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What are Long Term Services and Supports (LTSS)? Who Uses LTSS? What is a No Wrong Door (NWD) System? Why Do We Need a NWD System? What Can We Do in Our State? Agenda 2

What are Long Term Services and Supports? 3 No Wrong Door System

Assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) provided to individuals who cannot perform these activities on their own due to a physical, cognitive, or chronic health condition that is expected to continue for an extended period of time, typically 90 days or more Definition of LTSS 4 AARP

Could be paid or unpaid services (informal supports) Delivered through institutional and home and community based settings Definition of LTSS 5

Who Uses LTSS? 6 No Wrong Door System

Top-ranked causes 1Mental health condition 2Developmental disability 3Speech impairment 4Birth defect 5Intellectual disability Children Have a Mix of Disability Types Physical: 250,000 I/DD or other cognitive: 270,000 Mental health: 140,000 Source: Author’s analysis of data from the 2012 National Health Interview Survey 7

Top-ranked causes 1Intellectual disability 2Paralysis & nervous system 3Back problem 4Mental health condition 5Developmental disability Adults 18–44: More Physical Disability Physical: 510,000 I/DD or other cognitive: 230,000 Mental health: 180,000 Source: Author’s analysis of data from the 2012 National Health Interview Survey 8

Top-ranked causes 1Back problem 2Arthritis 3Diabetes 4Paralysis & nervous system 5Asthma, breathing, lung Adults 45-64: More Aging-related Disability Physical: 1,500,000 I/DD or other cognitive: 90,000 Mental health: 290,000 Source: Author’s analysis of data from the 2012 National Health Interview Survey 9

Top-ranked causes 1Arthritis 2Heart condition 3Diabetes 4Dementia 5Stroke Older Adults: Mostly Aging-related Physical: 2,400,000 I/DD or other cognitive: 550,000 Mental health: 270,000 Source: Author’s analysis of data from the 2012 National Health Interview Survey 10

What is a No Wrong Door System? 11 No Wrong Door System

No Wrong Door System/Access to public LTSS programs Consumer-directed services Workforce development Support for family caregivers Transition & diversion Intersection of health/medical and LTSS/social Payment systems Quality & outcome measurement Youth Transitions Major State LTSS Components/Policy Issues 12

State Governance and Administration Public Outreach and Coordination with Key Referrals Sources Person Centered Counseling Streamline Access to Public LTSS Programs No Wrong Door System Functions 13

One-Stop Coordinated System w/ Consistency – Visible and trusted – Not just one entity or network – Built upon existing access functions and places known to individuals and eligibility determination – Single standard process Common protocols & information exchange Objective/Neutral/Person-Centered Seamless & Person Friendly – Tell your story only once – Streamlined access to LTSS Both use of private resources and public programs No Wrong Door System Characteristics 14

Why Do We Need a NWD System? 15 No Wrong Door System

Make it easier for individuals to access public and private programs that provide LTSS Reduce the financial burden on our state’s public programs including Medicaid system Provide in-depth person-centered counseling to citizens that are vulnerable or in crisis Our NWD System will: 16

12 Million People Need LTSS Source: Author’s analysis of data from the 2012 National Health Interview Survey & 2010 Census 17 Children Working Ages Older Adults

Many LTSS Users Live in or Near Poverty 2010 Federal Poverty Level = $11,170 for single, $23,050 for family of 4 Source: Author’s analysis of data from the 2012 National Health Interview Survey 18 Children Working Ages Older Adults

Primary Payer ChildrenOlder Adults Working Ages Source: Author’s analysis of data from the Medical Expenditure Panel Survey 19

In 2009 (the most recent year for which data are available), the average annual expenditure for state institutions was $188,318, compared to an average of $42,486 for Medicaid-funded home and community-based services LTSS Costs 20 National Council on Disability

A Case Study in Early Diversion from Long Nursing Facility Stays 21 No Wrong Door System

Data Indicates that the Chances of Becoming Medicaid Eligible Increases with Longer NF Stays Source: The Lewin Group analysis of CMS CCW 2007 Timeline File enhanced with MAX data. 22

As Short Term Stays Leave, Increasing Number of the Cohort End Up on Medicaid Source: The Lewin Group analysis of CMS CCW 2007 Timeline File enhanced with MAX data. 213,000 Medicaid at Entry 315,000 Medicaid at 6 Months 23

Wide Variation in 6 Month Spenddown Rate Among Admissions Beyond Post Acute Stay MA Source: The Lewin Group analysis of CMS CCW 2007 Timeline File enhanced with MAX data. 24

Spend down 14-16% Spend down <14% Spend down 16-20% Spend down >20% *National Average = 18.1% Source: The Lewin Group analysis of CMS CCW 2007 Timeline File enhanced with MAX data. 6 Month Spenddown Rate Among Admissions Beyond Post Acute Stay 25

Wide Variation in Medicaid at Admission Among Medicare Beneficiaries National average 27.3% 26

Medicaid Admit 20-25% Medicaid Admit <20% Medicaid Admit 25-35% Medicaid Admit >35% *National Average = 27.3% Source: The Lewin Group analysis of CMS CCW 2007 Timeline File enhanced with MAX data. Percent Medicaid at Admission Among Medicare Beneficiaries 27

Beyond post acute stay spend down rate – National average = 18.1% – 27 states with higher than the national average – 4,900 individuals difference from state to national avg – Nearly $10M/month in Medicaid spending Medicaid at admission rate – National average = 27.3% – 21 states with higher than the national average – 50,200 individuals difference from state to national avg – $100M/month in Medicaid spending Moving High States to National Average Could Save $110M per Avoided NF Month 28

What Can We Do in Our State? 29 No Wrong Door System

No one agency or network has the capacity, expertise or authority to effectively carry out all the NWD System functions for all the different populations that will be served by the NWD System. At a minimum, the following state agencies should be involved in the planning process: – State Medicaid Agency – State Unit on Aging – State agencies that serve or represent the interests of individuals with physical disabilities and intellectual and developmental disabilities – State authorities administering mental health services State Agency Collaboration Needed 30

Articulate a Government-wide Vision – Cross department and cross-disability – Engage all stakeholders in setting the Vision Plan to that Vision – All policy and funding decisions checked against Vision – Determine whether new initiatives/flavor of the month also within the Vision (or whether Vision needs to be modified) Execute the Plan – Develop a work plan and strategy to fulfill the Vision Monitor the Execution with Data – Develop measures & reports that indicate progress toward the Vision Regularly Reassess the Vision What Do Successful States Do Differently? 31

Bring together an executive leadership team and formulate the government-wide vision around our state’s LTSS system Follow successful states – Articulate a Government-wide Vision – Plan to that Vision – Execute the Plan – Monitor the Execution with Data – Regularly Reassess the Vision Lead NWD Efforts in Our State 32