Texas makes "huge strides" in improving Medicaid long-term care services

Marc S. Gold, director of the Promoting Independence Initiative in the Texas Department of Aging and Disability Services, says that the state has made "huge strides in attendant services" since the 1980s.

At that time, Texas was the only state to take advantage of a demonstration waiver program called the Frail Elderly program, which allowed states to provide attendant services up to 300% of the Federal Poverty Level. Texas has had this program, now called the Community Attendant Services program, in place ever since.

"Overall, including individuals [in] both the disabilities and older population, we are serving approximately 71% of the population in a community-based service program," says Mr. Gold.

Services given with no wait

Mr. Gold notes that in addition to looking at overall dollar expenditures, it's important to look at the actual number of individuals being served. Part of the problem, he explains, is that some statistics on long-term care programs don't include managed care data.

In 2008, Texas expanded managed care for its older and physically disabled population to most of the urban areas in the state. "Those numbers aren't being included, and that is a big problem," says Mr. Gold. "When you do include those, it's pretty significant in showing the direction that the state of Texas has gone."

He explains that one advantage of managed care is that individuals on Supplemental Security Income (SSI) are given services immediately. This is because in the managed care areas, individuals get waiver-type services as an entitlement instead of going on interest lists. "That is a big deal, because Texas, like many states, has long interest lists. We don't call them waiting lists, because individuals haven't been predetermined to be eligible," says Mr. Gold.

"The other big area where the state of Texas has really succeeded and excelled is our Promoting Independence Initiative," says Mr. Gold.

One major focus of that program is the relocation of individuals from intermediate care facilities for persons with mental retardation (ICF/MRs) with nine or more beds, and from nursing facilities.

What they get is an expedited access to their waiver program, which normally has a multiple year wait time," says Mr. Gold. Since 2001, more than 3,000 people have been relocated from private facilities and the publicly funded ICF/MRs.

The state of Texas has been actively relocating individuals from nursing facilities for nine years. "A large part of the MFP demonstration that was included in the Deficit Reduction Act was based on the activities in the state of Texas," says Mr. Gold. "We have moved out over 21,000 individuals since 2001."

For the MFP demonstration, all of the original benchmarks were met in 2010. "So, we are going to ask for an extension for those," says Mr. Gold.

Under the MFP demonstration, incentive money is provided for privately owned ICF/MRs with nine or more beds to voluntarily close their facility, change their business plan, and offer waiver spots to individuals.

Five facilities have been closed to date, with five more pending. This comprises 700 to 800 beds. "We are providing incentives to close the facilities and offering people choices. We are taking the money and putting it back into the community," says Mr. Gold. "That is something we have been very successful with."

All ages, complexities

Individuals with co-occurring behavioral health and physical health needs who are currently residents of nursing facilities are able to receive additional services than they would normally receive under the waiver program.

"That program, too, has been very successful in moving people who may have been caught in that cycle," says Mr. Gold. "We have about 88% remaining in the community for that population."

The program was originally implemented in San Antonio and is now being expanded to all of the contiguous counties and the Austin area.

Impressive results over the long term have for the most part dispelled the initial concerns voiced when the program was first being talked about in the 1980s. "There were obviously a lot of concerns by all the stakeholders — the provider base, advocates, families, and guardians — about how to serve a nursing home population successfully in the community," says Mr. Gold.

The biggest worries involved individuals with more complex needs. To alleviate these concerns, relocation specialists were hired to act as facilitators.

"They also work as housing navigators for individuals who have lost their community supports," says Mr. Gold. "One of the biggest barriers for individuals who have been institutionalized for a period of time is housing."

In addition to working with nursing facilities, the program is also working with home health agencies. The goal is for them to take on more individuals with complex needs, such as patients on ventilators.

Initially, Mr. Gold himself assumed that it would be the younger disabled individuals who would take advantage of the opportunity. "But our data demonstrated we were serving a large population over 60," he says. "We have 16 people right now over 100, who are living successfully in the community, as a result of MFP." About 25% of the population receiving Home and Community Based Services are over 80.

The program has also had good results with showing that developmentally disabled individuals who have been in the larger ICF/MRs, both private and state-supported, can be served successfully in the community.

"This impacts individuals of all ages and complexity levels," says Mr. Gold. "With history, experience, and word of mouth, it's really removing those doubts. People want to at least give it a try."

Texas' MFP data has not shown higher levels of remission, increased levels of abuse or neglect, or acute episodes occurring for individuals after they've relocated. Mr. Gold notes that when looking at overall costs, one has to consider not only the long-term services cost, but also acute care costs and residential costs.

"If you were to look at our legislative appropriations request, it will demonstrate that on average, the cost is cheaper to serve an individual in a community-based setting," says Mr. Gold.

Contact Mr. Gold at (512) 438-2260 or marc.gold@dads.state.tx.us.