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Cost shifting is the issue with nursing home diversion Program
For decades, a California long-term care program provided case management for about 12,000 elderly Medicaid clients who qualify for placement in a nursing facility but want to remain in the community, but it is now faced with total elimination.
The local Multipurpose Senior Service Program (MSSP) has 41 sites statewide, all non-profit agencies who provide the case management staff, according to Governor Jerry Brown's budget proposal. Clients must be 65 years of age or older, currently eligible for Medi Cal, be appropriate for case management services, and certified or certifiable for placement in a nursing facility, according to the proposal.
The budget proposes to eliminate the MSSP program, which operates under a federal Medicaid Home and Community-Based, Long-Term Care Services Waiver, says Sarah Ludeman, spokesperson for the California Department of Aging. This would result in savings of $19.9 million in general funds for 2011-2012, says Ms. Ludeman, and would also result in the state losing $19.9 million in federal funds.
In addition to case management services, says Ms. Ludeman, MSSP funds are used to provide adult day care, housing assistance, chore and personal care assistance, protective supervision, respite, transportation, meal services, social services, and communications services.
The MSSP program assists seniors in obtaining access to these services elsewhere in the community or through state programs first, and uses MSSP funds as a last resort for any potential gaps in needed care, according to the budget proposal.
Due to the state's fiscal condition, and the need to close a $25.4 billion budget gap, MSSP is one of many state programs being proposed for elimination, says Department of Finance spokesperson H.D. Palmer.
The estimate of $19.9 million in savings assumes that the policy is implemented June 1, 2011, after appropriately notifying the federal government, beneficiaries, and providers of the change, says Mr. Palmer. Both houses of the legislature have heard the issue, but at press time had not taken any action on the Governor's proposal, he reports.
All hands on deck
On the morning of January 10th, Eileen M. Koons, MSW, ACSW, director of Huntington Senior Care Network, and her staff heard that their program was up for elimination. "We statewide MSSP sites took an 'all hands on deck,' 'drop everything' approach."
The program had already had a 10% reduction in 2008, says Ms. Koons. "That was hard to weather, but we figured out to how to survive with that. We have been flat-funded for the 28 years of our existence," she says.
Ms. Koons says that she was worried about the program being targeted for a reduction, but was shocked to find it was slated to be cut altogether.
"This is a long-standing program with a strong history of high-quality services and no issues of fraud, waste, or abuse," says Ms. Koons. "It's openly acknowledged to be a cost-saving alternative. As a nursing home diversion program, it's exactly the population that needs to be focused on."
Cost shift wasn't considered
During a briefing on the health and human service cuts, Ms. Koons and her colleagues asked agency staff why the program was targeted for elimination. "The response that we got then, and all the way through since then, is that they scored the savings of elimination and did not attempt to quantify the cost shift. It was as simple as that," she says.
Ginni Bella Navarre, the Legislative Analyst Office (LAO)'s senior fiscal and policy analyst, acknowledges that the impact of cost shifting wasn't considered. "The assumption was made that the entire cost of the program would be saved," she says.
Ms. Navarre says that the LAO's recommendation is that the infrastructure of the program should be maintained, with a $5 million reduction in funding. "Given the general fund condition, and the need to achieve savings, we recommend reducing General Fund support for MSSP by $5 million in 2011-12. If the legislature is considering reductions in other community-based programs throughout the state, we recommend that they consider maintaining the infrastructure of the MSSP program," she adds.
The LAO also recommended that the legislature encourage the Department of Aging to work with the federal government to reduce administrative costs associated with administration of the waiver, says Ms. Navarre.
"That way, if they are getting a $5 million reduction, maybe they can achieve some of that savings in operational costs," says Ms. Navarre. "That would limit the impact on the actual number of people they are able to provide services to."
Different from IHSS
A common misconception, says Ms. Koons, is that the work of MSSP is duplicative with the services provided by the state's In Home Supportive Services (IHSS). With MSSP, says Ms. Koons, the primary service is care coordination/case management, and ability to pay for some ancillary services not funded by other state Medicaid programs, after exhausting family and community resources.
Most MSSP clients also receive funding for personal services that may allow them to remain at home through IHSS, says Ms. Koons, but MSSP provides a completely different service. "A lot of our clients depend on IHSS to stay at home, so that's one of the resources we make sure is working OK," she says. "We are more of a wraparound service. We are driven by a care plan that looks at the big picture."
Ms. Koons says that this includes working with the patient and caregivers to address the client's health care and social service needs, home safety, managing medications in the home, ensuring regular access to medical care, and end-of-life issues. "It's much different from providing assistance with tasks that need to be done," she says. "We are replicating all the things that a nursing home would attend to, in the home setting."
While IHSS benefits are sufficient for the vast majority of participants, says Ms. Koons, the population served by MSSP needs much more. "IHSS is not enough for them," she says.
Ms. Koons directs a hospital-based MSSP site, so many of the referrals she receives are discharged patients who already have IHSS but need more support to be able to stay at home. "Some of these patients go to a nursing home for a short time, but then we can help them return home and enroll them," she explains.
All participants have multiple chronic conditions, many are taking 10 or 20 medications every day, and many have impairments in their physical abilities, says Ms. Koons. "These are all indicators that these people are going to need more help. And guess what, they do," she says.
Ms. Koons says that California was "very visionary" in starting the program 28 years ago. "Maybe back then, they didn't have all the data to know why and how this was important, but now all the data is coming out to say this population needs more care coordination. That is what our program is designed to do," she says. "It shouldn't be a surprise to anyone."
About 90% of MSSP recipients rely on IHSS services, notes Ms. Navarre. "So if the legislature is going to be considering reductions to IHSS, then we suggest they consider maintaining the infrastructure of MSSP for these highly impaired recipients," she says.
Impairment levels range widely for IHSS recipients, says Ms. Navarre, while MSSP requires that participants quality for placement in a skilled nursing facility.
Ms. Navarre says that it's simply not possible to know how many of the MSSP recipients would actually go into a skilled nursing facility if the program ended. "It depends partly on their level of impairment, but based on their personal choice, they may not end up going," she says. "It is hard to predict who would actually end up costing the state money."
A side-by-side comparison of the cost of the MSSP program and nursing home care may be misleading, adds Ms. Navarre, because MSSP recipients are also accessing other community-based programs which add to the cost of keeping them in the community. "The state doesn't have a system that tracks what other community-based services an MSSP recipient may be receiving, so it hard to even quantify how much someone is costing in the community," she says.