CT Money Follows the Person Quarterly Report - UConn Health · Target Population Summary for...

1

MFP Benchmarks 1) Transition 5200 people from qualified institutions

to the community 2) Increase dollars to home and community based

services 3) Increase hospital discharges to the community

rather than to institutions 4) Increase probability of returning to the community

during the six months following nursing home admission

5) Increase the percentage of long term care participants living in the community compared to an institution

CT Money Follows the Person

Quarterly Report

Quarter 4, 2015: October 1, 2015 – December 31, 2015 (Based on latest data available at the end of the quarter)

UConn Health, Center on Aging Operating Agency: CT Department of Social Services Funder: Centers for Medicare and Medicaid Services

Benchmark 1: The number of demonstration consumers transitioned = 3,162

(non-demonstration transitions = 251)

33% 33% 35% 38% 40% 41% 43% 45% 45%

67% 67% 65% 62% 60% 59% 57% 55% 55%

0%

20%

40%

60%

80%

2007 2008 2009 2010 2011 2012 2013 2014 2015

Benchmark 2 CT Medicaid Long-Term Care Expenditures

Home and Community Care Institutional Care

47% 47%

49% 50%

51% 52% 52% 52% 53% 53% 53% 51% 50%

49% 48% 48% 48% 47%

40%

50%

60%

2007 2008 2009 2010 2011 2012 2013 2014 Q12015

Benchmark 3 Percentage of Hospital Discharges to Home and

Community Care vs. Skilled Nursing Facility

Home and Community Care Skilled Nursing Facility

28% 25% 24%

27% 28% 31% 32%

31% 38%

35% 37% 37% 38%

36% 36%

0%

10%

20%

30%

40%

Benchmark 4 Percent of SNF admissions returning to the community

within 6 months

52% 52% 53% 54% 55% 56% 58% 59% 60%

48% 48% 47% 46% 45% 44% 42% 41% 40%

30%

40%

50%

60%

2007 2008 2009 2010 2011 2012 2013 2014 2015

Benchmark 5: Percent Receiving LTSS in the Community vs. Institutions

Home and Community Care Institutional Care

61%

80% 78% 78%

39%

21% 22% 22%

0%

20%

40%

60%

80%

100%

baseline 6 month 12 month 24 month

Happy or unhappy with the way you live your life*

happy

unhappy

2

257

188

123

180 163

193

119

220

317

159 194

231

325 341 327 311

372

331 313

226 214

604

709

352

566 587

508

449

0

100

200

300

400

500

600

700

800

Nu

mb

er

of

Pe

op

le R

efe

rre

d

Quarter

Referrals to Transition Coordinatorsᵗ: Q1 2009 to Q4 2015

ᵗExcludes nursing home closures *Inrease in referrals reflects the ongoing adjustment to MFP reorganization

19

38 43

62 60

74 98

83 66

107 152

109 114

120 110

166 132

167 147

166 121

117 159

199 163

214 201

206

0 50 100 150 200 250

2009 12009 22009 32009 42010 12010 22010 32010 42011 12011 22011 32011 42012 12012 22012 32012 42013 12013 22013 32013 42014 12014 22014 32014 42015 12015 22015 32015 4

Number of Consumers Who Transitioned

Qu

arte

r

Number of Transitions by Quarter: 12/2008 - 12/31/2015

3

42% 37% 38% 40% 30%

21% 10% 8% 8%

12%

35% 48% 49% 47% 56%

3% 5% 4% 5% 2%

BENCHMARK FORTRANSITIONS

Referrals (n=6383) Signed InformedConsents (n=5593)

Transitions (n=3162) Closed w/oTransitioning

(n=1301)

Target Population Summary for Referrals through Q4 2015 (Demonstration Only)

Physical Disability Mental Health Elderly Developmental Disability

72.9%

13.6%

9.3%

1.9% 2.2% 0.2%

Qualified Residence Type for Transitioned Referrals: 12/4/08-12/31/2015

Apartment Leased By Participant, Not Assisted Living

Home Owned By Family Member

Home Owned By Participant

Apartment Leased By Participant, Assisted Living

Group Home No More Than 4 People

Not Reported

301

1194

453

739

408

44 126 113 130 61

0100200300400500600700800900

100011001200

Eastern North Central Northwest South Central Southwest

Cumulative Number of Clients Who Transitioned and those with Home Modifications by Region

Transitioned Home Modification

Note: Track 2 referrals not included.

Reinstitutionalization: 13% (324) of participants who transitioned by December 31, 2014 were in an institution 12 months after their transition.

4

216

1165 1530

162 338

2 46 124 251

49 15 1 0

500

1000

1500

2000

ABI PCA Elder DDS MentalHealth

Katie Becket

Cumulative Number of Clients Who Transitioned and those with Home Modifications by Waiver

Transitioned Home Modification

40% 39% 34%

56% 57% 61%

3% 4% 5%

0%

20%

40%

60%

80%

100%

6-month 12-month 24-month

Consumers under age 65 who are working and those who would like to work

Currently workingNot working and don't want to workNot working but want to work

14% 13% 13%

85% 87% 86%

1% 1% 1%

0%

20%

40%

60%

80%

100%


Consumers 65 years and older who are working and those who would like to work

Currently workingNot working and don't want to workNot working but want to work

30% 30% 27%

63% 62% 65%

7% 8% 8%

0%

20%

40%

60%

80%

100%


Consumers under age 65 who are volunteering and those who

would like to volunteer

Currently volunteering

Not volunteering and don't want to volunteer

Not volunteering but want to volunteer

17% 14% 12%

80% 83% 84%

3% 3% 4%

0%

20%

40%

60%

80%

100%


Consumers 65 years and older who are volunteering and those who

would like to volunteer

Currently volunteering

Not volunteering and don't want to volunteer

Not volunteering but want to volunteer

5

75%

88% 90% 90%

26%

12% 11% 10%

0%

20%

40%

60%

80%

100%


Happy or unhappy with your help around the house or in the community*

happy

unhappy

33%

85% 84% 80%

26%

6% 6% 8%

41%

9% 10% 13%

0%

20%

40%

60%

80%

100%


Do you like where you live?*

yessometimesno

48% 46% 43% 52% 54% 57%

0%

20%

40%

60%

80%

100%

6 month 12 month 24 month

Did family or friends help you with things around the house?*

yes

no

MFP

Quality of Life Dashboard

As of 12/31/2015

83% 95% 95% 94%

17% 5% 5% 6%

0%

20%

40%

60%

80%

100%


Do the people who help you treat you the way you want them to?*

yes

no

58% 52% 52% 53%

42% 48% 48% 48%

0%

20%

40%

60%

80%

100%


Depressive Symptoms*

yes

no

4.07

5.13 5.14 5.09

0

1

2

3

4

5

6


Average number of areas of choice and control*

43%

55% 58% 58% 57%

45% 42% 42%

0%

20%

40%

60%

80%

100%


Community integration - Do you do fun things in the community?*

yes

no

*indicates statistically significant differences

6

Quality of Life Interviews Completed

(Cumulative data through 12/31/15) Baseline interviews done prior to transition, n=3,500 6 month interviews done 6 mos after transition, n=2,535 12 month interviews done 12 mos after transition, n=2,153 24 month interviews done 24 mos after transition, n=1,474

13% 15% 13% 12%

87% 85% 87% 88%

0%

20%

40%

60%

80%

100%

baseline 6 month 12 month24 month

Healthcare unmet need*

yes

no

90% 90% 89%

36% 30% 29%

0%

50%

100%

6 month 12 month 24 month

Have or Need Assistive Technology (AT)?

Have AT Need AT*

84% 92% 93% 93%

16% 8% 7% 7%

0%

20%

40%

60%

80%

100%


Personal care - unmet needs*

0 unmet needs 1 or more

2.16

2.08

2.13

2.13

1.00

2.00

3.00


me

an s

um

mar

y sc

ore

Activities of Daily Living scores Range 0 - 6; 0=can do all ADLs independently;

6=need assistance with all

3.99

4.18 4.26

4.22

3.00

4.00

5.00


me

an s

um

mar

y sc

ore

Instrumental Activities of Daily Living scores Range 0-7; 0=can do all IADLs

independently; 7=need assistance with all*

7.5% 11.7% 11.2% 11.8%

49.3% 44.3% 43.4% 42.2%

35.8% 33.0% 34.5% 35.1%

7.4% 11.1% 10.9% 10.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Rate Your Overall Health*

excellent good fair poor

7

Transition Challenges through 12/31/15

Transition coordinators (TCs) and specialized care managers (SCMs) complete a standardized challenges checklist for each consumer. There were a total of 9,884 MFP referrals to SCM Supervisors. Challenges checklists were completed for 6,709 of these referrals, representing 6,226 consumers. Excluding the referrals which indicated “no challenges,” the challenges checklist generated 39,134 separate challenges. Of these, the most frequently chosen challenge was physical health (17.0%), followed by challenges related to housing (15.3%), services and supports (13.6%), mental health (12.5%), and consumer engagement (9.8%).

6%

16% 20%

13% 14%

29%

38%

54%

33% 27%

37%

56%

6%

18% 19% 23%

12%

24%

36%

49% 46% 45%

50%

66%

0%

10%

20%

30%

40%

50%

60%

70% Transitioned Closed before transitioning

Type of challenge by

transition status The figure below shows the percentage of each group (those who transitioned and those who closed before transitioning) which had each challenge. For example, of the referrals that closed without transitioning, 66 percent had a physical health challenge. Conversely, 56 percent of referrals that did transition had physical health challenges.

Nine of the twelve challenge categories had statistically significant differences between the two groups.

Other challenges, 1.4%

Facility related, 2.8%

Other involved individuals, 3.6%

Legal issues, 4.3%

MFP office /TC, 4.4%

Financial issues, 7.5%

Waiver/HCBS, 7.8%

Consumer engagement,

9.8%

Mental health, 12.5%

Services and supports, 13.6%

Housing, 15.3%

Physical health, 17.0%

Be sure to check the LINK to the full Transition Challenges report. http://uconn-aging.uchc.edu/money_follows_the_person_demonstation_evaluation_reports.html

http://uconn-aging.uchc.edu/money_follows_the_person_demonstation_evaluation_reports.html

8

Types of Challenges – through 12/31/2015

Shown below are the six most common challenge types

56% 31%

5%

2%

8%

Physical health Current, new or undisclosedphysical health problem

Inability to manage physicaldisability or physical illness incommunity

Medical testing issues ordelays

Missing or waiting for physicalhealth documents

Other physical health issues

18%

34% 28%

17%

4%

Mental health

Current or history ofsubstance/alcohol abuse w/risk of relapse

Current, new, or undisclosedmental health problem

Dementia or cognitive issues

Inability to manage mentalhealth in community

Other mental health issues

6% 3%

15%

6%

48%

3%

19%

Housing Delays related to housing authority,agency or housing coordinator

Delays related to lease, landlord,apartment manager, etc.

Needs housing modificationsbefore transition

Ineligible or waiting for approvalfrom RAP or other housingprograms

Lacks affordable, accessiblecommunity housing

Housing related legal, criminal orcredit issues, including evictions orunpaid rent

Other housing related issues

9%

15%

9%

54%

13%

Waiver /HCBS Current waivers or HCBSprograms do not meetconsumer needs

Ineligible for or denial of HCBSprogram or waiver services

Targeted waiver full

Waiting for evaluation,application review from waiveror HCBS agency/contact

Other HCBS or waiver programissues

6%

11%

9%

38%

18%

6%

7% 5%

Services and supports

Lack of alcohol, substance abuse,or addiction services

Lack of AT or DME

Lack of mental health services orsupports

Lack of PCA, home health, orother paid support staff

Lack of transportation

Lack of any other services orsupports

Lack of unpaid caregiver toprovide care/informal support

Other issues related to services orsupports

For the full report on transition challenges through 12/31/2015, use the link on page 7 to

get to the Center on Aging website.

12%

35% 35%

10% 8%

Consumer engagement

Disengagement or lack/lossof motivation

Lack of awareness orunrealistic expectations

Lack of independent livingskills

Language or communicationskills

Other consumer relatedissues

9

21%

26%

21%

6%

6%

11%

3% 4%

1% 1%

Percentage of Closed Cases by Closure Reason: October - December 2015

Transitioned to community before informed consent signed Participant changed their mind and would like to remain in the facility COP/Guardian refused participation

Other

Exceeds physical health needs

Participant would not cooperate with care planning process Reinstitutionalized for 90 days or more

Participant not aware of referral & does not wish to participate Participant moved out of state

Exceeds mental health needs

162 197

117

284

156 168

109 119

362

226 214

604

709

352

566 587

508

449

160

121 117 159

199 163

214 201 206

72 92

19 40 44

30

19 23

81

71 57 19 22

57

29

36 40 46

0

100

200

300

400

500

600

700

800

Oct-Dec 13 Jan-Mar 14 April-Jun14 Jul-Sep 14 Oct-Dec 14 Jan-Mar 15 April-Jun15 Jul-Sep15 Oct-Dec 15*

Nu

mb

er

Quarter

Comparison of Closures, Referrals and Transitions per Quarter

Total closures excluding: died, nursing home closure, completed participation, non-demo transition servicescompletedNew referrals excluding nursing home closures

Total cases transitioned

Closures per 100 new referrals

Transitions per 100 new referrals

* Note: Total closures this quarter were higher due to clearing a backlog at Central Office.

10

Meet Serita Raymond

Serita Raymond is a very happy 28 year old, with many goals. Serita came to the United States at 9 years old from Jamaica to live with her father and stepmother. She worked as a Certified Nursing Assistant at two rehabilitation facilities and was going to school for nursing. In July, 2013 Serita and her then four year old son went to visit her family in Jamaica. Three days into the vacation Serita had a stroke that left her with paralysis on her right side. She returned to the United States a month later and moved into a rehabilitation facility, where she spent 21 months working on her rehabilitation. After leaving the facility through the MFP program, Serita focused on regaining her independence by continuing speech and physical therapy. Although she works very closely with her Recovery Assistant, who helps her with everyday activities, Serita states that she likes to do things on her own. “I want to be able to do everything on my own to help myself.” Serita describes her condition as though everything in her mind has switched around, making things that can take a minute to do take a lot longer. Serita lives by herself in her own apartment. She says, “I am so thankful for the MFP program, if it wasn’t for them I wouldn’t have this place.” Serita enjoys going to the gym, which is conveniently located in her apartment complex. She has completed her formal physical therapy, but she still follows the same exercise routines to continue to improve her abilities. She enjoys the weekends where she spends time with her son, who now lives with his grandparents, and attends church on Sundays. Serita also volunteers every Thursday at her former rehabilitation facility, where she distributes announcement and documents to several floors and socializes with the residents. One major goal for Serita is to one day have her son living with her. She also wants to start driving again; she will soon have an assessment that will determine if she can start driving her car. She is currently enrolled at a local community college to obtain a certificate as a Community Health Worker. “I’ve had so many people help me and I know I can do the same for someone else.”

MFP Demonstration Background

The Money Follows the Person Rebalancing Demonstration, created by Section 6071 of the Deficit Reduction Act (DRA) of 2005 (P.L. 109-171), supports States’ efforts to “rebalance” their long-term support systems. The DRA reflects a growing consensus that long-term supports must be transformed from being institutionally-based and provider-driven to person-centered and consumer-controlled. The MFP Rebalancing Demonstration is a part of a comprehensive coordinated strategy to assist States, in collaboration with stakeholders, to make widespread changes to their long-term care support systems.

One of the major objectives of the Money Follows the Person Rebalancing Demonstration is “to increase the use of home and community based, rather than institutional, long-term care services.” MFP supports grantee States to do this by offering an enhanced Federal Medical Assistance Percentage (FMAP) on demonstration services for individuals who have transitioned from qualified institutions to qualified residences. In addition to this enhanced match, MFP also offers states the flexibility to provide Supplemental Services that would not ordinarily be covered by the Medicaid program (e.g. home computers, cooking lessons, peer-to-peer mentoring, transportation, additional transition services, etc.) that will assist in successful transitions. States are then expected to reinvest the savings over the cost of institutional services to rebalance their long-term care services for older adults and people with disabilities to a community-based orientation.

Photo credit: Alba Santiago

CT Money Follows the Person Quarterly Report - UConn Health · Target Population Summary for...

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