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

2. 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

3. 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.

4. 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.

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

6. Promoting Flexible Funding to Support Long Term Living Susan C. Reinhard Director AARP Public Policy Institute Columbus, Ohio August, 2007

7. Goals Overview of Global/Unified Budgets Important components that will lead to success Specific State examples Key indicators of success

8. 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.

9. 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.

10. Key Concepts Flexible Funding is essential but not sufficient force for change…….

11. 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

12. Budget Strategies Money Follows the Person (MFP) Planned Parity Global Budget (Pooled Financing; Unified Budget)

13. 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

14. Indicators of Success CMS Benchmarks Indicators of Success CMS Benchmarks Statutorily Mandated:  Number of eligible individuals in each target group of eligible individuals assisted in transitioning from an inpatient facility to a qualified residence each year.  Qualified expenditures for HCBS during each year of the demonstration program.

15. Indicators of Success CMS Benchmarks Indicators of Success CMS Benchmarks Potential Additional Benchmarks –Percentage increase in HCBS versus institutional long-term care expenditures under Medicaid. –Utilization rates for a one-stop shops. –Flexible financing strategies, such as global or pooled financing or other budget transfer strategies that allow “money to follow the person”.

16. Indicators of Success CMS Benchmarks Indicators of Success CMS Benchmarks Potential Additional Benchmarks –Increases in available and accessible supportive services (i.e., progress 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).

17. 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

18. Vermont: Systems Change Small state with steady drive to change Total population = 608,823 An aging state - 5th oldest in the nation Known for stakeholder meetings “Shifting the Balance” law led by a key legislator (also a nursing home administrator)

19. 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

20. 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

21. Patrick Flood, VT DAILS

22. 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

23. Goals for Vermont’s 1115 Waiver Serve more people (within their cap) Develop a more balanced LTC system Reduce NF use Manage the LTC costs

24. Vermont’s Plan Slow, incremental steps Before Choices for Care – waiting lists and entitlements Now: 3 Eligibility Groups –Highest –High –Moderate

25. Nursing Facility Home Based Waiver Enhanced Residential Care Waiver Below Nursing Home Level of Care High Low Acuity of Need Current Eligibility threshold CURRENT SYSTEM ELIGIBILITY

26. Choices for Care Eligibility Highest Need Moderate Need Group High Low Acuity of Need Current & Future Level of Care for Eligibility Proposed Level for Entitlement Group High Need Group

27. Choices for Care Eligibility Groups Highest, High, and Moderate Need Groups Highest Need Group Funding for services is always available Consumer chooses services at home, Enhanced Residential Care Home, Assisted Living Residence, nursing facility or other approved location

28. Choices for Care Eligibility Groups High Need Group Serve most, if not all, but enrollment depends on availability of funds This group may access nursing facility care if funds are available.

29. Choices for Care Eligibility Groups Moderate Need Group Not “nursing home level of care” Preventive services, like Homemaker and Adult Day Case management Enrollment limited to available funds

30. 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

31. Global Budgeting Global Budgeting Global Budgeting provides a budget appropriation format that allows LTC dollars to be used in the most cost- effective manner

32. Goal of Global Budgeting Move from a provider-based system to a consumer- based system –With appropriations attached to each program provider  to appropriations attached to each client Individuals receiving supports drive resource allocation decisions, as they move through the long term care system –Milne, 2005

33. 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

34. Global Budget Does not change nursing home entitlement (unless 1115 waiver) Does not entitle consumers to HCBS, but can help move in that direction Works best if no waiting lists, but can help with nursing home transition efforts

35. Global Budget--State Examples See Hendrickson & Reinhard, 2004 Oregon Washington New Jersey Colorado

36. Oregon: A Pioneer with a Blueprint Legislature set forth philosophy of Choice, Independence and Dignity in 1981 Serve more people and lower cost per case Home and community care for private and public pay--stimulate the market, pay independent providers (including family members), allow nurses to delegate to paid “lay caregivers”

37. Oregon: A Pioneer with a Blueprint Single entry access and partnerships with local government, Board of Nursing, providers Single state agency to administer Medicaid LTC, Older Americans Act and state funded programs Foster prevention and primary health care

38. 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) §74.39.005) 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).

39. Washington…. …. The legislature further recognizes that persons with functional disabilities should receive long-term care services that encourage individual dignity, autonomy, and development of their fullest human potential. (RCW 74.39.001) The legislature further finds that the public interest would best be served by a broad array of long-term care services that support persons who need such services at home or in the community whenever practicable and that promote individual autonomy, dignity, and choice. (RCW 74.39A.005)

40. Washington 1993 legislature approves relocation of 750 nursing home clients to HCBS 1995-1997 budget reduces NH caseload by 1,600 clients NH “bed need” assessment includes availability of home/community care Aging and Disability Services Administration

41. Washington Global Budget: Budget structure consolidated with significant management flexibility Caseload Forecasting Council projects NH & HCBS trends Aging and Disability Services Administration

42. Washington Success: NF Caseload Trends Figures for July each year

43. Washington Success: HCBS Trends Figures for July each year

44. Washington Success: LTC Spending Trends Based on data from the Washington Aging and Disability Services Administration

45. WA: Shifting spending balance

46. WA: Elders and Adults

47. 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) 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)

48. Long Term Care: You Decide Where! AARP Long Term Care Summit, March 23, 2004 AARP NJ 2004 Social Impact Agenda 1. $ Follows Person 2. Fast Track Eligibility 3. Global Budget 4. Bill of Rights

49. Global Budgeting per 2004 and 2005 Executive Orders to “provide the Department of Health and Senior Services with the authority and flexibility — to move beneficiaries to the appropriate level of care based on their individual needs” Parity legislation Current NJ Policy and Budget Initiatives

50. New Jersey Success 3,500 fewer Medicaid beneficiaries in nursing homes 10.4 % reduction in census, surpasses almost all states in recent years

51. Source: NJDHSS, Sept 15, 2004 Trenton, NJ

52. Global Budgeting: The Colorado Experience By Dann Milne, Ph.D. Consultant Ph: 303-399-6736 dann_milne@hotmail.com

53. Vision for LTC --1990 View Long Term Care as a System To design a system to efficiently allocate scarce resources for LTC A planned effort to reduce the growth in Medicaid spending and to give clients choices of LTC services and settings Administrative reorganization/consolidation removes: fragmentation of program authority, state budget process barriers, and program operations barriers

54. Before: Appropriations were on a service by service basis. Expenditures controlled for each program budget item –Administrative barrier was lack of budget transfer authority –Agency could not overspend its HCBS program budget, even if the nursing facility budget was decreasing –Milne, 2005

55. After: Global Budget in 1991 ne appropriation for all LTC services; by Elderly, SSI/Disabled, TANF, etc. eligibility categories –Automatically allows funds to follow clients as they move from service to service as their needs and preferences change

56. 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

57. 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 is US in 2003 –Milne, 2005

58. 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

59. What We Know About Change Not Easy Not Fast Worth it Possible

60. Guiding Principles Change Dynamics Dialogue Consensus Courage Persistence

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

62. The Changing Face of Long-Term Care: Ohio’s Experience 1993-2005 Robert Applebaum August 17, 2007. Scripps Gerontology Center Miami University Oxford, Ohio

63. 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 (1993-2005).  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 2005.  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 2005.  The number of residential care facility beds has increased from 8,700 in 1993 to about 43,000 in 2005.

65. Projections of Disability Among Ohio Population 2005-2020 YearTotal PopulationPopulation with Some Disability Population with Severe Disability 200511,464,042789,115304,511 201011,764,333821,727314,650 201511,960,864837,860329,419 202012,177,857852,397348,129

67. Estimated Proportion of Ohio's Population with Severe Disability in Different Long-Term Care Settings

68. Ohio Medicaid 2005  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.

71. 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…

72. Cumulative Length of Stay as a Nursing Home Resident for a Cohort Admitted between Jul-Aug 2001, and then Followed until June 30, 2004

73. Proportion of Total & Medicaid Nursing Home Residents Still Living in a Facility

74. Nursing Home Utilization in Ohio: 1993-2005 Adjusted Nursing Facility Beds Average Daily Census Nursing Facility Occupancy Rate (%) 199393,20484,53690.7 199596,57986,72889.8 199799,30284,64387.7 199995,70179,21683.5 200194,23178,42783.2 200390,71276,85084.7 200591,27478,83586.4

76. Over the Twelve Year Period (1993-2005)…  Occupancy rates dropped from 90.7% to 86.4%.  The average daily nursing home census dropped by 5,700 individuals per day.  The average daily Medicaid nursing home census dropped by 3,840 individuals per day.  The private pay average daily census dropped by 7,440, while daily Medicare Census has increased by 5,580.  Proportion of under 65 residents increased from 6.8% in 1994 to 14.1% in 2004.

77. Ohio’s nursing home residents are very impaired, & they are more disabled than they were 12 years ago.

78. PASSPORT: Ohio’s Major Medicaid Home & Community- Based Long-Term Care Services Program for 60+ Population

80. Demographic Characteristics of Ohio’s PASSPORT Consumers:1994-2004 December 1994 (Percentages) December 1999 (Percentages) June 2004 (Percentages) Average Age 77.776.0 Gender (Female) 8080.779.8 Marital Status Never Married 5.2 5.7 6.3 Widowed 59.856.951.4 Divorced/Separated12.219.923.0 Married 20.817.519.3 Average cost of care plan per month N/A $1,050 Percent with active caregiver N/A 68.3 Number of consumers served 7,16115,53022,560

81. Functional Characteristics of Ohio’s PASSPORT Consumers: 2004 (Percentages) Average number of ADL impairments (out of 6) 3.0 Average number of IADL impairments (out of 6) 5.0 Supervision needed 24 hour 8.1 Partial time 11.1 Incontinence 21.2 Number of prescribed medications 0 35.0 1 to2 2.4 3 to 5 9.4 6 to 10 26.8 11 to 15 17.9 16 or more 8.5

82. Distribution of 12 Month Service Plan Cost (Annualized)

83. PASSPORT consumers’ needs for assistance have remained relatively constant over the past twelve years.

84. Reasons for Disenrollment from the PASSPORT Program

85. Average Per Diem for Nursing Home Residents in 2005 Dollars:1992-2005

86. Medicaid PASSPORT & Nursing Home Annual Expenditures Average annual PASSPORT expenditures per consumer were $15,590 ($2,280 of that was for assessment, administration & case management). Average nursing home expenditures: Age GroupAverage Daily NF Exp. Average Annual NF Exp. 60% of Average Annual NF Exp. 60 and Older$133.99$48,906.28$29,343.76

87. Private Pay Nursing Home Residents Who "Spent-Down" to Medicaid, Over a Three Year Period (2001-2004)

88. Proportion of Nursing Home Residents Using Medicaid, Over a Three Year Period (2001-2004)

89. Comparison of PASSPORT, Assisted Living, and Nursing Home Consumers (Demographic Characteristics) PASSPORT Assisted Living Nursing Home Average Age 76.7 78 82.8 Gender Female 76.777.6 71.1 Race White 78.787.1 83.0 Marital Status Married 19.8 9.7 14.3

90. Comparison of PASSPORT, Assisted Living, and Nursing Home Consumers (Functional Characteristics) PASSPORT Assisted Living Nursing Home ADL Bathing 96.0 94.0 91.6 Dressing 60.1 64.2 81.8 Eating 10.9 9.7 33.3 Toileting 21.1 35.1 76.3 Grooming 32.9 39.6 81.9 Number of ADL Impairments 0 0.8 0.0 7.2 1 3.5 6.0 7.2 2 34.5 20.1 4.7 3 33.6 25.4 5.7 4+ 27.5 48.5 75.3 Average Number of ADL Impairments 3.0 3.3 4.4 Incontinence 14.1 23.1 62.3

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

94. 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.

95. 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?

96. Ohio Department of Aging Questions for the Subcommittees

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

98. 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?

99. 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?

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

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

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

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

104. Ohio Department of Aging 1-800-266-4346odamail@age.state.oh.uswww.goldenbuckeye.com/ultcb