Oregon’s Long Term Care System Jim McConnell, Director Multnomah County Aging & Disability Services August 2002

2 Multnomah County Aging and Disability Services County-based Area Agency on Aging State contract to administer Medicaid Long Term Care Eligibility and Case management (Oregon Law ORS 410) Medicaid provider payments stay with the State

3 Multnomah County Funding Sources (FY )

4 AAA LTC System Referrals people needing help relatives, friends human services agencies; hospitals health care; gatekeepers; police 24 hour HELPLINE Access points Eligibility determination (Food Stamps,Financial, LTC, Health Plan, Vets) Case Management Senior center/meals Info & assist., outreach PAS/Relocation Protective investigations Insurance/ housing assist, Enrollment in managed care health plans. Community Services : Transportation, day care, legal, respite, guardian, meals In-Home Services : Home/ personal care, chores, live-in, medical equipment, meals Housing Options: ACH, ALF, RCF, NH,other Caregiver support Other Community Resources:MH, DD, Voc ReH.,Employment

5 Aging & Disability Services - Values Be customer driven Involve people in the decisions that affect them Promote client independence and choice Use client and public resources with the utmost effectiveness Act with personal and professional integrity

6 ADS – June 2002 ClientsMedicaid27,518 N.Facility 1,340 Adult Foster care 1,479 RCF 531 ALF 338

7 ADS – June 2002 (contd.) After Hours 449 Spec.Living 38 In-home 3,944 Food Stamps only 2,191 Health 26,933

8 ADS – June 2002 (contd.) Public Guardian(new) 33 Transportation 437 Protective 245 Financial Assistance 19,270 SSI Liaison 893

9 How the Oregon system evolved

10 Senior Advocates Wanted integration of services i.e. Senior centers, meal sites, Medicaid case managers, etc. Health services were not included. State developed a test model – FIG waiver. Legislature passed new law in 1981.

11 Two State Initiatives Long term care – designed to promote alternatives to nursing homes/client independence Oregon health plan (OHP) – designed to mainstream health care for low income persons OHP original plan was to be a public/private plan for all Oregonians

12 Oregon Long Term Care 1981 legislative mandate: “…a growing elderly population demands services be provided in a coordinated manner…; That the elderly and disabled citizens of Oregon will receive the necessary care and services at the least cost and in the least confining situation…it is appropriate that savings in nursing home…allocations…be reallocated to alternative care services…”

13 LTC System Development state initiatives to control LTC spending e.g. - Oregon Project Independence (OPI) FIG waiver Pre-admission screening governor’s commission/coalition - draft legislation.

14 LTC Development (contd.) 1981 Legislation (SB955) - Philosophy * Independence, Choice, Dignity * Savings from Nursing Homes to go to CBC - Single State Agency\Combined Funding - Local/AAA administration of LTC - Advisory Committees at State and Local level

15 LTC Development (contd.) Enhanced Single Entry (Financial and Food Stamps added) - Use of Single Client Assessment Statewide (360) - ADLs All regulation of Homes transferred to SDSD 15

16 LTC Development (contd.) 1990 Disability Transfer to SDSD Planning for Integration of Health and LTC?

17 Nursing Facility/Community-Based Care

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19 Oregon Health Plan development 1994 Oregon Health Plan - managed care - AAA choice counseling Managed Care/Capitation Contracts with HMOs/PCCM/Fee for service

20 OHP development (contd.) Benefits Limitations-Health Care Commission Medicaid Waiver – 1115 Dual Eligibles – mandatory with exceptions Statewide – if plans are available All ages

21 Multnomah Co.OHP Enrollees – June 2002 Elderly – 7792 Persons with disabilities – 13,106 Spending - $12 million Receiving benefits – 3.74% 5 Plans (incl. PACE) – 86%

22 AAA Developments Transfer of State staff to AAA Eligibility Workers became Case Managers Co-location in Senior Centers Enhanced Outreach (Gatekeeper) and Information and Referral Extensive Development of Alternative Living: 600 Adult Foster Care Homes Specialized Adult Foster Care Homes Services in congregate living

23 AAA Developments (contd.) Assisted Living Facilities Enhanced Protective Service Investigations & Interventions (funded by Medicaid) Participation in PACE (400 Medicaid clients) Enhanced advocacy by seniors for Medicaid services at local and state level Enhanced case management quality with Multi-Disciplinary Teams.

24 AAA Developments (contd.) Increased Title XIX Medicaid Funds available by using local government funds for match Local AAAs/HMOs consortium Enhanced transportation system Employment Initiative – 1998 Veterans Initiative

25 Key Elements in LTC Single State Agency Single Local Agency/coordinated funding Easy Access at local level Case Management continuum (I&R to Protective to Guardianship)

26 Key Elements Empowered Case Manager Assessment Care Planning Eligibility Service Broker Authorize payments State/Local Partnership in: Policy Development Quality Review Planning

27 Key Elements Expansive Federal Waiver. Community-Based/Social Model Preference. Broad Continuum of services/options. Provider Network. Cooperating Partners i.e. Health, Housing, Mental Health, Law Enforcement, Transportation, etc.

28 Key Elements Liberal Nurse Delegation Act Values - Independence, Choice, Dignity, Least Intensive Intervention Standard Statewide Assessment Statewide Service Priority List

29 CASE MANAGER FUNCTIONS Determines eligibility Develops, implements, and monitors holistic care plan Coordinates medical care, as necessary, with primary care practitioner and/or ENC Locates and prior-approves all LTC and community based services

30 CASE MANAGER FUNCTIONS Provides advocacy and linkages to various other services Uses MDT for consultation Provides choice counseling Processes fee-for-service prior authorization requests

31 Use of Medical Professionals Pre-admission screening clients at risk of entering nursing facility Branch Nursing Consultation teamed with case manager Quality Assurance RNs random site visits

32 Medical Professionals (Contd.) Liaison with ENCC at HMOs Multi-Disciplinary Teams consultation on complex cases Private Duty Nursing in home care, training, supervision

33 Multnomah County in Partnership with Local Business (2002) 36Nursing Facilities 600Adult Foster Care Homes 2,100 Housekeepers & Live-In Attendants 30Contract Registered Nurses 3Housekeeping Agencies 37Residential Care Facilities 14 Assisted Living Facilities 4 Managed Care Plans

34 ADS and Health system Eligibility/enrollment/dis-enrollment Options-Managed Care(4) /FFS/PACE/SHMO Case Manager/ENCC liaison Joint Case Manager tracking demo: Diabetes High Risk Joint discharge planning

35 What have we learned? Case Management is our core mission. Empower the CM/client to make all systems work for the client – including Health, Housing, Mental Health, etc. Integration with one specialty. e.g. Health, means dis-integration with others. All business plans have limitations e.g.

36 Fully integrated/fully capitated PACE-style model-costs controlled. Efficient, flexible Gov.$$, cost-savings in Medicare stay in the community, high quality,intense service mix In Portland, people have become patients – and live in the system Client gives up some choices Health-based model

Oregon’s Long Term Care System