Nursing Facility Level of Care Initiative: An Update Minnesota Department of Human Services Continuing Care Administration Aging and Disabilities Odyssey Duluth, MN June 17,

Presenters Douglas Silverman –MN DHS, Aging and Adult Services Division –Program Administrator –Policy Integration Unit Jolene Kohn –MN DHS, Aging and Adult Services Division –State Programs Coordinator –Policy Integration Unit 2

Outline Background NF LOC Criteria Estimated impact Implementation work plan Available supports for individuals 3

Background Nursing Facility Level of Care (NF LOC) changes Essential Community Supports (ECS) Enacted in the 2009 Legislative session Part of a larger strategy aimed at sustainable long term care Ensure availability for those with greatest need 4

NF LOC Delay Due to Federal Legislation (ACA) States signed Maintenance of Effort (MOE) agreements Delayed implementation –2014 for adults –2019 for people under age 21 5

Nursing Facility Level of Care Legislation Current NF LOC criteria are relatively low compared to other states Legislation strengthens NF LOC criteria to direct people with lower care needs to other supports, including new program under ECS Meet increasing demand for services Improves equity and access statewide 6

For Medicaid payment for NF services Eligibility for certain long-term care waivers (EW, CADI, BI-NF) State-funded Alternative Care (AC) Doesn’t affect other payor criteria (Medicare, e.g.) Criteria is found at Minnesota Statutes, section , subdivision 11 Effective January 1, 2014 for ages 21 and older Nursing Facility Level of Care Legislation 7

Applies to all new applicants 21+ with an eligibility start date on or after 1/1/14 Applies to current HCBS participants at their next reassessment on or after 1/1/14 –Person was previously opened to EW, AC, CADI or BI-NF, and eligibility span overlaps with 1/1/14. –Transition for current HCBS participants will occur over 12 months as reassessments are completed. 8

Reasonable operationalization of current criteria, decision-making by LTCC staff A person must demonstrate at least one of the following: 1. Need for assistance with ADLs 2. Need for ongoing clinical monitoring 3. Significant cognitive, memory, or behavioral needs 4. Risk of institutionalization NF LOC Criteria 9

Activities of Daily Living: Bathing, dressing, grooming, walking, toileting, positioning, transfer, eating. An individual meets LOC criteria based on ADL if they: –Need assistance in 4 or more ADLs, OR –Need assistance with toileting, or transferring, or positioning that can’t be scheduled. Assistance = dependency as defined for case mix classification NF LOC Criteria: ADLs 10

NF LOC Criteria: Clinical Monitoring Clinical monitoring meets the description and requirements used for case mix classification Clinical monitoring must be needed at least once every 24 hours 11

NF LOC Criteria: Cognitive-Behavioral This criteria reflects needs that are assessed in several ways: –Mental Status Exam (memory) –Self-preservation (capacity to respond to changes in the environment) –Need for staff response to “behavior” –Orientation 12

NF LOC Criteria: Institutional Risk The individual lives alone (or will alive alone) AND – Has had a fall resulting in a fracture within the last 12 months OR –Has vision or hearing impairment that affects ability to maintain community life OR –Is at risk of maltreatment by others or at risk of self-neglect 13

NF LOC Determination NF level of care can be determined by a face-to-face LTCC assessment (MnCHOICES) Telephone screening as part of PAS for NF admission The criteria based on institutional risk must be determined in a face-to-face assessment 14

NF LOC and Nursing Facilities LOC determined at admission via PAS LOC must be re-established at the first MDS quarterly that occurs after admission for continuing MA eligibility for payment of NF services RUGs categories, MDS and LOC: all categories except PA1 and PA2 contain information that establishes LOC PA1, PA2: complete LTCC 15

Nursing Facilities For MA payment for NFs, must meet criteria at both: –Admission into facility –90 days after admission into facility Admissions on or after 10/1/13 may be affected if criteria not met at MDS quarterly Admissions prior to 10/1/13 are NOT affected by revised LOC 16

Nursing Facilities For private pay, PAS must be completed regardless of payor source for all admissions Private pay will be reevaluated using last MDS quarterly assessment before MA eligibility start date NF staff will need to be aware of and begin timely discharge planning for all residents not likely to qualify at 90 days 17

Home and Community Based Programs May affect access to public programs that require NF LOC: –EW –CADI –BI –AC Rolling assessments for current participants, not all on 1/1/14 18

Estimated Impact – HCBS Sample Based on 2011 analysis of all individuals in EW, AC, CADI, BI-NF in the programs July, 2011 Total numbers of enrollees evaluated –EW – 23,000 –AC – 3,100 –CADI – 16,960 –BI –

Estimated Impact - EW EW: 3,068 (13%) would not meet revised criteria –Of those, 2,822 (92%) live in own home or apartment –Of the 3,068, 337 (11%) were receiving CL or 24-hr CL 20

Estimated Impact – AC, CADI, BI AC: 268 (8.5%) would not meet modified criteria –All AC lived in own home or apt CADI: 501 participants would not meet modified NF LOC criteria BI: All participants remained eligible 21

Estimated Impact - NF May affect MA payment for NF services for lowest two RUG categories –PA1 –PA2 About 1.5% of all NF admissions fall into one of these groups –986 people out of 68,547 admission assessments that occurred 4/1/12 - 3/31/13 – These individuals can still be assessed to meet LOC with LTCC assessment 22

Available Supports 93% of EW sample participants would remain eligible for MA basic health care –State Plan services –PCA 7% will lose eligibility for MA (SIS) Essential Community Supports: strategy to provide support to the “transition” group who lose program eligibility due to revised LOC (must be on a program ) 23

Available Supports AC: 268 individuals will not meet modified NF LOC criteria –100% are eligible for Essential Community Supports CADI: 501 participants will not meet modified NF LOC criteria –100% remain eligible for MA State plan, PCA –Essential Community Supports: strategy to provide support to the “transition” group who lose program eligibility due to revised LOC (must be on a program ) 24

Lead Agency Notification Notifications –For HCBS, notice to lead agencies that includes individuals, who based on their last assessment in MMIS, may not meet revised criteria at their next reassessment 25

Essential Community Supports New program will provide specific services People who do not meet NF LOC criteria Based on analysis of needs and services of original sample groupthat did not meet revised criteria –What services were they most likely to be receiving? –Address emerging needs 26

Essential Community Supports To be run like AC with allocations to counties $400/month budget Must live in own home or apartment Case management - $600/year for transition group 27

Essential Community Supports Must live in own apartment or single family home Cannot be provided in –Board and lodge –Non-certified boarding care –Corporate/family foster care 28

Essential Community Supports- New Program for Seniors “Legacy” group –Not eligible for MA –Age 65 or older –Meets Alternative Care financial criteria –Have been assessed to need and can benefit from services available under ECS –Does NOT meet LOC criteria 29

Essential Community Supports- Transition Group Transition group: 12 month group –Must have been on waiver on and immediately prior to eligibility for ECS (i.e. still on the program at reassessment) –Loses eligibility at reassessment due to changes in LOC criteria –Any age –Continue to be financially eligible for MA or AC –Can benefit from ECS services available –One-time case management benefit 30

Essential Community Supports Service coordination Homemaker Chore Caregiver training and education PERS Home-delivered meals Service definitions identical to AC/EW New service: Community Living Assistance 31

Essential Community Supports Service Coordination –Reimbursement up to $600 in a service year –Performed by case manager, case aide employed by or under contract with the lead agency For the transition group only, $600 for service coordination is outside of $400 per month budget 32

Essential Community Supports Service Definitions Homemaker may include: –Meal preparation –Routine household tasks –Assistance with arranging transportation –Companionship –Informal emotional support –Social stimulation –Monitoring the safety and well being of the client 33

Essential Community Supports Service Definitions Chore Services Support or assist individual or primary caregiver to maintain home –Heavy household chores –Moving or removal of heavy items –Shoveling snow and lawn maintenance –Customary service charges –Extermination and pest control 34

Essential Community Supports Service Definitions Caregiver Training and Education Family and informal caregivers who provide direct services –Parent –Spouse –Adult child –Other relative Not paid, not employed by provider 35

Caregiver Training and Education Caregiver training: Instruction about –Treatment regimens –Disease management –Nutrition –Personal/physical care –Behavior management –Family dynamics –Caregiver roles –Use of equipment 36

Caregiver Training and Education Caregiver Education includes: –Coaching –Guidance –Instructions Directly related to providing care to the person receiving services Must be documented in support plan 37

Essential Community Supports Service Definitions Personal Emergency Response Device or System (PERS) –Summon help in an emergency without dialing the telephone –Press an alert or panic button worn on a pendant or bracelet in event of fall or other emergency 38

Strategies to Support NF LOC Streamline Preadmission Screening (PAS) Senior Linkage Line will conduct PAS –October 1, 2013 Return to Community MDS Section Q Face-to-face assessments for <65 39

Strategies to Support NF LOC Relocation Services Coordination Care Coordination in MCOs Moving Home Minnesota ECS MA State Plan, PCA NF discharge planning 40

What Doesn’t Change Appeal rights for individuals Lead agency notification requirements Provider discharge requirements Provider notification requirements Other eligibility criteria for HCBS Other criteria for NF payment (MA LTC eligibility, claims edits, e.g.) Health plan requirements for provider authorization and billing 41

Implementation Plan External stakeholder workgroup Internal workgroups Referral protocols Training Communications: bulletins, legislative notices to recipients, e.g. Systems improvements Evaluation 42

Evaluation Contractors will evaluate these initiatives: NF Level of Care Essential Community Supports Return to Community Initiative PCA and Home Care Reform DHS Evaluation of NF LOC as required by legislature 43

Training The following groups will be trained on NF LOC changes and ECS program: –Lead Agencies –Financial Workers –Area Agencies on Aging –Title III Nutrition Service Providers –Provider Network –Other stakeholders 44

Training Opportunities Roadshows: First Contact/PAS/NF LOC (NF and Lead Agency Staff) –St Cloud – 8/7/13 –Brainerd – 8/8/13 –Arrowhead – 8/12/13 –Mankato – 8/13/13 –Rochester – 8/14/13 –Marshall – 8/19/13 –Fergus Falls – 8/20/13 –Crookston – 8/21/13 45

Training Opportunities Conferences (Providers) –Care Providers Billing Institute – 7/17/13 –Aging Services Billing “University” – 8/15/13 –Care Providers Convention – 11/18-20/13 Videoconferences (Lead Agency Staff) –10/24/13 –11/14/13 –12/12/13 More to be added! 46

Legislative Resources NF LOC Legislation –Criteria: MN Statutes , subd. 11 Essential Community Supports –Minnesota Session Laws –Chapter 108, Article 7, Section 13 –MN Statutes 256B.0922 (later in summer) 47

Contact Information Doug Silverman Jolene Kohn Website: 48

Thank You! 49

Questions? 50