot project. (G) Reasonable assurance', ssurance that services provided will be responsive to the religious.. cultural, and language needs of beneficiaries. (H) Assurances that providers who serve the needs of special populations such as religious and cultural groups or residents of multilevel facilities as defined in paragraph(9) of subdivision (d) of Section 15432 of the Government Code and community care retirement communities as defined in subdivision(u) • of Section 1771 of the Health and Safety Code, will be able to continue to serve those persons when willing to contract under the same terms and conditions as similar providers. (1) Specific alternative concepts, requirements, staffing patterns, or methods for providing services under the pilot project. (J) A process to assure that Medi-Cal dollars are appropriately expended in accordance with federal requirements. (K) A description of how the pilot project site will maintain adequate fiscal control and ensure quality of care for beneficiaries. (L) A description of how the pilot project site will coordinate, relate to,or integrate with Medi-Cal managed care plans, local managed care plans,and other organizations which provide services not part of the pilot project. (M) A proposed timeline for planning and startup of the pilot project. (N) An estimate of costs and savings. (0) Demonstration of the financial viability of the plan. (c)The administrative action plan shall reflect a planning process that includes long-term care consumers,their families,and organizations that represent them, organizations that provide long-term care services, and representatives of employees who deliver • direct long-term care services. The planning process may include, 7 I I I I but is not limited to, the members of the local advisory committee i required pursuant to Section 14139.31. (d) The administrative action plan shall receive the approval of the county board of supervisors before it is submitted to the department for final state approval. The board of supervisors shall present evidence of the commitment to the administrative action plan of all publicly funded agencies that currently serve consumers who will be eligible under the pilot project, and all publicly and'nonpublicly funded agencies that will be responsible for providing services under the pilot project. This evidence may include resolutions adopted by agency governing bodies, memoranda of understanding, or other agreements pertinent to the implementation of the plan. 14139.31 . In order to be selected, a pilot project site shall demonstrate that it has an active advisory committee that includes consumers of long-term care services, representatives of local organizations of persons with disabilities, seniors, representatives of local senior organizations, representatives of employees who deliver direct long-term care services, and representatives of organizations that provide long-term care services. At least one-half of the members of the advisory committee must be consumers of services provided under this chapter or their representatives. 14139.32. (a)The administrative action plan shall identify the funds Ito be transferred into the consolidated long-term care services fund. (b) The funds shall include Medi-Cal long-term institutional care, the Medi-Cal Personal Care Services Program, and the In-Home Supportive Services Program and may include funds from the following programs and services: (1) Multipurpose Seniors Services Program. (2) Alzheimer's Day Care Resources Centers Program. I (3) Linkages Program. (4) Respite Program. (5) Adult Day Health Care Program. (6) Medi-Cal home health agency services. (7) Medi-Cal home-based and community-based (8) Medi-Cal hospice services. (9) Medi-Cal acute care hospital services. (10)Other Medi-Cal services, including, but not limited to, primary, ancillary, and acute care. (c) Optional program funds enumerated in subdivision(b)of Section .14139.32 shall be included in the long-term care services fund in any case where a program was funded prior to its integration I I " I I I I 8 I • into the pilot project. (d) In determining which project sites to select for participation in the pilot program, the department shall give preference to those sites that include funds from the largest number of programs existing within the project site at the time the site applies for selection, provided the administrative action plan meets all other selection criteria. With the exception of up to one rural county, preference shall be given to project sites that include primary, ancillary, and acute care in the consolidated fund, provided their administrative action plan meets all other selection criteria. 14139.33. The administrative action plan shall delineate the services to be provided to all eligible beneficiaries. At a minimum, services to be provided shall include all of the following: (a) Care or case management, including assessment, development of a service plan in conjunction with the consumer and other appropriate parties, authorization and arrangement for purchase of services or linkages with other appropriate entities, service coordination activities, and followup to determine whether the services received were appropriate and consistent with the service plan. Service coordination activities shall ensure that the records of each beneficiary are maintained in a consistent and • complete manner and are accessible to the beneficiary or his or her family, and providers involved in his or her care. This shall be the case whether a beneficiary resides in his or her own home or in a licensed facility. (b) Education of beneficiaries, their families, and others in their informal support network, including independent living skills training to maximize the independence of the beneficiary. (c) In-home services. (d) Adult day services. (e) Institutional long-term care. (f) Hospice services. (g) Linkages to acute care services and primary care services, if they are not included in the integrated plan. 14139.34. The administrative action plan may also include any of the following services: (a) Transportation. (b) Home modification. (c) Medical services, including, but not limited to, primary, ancillary, and acute care. (d) Housing and residential services. (e) Other services. determined by the pilot project to be necessary to meet the needs of eligible beneficiaries. • 14139.35. The department may exempt a pilot project site from the 9 i i i requirements of subdivisions(d) and(f) of Section 14139.33 if both the i following conditions are met: (a) State funds were not being used in the geographic area covered by i the pilot projects to provide those services at the time of application to the pilot program. i (b)The pilot project site can demonstrate to the department how it plans to develop these services,and within what timeframe, during the pilot program. i 14139.36. (a) If primary ancillary,and acute care are not included among the services offered by a pilot project site, the i administrative action plan shall include all of the following: (1) A mechanism for tracking the usage of these services by i beneficiaries of the plan. (2) Provisions for the future inclusion of those services in the integrated plan, including the process and timeline by which they will be integrated. (b) Tile department shall. in consultation with the pilot project sites, apply to the federal health care financing administration for a waiver that allows the pilot projects to include medicare funds in the long-term care services fund. Upon receipt of the waiver, within a time period to be designated by the department specific to each site,each pilot project site shall assume responsibility for primary, ancillary, and acute care services. 14139.37. The administrative action plan shall delineate specifically how the pooled funds will be used to deliver services to all eligible recipients in the geographic area covered by the pilot project site. 14139.38. Participating counties shall continue their financial maintenance of effort for each of the programs integrated %%ithin the pilot program under this article. The amount of a county's maintenance of effort shall be the same as if the program were not integrated within the pilot program pursuant to this article,and funds equal to this amount shall be deposited in the local consolidated long-term care services fund. 14139.4. (a) The long-term care services agency shall be responsible and at risk for implementing the administrative action plan. The long-term care services agency shall do all of the follo%%ing: (1) Respond,or provide for response to,consumer needs on a 24-hour, seven-day-a-week basis. (2) Conduct comprehensive assessments. (3) Determine eligibility for long-term care services based on the assessment information. �I I I 10 I • 4 Provide for contractual arrangements for the provision of and ( ) g payment for,sufficient services to meet the long-term care needs of the eligible beneficiary in his or her home,-community,residential facility, nursing facility,or other location based on the mix of programs or services included in the administrative action plan. (5) Provide linkages to acute care hospitals. (6) Maintain control over utilization of services that are authorized. (7) Monitor the quality of care provided to consumers. (8) Maintain a consumer grievance process. (9) Manage the overall cost-effectiveness of the pilot project for its duration. (b) Services may be provided through contracts with community-based providers. In instances where a specific service does not exist in the community,the long-term care services agency may facilitate the development of local programs that provide these services or may provide the services directly, if doing so can be demonstrated to be cost effective. 14139.41. (a) For purposes of this chapter, "eligible beneficiaries" shall be defined as persons meeting all the follow)criteria: • (1) Are Medi-Cal eligible. (2)Are functionally or cognitively impaired. For purposes of this paragraph "cognitively impaired" means having caused by organic brain disorder or disease. (3) Are adults. (4) Need assistance with two or more activities of daily living or are unable to remain living independently without the long-term care services provided through the pilot program operated pursuant to this article. (b)To the extent eligible beneficiaries also receive services from a regional center that serves a pilot project site, the pilot project shall delineate in its administrative action plan how services will be coordinated by the two agencies. 14139.42. (a) Each pilot project site shall serve all eligible beneficiaries who live in the geographic area served by the long-term care services agency. In order to eliminate duplicative administrative costs and to achieve a more efficient delivery system, pilot project.sites shall also serve non-Medi-Cal eligible individuals who, but for the implementation of the pilot project,would have received services from programs whose funds are included in the consolidated long-term care services fund. (b) Funding sources allocated for persons who are not eligible for • ll i Medi-Cal benefits may be integrated into the consolidated long-term care services fund. To the extent those funds are spent on services for persons who are not eligible for Medi-Cal benefits, they shall be segregated from capitated funds for Medi-Cal beneficiaries. No funds derived from the capitated Medi-Cal rate may be used for persons who are not eligible for Medi-Cal. 14139.43.This article shall not preclude a long-term care services agency from entering into additional agreements, separate from the pilot project, to serve.additional individuals or populations. 14139.44. Pilot project sites shall ensure provider reimbursement rates that are adequate to maintain compliance with applicable federal i and state requirements. 14139.5. The department shall set a capitated rate of payment that is actuarially sound and that is based on the number of beneficiaries who are eligible for Medi-Cal benefits to be enrolled in the pilot project,the mix of provided services and programs being integrated, and past Medi-Cal expenditures for services. The rate shall reflect, and the contract shall delineate, the rate at which the local long-term care services agency shall assume the total risk and the mechanisms that shall be used, which may include, but are not limited to, risk corridors, reinsurance,or alternative methods of risk assumption. 14139.51. If the department determines that a program or programs cannot reasonably be capitated, funds may be transferred separately from the capitation payment. The amount of those noncapitated funds shall be based on amounts that would have been expended by the state for those programs in the absence of the pilot program implemented under this article. It is the intent of the Legislature that, if any local pilot project i experiences net savings, those savings shall be used for project expansion and improvement, or to build the required tangible net equity,or if there is no need for expansion or improvement or to build tangible net equity, may be shared by the long-term care services agency and the state. 14139.53. (a) The department shall develop criteria to ensure that pilot project sites maintain fiscal solvency, including by not limited to, the following: (1) The capability to achieve and maintain sufficient fiscal tangible net equity within a timeframe to be specified by the department for each pilot project site. (2)The capability to maintain prompt and timely provider payments. 12 • (3)A management information system that is approved by the department and is capable of meeting the requirements of the pilot program. (b)Any pilot project established under this article shall immediately notify the department in writing of any fact or facts that are likely to result in the pilot project or the long-term care services agency being unable to meet its financial obligations. The written notice shall describe the fact or facts,the anticipated financial consequences, and the actions that will be taken to address the anticipated consequences, and shall be made available upon request unless otherwise prohibited by law. 14139.6. (a) It is the intent of the Legislature that local entities that are potential participants in this pilot program shall be assured of sufficient time to plan their pilot projects, and that the selected pilot project sites shall be assured of sufficient time to phase in the implementation of their programs. To that end, it is the intent of the Legislature that the department, in consultation with potential pilot project sites and the pilot program working group, shall develop a realistic timeline with guidelines for the planning and implementation of pilot projects. (b) Nothing in this chapter shall prohibit the department, in consultation • with the pilot program %vorking group, from establishing a two-stage selection process in which local pilot project sites may be selected on a preliminary basis. Final selection of local pilot project sites shall be based on the completion of an administrative action plan that the department determines satisfactorily meets the selection criteria. 14139.61. The department may adopt:emergency regulations as necessary to implement this article in accordance with the Administrative Procedure Act, Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code. The initial adoption of emergency regulations shall be deemed to be an emergency and considered by the Office of Administrative Law as necessary for the immediate preservation of the public peace, health and safety,or general welfare. Emergency regulations adopted pursuant to this section shall remain in effect for no more than 180 days. 14139.62. Contingent on the availability of funding, the department shall evaluate the effectiveness of each pilot project on a schedule that coincides with federal waiver reporting requirements,and shall make this information available upon request. The department's evaluation shall include, but not be limited to, the.following: • 13 (a) Whether or not the pilot project has reduced the fragmentation and o. improved the coordination of the long-term care delivery system in the pilot project area. (b) Whether or not the long-term care delivery system is more efficient and makes better use of available resources. (c) Whether or not the goals identified in Section 1413 9.11 have been met. SEC. 2. Article 4.1 (commencing with Section 14139.7) of Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code is repealed. O 14 �®��s� O O Supporting Document 3 CONSUMERINPUT FORUM REPORT . '...(January - July z000) Six Consumer Input Forums were hosted throughout the county by the Consumer Input Design Team of the Long-Term Care Integration Pilot Project(LTCIPP)between the months of January and July of 2000. The purpose of the forums was to hear input from consumers and providers of long-term care services regarding what is working in the current system(s)and to solicit recommendations of how the system(s)could be improved. Two of the forums were hosted for residents of low-income housing complexes(Silver Oaks Apartments for Persons with Disabilities in Oakley[15 participants])and Nevin Plaza for senior residents(38 participants);one forum was at the Bethel Island Nutrition Site(25 participants);one was at a community center in Pittsburg(11 participants)and one at a senior center in Pleasant Hill (4 participants). A sixth forum,for Care Managers, was held in Martinez(18 participants). A total of 111 persons participated in the forums. Most of the attendees were users of services(62%), while a smaller number were caregivers(38%). The ethnicity of the attendees was mixed; 33% • African American,5%Asian Pacific Islanders,49%Caucasian,9% Hispanic and 1% Native American and 3%Other or unknown. A majority of the participants were women(78%). The ages varied with 23%of the participants under 60 years old, 14%60-65 years old, 32%65-75 years old, 23%over 75,and 8% unknown. The users of services varied from being independent to quite frail and in need of assistance to participate in the forum. With the exception of the Bethel Island Nutrition Site participants(where all but one of the participants were not MediCal eligible)and the Care Managers,most of the forum attendees fell into the category of MediCal eligible-aged, blind or disabled. Each forum opened with brief self-introductions,a short overview of the LTCIPP and the purpose of the forum. A facilitator at each of the forums asked a series of 4 questions and answers were recorded. Often,there were questions asked by the participants regarding available services. Appropriate referrals were made whenever possible. Participants voiced appreciation of the opportunity to share their thoughts and opinions. The following questions were asked: 1. What services do you (or the person[s=l you care for)currently have/use to assist you to live independently or to improve the quality of your life? • 2. What services do you (or the person[s]you care for)not have(but would like to have)to assist you in living independently or to improve the quality of your life? August 2000 1 3. What could make it easier for you(or the person[s]you care for)to receive the services that you want/need? 4. What is your(or the person[s]you care for) main unmet transportation need? What changes would you like to see in the transportation system? The Consumer Input Design Team recognizes that many consumers of the long-term care target population are unable to attend forums due to physical limitations. The Team knows that input from this homebound population is critical. To accommodate this need,Consumer Input Design Team members are in the process of interviewing homebound consumers through individual referrals from several community agencies. Thirty-five interviews are currently in process. Additional interviews are expected. Input gleaned from these interviews will be added to the input outlined in this report. On the following pages you will find each of the questions and an overview of the answers to date. It is interesting to note that many of the themes were similar in each of the focus groups. Areas of particular concern to a geographic area are noted. O August 2000 2 1. WHAT SERVICES DO YOU CURRENTLY HAVE/USE TO ASSIST YOU TO LIVE INDEPENDENTLY OR TO IMPROVE THE QUALITY OF YOUR LIFE? "I don't know what services there are!" "1 gave up trying to get services. First they told me that 1 could get MediCal. Then they told me 1 couldn't. And they kept asking me questions. It became too complicated." Most forum participants reported using the following services: • Medicare • MediCal • IHSS • Paratransit • Special rates for utilities • Low-income housing(independent:living) Other Services used by participants included: • Adult Day Health • Assisted Living • Board and Care • Support Groups • HMOs • Congregate Meals • Independent Living Resource • Veterans Services • Brown Bag(food program) • Senior Legal Services • Case Management • August 2000 3 2. WHAT SERVICES DO YOU (or your clients) NOT HAVE BUT WOULD LIKE TO HAVE)TO ASSIST YOU IN LIVING INDEPENDENTLY OR TO IMPROVE THE QUALITY OF YOUR LIFE? "1 don't understand the forms. I couldn't find anyone to help me. I just gave up." "I can't afford the medications that 1 need." "They sent me a walker. It was in a box and it needed to be put together. I couldn't open the box. A neighbor helped me, but he didn't know how to put it together. It's still in the box." "I couldn't find anyone to pay for the pillow that I needed for my wheelchair, but MediCal paid my hospital bill when I was hospitalized with sores that I got from not having the pillow." "Sometimes, two hours a month is not enough. I want to have enough time with a client to get the job done...!" "No one comes to the consumer...Everyone expects the consumer to come to them—and the consumer just can't do it!" Themes that we heard repeated in ALL of the forums included: • Assistance with Navigating the System more information => better referral services more case/care management more intensive care management communication between agencies serving the same consumer specialized care management for persons with Alzheimer's and other forms of dementia => nurses/social workers in the home => assistance with understanding eligibility and application procedures => consumers need an educated advocate to assist in accessing the appropriate resources => assistance with advocacy and legal needs • Transportation more affordable,accessible and reliable transportation => errand and escort services/ Shopping services • Pharmaceuticals => additional assistance with pharmaceutical costs => assistance with medication management • Medical => better monitoring of medical needs better communication with medical staff August 2000 4 Additional Themes repeatedly heard in all forums (except for Bethel Island): • In-Home Care => additional IHSS hours(to allow people to stay at home and not have to go into a nursing facility) => task oriented assignment of hours based upon reasonable time to perform the job in a quality manner => back-up caregivers =* assistance with hiring caregivers • Home Visits =:> bring services, including medical care,into the home => more nurses in the community for seniors and disabled persons => more "Friendly Visitors" • Health Care Services =::,, more geriatricians => more mental health services => need for at-home substance abuse intervention programs => dentists who accept MediCal • Housing => more affordable and appropriate housing =* care managers in housing facilities and residential facilities => need for emergency shelters(hotel vouchers are not appropriate for many of the persons in this target population) • Equipment => accessibility to needed assistive equipment and repair of such equipment instruction and assistance on use of durable medical equipment changes in the regulations about how wheelchairs are issued home modifications • Basic Needs assistance with nutritional needs/food financial assistance for emergency needs • Support => support groups for users of services and caregivers • August 2000 5 • Abuse Prevention => programs,to assist consumers to rid themselves of abusive caregivers in their home or in residential or nursing facilities O => more oversight of caregivers at nursing facilities • Social => affordable and accessible social events • Difficulty accessing all services => participants from Bethel Island stressed the difficulty of accessing services due to the remoteness of the island. 3. WHAT COULD MAKE IT EASIER FOR YOU TO RECEIVE THE SERVICES THAT YOU WANT/NEED? "lam always waiting. Waiting for a call back, waiting for my ride, waiting for my case worker-always waiting." "1 wish that I had someone to talk to about what choices to make." "Sometimes I am afraid for my safety." • Respect from the "system" O => being treated as "equal to", rather than "less-than" need for client-centered system providers need to understand that this population has a difficult time getting out and about return phone calls having more of a voice in decisions affecting"me" => more appropriate discharge from hospital (currently discharge is often made prematurely with no caregiver in place) need for more service providers => increased attention to cultural and ethnic diversity increased multi-lingual services • Information => more accessible information to consumers at all levels (including those in nursing facilities). => better understanding of services/more understandable information => better understanding of eligibility requirements August 2000 6 • Mental Health Services => system designed to listen to client with mental health needs • advocates for mental health clients more staffing for mental health services add therapist to IHSS team to assess and refer to mental health resources • Easier eligibility => simpler eligibility procedures => less stringent policies => less paperwork =:;. assistance with filling out forms • Better communication systems => less phone numbers =* the opportunity to talk to a real person • Caregivers => better training for caregivers train caregivers to understand the needs of the consumers("continuum of caregiving) better pay for caregivers => medical benefits for caregivers • => emergency respite services for caregivers 4. WHAT IS YOUR MAIN PROBLEM WITH THE TRANSPORTATION SYSTEM? WHAT CHANGES WOULD YOU LIKE TO SEE? "I got to the doctor's office too late to see the doctor and I had to wait 2 hours before being picked up to go home." "I can't afford the ride to BART. I try to walk, but my oxygen doesn't always hold out" "I get on the van. Get dropped at the BART station and wait for another van. It takes me all day." • Main Problems =* Lack of clear information => Accessibility to service is difficult => Too expensive Waiting periods too long • Rides often too long and out of the way Reservation limitations August 2000 7 => Unreliable pick-up and drop-off times Lift equipment often not working => Limited wheelchair accessibility O => .Geographic restrictions => Safety issues/feelings of vulnerability => Inequities from one service to another => BART elevators often not working Suggested Changes • Expanded Services expanded hours guaranteed ride home,if appointment is running late => express bus service => more accessible services =:> more door-to-door service => expanded escort services more taxi vouchers => choice of sedans instead of only vans => more bus stops/covered bus stops => less geographic restrictions O => better coordination between systems => more group trips • Information easily accessible and understandable information easier eligibility => large print schedules • Reservations => more same day services short service request availability • Drivers => provide sensitivity trainings to drivers => provide trainings to drivers re: geographic areas provide better pay for drivers August 2000 8 Notes .................. ...... Supporting Document 4 LTCIPP DESIGN TEAMS: PURPOSE, MEMBERSHIP AND WORK COMPLETED 1999 - 2000 CONSUMER INPUT DESIGN TEAM The goal of the Consumer Input Design Team was to ensure that the design and the implementation of the Long-Term Care Integration Pilot Project includes on-going consideration and input from the consumers' perspective. Products of this group incluced: • DEFINITION OF CONSUMER • CONDUCT FOCUS GROUPS AND INTERVIEWS • DOCUMENT FINDINGS MEMBERSHIP • Dennis Greenberg Peggy Nichols—Co-chair Benefits Specialist Executive Director Independent Living Resource Lions Blind Center Jeanne Greenberg E.R. Riggall,M.D. Caregiver Alameda/Contra Costa Medical Association Helen Hall Consumer Advocate Gordon Shasky Chair Leah McIntosh IHSS Public Authority Health Insurance Counseling&Advocacy Program Doreen (Pam) Steneberg—Co-Chair Consumer Advocate Hilda Newall Executive Director Ellie Strauss Bedford Center Elder Abuse Prevention • SCOPE OF SERVICES DESIGN TEAM • The purpose of the Scope of Services Design Team was to identify, describe and recommend the specific services to be provided for an effective Long-Term Care Integrated Pilot Project in Contra Costa County. Products of this group included: • VALUES • DEFINITION AND PHILOSOPHY OF CARE COORDINATION • LEVELS OF CARE COORDINATION • SCOPE OF SERVICES DESIGN TEAM RECOMMENDATION OF SERVICES MEMBERSHIP Claude Battaglia Judith Kuftin Benefits Counselor Information &Assistance Supervisor Independent Living Resource CCC Aging and Adult Services Joanne Best—Co-chair Kathy Radke—Co-chair Executive Director Project Manager Independent Living Resource Peer Counseling CCC Health Services Linda Fodrin-Johnson Director Gill Shepard • Elder Care Services Marriage and Family Therapist Board Member, Senior Outreach Services Ruth Gay Dirctor, East Bay Office Ellie Strauss Alzheimer's Association Elder Abuse Prevention Paul Kraintz Dawn Wardlaw-Kays Administrator Public Health Nurse CCC Public Health Department Multipurpose Senior Services Program Nancy Whaley Recreation Supervisor Pleasant Hill Senior Center • TRANSPORTATION DESIGN TEAM The purpose of the Transportation Design Team was to determine the scope of transportation services needed for long-term care consumers, and to recommend how transportation services can be integrated into the LTCIPP. Products of this group included: • TRANSPORTATION POLICY STATEMENT FOR LTCIPP • "USER FRIENDLY"GLOSSARY OF TRANSPORTATION TERMS • INVENTORY OF TRANSPORTATION SERVICES IN CONTRA COSTA • INVENTORY OF"SPECIAL NEEDS"TRANSPORTATION COMMITTEES IN CONTRA COSTA • RECOMMENDATION FOR A MOBILITY MANAGER INV[EMBERSHIP Janet Ableson Gary Demut EI Cerrito City Council Consumer Advocate Consumer Bill Liskamm • Alice Armes Paratransit Coordinator Assistant Manager of Accessible Services CCC Transportation Authority County Connection Ilene Lubkin—Co-chair Jacob Avedon Advisory Council on Aging Metropolitan Transportation Commission Evelyn Rinzler Ombudsman Kitty Barnes CCC Health Services Consultant Advisory Council on Aging Liz Vargus Senior Nutrition Program Paul Branson—Co-chair CCC Health Services Transportation Coordinator CCC Employment and Human Services Gerry Witucki Advisory Council on Aging Dorothy Clinton Consumer Advocate Deborah Workman Program Director Elder Abuse Prevention • SUPPORTIVE HOUSING DESIGN TEAM • The purpose of the Housing Design Team was to determine the range of housing options needed to enhance long-term care for consumers and to recommend how housing options can be integrated into the Long-Term Care Integration Pilot Project. Products of this group included: • OVERVIEW OF HOUSING IN CONTRA COSTA • HOUSING VALUES FOR CONSUMER, PROVIDER AND COMMUNITY MEMBERSHIP Yvonne Beales Daisy Lopoz Assemblyman Tom Torlakson's Office Owner/ Operator Pittsburg City Council Board and Care Homes Barry Cammer Etta Maitland—Co-chair Director of Barcelon Associates Executive Director President, Community Housing & Ombudsman Services of Contra Costa Supportive Services, Inc. Barbara McNair Michael Dugan—Co-chair Manager, Policy and Planning Principal CCC Area Agency on Aging Living for Seniors • Charlotte Perry Lori Ganz Hayward State University Director of Resident Services Eden Housing Georgette Redondo Consumer Advocate Jennifer Hansen Hospice and Palliative Care Judy Wallace of Contra Costa County Consumer Advocate • SERVICE DELIVERY SYSTEM DESIGN TEAM • The purpose of the Service Delivery System Design Team was to develop a care-coordinated service delivery system for an effective long-Term Care Integration Pilot Project which will would integrate medical, psychosocial, home and community-based services , encourages consumer choice, and facilitates the provision of care in the most appropriate, lest restrictive setting. Products of this group included: • GRID OF CURRENT SERVICES • POTENTIAL SERVICE DELIVERY MODELS MEMBERSHIP Linda Anderson Diana Jorgenson Case Management Division Manager Executive Director CCC Office of Aging and Adult Services Contra Costa Public Health Develpmental Disabilities Council Carole Brekke Consultant Eldon Luce Executive Director Deborah Card—Co-chair IHSS Public Authority Public Health Manager • CCC Public Health Department Ken Salonen Geriatric Services Loren Cole CCC Regional Medical Center Executive Director Senior Outreach Services Linda Schaefer Clinical Supervisor Paul DeMange—Co-chair Senior Peer Counseling Program Director Independent Living Resource Bjorg Wasserfall Case Managent Supervisor Senior Outreach Services • • RESOURCE ALLOCATION AND FINANCE DESIGN TEAM The purpose of the Resource Allocation and Finance Design Team was to recommend: • resources which could support a Long'Term Care Integration Project, • eligibility statndards for enrollment, • governance options Products of this group included: • GRID OF CURRENT FUNDING SOURCES • RECOMMENDATIONS FOR LTCIPP ELIGIBILITY • OVERVIEW OF THE COUNTY'S MEDI-CAL AGED, BLIND AND DISABLED POPULATION • THE ROLE OF GOVERNANCE AND A LTC ADMINISTRATIVE AGENCY MEMBERSHIP Stephen Betz Gerald Sharrock Management Analyst Advisory Council on Aging CCC Office of the Administrator Dana Simon Kathleen (Kagey) Dorosz Field Representative Elder Abuse Prevention SEW Health Workers Union, Local 250 • Julie Kelley—Co-chair Bill Weidinger Assistant for Program and Policy Divsion Manager Task Force Member In-Home Supportive Services Program Trudi S. Riley Bette Wilgus Elder Law & Estate Planning Attorney Director Law Office of Trudi S. Riley Mount Diablo Center for Adult Day Health Robert Sessler—Co-chair Laura Wittenburg Director Case Manager Aging&Adult Services Bureau Options for Seniors CCC Employment& Human Services Dept. i 1 ......... ..... .............. ............... Notes ............. ........ . ..... 1 .......... ......... ... ...................................................... ........... ...... _i_ 1 .......... .......... .......... ............... .............................................................................................. ............. ........... r- ........... Supporting Document 5 • PHASE I -ACCOMPLISHMENTS TO DATE On a complementary track to the planning for a fully integrated and captiated system of long-term care health, social and supportive services has been the the work of Phase I: Better Coordination of Existing Services. In the area of Increased Coordination of Existing Services, major accomplishments include: • CORD (Contra Costa Community Online Resource Database) has been created through a contract between the non-profit Contra Costa Crisis Center and the EMS, HS and Community Services Departments of the County. This online database reduces fragmentation and duplication of efforts, while offering easily accessible, up-to-date resource information. You can connect to CORD @ http://www.crisis-center.org/CORD.html • • Aging and Adult Information and Assistance(in addition to offering professional resource assistance to callers) now provides a "single point of entry"and intake for Adult Protective Services, In-home Supportive Services and Linkages Care Management Program. • A Mental Health clinical specialist from Contra Costa Health Services has been placed in Employment and Human Services' Aging and Adult Services Bureau, as a mental health consultant, increasing the bureau's ability to work with difficult cases by expanding its multi- disciplinary team. In addition, Contra Costa Health Services has taken a proactive approach to increased collaboration between the Health Services and Employment and Human Services Departments, by spearheading an Adult Services Task Force "to explore services currently provided by EHS • and HS to determine ways to work together to provide comprehensive, coordinated and I i I consumer-friendly programs for adults who are disabled,aged, or medically fragile". Proposals being developed by this interdepartmental Task Force include: I I • expansion of EHS's Adult Services Information and Assistance Program by inclusion,of I Health Service's medical social workers in the program, • an interdepartmental confidentiality "release"form, I • expansion of interdepartmental case (care) management standards, protocols and teams, I • shared screening, assessment and referral tools, I • a common MIS system for client tracking, data reporting and analysis, and outcome I I measurement and reporting. I I I I I I I I I I I I I I I I I I I I i I I I I I I I I I 1 \ './ --�'�-- \ Supporting Document 6 • MEDI-CAI,DATA FOR CALENDAR 1997 (preliminary data—a working document) 1. Number of MediCal Aged, Blind, or Disabled (ABD) Eligibles: 29,656 2. Eligibles with at least one month during the year on Medicare: 17,131 (57.8%) 3. Eligibles with at least one month during the year on Fee-for-Service: 28,060 4. Eligibles with at least one month during the year in Managed Care 2,419 5. Eligibles in both Fee-for-Service and Managed Care during the year 825 6. Type of MediCal eligibility Aged 10,543 Disabled / Blind 16,587 Previously Disabled (but 65+) 2,907 7. HIV-positive at least one month: 649 8. Developmentally disabled at least one month 1,568 • 9. Of the 29,656 MediCal eligibles, 5,498 (18.5%) had no MediCal expenses during the year. 10. Total MediCal ABD expenditures in year $109,470,290. 11. Average expenditure per eligible $3,691. 12..Average expenditure per user $4,531. 13. Average expenditure per HIV-positive user $3,666. 14. Average expenditure per Developmentally Disabled user $4,309. 15. Total IHSS authorized (not paid)expenditures $22,424,646. 16. Eligibles with IHSS authorized expenditure in at least one month 4,967 17. Average annual authorized IHSS expenditure per user $4,515. 18. Average total MediCal expenditure per eligible, under age 65 $3,091. 19. Average total MediCal expenditure per eligible,over age 65 $4,443. • 20. Average total MediCal expenditure per user, under age 65 $3,907. 21. Average total MediCal expenditure per user, over age 65 $5,264. I I I I I. I I M O co 0 . CO ;CO) : 0O 'O ' (D rl— LO , f- . N r- qct Il , M ; I 17 Un cM : M :Nq UIf� ! CN! � 1 � IM1Cn ; � iN : :ao (D 0 :(O . q ; OD CD LO U) ICO ;co 00 h ! 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Cl) 0 w � M � � ti W J 0) O M O 0) IL m O M Lr "t �- w 0 J 0 W Z Q fn W J CL m ti D J w LU Ld 0 It It a Z W �t cD r- 00 Lo c(D ti 0 i i i i NON-IHSS MEDI-CAL ABD EXPENSES FOR JUNE,1997 i IHSS VS. NON-IHSS ENROLLEES When comparing IHSS under and over age 65, note that Medicare expenditures are not included in these tables. This information is not yet available. For IHSS enrollees, 94%of the age 65+group are on Medicare, compared to 39% in the under 65 group. Total expenditures for both groups, and especially the older group, are therefore understated. TABLE MEDI-CAL EXPENDITURES i IHSS NON-IHSS IHSS ENROLLEES, ENROLLEES, ENROLLEES UNDER AGE 65 AGE 65+ PROGRAM (N=21,607) (N=1,666) (N=2,096) Nursing Facility A Level ICF $55,470 $261 $0 Nursing Facility A Level ICF-DD 178,146 0 0 Nursing Facility B Level SNF 3,411,644 10,504 72,904 Inpatient Hospital 1,072,644 176,146 102,103 Physicians'Services 366,193 46,890 42,866 Adult Day Health Care 35,860 17,129 41,833 Home Health Care 18,791 23,448 2,359 Hospice Care 82,265 8,529 0 e Pharmacy 1,243,149 214,234 209,190 Hospital Outpatient 132,075 28,616 7,138 Outpatient Clinics 352,763 45,902 16,481 Durable Equipment 57,402 46,312 25,135 Hemodialysis 117,795 45,523 25,409 Medical Transportation 73,651 22,426 18,970 Laboratory Services 23,922 3,689 650 Other Services NOTE 136,399 52,918 29,804 TOTAL $7,358,1691- $742,527 $594,842 i TOTAL, PER ENROLLEE $340.55 $445.69 $283.80 i NOTE: "Other Services"includes optometrists, podiatrists, blood bank, PT/OT, Mental Health, prostheses, substance abuse services, State Hospital, respiratory care, etc. These data are not available separately in the State database provided to counties. i NON-IHSS MEDI-CAL ABD EXPENSES FOR JUNE, 1997 IHSS VS. NON-IHSS ENROLLEES TABLE II EXPENDITURE PER ENROLLEE IHSS NON-IHSS IHSS ENROLLEES, ENROLLEES, ENROLLEES UNDER AGE 65 AGE 65+ PROGRAM (N=21,607) (N=1,666) (N=2,096) Nursing Facility A Level ICF $2.57 $0.16 $0.00 Nursing Facility A Level ICF-DD 8.24 0.00 0.00 Nursing Facility B Level SNF 157.90 6.30 34.78 Inpatient Hospital 49.64 105.73 48.71 Physicians'Services 16.95 28.15 20.45 Adult Day Health Care 1.66 10.28 19.96 Home Health Care 0.87 14.07 1.13 Hospice Care 3.81 5.12 0.00 Pharmacy 57.53 128.59 99.80 Hospital Outpatient 6.11 17.18 3.41 Outpatient Clinics 16.33 27.55 7.86 Durable Equipment 2.66 27.80 11.99 Hemodialysis 5.45 27.32 12.12 Medical Transportation 3.41 13.46 9.05 • Laboratory Services 1.11 2.21 0.31 Other Services 6.31 31.76 14.22 • i I I NON-IHSS MEDI-CAL ABD EXPENSES FOR JUNE, 1997 IHSS VS. NON-IHSS ENROLLEES I TABLE III USERS I IHSS NON-IHSS IHSS ENROLLEES, ENROLLEES, ENROLLEES UNDER AGE 65 AGE 65+ PROGRAM (N=21,607) (N=1,666) (N=2,096) I Nursing Facility A Level ICF 79 1 - Nursing Facility A Level ICF-DD 53 - - ..Nursing Facility B Level SNF 1,519 7 37 Inpatient Hospital 300 43 51 Physicians'Services 4,642 473 695 Adult Day Health Care 54 26 58 Home Health Care 48 36 11 Hospice Care 38 4 - Pharmacy 8,899 931 1,320 Hospital Outatient 1,268 205 99 ,Outpatient Clinics 2,280 253 222 Durable Equipment 487 211 398 Hemodialysis 151 52 52 Medical Transportation 412 79 78 Laboratory Services 531 62 18 Other Services 1,630 283 311 I I I I I I I I I I I I I I i I I I I I NON-IHSS MEDT-CAL ABD EXPENSES FOR JUNE, 1997 IHSS VS. NON-IHSS ENROLLEES TABLE IV EXPENDITURES PER USER IHSS IHSS NON-IHSS ENROLLEES, ENROLLEES, ENROLLEES UNDERAGE 65 AGE 65+ PROGRAM (N=21,607) (N=1,666) (N=2,096) Nursing Facility A Level ICF $702.15 $261.00 $0.00 Nursing Facility A Level ICF-DD 3361.25 0.00 0.00 Nursing Facility B Level SNF 2245.98 1500.57 1970.38 Inpatient Hospital 3575.48 4096.42 2002.02 Physicians'Services 78.89 99.13 61.68 Adult Day Health Care 664.07 658.81 721.26 Home Health Care 391.48 651.33 214.45 Hospice Care 2164.87 2132.25 0.00 Pharmacy 139.70 230.11 158.48 Hospital Outpatient 104.16 139.59 72.10 Outpatient Clinics 154.72 181.43 74.24 Durable Equipment 117.87 219.49 63.15 Hemodialysis 780.10 875.44 488.63 Medical Transportation 178.76 283.87 243.21 • Laboratory Services 45.051 59.501 36.11 Other Services 83.681 186.991 95.83 • \ .......... l4otes ............. ............... ..,.. ................ \ ................................... \ .............. ............ ............. .......................................................... ......................... Supporting Document 7 • A Vision of an Integrated Adult and Aging System of Care Based upon the work of the Design Teams and the LTCIPP Task Force Independent r p GOVIERNING BODY �� Responsible for : Ombudsman / => Mission ; QA �yk Fiscal it Policy ;; t Contracts Responsible for: Ad ministrative • Financial admin ;; LTC AGENCY • Admin procedures 0 Contract admin ;; • MIS All Medi-Cal Entry/ Info Unit In only • Evaluation /QA • Screening eligible • Constituent Relations �� ,� • Enrollment „ Referral to ABDs • Initial Assessm nt n u -___=-________________ other programs Linkage with: as appropriate • Medical Provider Network and PCP: Care Coordination • County Clinics Inter-disciplinary • Community Networks Team • Managed Care Orgs. • Other? Care Plan (Services offered) • Education • Prevention Services Medi-Cal State Plan services, • Abuse/Crisis Intervention such as: • In-Home Support Services Inpatient Hospital Hospital Outpatient • Adult Day Services • Clinics • Residential Care/Assisted Living • Institutional Care Pharmacy • End of Life Care Durable Equipment • Transportation Hemodialysis • Durable&Assistive Devices Lab Services Plus others (to be determined) • Legal Assistance • Spiritual Support , *ABDs—aged, • Plus others (to be determined) blind or disabled Vendor Contracts • 1F Notes • • Supporting Document 8 • SCOPE OF.SERVICES DESIGN TEAM SERVICE RECOMMENDATIONS . For the Long-Term Care Integration Pilot Project . ♦ denotes Mandatory Service as outlined in AB 1040 ❖ denotes need for Waiver or Change in Regulation (when using MediCal $) - . .......: .:.....: ..u.... `.is: .. ARE.MAN GE (a collaborative process between a client/ consumer* and care manager, which assesses consumer needs,educates, plans, implements, coordinates, monitors and evaluates options and environmental needs, using formal and informal available resources, to promote quality health, social and support services which meet the needs of the consumer) Levels of Care Management /Advocacy 1. Information and Assistance—telephone screening and referral to appropriate programs to meet consumers' needs, or linkage with Care Management Team. 2. Care Management I - provides information regarding available services and assistance with access to these services as necessary. 3. Care Management II — active involvement with consumer in determining service • needs,developing the care plan, identifying the services, accessing these services and monitoring and evaluating for care plan efficiency. 4. Care Management III— Care Management Il +develops support system for consumer. * Direct Support—hands-on assistance is provided by the Care Manager or member of a multi-disciplinary team when it is inappropriate/ or not possible to access. EDUCATI N. ..... (education of consumers, their families, and others in their informal support networks to maximize the independence and choice of the consumer) Including„ but not limited to: =::> Abuse => Chronic conditions Consumer rights Independent living skills training => Information and assistance Long -term care options • Nutritional Counseling => Substance Abuse Prevention Social / Recreational Activities Revised 3/01 1 I I i ............ �. HOMES IN - (excluding skilled nursing facilities, intermediate care facilities, and acute care facilities) • IN-HOME SERVICES/DOMESTIC I (assistance with Instrumental Activities of Daily Living[IADLs] such as cooking, (cleaning, shopping, household cleaning, laundry, and transportation to necessary appointments) I I • IN-HOME SERVICES/PERSONAL CARE (assistance with ADLs such as bathing, dressing, grooming, transferring,toileting, eating, continence and ambulating) I I • IN-HOME SERVICES/PROTECTIVE SUPERVISION (observing consumer in order to safeguard the consumer against injury, hazard, or accident) I • ❖ IN-HOME SERVICES/PARA-MEDICAL CARE I (para-medical services, which may be administered by a caregiver when taught& monitored by skilled professional; such as medication management, wound care, trach care, etc ) (There are issues being discussed and researched regarding this recommendation concerning standards of safety and comfort level for the consumer and caregiver when: paramedical services are performed by caregiver vs. high cost of care, if performedllby professionals) I I • IN-HOME SERVICES/HOME HEALTH CARE (skilled health care administered by a professional;to provide intermittent skilled nursing and other therapeutic services such as physical therapy, speech therapy, occupational therapy, I registered dietician services and home health aide services, in accordance with a plan:of treatment prescribed by the attending physician) I ' I • ❖ NUTRITION/FOOD SERVICES I (access to groceries, preparation of meals at home;congregate meals and home-delivered meals, and oral/liquid nutritional supplements) I • EMERGENCY RESPONSE SERVICES I (interim service provided in a consumer's home during a crisis or emergency situation. I . I I II I I Revised 3/01 2 I I • 4- CAREGIVERS SUPPORT/RESPITE (includes assessment of caregiver needs, including the provision of information and • education on health promotion and disease prevention, emotional support, peer support and respite care) "DAV.: 9kWU8 (Adult Day Services have been shown to improve quality of life, improve or maintain health, delay institutionalization,facilitate the ability to remain living at home in the community, and enable respite care for caregivers) 0 ADULT DAY HEALTH CARE (a day care program that provides social, recreational and health services, as well as care and supervision for persons needing physical rehabilitation and/or maintenance, while offering respite to caregivers) • e.- SOCIAL DAY CARE (a day care program which offers social and recreational activities to client consumers, while offering respite to caregivers) RESIDENTIAL FACILITY LONG-TERM-CARE,:-: '.....'­ (for persons who require the continuous availability of services for the treatment of illness or injury, but do not require the full range of services provided in an acute care hospital, and cannot receive these services at home. These facilities provide nursing and rehabilitation, as well as custodial care,for people with serious health/ mental health/dementia related needs; includes 4- Residential Care Facilities/Assisted Living,ICFs-Intermediate Care Facilities, SNFs - Skilled Nursing Facilities and locked or secured facilities) ...... ............ (comprehensive care specifically designed for terminally ill persons, offering an individualized program of medical, nursing, unskilled, social, psychological, and spiritual support. Provides pain and symptom management plus psycho-social and spiritual services for the consumer and family) • Revised 3/01 3 i .a .....:...,.. :r ♦. HEALTH SERVIC S � : => Primary Medical Care * => Acute Medical / Psychiatric Care * * specifics to be determined => Alternative Health Practices I I I • MENTAL HEALTH SERVICES I (assessment and counseling to assist persons with family problems, loneliness, depression, anxiety, grief and other mental /emotional issues and provisions for crisis residential services.) I • PHARMACY AND MEDICATION SERVICES I (including medication education, monitoring, management, access, delivery, dispensing, and access to a pharmacist)(inclusion of some vitamins) I REHABILITATION AND HABILITATION SERVICES (home assessment regarding rehab needs and access to and provision of different types of I therapies to assist in recovery and recuperation, and acquiring, retaining and improvin;;the self-help, socialization and adaptive skills necessary to reside successfully in home aInd community-based settings) I • PREVENTION AND WELLNESS SERVICES (access to appropriate screening procedures including, but not limited to, nutrition, podiatry, vision, hearing,dental, blood tests and growth and function tests) I • ❖ SUBSTANCE ABUSE INTERVENTION (access to appropriate screening, counseling and rehabilitation services to assist those with alcohol, drug, smoking,food and other addictions) I I OC RE E ER: S ASSURAN S VI E AL : (services which include communication devices, or periodic telephone contact/ visiting to verify the consumer is safe or to offset social isolation) I I I I Revised 3/01 4 I • :TRANSPORT TI N. A O _ .:..:...:::.::::. (including medical appointments and other necessary destinations) • PUBLIC AND PRIVATE FIXED ROUTE AND PARATRANSIT SERVICES ■ ERRAND AND ESCORT SERVICES (assistance and escort services for medical appointments, and other necessary destinations) ■ MOBILITY MANAGER (by working with Care Coordination teams, is responsible for providing information and advocacy regarding the best transportation options for consumers.) ACCESSIBILITY.AND'MOBILIZ'Y PROVISIONS` • ❖ HOME MODIFICATIONS (provision of modifications and repairs necessary to provide an environment that is safe and functional for the consumer) • ❖ DURABLE AND ASSISTIVE DEVICES (will need waiver for more flexibility) (timely provision, assembly and training for the use of necessary assistive devices and • durable medical equipment for the consumer) INTERVENTION • ❖ CRISIS INTERVENTION (provides emergency assistance to consumers in crisis situations, including, but not limited to emergency shelter,food,financial assistance, and crisis residential) • ABUSE INTERVENTION (resources for protecting the welfare and safety of the consumer in their homes and communities from physical, emotional, neglect and financial abuse) `BENEFIT :: TS 14 ;ADV. CAC -AND:;::•:L'EGAI ASSISTANCE - : ....:.... ........ (as it relates to eligibility /entitlements) SPIRITUAL AND CULTURALSI[1PPORT • (honor and support the consumers individuality V'in these areas)' Revised 3/01 5 Notes • • • SupWrting Document 9 TRANSPORTATION POLICY STATEMENT For the LTCIPP Access to transportation is key to maintaining quality of life for all individuals. Ability to travel reduces isolation and maximizes independence and provides access to essential services, resources, and socialization. An accessible transportation system must be safe, reliable, convenient, affordable, and user friendly, in order to meet the basic needs of the community. Seniors, people with disabilities, low-income individuals and people living in outlying or more rural areas of the county nnust have equitable access to these resources. People who require errand or escort services, due to disability, must also be accommodated by the transportation system. • Transportation includes: Fixed-Route • Regularly scheduled service that follows a fixed route with specified stops • Required to be wheelchair accessible • No eligibility requirements Paratransit • Demand responsive curb-to-curb or door-to-door (non-fixed route) service by advance reservation • Eligibility requirements generally apply Errand/Escort • Services which provide individuals to accompany consumers who cannot travel alone due to physical or cognitive impairment, • Or to travel on behalf of those individuals who require assistance with basic needs such as shopping for groceries or pharmaceuticals July 2000 forting,Document 10 • Contra Costa County LONG-TERM CARE INTEGRATION PLANNING PROJECT A Collaborative Effort of the Health Services&Employment&Human Services Departments Date: January 9,2001 To: Task Force From: IIousing Design Team Subject Recommendations PHILOSOPHY OF HOUSING Mission Seniors need to live in their "home", incorporating services and housing modifications so as to allow them to age in the same place. Economic reality often requires that low-income individuals, who require a higher level of care, must move to a new place; thus, aging-in-place continues. The housing component and service components must become integrated in order to meet the human need. Values • The following values should be incorporated within any housing component: ➢ Housing and appropriate services must together be affordable to both the individual and the community. ➢ Decisions should be made by an informed Consumer and their family/representative (self determination). ➢ Informed choice by the consumer of their selection of "place", should include consideration of the "least restrictive environment", acceptable level of personal risk, desired privacy, necessary socialization, adequate nutrition and respect the of individual cultural values. Goals ➢ There must be access to service co-ordination(case management) at all levels. ➢ There should be adequate, affordable, safe housing in a variety of levels for the aging and dependent adult community in this county. Adequacy should be both in terms of quantity and in quality service. ➢ Housing should be an integral part of Long Term Care planning considerations. ➢ Aging-in-place"in one's own home" should not be defined as the traditional "home" but as a"home environment' where they are currently living. Their"home" may change as their needs change,and they will once again be aging-in-place in their new"home" environment. Summary: Funding for low-income seniors and disabled housing is sorely inadequate. Funding for affordable housing with integrated services is virtually non-existent. This must to change if we are to meet Long Term Care goals. Funding to create the needed housing with integrated services needs to draw upon the resources of the local, state and federal governments including creative blending of monies froth various housing and service funding sources. Irrespective of the above discussion, establishment of rules and regulations need to be made recognizing that our knowledge, comprehension of human need and teeluiological wisdom continue to change. Flexibility, care and understanding need to be the watchwords. Team member continents As part of long-term care we want choice. • Jf e should give high value to aging in place, wherever that may be. • Affordability and quality(of place and delivered services) are paramount. • Education and prevention should be part of the long terns care as it will retard the onset of the disabilities of aging and potentially enhance the quality of life. An ability to modify one's current "home" to address "accessibility" should be considered before long-term care is needed. • We need to expand services and housing, and various assisted living options. • Develop a system with the integration of housing and services at all levels. If you are living in your own home, if you move to another level, including nursing homes, it should always be safe, adequate and affordable with integrated services. Keeping people in the least restrictive environment may affect choice. The Consumer Directed model should use care-managers to help the person explore their options, including the option of choosing more risk in return for more.independence. How this works with dementia clients is always the hard question, as they are, by definition, unable to make reasoned choices. (One member noted that as technology and medicine make advances in treating dementia, there may be a cure, so this problem may, long terns, not exist). The need for flexibility in mandated standards as is evidenced in handicapped environments, where current design is based upon abilities of younger people, not for aged disabled with limited upper-body strength. • It was suggested that the cost to retrofit one's house to meet disabilities could/should be a medical reimbursement. Train managers or hire part-time care managers located where seniors congregate or live. They could provide intervention to delay or prevent the need for assistance, and allow them to age in place. 0 Look for monies from [IUD, or Medi-Cal waivers for "Adaptive Reuse. " SuaDorting Document 11 LTCI Development Readiness This document is designed to provide potential Long Term Care Integration (LTCI) pilot projects the information needed to evaluate their own readiness to seek future grants or to prepare detailed proposals for LTCI. An acceptable detailed proposal that demonstrates commitment and a reasonable approach to achieve full LTCI would be necessary to engage the state level resources required to initiate LTCI development phases. The shaded areas are information only, as they go into further detail that would be required in an Administrative Action Plan. I. LONG TERM CARE INTEGRATION PILOT PROJECT Summary Based on the following questions describe the proposed LTCI Description of project. Proposed Project 1. Provide an overall description of the full continuum, at-risk pilot project as is currently envisioned. 1 Include a brief description of the: • Planned governance structure; • Organizational structure; • Service delivery system; • Care management operation; • Quality assurance method; • Financing and payment structure. 2. Describe the significant steps or phases that will lead to the envisioned full continuum, at-risk LTCI. • Explain the reasoning behind each step/phase to describe how each phase will lead to full continuum. 3. Indicate anticipated challenges or barriers and explain how the plan, as it is laid out, is designed to deal with them. 4. Explain the logic of choosing this LTCI implementation approach for your area and why it is expected to be successful in achieving full continuum, at-risk LTCI. • ' It is recognized that the current description for full LTCI may be revised as experience is gained through implementation steps. 1 i I I For eachro osed phase of LTCI the following p p p g information is required. For each of the following elements, describe the progressive steps leading to full continuum, at-risk LTCI. Geographic 1. Define the geographic area to be covered consistent with Area to be Welfare and Institutions Code Section 14139.3(a). Covered Single county • Multi county (contiguous) • Subcounty unit 2. Identify the zip codes to be included. I Funds for W & I Code Section 14139.32 identifies all of the program funds Services and that must be included. In selecting sites for LTCI, consideration Programs to will be given to those seeking to consolidate the most be Included in comprehensive mix of programs and services. the LTC Consolidated 1. List each program and Medi-Cal service to be included. • 2. Describe how the mix of funding sources supports coverage of the full continuum of medical, social, and supportive services. Include all sources of funds to be consolidated into the integrated fund. 3. If any particular programs or services are not included, explain why they are proposed for "carve out" and when they will be added. Also indicate how coordination willloccur in the meantime. I 4. Based on Section 14139.36(b), specify whether or not Medicare funding will be included in this phase. 5. Describe methods of coordination with programs that will not be consolidated (i.e. Older Americans' Act, Caregiver Resource Center, etc.). I I I I 2 • Scope of W & I Section 14139.32 requires a number of program funds to q p 9 Services to be be consolidated. Note that, per 14139.32(c), included among Covered them are primary, ancillary, and acute care. The services listed must include those that are covered by the program funds to be consolidated.2 1. Using the following chart format, list and define each type of service (indicating new services to be included in the project). The definitions of service must be specific and include any limitations to service utilization or authorization. List the matching funding source that will be transferred into the consolidated fund. Type and Definition Limitations to of Service Program Utilization or Funding (Existing or New?) Coverage Authorization Source • Population to W & I Code Section 14139.41 defines LTCI eligible be Covered beneficiaries.3 1. Define the population to be served consistent with the W.& Code. Continued on next page • Z Services previously provided by existing programs must be included in the proposed scope of services. Consistent with W&1 Code 14139.43.it is understood that some counties will choose to serve a broader population. 3 i i i i Population to 2. Specify whether adult will be determined by age: 18 or 21. be Covered Include the premise for selected age factor. i (Continued) 1 3. For each phase, identify any sub-population (covered by the definition in 14139.41) not included, other than individuals under the age of 18 or 21. • Explain the reason for those exclusions; • Describe how and when the excluded sub-population will eventually be covered by the pilot. i i Non-Medi-Cal W & I Code Section 14139.42 requires that sites also serve Population to non-Medi-Cal eligible individuals who, but for the be Covered implementation of the pilot project, would have received services from programs whose funds are included in the consolidated long-term care services fund. i i 1. List any program to be consolidated that would require covering a non-Medi-Cal eligible population. i 2. Define the non-Medi-Cal eligible population to be covered. • 3. Describe the scope of the specific services to beiprovided to the non-Medi-Cal eligible population consistent with those services that would have been available in the absence of consolidation. 4. Describe the mechanism to segregate the funds for persons not eligible for Medi-Cal benefits from the capitated Medi-Cal funds. i i i i Stakeholder 1. Describe the collaborative process to develop and administer Involvement the pilot project which demonstrates a willingness'and commitment to work with local community groups,' providers, and consumers to obtain their input. Refer to W & I Code 14139.31, 14139.3(b)C, 14139.3(c). 4 • 11. ORGANIZATIONAL STRUCTURE AND SERVICE DELIVERY SYSTEM Overview 1. Identify and describe the local entities currently managing the delivery of services to be integrated into the pilot project. Also identify overlap and duplication of services. (Consider this the problem statement.) 2. Describe specific improvements being proposed under the pilot project, (e.g., requirements and changes in proposed staffing patterns, oversight, or methods for delivering services). 3. Describe how the proposed service delivery system will: • Change from the current system; • Reduce or eliminate incentives to shift consumers between programs and services; • Improve system efficiency (e.g. reducing/eliminating duplication and administration); • Enhance access and service quality; • Maximize the use of home- and community-based services to the extent feasible. • 4. From the consumer's perspective, how is the proposed model going to improve care to consumers? 5. Describe how the pilot project will coordinate, relate to, or integrate with Medi-Cal managed care plans, local managed care plans, and other organizations which provide services not part of the pilot project. Refer to W & I Code Section 14139.3(b)(3)(L.). 6::sDescribe;=#teoiYmuniy' :outreach proposal=includng;use;;ofnew •::�.r *.fit M.;�vs't t•"'i!" ."!i �` � i� �1\'tt'sf'� •,or;;existn �cesoui:ces. .. �,,.�.;;::� �-�"<:...+ , ^ ti::�. ;y. . .r..;t9........_:.x...,._,.�,:,.:rffi..,.�.�...._....�..,.-..�_.: ;_,.,�1.:>=_.a.---y....._...'::s..�tom:•;.......��.::t..:zr^.�!L'. 3' �.=n:S.3la_wL�i: 7 . _Descnbehow':thei=:pilot"projeet:willcie�tv .eto =gym nan main tain;wr�tten policies that;add_ressthe;member':s:rlghtsgandLty .'."d..: 'a.=' rte.', i; ;�. �Y.: .,S�Z.;.C:'ii:;__;f.t:i5.: d, {+.;^�, z res(oislilities;and;w�ll'communicate th'ese4:to:its;mernbersb and:.l. ro .. :Cr� . ...4; Pvides :The` Tolicies'sl odldib'diude wbut:are;riot limited to.• Membe'r<s ri ht to`be;treatea;-witfi'res •` Th'ei f vid " o tie;:' �:o ;ed:with inormatio`n:ab, out tf:e htt or anizaton=and> fsservices _:r::.::t:..'•: =;; ; . r • Continued on next page 5 I i ..y,:; _ •:h: ;�.':� '.,,1.:: �': a - :?�:�y .r.e:tiL"':s 1.5�:'.62:..ki:>:z:r Overview •; Tfie" i t o "'artie'i ate in dec sioh'.. akin =re ardin :the`r''K Continued �, � �: r: :.' - � `/''�. ,s;' a'va t:9' ,:. X^:.J••t # '1't• !::s" .,. ..1 wg..�n,�.,h.N i..�.'''_a•,x �,3 'i.: .�. .+..^x Yt} r. �", ..p"_,�' E •: a,.f-.t:i ,e:; ! <..�,.. ;•°=l"herhttoroice: ri�e�,vanees abouttherganizatio, '• '':gra .nc, --!S.;i { �.,,.ag '�-�4Care:�received`���...:�• :� i�;>14: �• .: :�grT""�zifq.` •4'.K-_. �:.. .,�-,•.'..fu;rx; :Y�.z.,y:±:• tk3;7's"' 'k•... � __ � i•�'q'-'PT �e�7�'.ht: o�ra��.: �c : :; �'. -" ;.w ; ' �.r;�s;::..'`�, -�1:. ,,e�.• �,€;?:�:> !� „g t eguesf a.airYtiearing 'to. ave access to their s `hs:3.-. atr,Wm •r,; abs: edical`records a d:�to.ciisenrol �:. � � ;�'�° �.� f`yl= Member;"esponsibilities4-to proA a-curate infortnation::fo >.±.:{ :.,,:.;•at.t> .t..i:i= >.ti. 7�. v-•6 s '.kr':+Q'.yw•,:•-:-; `S�`:Y'2;s ;' s.•:1s.�� i*the;professional sta"fif follow instivctions;andreooerate::_. :r yt. .,_.•': .�4:�a:.l'.`::t.l.� .i;+• ,:.i?3•n .;:AN ..Y.N:•:• r:� e�_ �'. :•?f:'":.Y` ??':'=¢i':r..'�a�.. 1 �s..4.. w.!: �•R�.^r�h`,:,tif,':`t'�x''i�.''v :+A�'�s� �ze.X;i� ^,1 �:.N'� ,r�..^.�b�i:}Se:.s'.. �•y••'Ywiththe. �ro�ide�s, :��,<_<��:,, j.' :�.' �:, .�;:� :m`I...r:••t.:i_>�,�''��: i,;:..... .::,qev.,•;. ...<.is..,,•�``' t."s"r,�;,_ .x�:y. ._.�r;,..t`•tp;:�:,w,�':M °°`.'`r'..�y;a��:tit _ :�.w�.�.,. .Procedurestormonitor� e-meance's%"steml. :.' !-AiJdluding=timelyxesolution:' 'P" :: -an isfeedbac tto;-com Tainan "and-•:ensura :ce.that'th grievance , n e �:is��,repo ...:. ........... .. el�' ,': �>.... .-., ::;r.: ,9.z;"-:.tY. -���:�>' "}:sF.riF;--:• _ a.x•� s-x., „l=•. •r:�3?:':i:"•i�y'.. �ati'`;c:'.-31�y' ',: i�::..r ... a ro riate:lev Procedures:toensure:tfemer%ibers;;n tttoco:rficieitialif ' ,. . ical'i..,wy-..,t�..:•dt . � r :.:3:. :�}:_ :•fix-:r':�^i,..._.a ,..f < 'a. :Methods toconduct suryeys:of:membersatisfaction '; 3 • p::::c�•::;:-..:,,,.:....::-i,;r�:'.: •'.:^ ;::s'.x_;, E. .+.r.::'::<-,•...:r:.�: -;.: _.¢;,. r_ _ ...,.r.:rc:-::•':-'aye;.._.. t_ 8. Describe the�measarable:outcomes=that the'` ilotro ect:;:? :;' ' s` ro osest o:achieve .... vs:: P. P v r., .:... .. :.... .-':sem}.,xu .. . x:;•; 9. Descr'ibe'thd", ro` ose, -p an Ad.-measu`'e the3�%� t�� ``6i§ . : �..>; PP,::•,�,.� ,. .. ..� _s ou;comes: ` • Local Long 1. Name and describe the local agency proposed to administer the Term Care pilot project for each phase. Services Agency 2. Describe the local agency's organizational structure" Include a chart depicting upward and downward reporting relationships, responsibilities, and accountability of the local administrative agency. • Composition of the agency must be adequate to support the administration and oversight of the system proposed. • Composition of the agency must demonstrate commitment to meet the goals of the LTCI program. 3. How does this proposed structure overcome the barriers/problems identified in Section 11 A, Overview, Item 1, background/problem statement? I Continued on next page 6 • - .-r--. •:r.,;.: :'Fi'"' :��.-sa&T.'."-cr.,:-�c;r,�r': r��r:ar--,.. Local tong 4 ; D`escribe,tfiefunctionalstructuceoft le oca administrati e ` u. t`Q wv;. 'd- Term w,-a' T Term Care ,tnliod: a=I"rel d' 3A> Y: = Wagencty.,�,.V� gover. .,9�t. :�y : a_ u ira9':... a=, `moi ..k. 'sF'wTc v r4 ',..�.r[.t.,y Servicesy � � F ..xaR 4 x�: +,-�•:�R.?� •'n - i. _ .int•, �.;., vi:r::'X; l,'" Agency ='• .,;<�. _><� ::.:... •. �::� _::;,• � �; :;... �; a�>, es oisib;iliies. .M: }: "`+. 7'. CL ♦♦ i�<i e:ir?y'YFrt:F •','.. �,,n'. t[.x/.`Y��, ;fF.. f•t, f.rr'; C.e'13�'S%Y:': '.;u'G?-:r:`3-•-"„�y:.;.. }�,S'��3 � 1.... (Continued) w�:��• r4.w: ..uta! .�,:x' i-: � r.;».+azy ��<�E:'•.:.3.�y�,•yOr� T=�w� x�•diu'if,�crl'. cnac: k"•"-�.ua:.•....uit;�>at:::�:...v_ r�:'2�T�':sxu.sa._sv..�..:t_;:L�:�:�'. s_ ....:i$a,�- Iso e%18:4fund ion al of anizationly;'c�-f art de ictiri �tbj.9 �., ' ::h�;:w;�_ k��;:•.' ;.�;,,7 v:•§�:..;;o:zi ...:5..:: riK':r?:..;.k: +r:is�>•>.�;: ,•.G�. --�r.$�°�,r=..•v +C..�..F,r.•�::' relati*�b�hsF►i ';of tl%e'`local;admiriisteativesa enc` fo`seW.Ipe `' :..��' .... ., T:�... oo ,'ri:; _ ,.�:f.��` `��.,�T'�;4�'. %=A.�;'?i.,yt^�lc,atir i�.c:'•'•`�'3..4,:i<`.:,'!: �� y':s.;h.:: ;' ',�.i�vR!;'•:.�15�,��.tt5..$ai'i`;tr'..� `-� �'Y �i�:^t^ �%t;•�:;.'a"�,;,'c:...>1� �,4�-','-'^,:'F,• [�iRc"•�f ."�' .3r":.:. Yf"Responsibilities'`and�`roles�must�be`lo ica�.an`d�,�dernonstr t_e rt,.r::t, :s;• !�;` �;;?:#',:i::..�r:L`-:�'r S':e"%'g,'r: �`_ 'r r�... �'3�,.»��^. -try• t � w� i a sound, ro ect or a z •� N ` p; gw ni atiori:adequatesu e�Jrsion „;y'3>.°X:' +•^•:: h:..52':�:.r_ 1'�. a•"G6 E: ,rk`t::�'�•;=.�a ¢ no-.rf`a.:. '•.�rtr••..y".:rr.. •?1i�•.�v'•'.?', i.r.. si'r';;k. .�:kVt;r� �;i .t• '"�%`'X"": 4:. .�r�..Z••r�:'�..z5'.':"!:Q_.rv_i ta :. i°'.�x. :s• x ::,::,�: ..r',c ,!;55�'.'.f -..1: A,'::;k:'`•,Ftf,�-f''-'r`• , '•�;:<: . Relationship s,with dir y 3::`:f:K ( t:: ::l:Ct' .� �;EY p eet''care,`p:ro�iders.;must;beafu ;.described: a ��=.su `erviso 'artrers .i���_ :>57'r•: '�?•s�-�qr:� �;� :•�•-P,roposed;organization:rrmust°melude�suff cienttstaff ngtto;�; ? .:.�'i� ..�5�: :5�,. .�;:: - r:l.. ..�'::;t..v:iis.'•.�r,..:. y"Y.._.a.;ba n! - .:support'�effective�managerrienf� f�the;p ��� �::, e Delivery 1. How will the delivery system be organized? • System Will existing networks be used or will new ones be created? • Will specific networks be created for certain sub- populations? • Who will approve/authorize services? • Who will pay for the service? • From whom and how will direct care providers be reimbursed? 2. What are the incentives to provide appropriate quality care while maintaining cost neutrality? 3. Discuss how services between network and non-network providers will be coordinated. Consumer 1. Describe the planned assessment/referral system and Services consumers' access to needed services. • Continued on next page 7 i i i r i Consumer 2. Describe how the process ro osed will avoid repeated p P P Services assessments when a client needs additional services or needs (Continued) to transition to another care setting? 3. Indicate if any screening criteria will be used prior to a;full-scale assessment? _ 1 4. Describe how the proposed delivery system will address: • The need for consumer choice; • The proposed plan to respond to consumer needs on a 24- hour seven-day-a-week basis; How beneficiar'ies'and='th`er:famil' rnerrSbers wlltie educated-'°- n F= ew o t-ten s e- --h Tfie:.: �o :osed; 'rocess:,16 solicit'acid;docume:r t'thee': con"siderati, -of`consumer:and #amity preferences;F;forcare;: e iii` o" (ions s . s� x; •''Tte' ro posed' lanto:assuce 3thattfie's`stem xand service`s' r x :..;....� =' sous cul.ur.- ..i:;al .: nd {:ta�•:. rovidedz,will:Gb_e:;res o`nsive to:tY a elr ' sa ... ... .. ...-:. �.:..Vii:: ... tan ua a needs=ofconsumers, r >. 9._.9..,:: . .. :The ad udicat�o = ' n rocess:f o��consume�== p -MITpjaints`and providef;ap eats:,; id "ro O8 , o ., . , 5 :Prov e a:p p. ed c nsumers`13i11 of Riglts::' a 6. Describe the proposed plan to address the care plan, development for cognitively impaired consumers. Quality I Describe tf e.a ' coact tf e`couht =erit'if will ruse'fo�orionize Y e.. Assurance quality) ,lriclude3the=follows :as, E,:ct_ssof:ff: q Y 9 P and �- Account- r ' - - - :•:_. Y.�: :a_ : .. ualit ;�assu,arice., ., �;= ..�.;.�- _: ,,: - � .•1za_ .�:;ta; ....w :�?.:.. ' .:J::,.:;.:':.x'. .:/!'.54.. ...,!';.:,: .."�- rv.�Y., ,Fi:>t.0+,.Y y:.:-';ie:•.:.�:.'. 4'E+ ability <� Partici ation in-the `trait mala' ement, "Process; : :: P q Y, Q _ D Internal :. n 'vemen.;��o ram;stars <: • •Performancemeasurements��: - `: •. Qua I ,•.. _ .a: r•. r„s• y Y. ,F i• , i 2. Describe how quality assurance will be addressed through the proposed service delivery system. • Specifically, what will be the responsibilities of service providers regarding quality assurance? Continued on next page 8 • Quality 3. Describe the plan to monitor the quality of careP rovided to Assurance consumers. and Account- . Overall, who has the responsibility for overseeing all aspects ability of quality of care? (Continued) e What entity is accountable for beneficiary outcomes? T:�, ;.:'K•'P•-" �., c:Tr.'..t • ,.1NhatRa a„the o:utcome3:measures against whicli tl et�}plantand ..�' .: {.QT rv..� ,�?� _:i::..:,?8: :A� •:.•v:t"•'J� d..s�n}�t,5.izt.Al m'fi.l�"'f• ==its s'eniiceR' inviders:wdl. e b ' �' �; , t5;�,w p� b :held accounta le?- _ .�xj;•:." `:tii: .'l'}.':Y:'.: `":S:i •" .. 'rxP.. `{�'.•i>".:�,,_.•'.,,- ,.�y�G?:!a:,: c'�:• !04 osed rocess<,to conduct;fgllow-u _ ,,.r;•� Describe`j e r-^6 �, i 'P; .p : P i ven kation that the<individual;carea{<la`nrwas:im"'I.ernented:"an . ':• •:•;:!r`::•r,�p;>t: .r�.i. .P'' • :�Deseribe proposed systems for qualityassurance and -�Art��14N•;3�1 ` uttilizationreview .. r-' .i y{r.1`� Y l�• 'fes! it)'• 1.. •i. •f Care 1. Operationally, define care management and describe how it Management will operate in the proposed integrated system. • Who/what organization will provide care management? • Will there be single/multiple care management agencies? • What entity will be responsible for oversight of care management? • How will the proposed care management structure eliminate duplication of care management responsibilities? • What control does the care manger have over services and which services are managed? • How does the proposed care management structure promote continuity across primary, acute and long term care? • How will the proposed care management structure assist clients in accessing services and assure that the approved services that are provided meet the clients' current care needs? • How will the proposed care management structure assist clients to transition from one level of care to another? ,- ..-.- ,s.=-. . .--,T -�- ylNhat-`aextFe:pofessional qualifcationsfor:care.managers ..ti: ..:Y:•i,x.:::•°.?�•=`i.�s.:.t.�e;-fi'•";t, -, • Who is thepnmarycare a'ge = ; man rafid h'ow.is;.that `, S :y3S• s.:'i'. wi7*;•= <'�pw?•hrv'j Vii...>`';Cy::i 7:•' :`^:. ::fir..r,.,. Q determined.. jz�, - xif":. ..{r.<r' ••:7z�r:•.i:c.:t tr>.,�".pxiG.:;•'aa rte,• •.c;4%�c`' :i= '7�?....:C,u� li�. ':�s:a. :s.. .r_. ,.�i'•:;i.+x:' :E;';?`�'..r,. ,• =What`:would;: a"then ecific res�1oh'MilitiesF;of,=tkie lon/y��term!: :R.t,r„ ..lJ..-.:t•sq.:.:!,`'e.-ti..:y• -::^K;. `�•." ;_ ;'''i r;. care.agencytfe;cae�man agement ufunctrorandthe service :de- .i$:•, <:-:i;; 'Cti:d;;;•�r.';:z�i'" .ta.: e.# :a;�F.''`'::4`I`�'..•,7.a;`:;,a"::;'. �+'Fi lve;N_:;netv+ocK�;(`'�rouiders•. :Y .,,.:.,..BN ��.:.:;�>:r,;:�;:,: �=�;<;,";rt::�:,.�,•._:. .� e; .;d-G:;•z;,-,;n;:,•:!..::,y :l": .1^�:i.,.'>--''.: `i.'$`!`IS"<r.t'+�"'3' `bs`•ir';-_�t'-i.f,::.�., ;ij-..^;k`�•ktflt•' - • ..Ar,.e:all:eligibles c d - Y.." :ares-candidates:�F � determined eli'`itle'for.care- .� -management- • Continued on next page 9 I I I Care How.;will nae`rnber`-ec 'rds :centrafi2ed?-i�':: ,..•».xY.;;'„`':�aC`.:• ',,j:$:_ :1.i",,,':�'- .i:•:,;t"•"'.F':' a,�•,.. . �C'Y64�C i •:sl'l�•ly'F''e'v.Yfir-�f,Z�...F,:�.:r:�L ? .3�.::Lnif'.i.a:jf.�.�.s.•i'�:i't`>r i• Jl. ...r,..e:!A Managementf :.;`.< ,.. b.<n; .How willYthe.'ad�e uac: �of kae�,eare:mana ement� "-r;'o ramb q Y� g: p e: ,J;;:�.J:�..•c�';,•rc...x�,.�i�i-.s.;�'i?,*.��.'t.3r'yi?+ :{;�. ;;a+�:1t.�`';fx.•^ y�'',i`i;<,^, Continued = .nr : . , 63'. ., qz . (Continued) :;valuated?<=:, f : : Ni ,yamN . Y t:•. } SP `'.i :: Y'' ?.:."q Aze s,:',_`.' tyr; r; '•.�;_ i:;" .�How�.will�� ualit ;af�care:��e�rrieasured'?'=�`;°� ;��:��x���:��' �?�;��:•:��=. "1Nhat<criteri will cletermin'e access of the;: , �<°r - .SK'i�e...�. :��.-�h'D,; "%:�X:•:;n-..�✓:qY. i.rx jS A'�'::'.�.-;:;��1_ �=a>":.*'+,,:�x:" '+�r�.,.r.S:`..:: `:I11aIla I Fiscal 1. Based on available data, provide a description of the following: • Current service utilization and costs by funding source; • Estimate of beneficiaries served; • Trends in caseload growth and specific rate increases. Also provide a description of how estimates were calculated and the assumptions used. 2. To the degree possible, provide an estimate for any anticipated increase in costs (e.g., for expanded utilization of any existing or new HCB services). Provide a description of how estimates were calculated and the assumptions used. 3. To the degree possible, provide an estimate for any anticipated decrease in costs (e.g., for lower utilization of other services). Provide a description of how estimates were calculated and the assumptions used. 4. Explain the financial viability of the proposed LTCI service delivery system. 5: DemonsttateYthe capability'of'theaproject to.:achieve and maintasn ; . sufficients;fiscal tan ible vete ui 4Tt�is uestion kzw "•ed:=Care.. .:b:':'.'.,.' .-:'..'n.•;':'.'i'....:..: .. ...�.. ..-.t...':i.�i-.'. ^'t;,j:� ::3.:�'i'Y:'..;�.'.t.i:`°•.:;::.:`�n..�'.'..F-.��:5. :.Y.: ..��,, �� ;:Division.to<develo :,criteria:'for��ciernoristratin� :#iscaltan� ibleiet�u .. .. alt .'� :�4..... ... 'T,..::!.:•.s":...:i... _ .;1:::.,,..:„'*: ..q. Y. - - Fit•: f. .,a�. w 6 Wh`a-t monitoring mechanisms.will be in place to maint,ainFx ;; °_ adequatefscal control of the pilot protects 7: Explainhow.the.:proposed plan:`maxiinizes theyfundinavaif:able fpr a n " . �... direct," ervices•'and mr—MUNI s 2 `' -: " F. • ' F••� minimizes expenditure:sfor:adriiiriistration:4 Continued on next page 10 • ._�.. ,.. �.S'::ya_ __ _ _ -- �.@ - r.iA�':'�1 u:9-'•-i�}�:Yv:7*Tt,-S..,,�w,. a^'!$•[ Fiscal iiwills`e"`icesfhafareav ilab e t rou fi>t `" �$,' bHoV. a I;,,� F �l� hey rowders��r: ya��[• :: w• :x . .:.. .;k " r,.. �. (Continued) W �chased?'z:���� �,�at'�°;���;�;� ���;�3���•"'�-�� (4-»:,...w��w 4.:.rt'+pwu:���v::..rc.r.,:::..�t±::r�.d.�..tw:.•�:....r.sS•S..u::;�':_:ii.:l.�;.`Ya°� tl�::3�•3�7�r.��'"�'.'Ji�4£!:"rp 'JD `r..`ocessTto::be,usedfoi`;:clanin;J;andj` a,';mentsfor '�; - :�:�: :?}9.;-,K: •.� :yam;::;:-� `�:-�: urs::<�.;:.� = ;t�•�•. .z._ •y ;,,,. �, ,:,,> �:.�r��. ;�- .:c , o Descri e a.x ason r ,able a of k ab in• . ...:. ..._� • a�r%d?�w: odo odetaer, - `a `:;meth'` "lo �t ine ..r,:r._3':., c,F�;:., �:cr.v'i:_��%'� :rf,•;:.s, :�i:.�t;�•-'.y'°•.�,r,.�:.41'r??..=e�s�':2''?i'x"';`;;: a'menfaiounts:for reiinbursementof<�direct care- roviders• ::: es• fie;: �ro•e"ct`is`consfde i- `'u•� •�` �'`'�`�"'°•�' 11 :Discuss;an strate i yt � r n'g�fo'r�sfaring�•�d "�,-,�.w„.,r., ;.:, _�_�: ::�s•��'�. a:>.�::ham.. -:,:,.::�.�� �'����.�,�'•;� � �;: >.���rsk :�For�exam •-fe��;will�%ei :si:ances�rovis�on�s�or�risk=�c©�rridors��<`�� •fig., �. ;x.. `'s;,? ::���'' �ti>�:':... :,:i._. �..». c� ��i�rv_.3..1 =``be utilized. .��;.� v:;�;:_.s:,::;�;� .� ., �.�.. •�,.. Feasibility 1. Identify the significant local barriers to LTC[ that have been (Project encountered and explain how problems/issues have been Challenges) overcome. 2. Identify any local barriers that have not been resolved and • discuss how they will be overcome. 3. Discuss whether the skills and expertise with the required certification/ licensure are currently available in-house. If not, how will they be secured? LTCI Project 1. Provide a proposed implementation work plan that includes a Implemen- timeline with milestones as it applies to phasing in the LTCI tation project (e.g. the target population, delivery system, scope of services and infrastructure development). 2. If proposed implementation is to be phased in, describe each phase in detail, including the following elements: • How it will be accomplished; • How it will affect consumers; • Anticipated time frames related to each phase. Continued on next page • 11 LTCI Project 3. Demonstrate the commitment to the administrative action Implemen- plan of publicly funded agencies that currently serve LTCI tation eligible consumers and publicly and non-publicly funded (Continued) agencies that will be serving eligibles under the proposed LTCI project. Program 1. Describe the manner in which contracts with service Administration providers are to be administered. • To whom will contractors be accountable? • What entity/entities will be the decision makers? 2. Describe the process for enrollment into LTCI. • Who will administer this process? 3. How will individual program data reporting requirements be met with regard to funding source? 4. Provide a description of the process to assure that Medicaid dollars are appropriately expended in accordance with federal requirements. Management 1. What do you conceptualize as your Management Information Information System (MIS)? System The MIS system should have the capabilities to provide data on LTCI services: • All eligibility data; • Members enrolled in the plan; • Provider claims status and payment data; . Encounter-level social, medical, and supportive care services delivery data; • Provider information; • Costs. 12 • III. DEVELOPMENT GRANT WORK PLAN AND TIME LINE Work Plan 1. Provide a scope of work for the LTCI development grant. and Time Frame 2. Provide a work plan with milestones and timelines. Identification 1. Identification of Applicant Workgroup (Local Organizing of Applicant Group) Workgroup Describe the applicant organization, i.e., the agency designated to be responsible for overseeing and coordinating the planning and development of the proposed program; • Include the organizational structure and staff composition; • Include a description of the role of an active advisory committee which is to be comprised of consumers and providers; • Describe the role of the Board of Supervisors; • Describe the applicant's relationships with local agencies • and consumer advisory committees, the BOS, etc. • 13