Services for Older Adults: A Changing Landscape
for In-Home Care
January 15, 2014
Public Health Practice Grand Rounds
presented by the
Mid-Atlantic Public Health Training Center
Maryland Department of Health and Mental Hygiene
Services for Older Adults:
A Changing Landscape for In-Home
Care
Mayor Of Baltimore - Stephanie Rawlings-Blake
Office of Aging and CARE Services
Baltimore City Health Department
Health Commissioner – Dr. Oxiris Barbot
Arnold Eppel, Director - Office of Aging and CARE Services
Programs that currently provide
Long Term Services Support (LTSS)
• Department of Health and Mental Hygiene (Medicaid)
– Home and Community Based Waivers
– Medical Assistance Personal Care Program (MAPC)
– PACE (Program of All-Inclusive Care for the Elderly)
• Maryland Department of Aging
– Senior Care
– Veteran-Directed Home and Community Based Services
– Caregiver services
• Maryland Department of Disabilities
– Attendant Care Program
• Maryland Department of Human Resources
– In Home-Aide Services
– Project Home
Why home and community based
living?
What trends are we seeing locally
Nursing Homes & Assisted Living
• Nursing Homes are utilizing a higher percentage of
their beds for short rehabilitation (reimbursement
rates for rehab is greater)
• 3 Baltimore City Nursing Homes have closed in the
last 2 years (Genesis Hamilton, JH Bayview,
Ravenwood) - 436 total beds
• Assisted Livings sites have increased 20% from 315 to
378 (new sites in 2013)
Chronic Disease Self Management Programs
(CDSMP) in the community setting
• Area Agencies on Aging (AAA) have worked with the
CDSMP and DSMP-Diabetes, Stanford University model.
The purpose is to help those persons to self manage their
chronic disease. The Chronic Disease Self-Management
Program is a workshop given two and a half hours, once a
week, for six weeks, in community settings such as senior
centers, churches, libraries and hospitals. People with
different chronic health problems attend together.
Workshops are facilitated by two trained leaders, one or
both of whom are non-health professionals with chronic
diseases themselves. Outreach to find resources from
schools of nursing to assist in this effort are key to long
term sustainability.
CMS Innovation Grants
• Various models are being implemented nationally to create best
practices.
• The purpose is to assist prior patients in the community setting
with “Coaches” (e.g. Coleman Model) and define for these patients
the community resources that are currently and locally available to
them.
• Helping prior patients to prevent unnecessarily reentry to a hospital
inpatient setting. Compliance with physician orders, follow up
regarding rehab, coordinating physician appointments and
medication compliance. Understanding the physician orders are
the focus including follow up. This includes defining the patients’
short term and long term goals.
• Models to assist the caregiver and new ideas for innovation
Medicare Enhancements including Preventive
Services now covered under - ACA
• Annualized Wellness Plan
• Part B prevention services are now covered
at 100% beginning 2011 (Some exceptions
apply)
• Closing the donut hole for Part D by 2020
• Medicare Waiver: focus on preventive care
and keeping people out of hospitals as
Maryland works toward care coordination
Understanding Hospice, by educating
underserved populations to decrease
utilization disparities
• A focus is to help families understand what Hospice is and
what Hospice can do for the patient.
• Educating underserved populations and or others regarding
the barriers toward hospice services. Preference by
families for aggressive care, lack of knowledge, lack of
providers diverse staffing, religion, giving up hope, and
mistrust of the health care system.
• Concentrating on Communities who have limited access
based on resources available.
• Understanding the difference between Hospice and
Palliative care; where the goals of helping the patient with
a serious illness feel better are primary.
• 95% of all Hospice services are rendered in the home.
Current Reform Efforts
• Community options Waiver / Merger of
(Living at Home -ages 18-64 & Waiver for Older
Adults ages 50+) CW
• Community First Choice (created by section 2401
of the Patient Protection and ACA) CFC
• Balancing Incentive Program
• Maryland Access Point (MAP)/ ADRC
• Money Follows the Individual (apply for waiver
regardless of budgetary caps)
Reformed Medicaid Long Term
Services Support (LTSS)
• Home and Community Options Waiver* Merger of Older Adults
Waiver (OAW) and the Living At Home Waiver (LAH) 1915C Waivers
• Community First Choice (CFC)*
• Medical Assistance Personal Care Program (MAPC will now require
an AERS/ interRAI assessment and a Support Planning Assistant)
The redesign of two* of the three programs above will provide better
health, safety and additional quality of life for home based services to
be rendered.
MAPC –will now require an Adult Evaluation Review Service (AERS)
assessment . This will help in the delivery of tailored services, that are
now defined. Specific assistance with ADL’s, along with a support
planner will be provided to the individual. The plan of care will include
a strong emphasis on personal choice.
New Service Structure
• These two 1915(c) waiver programs will be merged into a
single waiver
– Reduces duplicate applications
– Offers a full menu of services to waiver participants
– Simplifies administration
• CFC services currently offered under the LAH and OAW
programs will no longer be offered as waiver services but
offered through CFC
– Maximize the enhanced Federal match
– Resolves inconsistent rates and policies across programs
15
New Service Structure for MAPC
• MAPC will remain in effect for individuals who does not meet an
institutional level of care
• MAPC will be revised to mimic the CFC program
– Move from a per diem rate to 15 minute payment units
– Offer Supports Planning and Self-direction options
• MAPC participants will be phased in between January and April
2014
• Individual participants will select and meet with a supports planner,
determine their desired level of self-direction, develop a new Plan
Of Service (POS) with an individual budget and hourly personal
assistance services, and then enroll by April 1st
• MAPC case rate will be effective for people remaining in MAPC until
April 1st
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Adult Evaluation Review Services
(AERS)
• interRAI assessment tool has now been implemented in Maryland
and is a comprehensive assessment tool that is required by CMS.
• “Core” set of assessment items that are important in all care
settings. These common items have identical definitions,
observation time frames, and scoring.
• RUGS (Resource Utilization Group) 1-7 a scoring based on physical,
behavioral, cognitive, rehab, (ADLs and IADL), special care,
extensive services, clinical complexities
• The interRAI assessment tool will now be utilized for MAPC, CFC,
Home and Community Based Options Waiver.
• Senior Care (State Grant for 60% median income 65+ at risk) ,
Assisted Living subsidy, Congregate housing and Adult Medical Day
Care are on the horizon.
Current Service Structure
Personal Assistance Services
Case Management/Nurse Case Monitoring
Consumer Training
Personal Emergency Back-up Systems
Transition Services
Home Delivered Meals
Assistive Technology
Accessibility Adaptations
Environmental Assessments
Medical Day Care
Nutritionist/Dietician
Family Training
Behavioral Consultation
Assisted Living
Senior Center Plus
MAPC
LAH
WOA
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New Service Structure
Personal Assistance Services
Case Management/Supports Planning
Nurse Monitoring
Personal Emergency Back-up Systems
Transition Services
Consumer Training
Home Delivered Meals 1
Assistive Technology 1
Accessibility Adaptations 1
Environmental Assessments
Medical Day Care
Nutritionist/Dietician
Family Training
Behavioral Consultation
Assisted Living
Senior Center Plus
1. Items that sub
MAPC
*CFC Services will be available to all waiver participants
CFC
Waiver
Rebalancing Principles
• Improved access to home and community-based services
(HCBS).
– Eliminate barriers to receiving HCBS.
– Coordinating services and increase collaboration
between agencies.
– Enhance person-centered focus.
• Shift focus from institutional settings to HCBS.
– Shift spending.
– Increase self-direction options.
– Take advantage of opportunities presented through
the Affordable Care Act.
Projected State Enrollment in Each
Program
Waiver
Participants
Receiving CFC
services 3,857
CFC-Only
Population
5,061
MAPC
Population 991
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Maryland Legislation establishing
Adult Disability Resource Centers
• Maryland Senate Bill 83 – passed in 2013
• Human Services Article, Section 10-1001(D)
• Purpose was to define ADRC and establishes Maryland
Department of Aging (MDOA) as lead agency
• Defines “options counseling”
• Identifies statutory partners
22
www.marylandaccesspoint.info
Accessing MAP
• Statewide Toll Free Phone Number
– Anticipated statewide number in early 2014
– Baltimore City is now using 410-396-CARE (2273)
• Website
– 3.0 procurement underway
– 10,500 listings
– Working with Brain Injury Assoc. of MD. ,Alzheimer’s
Association, and others
• In-Person
– 20 MAP sites statewide
– CIL staff co-located (Center for Independent Living) The
Image Center (serving Baltimore City and County)
Adult Disability Resource Centers (ADRC)
Maryland Access Point (MAP)
www.marylandaccesspoint.info/
• Designed to integrate Aging and Disability
services
• Single point of entry for information, telephone
screening, support, and services.
• Support for caregivers and the families who are
looking for answers.
• Options Counseling
• The website includes local and private resources
Options Counseling and
Money Follows the Person
• Options Counselors assist those persons living in
institutional care to consider transition of long term care
back into the community. Section Q of the MDS 3.0 (Min
data set) requires all patients to be part of goal setting.
AERS re-assessment is required for all patients who want to
transition to the community. Centers for Independent
Living (CILS), Area Agencies on Aging (AAA), ADRC’s will
help in the plan, alongside the nursing home discharge
summary to help organize the transition.
• Money Follows the Person approved by CMS and
developed to allow persons to transfer their Medicaid
reimbursable care services (primarily provided in the past
at the institutional setting) back to the community setting
as part of the state rebalancing of long term care systems.
MFP Participation
• MFP Participants generally receive their
services through an existing waiver program.
• Additional services are available to MFP
participants on top of waiver services:
– Housing Assistance
– Behavioral Health Specialist
– Flex Funds
– Peer Mentoring
Emphasis on Advance Directives:
Providing the consumer what they want
60% of people say that making sure their family is not burdened by tough
decisions is "extremely
important" but
56% have not communicated their end-of-life wishes
(Source: Survey by California HealthCare Foundation, 2012)
70% of people say they prefer to die at home, but
70% die in a hospital or nursing home.
(Source: Centers for Disease Control, 2005)
80% of people say that if seriously ill, they would
want to talk to their doctor about end-of-life care, but only
7% report having had this conversation with doctor
(Source: Survey by California HealthCare Foundation, 2012)
Emphasis on Advance Directives:
Providing the consumers what they want
82% of people say it's important to put their wishes
in writing, but only
23% have actually done it
(Source: Survey by California HealthCare Foundation, 2012)
34% of Marylanders report having an advance
directive, but
African-Americans are significantly less likely to have one, thus identifying a
new minority health disparity
(Source: Johns Hopkins Bloomberg School of Public Health study, 2010)