Ohio’s Unified Long-term Care Budget Building a Cost-Effective, Consumer Friendly Long-term Services & Supports System

Ohio Department of Aging Purpose To develop a comprehensive, flexible and transparent process for effective and efficient budgeting and service delivery that: –Encompasses both facility-based and home- and community- based long-term services and supports –Is based on consumer choice and differing levels of service need –Includes a seamless array of service delivery options –Features a consolidated policymaking and budget authority to simplify decision making and maximize the state’s flexibility

Ohio Department of Aging Desired Outcomes - Consumers Consumers will be satisfied with the services they receive and experience a higher quality of life. Ohioans will be encouraged to plan ahead for future service and support needs, as well as be better prepared to make informed decisions about their options.

Ohio Department of Aging Desired Outcomes - System A transparent budget for policymakers. A cost-effective system that links disparate services across agencies and jurisdictions. Consistency in provider rate-setting. Accurate expenditure forecasts.

Promoting Flexible Funding to Support Long Term Living to Support Long Term Living Presentation courtesy of Susan C. Reinhard, Director AARP Public Policy Institute

Ohio Department of Aging Key Concepts Balancing LTC = Achieving more “parity” in funding community and institutional options so consumers have more “real choice”. Set of Balancing Strategies, including increasing community capacity, informing people of options, funding/budgeting, nurse delegation and workforce, etc.

Ohio Department of Aging Financing Money Follows the Person = financing for services and supports moves with the person to the most appropriate and preferred setting. –Global budgeting –Texas MFP –Deficit Reduction Omnibus Reconciliation Act Rebalancing (Balancing) = reduced reliance on institutional options, increased community options.

Ohio Department of Aging Key Building Blocks PERSON Philosophy of self-direction and individual control in legislation, policies, and practices Community Life Coherent Systems Management Access Comprehensive information, simplified eligibility, and single access points Financing A seamless funding system supporting individual choice Services Responsive supports across settings and provider types Quality Improvement Comprehensive systems that assure quality of life and services

Ohio Department of Aging Budget Strategies Money Follows the Person (MFP) Planned Parity Global Budget (Pooled Financing; Unified Budget)

Ohio Department of Aging MFP Strategy Money Follows the Person = financing for services and supports moves with the person to the most appropriate and preferred setting Commonly starts from nursing home to HCBS-- State example is Texas Useful when long HCBS waiting lists and low occupancy in nursing homes

Ohio Department of Aging Planned Parity Strategy Can be separate LTC budgets (nursing home, HCBS); mandates reductions in nursing home budget and transfer of those savings to fund HCBS Aggressive policy and program actions required (universal screening, level of care criteria, pre- admission processes, etc.) Examples--Maine, Vermont in 1990s

Ohio Department of Aging Vermont Act 160 Shifted funds from nursing home to the HCBS appropriation Goal 60-40% institution/community Strategies: NF moratorium, expand residential alternatives, one time investments Five percent drop in NF supply

Ohio Department of Aging Act 160 “The reductions required … shall be redirected in FY 1997 to fund home and community-based services. For fiscal year 1998 and thereafter, the reductions required... shall be redirected … to fund both home and community-based services and any programs designed to reduce the number of nursing home beds. Any general funds redirected but not spent during any fiscal year shall be transferred to the long-term care special administration fund...” Department of Aging and Independent Living Services

Ohio Department of Aging Vermont 1115 Waiver Provide maximum choice of services and settings Eliminate institutional bias Promote early intervention Break link between 1915 (c) waivers and NF level of care

Ohio Department of Aging Global Budget Consolidating all of the components of long term care spending into a single state agency budget –Funding can follow the person as they move between services Placing the nursing facility, HCBS and state- funded personal care programs and budgets into a single division

Ohio Department of Aging Global Budgeting Global Budgeting provides a budget appropriation format that allows LTC dollars to be used in the most cost-effective manner

Ohio Department of Aging Global Budget Set a total LTC spending budget based on –projected LTC needs and preferences –planned policy and program initiatives Provide full administrative freedom to manage costs within the spending limit to respond quickly to consumer preferences

Ohio Department of Aging Washington: A Pioneer Legislature set forth philosophy ….establish a balanced range of health, social and supportive services that deliver long term care services to chronically, functionally disabled persons of all ages and to ensure that services are provided in the most independent living situation consistent with individual needs” (Revised Code of Washington (RCW) § ) and “to the extent of available funding, the department shall expand cost effective options for home and community services for consumers” (RCW, 74.39A.030).

Ohio Department of Aging New Jersey Strategy Budget and Policy Consolidation at state level for older adults Create more choices for HCBS services Help consumers find choices easily through single entry point (NJ EASE) and Community Choice Counseling (nursing home transition)

Ohio Department of Aging Patrick Flood, VT DAILS

Ohio Department of Aging Washington Success: LTC Spending Trends Based on data from the Washington Aging and Disability Services Administration

Ohio Department of Aging WA: Shifting spending balance

Ohio Department of Aging New Jersey Success 3,500 fewer Medicaid beneficiaries in nursing homes 10.4 % reduction in census, surpasses almost all states in recent years

Ohio Department of Aging Source: NJDHSS, Sept 15, 2004 Trenton, NJ

Ohio Department of Aging Indicators of Success in Colorado Reduced the rate of growth in LTC spending Saved 17% over projected LTC budget in 1994 Served 21% fewer in nursing facilities than projected –(Lewin Group study) In 1996, began serving more clients in HCBS than in nursing facilities (cross-over point) –Milne, 2005

Ohio Department of Aging Indicators of Success in Colorado Spent 51.1% of LTC budget on HCBS in 2001 Ranked 5 th in US –Profiles of LTC-2002, AARP Spent 32.7% of Elderly/Disabled LTC budget on HCBS Ranked 8 th in US in 2003 –Milne, 2005

Ohio Department of Aging Critical Elements to Support Transformation Vision, Mission Leadership and Partnerships Access to multiple financing sources (Medicaid HCBS & state plan, OAA, state general revenues) Streamlined financial and functional eligibility Comprehensive/single entry point Strong quality management system, including information systems

The Changing Face of Long-Term Care: Ohio’s Experience Presentation courtesy of Robert Applebaum Scripps Gerontology Center Miami University

Ohio Department of Aging Ohio Fast Facts… The population in Ohio who are most likely to need long- term care (those over age 85) has increased by 55,000 (38%) over the last 12 years ( ). Despite the population increase the number of nursing home beds in service has been reduced from a high of 99,000 in 1997 to about 94,000 in By 2050, there will be one million Ohioans over age 85. By 2020, Ohio will have more than 220,000 older people with severe disabilities, almost 26% more than The number of residential care facility beds has increased from 8,700 in 1993 to about 43,000 in 2005.

Ohio Department of Aging Estimated Proportion of Ohio's Population with Severe Disability in Different Settings

Ohio Department of Aging Ohio spent $11.5 billion on Medicaid. Medicaid was 24% of Ohio’s annual budget. 42% of Ohio’s total Medicaid budget was spent on long- term care. Ohio spent $2.6 billion on Medicaid nursing homes (ranks 9 th ) $1 billion on Medicaid ICF/MR facilities (ranks 5 th ). Ohio spent $950 million on Home and Community Based Care Waivers (ranks 26 th ). Ohio ranked 47 th in home care/nursing home expenditure ratio. Ohio Medicaid 2005

Ohio Department of Aging Average Annual Cost per Person FY 2005, Includes Medicaid Card Costs $2,491 $8K $10K $12K $22K $44K $54K $64K $99K $123K $21,372 $0 $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 $140,000 ABD CFC ODADAS ABD Community Mental Health PASSPORT Home Care NF MR Waiver ICF/MR Private ICF/MR Public

Ohio Department of Aging Ohio Nursing Facility Admissions

Ohio Department of Aging More than 56% of all those admitted to nursing homes: are no longer residents after 3 months almost 7 in 10 are no longer residents after 6 months by year end only one out of every 6 still there Short-Term Stay…

Ohio Department of Aging Proportion of Total & Medicaid Nursing Home Residents Still Living in a Facility

Ohio Department of Aging Nursing Home Utilization in Ohio Adjusted Nursing Facility Beds Average Daily Census Nursing Facility Occupancy Rate (%) ,20484, ,57986, ,30284, ,70179, ,23178, ,71276, ,27478,

Ohio Department of Aging Average Daily Nursing Home Census 1993 to 2005

Ohio Department of Aging Demographics of Residents in Ohio’s Certified Nursing Facilities: June 2004 (%) Did not meet level of care Low case mix score All other residents Percent of Residents Average Age Gender (Female) Marital Status Never Married Widowed/Divorced/ Separated Married

Ohio Department of Aging PASSPORT Usage

Ohio Department of Aging Functional Characteristics of Ohio’s PASSPORT Consumers: 2004 (%) Average number of ADL impairments (out of 6)3.0 Average number of IADL impairments (out of 6)5.0 Supervision needed: 24 hour8.1 Partial time11.1 Incontinence21.2 Number of prescribed medications to to to to or more8.5

Ohio Department of Aging Distribution of Ohio’s Medicaid LTC Utilization by Setting:

Ohio Department of Aging Number of Older Persons* Using Nursing Facilities or PASSPORT Services * Per 1,000 persons over age 60 in the population

Process & Decisions

Ohio Department of Aging The Process The Governor will appoint a workgroup. Legislative leadership will appoint four members of the General Assembly. The plan is to be completed by June 1, 2008, and must be submitted to the Joint Committee on Medicaid Technology and Reform. Seven subcommittees, building on existing efforts, will assist the workgroup.

Ohio Department of Aging Decision Roadmap Who will be served by the long-term services and supports budget? What does “long-term services and supports” include?

Questions for the Subcommittees

Ohio Department of Aging “Front Door” Subcommittee What will be the design of the “front door” to long-term services and supports?

Ohio Department of Aging Care Management Subcommittee What is the role of care management? Who benefits from care management? How will we interface with Medicare Special Needs Plans?

Ohio Department of Aging Quality Subcommittee How will we incorporate the CMS “quality framework” into all aspects of long-term services and supports, including nursing facilities?

Ohio Department of Aging “Unmet Needs” Subcommittee What unmet needs currently exist and what additional long-term services and supports should Ohio offer?

Ohio Department of Aging Consumer Direction Subcommittee How will we incorporate the key principles of consumer direction into the system?

Ohio Department of Aging IT Systems Subcommittee How will existing and planned IT systems be modified to accommodate a unified budget?

Ohio Department of Aging Budgeting Subcommittee How will the budget be built and what model will be used?

Ohio Department of Aging