The Senior Agenda Coalition advocates for a balanced long term care system which offers persons care choices that allow them to remain living at home and in community settings. We support the promise embodied in the Governor’s FY2009 budget plan to reform how the state delivers long term care to achieve this goal. However, reform of this magnitude needs to be discussed in an open and public way so that the end result is truly responsive to our constituents’ needs. The lack of detail to date on how the Governor’s ambitious plan would be implemented leaves us with myriad policy questions many of which are discussed below.
Uniform Assessment System
Basic to long term care reform is development of a uniform system of assessment to determine level of care needs and putting in place the infrastructure to implement the assessment system. A stakeholder group is currently working to develop a uniform assessment tool that can be used across state agencies. Key policy questions are:
What entities will be responsible for conducting the assessments (state employees or private agencies)?
What funding is in the budget to implement the assessment program?
What is the status of development of the uniform assessment tool?
Idea to consider: Washington state used state-funded case managers assigned to cover a small number of nursing homes to meet with residents about a
week after admission to start discussing diversion, seeing if they were interested and what steps and resources would be needed.
Level of Care Determinations and Service Allocation
Other state long term care reform efforts have involved implementing a system in which level of care and service allocation are based on criteria such as medical condition, ADL and skilled care needs, and cognitive ability. Key policy questions are:
How will the level of care be determined (community case managers, state staff)
and who will decide what services person qualifies for?
Is it the intent to change current policy regarding clinical criteria for nursing home admission, and if so, what is being contemplated and what is impact?
Is there an intent to use any sort of capitation or voucher based on level of care with the client able to choose services within the capitated amount?
Home and Community Services System Capacity
A successful diversion program requires system capacity to provide care in the home and other alternative settings such as adult day care. Currently, home care providers, adult day services and assisted living are seen as potential alternatives. However, current low reimbursement rates often make it difficult for these providers to recruit nursing and other staff needed to comply with regulations and provide quality care. In addition, recent increases in client co-payments for the DEA co-pay program of up to 50% and a freeze on enrolling new clients in the home care portion of the co-pay program may impact system capacity and serve as an incentive for persons to spend down to Medicaid or to defer services that help maintain function. Key policy questions are:
Are rate increments for home and community care providers under consideration and, if so, is this funding part of the proposed FY09 budget and can a phase-in begin in current fiscal year using Perry/Sullivan dollars so providers can strengthen their capacity?
Is there a need to review state licensing law or to create new alternatives such as adult day homes or assisted services within elderly housing?
Housing and Transportation
Central to relocating persons from nursing homes is the ability to locate adequate and affordable housing and to address the critical transportation needs of those relocated. Key policy questions are:
What is the inventory of available non-institutional residential alternatives and is it adequate to meet proposed number of persons to be diverted?
What is being planned to meet transportation needs of those in home
and
community settings and will new RIde co-share effect persons on
Medicaid wanting to use RIde for non-medical purposes.
Financial Issues
Medicaid eligible persons with long term care and support needs living in their own homes have different resource needs than those in nursing homes. Current resource limits ($4000 single; $6,000 couple) do not allow persons to have an extra cash cushion to take care of emergency expenses relating to household maintenance. In addition, for couples current rules regarding monthly maintenance allowance may serve as a disincentive. Key policy questions are:
Is there consideration being given to increasing the Medicaid resource test or income for persons living in their own homes?
Are spousal maintenance allowances adequate?
Information and Public Outreach
Too often most persons think nursing homes when they think long term care. Providing information and outreach to the public about the availability of home and community-based services is critical. Historically, the Department of Elderly Affairs and the state’s senior centers have played major roles in providing information to consumers seeking information about aging and long term care support services. Yet, the FY09 budget eliminates funding for Community Information Specialists (CIS) and reduces senior center grants. Key policy questions are:
What will be the impact of eliminating funds for the CIS program?
What funding will be dedicated to information and outreach in the FY09 budget?
Who will be responsible for this function?
Core Role of Department of Elderly Affairs (DEA) and Senior Centers
Traditionally, senior centers and the DEA have provided core support services that help persons remain independent and living in the community. The co-pay program subsidizes home care and adult day services. Other programs include nutrition programs (both congregate and home-delivered meals), subsidized transportation through RIde, and caregiver support such as respite.
Initiation of proposed co-payments for the RIde program will have a significant impact on access to congregate meal sites and senior centers. Based on RIde data, the average meal site participant using RIde for transport would incur costs of $573.75 if they maintained current usage.
Key policy questions are:
How will policy and funding changes made in selected areas such as co-pay and RIde impact the rest of the system?
How will support services provided by DEA and senior centers be integrated into long term care reform and should they become part of a global home and community services budget?
Should policy makers determine a set of core services crucial to maintaining persons in home and community settings and prioritize resources across departments to ensure these support services are available?
Managed Long Term Care
Some states have looked to managed care to contain long term care costs and broaden care options. Key policy question?
Does the Governor’s plan include development or a mandate for a managed long term care program?
