Equal footing needed with community-based services for LTC

When Michael P. Starkowski, commissioner of Connecti- cut's Department of Social Services, gave a recent presentation, a woman in a wheelchair approached him during a coffee break. She asked whether he had anything to do with Money Follows the Person (MFP), a Medicaid initiative that helps people transition from institutions to community living. "I said yes, very much so. It's one of the things we really believe in and have promoted," he says. "And she told me, 'I was in a skilled nursing facility for 11 years and moved out a month ago. You wouldn't believe what it's done for me.'"

Mr. Starkowski says that a success story like this flew in the face of some of the original expectations for MFP. "You have to be in a minimum of six months, so I thought we would catch all these people who'd been in there seven or eight months. You really didn't think you were going to be able to move somebody out that's been in a nursing facility for a long time, because their community support is gone, their assets and furniture are gone," he says. "But here's a person who had a disability, had been there for 11 years, went back into the community, and just feels it was the best thing we could have done for them."

Since January 2009, Connecticut has transitioned about 100 people out of 54 different skilled nursing facilities. MFP, part of a federal Medicaid "rebalancing" initiative that offers enhanced reimbursement for more cost-effective care, is the latest in Connecticut's programs that offer community-based alternatives for people who do not need institutional care with sufficient support services in place. "We have seen a significant savings as we help people get back into the community," reports Mr. Starkowski.

The goal is to move out about 700 people by 2011. "I think the program is catching a lot of steam right now. There is a pent-up demand of people trying to move back into the community if we can provide support for them," says Mr. Starkowski.

Finding adequate support is a major challenge, however. Connecti- cut's Gov. M. Jodi Rell, who authorized the MFP program, announced an initiative that will utilize stimulus funding for scholarships and other incentives to encourage individuals to go into the nursing profession.

"It will take time for that to come to fruition, in order to have adequate networks out there. Meanwhile, we have a shortage of nurses and health care workers, like everybody else is experiencing," says Mr. Starkowski. "We do have some people going into our personal care assistance program, which is a waiver program funded through Medicaid, but that's a handful of people."

Equal footing is needed

Laura Summer , author of the Washington, DC-based Kaiser Commission on Medicaid and the Uninsured (KCMU)'s September 2009 report "Efforts in States to Promote Medicaid Community-Based Services and Supports," and a senior research scholar at Georgetown University Health Policy Institute, also in Washington, DC, says one problem is that community-based and institutional long-term services are not on equal footing. "We need a more level playing field, I think, for the two types of services," says Ms. Summer.

Home and community-based services (HCBS) waivers have been the primary means of expanding community-based services, but the waiver process is cumbersome. Also, some states have more restrictive financial eligibility criteria for HCBS than for institutional services.

Applicants who wish to remain in the community also face significant challenges if the Medicaid eligibility determination is not done quickly. They may not be able to arrange for home modifications or for services they need while they are waiting for assurance that the services will be covered. Traditionally, institutional providers have been more willing to provide services before an individual is determined eligible for Medicaid.

Financial and functional eligibility determinations, assessment procedures, and the mix of available community-based services for individuals with disabilities may differ within and across states. "States that have established a single administrative agency, use a uniform assessment process, or use global budgeting for the provision of all types of long-term services and supports have been leaders in promoting community-based services," notes Ms. Summer.

Impact of recession

States in dire financial straits may not be able to do major redesigns of their long-term care programs. "On the other hand, in the past, states have looked at tough economic times as the impetus for innovation," says Ms. Summer. "I think that states are going to have to pay a great deal of attention to how they provide long-term care."

Most states already have coverage limits, enrollment caps, and waiting lists for community-based services. Two states in FY 2009 and seven states in FY 2010 imposed additional restrictions directed at HCBS programs, according to the September 2009 KCMU report, "The Crunch Continues: Medicaid Spending, Coverage and Policy in the Midst of a Recession." Although the majority of states still are taking action to expand and improve access to Medicaid HCBS, the KMCU report found that only 32 states are adopting these policies in FY 2009, compared to 42 in FY 2008.

"The bottom line is that states are continuing to work on reorienting their Medicaid long-term care delivery systems towards more community-based services. But in these times of fiscal stress, most states are focused on maintaining current levels of service for those already enrolled in the program," says Molly O'Malley, a senior policy analyst with the Henry J. Kaiser Family Foundation in Menlo Park, CA.

Going forward, states will be faced with the added challenge of the expiration of the American Recovery and Reinvestment Act (ARRA) funds. "That could force many states to make additional cuts to Medicaid eligibility and benefits, including potential reductions to HCBS," says Ms. O'Malley.

Jennifer Burnett, deputy secretary for the Pennsylvania Department of Public Welfare's Office of Long Term Living, says that since taking office in 2003, the state's governor has made long-term care reform a priority. "A critical element of the strategy was establishing a single point of accountability for the continuum of long-term care," says Ms. Burnett.

In 2007, the Office of Long-Term Living was established, as a joint office of the Department of Aging and Department of Public Welfare. The office is responsible for the management of eight home and community-based waivers serving the elderly and younger people with physical disabilities, the state-funded OPTIONS program for seniors, the Act 150 program of attendant care for people with disabilities, the LIFE PACE (Living Independence for the Elderly/Program of All-Inclusive Care for the Elderly), senior centers, adult day programs, domiciliary care, and Pennsylvania's Medical Assistance nursing facility payments.

"We have worked hard to rebalance the state's reliance on nursing facility care in the past two years, by shifting long-term care utilization," says Ms. Burnett. "The percentage of total long-term care recipients now receiving services in HCBS has increased nearly 6% in two years."

The number of adult day services centers has grown from 239 in 2006 to 256 today, and LIFE PACE centers, which numbered just four in 2003, will grow to 19 by 2010. "A renewed commitment to senior centers is an important component of the long-term care system, with a critical role in prevention," says Ms. Burnett.

A rapid assessment process is used in a Community Choice pilot program currently under way in 12 counties. Eligibility for services in the community is expedited using shortened forms, and post-verification of income and assets. This effort involved the Office of Income Maintenance, the office responsible for eligibility for Medicaid. 

"It allows individuals to self-declare their assets and income, while the lengthy process of verifying eligibility occurs after the person begins receiving services," says Ms. Burnett. "We are in the process of evaluating the outcomes and will make decisions about rolling this out statewide once the review of the pilot is completed."

Contact Ms. Burnett at (717) 783-9821, Ms. O'Malley at (202) 347-5270 or mollyo@kff.org, Mr. Starkowski at (860) 424-5054 or Michael.starkowski@ct.gov, and Ms. Summer at (202) 687-3595 or lls6@georgetown.edu.