1. ADRC National Meeting July 12, 2007 Melissa Hulbert Director, Division of Advocacy and Special Initiatives Disabled and Elderly Health Programs Group Centers for Medicaid and State Operations

2. Long-Term Care Where is the $$?

3. LTC Expenditures by Payer: United States, 2005 Source: Georgetown University Long-Term Care Financing Project

4. Total Medicaid and Long Term Care Expenditures in Constant 2005 Dollars, FFY 1980-2005 Source: Thomson/Medstat: CMS Form 64 Reports, adjusted for price increases based on the Skilled Nursing Facility Input Price Index.

5. Medicaid Institutional and Community-Based Expenditures in 2005 Dollars: FFY 1980-2005 Source: Thomson/Medstat: CMS Form 64 Reports, adjusted for price increases based on the Skilled Nursing Facility Input Price Index.

6. Medicaid LTC Expenditures for Older Adults and People with Physical Disabilities, in 1995 and 2005 1995 2005 Source: Thomson/Medstat: CMS Form 64 Reports

7. Medicaid LTC Expenditures for Individuals with MR/DD, in 1995 and 2005 Source: Thomson/Medstat: CMS Form 64 Reports 1995 2005

8. Quest for a “Balanced” LTC System  The organization, financing, and delivery of Medicaid-funded LTC services is biased towards institutional care.  Almost two-thirds of Medicaid LTC expenditures are devoted to “institutional” care*.  13% of NH residents are under age 65*.  40.9% of NH residents have no ADLs*.  80% of NH residents have no, or only mild, or moderate cognitive impairments*.  For residents with a LOS of +30 days, 11% of the nearly 2.8 million discharges from NFs were to the consumer’s home with no additional services and 28% went home with only home health services**.  Reasons for the Bias:  Mandatory NF benefit.  Funding follows the setting, not the individual.  The use of separate line-item budgets to pay for institutional services and HCBS.  Overcoming the effects of historically high NF occupancy rates and waiting lists. Sources: * CMS 2007 Nursing Home Compendium ** Research Triangle Institute: Money Follows the Person Initiative

9. A Balancing Act  “…reaching more equitable balance between the proportion of total Medicaid long-term support expenditures used for institutional services (i.e. Nursing Facilities [NF] and Intermediate Care Facilities for the Mentally Retarded [ICFs-MR]) and those used for community-based supports under its state plan and waiver options.“  A balanced long-term care system offers individuals a reasonable array of balanced options, particularly adequate choices of community and institutional options.

10. Critical Elements of a Balanced System  Improved Access to LTC Supports  Increased Choice and Control  Comprehensive Quality Management Systems  Information Technology to Support Systems Change  Seamless funding system that supports individual choice.  Adequate workforce to support community life.

11. Real Choice Systems Change Grants  FFY 2001-2006: CMS awarded 314 grants totaling $256.4 million to 50 States, DC, and 2 territories.  States use the grants to address issues such as; –personal assistance services, –direct service worker shortages, –transitions from institutions to the community, –respite service for caregivers and family members, –mental health transformation, –improving funding streams for services, –information technology to support systems change, –quality assurance and improvement, –integrating long-term support services with accessible and affordable housing  33 Nursing Facility Transition Grants between FY01 and FY02.  ADRC Partnership with AoA  Systems Transformation Grants –10 awarded in 2005, and 8 additional awarded in 2006. –address the need to coordinate and effect major change over multiple departments and agencies in a State to benefit individuals who receives long- term healthcare services. –Incorporated the ADRC model into the ST grants.  More information available at http://www.cms.hhs.gov/RealChoice / http://www.cms.hhs.gov/RealChoice / http://www.cms.hhs.gov/RealChoice /

12. Barriers to a Balanced System  Lack of individual planning for long-term needs.  Information regarding available public programs is fragmented.  Cumbersome eligibility determinations for public LTC programs  Limited IT infrastructure to support information sharing among public agencies.  Limited opportunity to offer choices at critical pathways. New Opportunities  LTC options outreach and counseling.  Comprehensive I&R services.  Streamlined application and eligibility determinations.  Web-based database and information systems.  Partnerships with providers to prevent long-term facility placements. ADRCs are Delivering on the Promise

13. Promising Future Opportunities  Greater promulgation of the ADRC or other SEP model  Partnerships with Centers for Independent Living  Greater collaboration with “facility” discharge planners – serving as the bridge with Medicaid.  Integral role in Money Follows the Person

14. Real Choice Systems Change Grants FY07 Solicitation Approximately $13 million in grants to qualifying States. The grant categories are: 1.State Profile Tool (SPT): and 2.Person-Centered Planning Implementation Grants (PCPIG). State Profile Tool  3-year grants in the amount of $350,000 to $500,000 per grant. Only one grant per State can be awarded.  Assist States to develop a consistent and systematic way to measure the degree and success of their efforts to balance their long-term support systems. States will develop ways to measure the reduction of institutionalization and increased opportunities for persons with disabilities to live in the community.  Elements to include: –Demographic data on the demand for LTC –Utilization and expenditure data by population type –Organizational structures and service delivery mechanisms –Consumer involvement –Structured summary of how the state is addressing the “critical elements”

15. Real Choice Systems Change Grants FY07 Solicitation Person Centered Planning Implementation Grant  Three-year grants to States are to be awarded in the amount of $350,000 to $500,000 per grant.  To assist States develop and implement a distinct Person-Centered Planning (PCP) model specifically addressing the consumer’s informal support system  States may elect to address any of the six optional components: –Self-Direction –Comprehensive Community-based Resource Directory (web-based) –Comprehensive Risk Management Strategy –Web-based Care Planning Tool –Evidence-based Practice(s) –Planning for Youth with Co-occurring Disorders  Applications are due to CMS by July 27 and awards will be made by September 28, 2007.

16. National Balancing Indicators  Develop a set of national indicators to assess States’ efforts to balance their long-term support system between institutional and community-based supports including characteristics correlated with improved qualities of life for individuals.  The selected contractor will work closely with FY 07 Real Choice Systems Change Grantees awarded “State Profile Tool Grants” to develop and test a set of measures and provide technical assistance to help build the data infrastructure necessary to support on-going collection of the measures.

17. Money Follows the Person Objectives 1.A nursing facility transition program that identifies consumers in institutions who wish to transition and assists them in doing so. 2.A financial system the allows Medicaid funds budgeted for institutional services to be spent on HCBS when individuals move the community. 3.Quality management system that ensures the provision of, and improvement of services in both HCBS and institutional settings. 4.Broader rebalancing efforts to support and foster facilitate transition and diversion.

18. Money Follows the Person Fundamentals  $1.75 billion over five years (January 1, 2007- September 30, 2011)  Participating states receive an enhanced FMAP for 12 months for qualified home and community based services for each person transitioned from an institution to the community.  Self-direction encouraged.  “Rebalancing” Benchmarks required.  States must participate in CMS’ national evaluation.

19. Money Follows the Person Phases of Implementation  Phase I and Phase II Grant Awards  Pre-Implementation Period –Operational Protocol (OP) Development  Operational Period –Upon approval of the Operational Protocol, states will be granted annual continuation grants.  Public Input Process – Required by Statute.

20. State Proposed Transitions Award Amount CONTACTPHONEEMAIL WI1322$56,282,998 Charles Wilhelm608.266.8402wilheca@dhfs.state.wi.us NY2800$82,636,864 Robert Sherman518.408.3744rxs16@health.state.ny.us WA660$19,626,869 Bea Rector360.725.2527rectobm@dshs.wa.gov CT700$24,207,383 David Parrella860.424.5116david.parrella@ct.gov MI2500$67,834,348 Michael Head517.335.0276head@michigan.gov OK2100$41,805,358 Dennis Pennington405.522.7587Dennis.Pennington@okhca.org AR305$20,923,775 Herb Sanderson501.682.8520herb.sanderson@arkansas.gov MD3091$67,155,856 Stacey Davis410.767.5954srdavis@dhmh.state.md.us NE900$27,538,984 Mary Steiner402.471.9567mary.steiner@hhss.ne.gov NH370$11,406,499 Susan Lombard603.271.3452slombard@dhhs.state.nh.us CA2000$130,387,500 Paula Acosta916.440.7544pacosta@dhs.ca.gov IN1039$21,047,402 Natalie Angel317.234.4753natalie.angel@fssa.in.gov TX2616$142,700,353 Marc Gold512.438.2260marc.gold@dads.state.tx.us SC192$5,768,496 Sam Waldrep803.898.2590waldrep@scdhhs.gov MO250$17,692,006 Steven Renne573.751.6922karen.a.lewis@dss.mo.gov IA528$50,965,815 Deborah Johnson515.725.1012djohnso6@dhs.state.ia.us OH2231$100,645,125 Enka Robbins614.466.4443robbie@odjfs.state.oh.us Totals23604$888,625,631 Money Follows the Person Phase I Grantees

21. Money Follows the Person Phase II Grantees State Proposed Transitions Five Year Commitment ContactPhoneEmail DE100 $5,372,007 Joyce Pinkett302-255-9616joyce.pinkett@state.de.us DC1110 $26,377,620 Robert Cosby202-442-5972robert.cosby@dc.gov GA1,347 $34,091,671 Judy Hagebak404-657-5467jhagebak@dch.ga.gov HI415 $10,263,736 Aileen Hiramatsu808-587-5721ahiramatsu@dhs.hawaii.gov IL3,357 $55,703,078 Theresa Eagleson217-782-2570theresa.wyatt@illinois.gov KS934 $36,787,453 Frank Stahl785-296-2081fzs@srs.ks.gov KY431 $49,831,580 Mary Walker502-564-7540mary.walker@ky.gov LA760 $30,963,664 Jerry Phillips225-342-3891jphilli2@dhh.la.gov NJ590 $30,300,000 Joseph Bongiovanni609-987-2040joe.bongiovanni@dhs.state.nj.us NC552 $16,897,391 Tara Larson919-855-4261 tara.larson@ncmail.net ND110 $8,945,209 Maggie Anderson701-328-2321soandm@nd.gov OR780 $114,727,864 Julia Huddleston503-945-6392julia.a.huddleston@state.or.us PA2600 $98,196,439 Linda Blanchette717-783-0508lblanchett@state.pa.us VA1041 $28,626,136 Karen Lawson804-225-2364 karen.lawson@dmas.virginia.go v Totals14127 $547,083,848

22. Money Follows the Person Qualified Individuals  Reside in an institution (6months – 2 year minimum period).  Institutions include: hospital, nursing facility, or ICF/MR. An IMD is also included to the extent that medical assistance is available under the State plan for service in the IMD.  Is receiving Medicaid benefits for inpatient services furnished by such inpatient facility.  Would need HCBS services in order to successfully reside in community based settings.

23. Money Follows the Person Qualified Residence  Where eligible individuals can move to. –A home owned or leased by the individual or the individual’s family member. –An apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual’s family has domain and control; or –A residence, in a community based residential setting, in which no more than 4 unrelated individuals reside.

24. Money Follows the Person Qualified Services  Qualified HCB Services –LTC services now offered under the State Plan or waiver program. –Supplemental or Demonstration Services that will not be offered to beyond the demonstration.  Enhanced Match for Qualified Services –Standard FMAP plus the number of percentage points that is 50% of the state share. –Example: Regular FMAP = 50% MFP FMAP = 75% {50%+.05(50%)}

25. Money Follows the Person Benchmarks  Statutorily Mandated: 1.The projected number of eligible individuals in each target group of eligible individuals to be assisted in transitioning from an inpatient facility to a qualified residence during each fiscal year of the demonstration. 2.Qualified expenditures for HCBS during each year of the demonstration program.  Potential Additional Benchmarks –A percentage increase in HCBS versus institutional long-term care expenditures under Medicaid for each year of the demonstration program. –Establishment and utilization rates for a system for accessing information and services by a date certain (i.e., the establishment or expansion of one-stop shops). –Establishment and utilization rates for a screening, identification, and assessment process for persons who are candidates for transitioning to the community that are put into use in the general Medicaid program beyond recruitment for the MFP demonstration. –Progress directed by the State to achieve flexible financing strategies, such as global or pooled financing or other budget transfer strategies that allow “money to follow the person”. –Increases in available and accessible supportive services (i.e., progress directed by the State in achieving the full array of health care services for consumers, including the use of “one-time” transition services, purchase and adaptation of medical equipment, housing and transportation services beyond those used for MFP transition participants).

26. Money Follows the Person Transition  How to Target Consumers for Transition? –Potential discrimination. –Can it be done at a reasonable cost? Conserve limited resources for those that are likely to benefit.  Developing NFT Infrastructure –Inform all residents about HCBS options. –Identification process. –Assessment and care planning. –Transition case management services. –One-time transition expenses (security deposits, household items, etc); –Monitoring and continued support of those transitioned.

27. Potential Role for ADRCs in MFP  Marketing and Information Dissemination  Collaboration in performing assessments and transition care planning  Identification of AoA and other support services  Support States in the identification and referral of individuals for transition  Work with the states to develop benchmarks that support broader MFP goals –Diversion –Streamlining eligibility –Flexible funding

28. For Additional Information Websites for all information: www.cms.hhs.gov/newfreedominitiative www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp www.hcbs.org