Seniors and People with Disabilities Division James Toews, Director April 2009

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Seniors and People with Disabilities Division

James Toews, Director

April 2009

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Day 1, April 15: Introduction and description of SPD services

Day 2, April 16: SPD budget

Day 3, April 20: Major program area – Services to Seniors and People with Physical Disabilities

Day 4, April 21: Major program area – Services to People with Developmental Disabilities

Day 5, April 22: Public testimony

Day 6, April 23: Major program area – Program Support and Central Administration, Wrap-up

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SPD Mission

The mission of the Seniors and People with Disabilities Division (SPD) is to assist seniors, and people with disabilities of all ages, achieve well-being through opportunities for community living, employment, family support and services that promote independence, choice and dignity.

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SPD goals Help seniors and people with disabilities remain as

independent as possible Help sustain seniors and people with disabilities with the

supports they need to maintain quality lives in their home communities

Honor choices made by seniors and people with disabilities about their own lives

Promote value-driven commitments in statute and policy Partner with advocacy groups, commissions and councils,

local government partners, and community services

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· Boards & Commissions· Legislature· Intergovernmental Relations· Continuous Quality

Improvement

Assistant DirectorJames Toews

DHS Seniors and People with Disabilities

Deputy Assistant Director

Cathy Cooper

Senior and Disability Services

Jeanette Burket

Federal Resource & Financial Eligibility

DeAnna Hartwig

Developmental Disability Services

Mary Lee Fay

Licensing & Quality of Care

Mary Gear

Monitors & enforces standards of care & quality in long-term care (LTC) settings. Activities include:· Quality Assurance· Provider Training & Technical

Assistance· Provider Contract Management· Licensing & Certification of LTC

Facilities & Programs· Policy Development· Protective Services· Community Nursing· Estab. of Standards of Care in

Adult Foster Homes, Res. Care Facilities, Assisted Living & Nursing Facilities

Field· CCMUs

Provides management & oversight of programs to seniors & people with disabilities.· In-Home Supports· Home Care Worker Program· Oregon Project Independence

(OPI)· State Unit on Aging· Aged & Physically Disabled

(APD) Field Services· Case Management· Home Care Commission· Rule & Policy Development· Technical Staff Training

Field· Medicaid/Older Americans Act

(OAA)· State, Contract & Transfer Area

Agencies on Aging (AAA) Type B· Oregon Project Independence (OPI)/

Older Americans Act (OAA)/Type A’s

Provide oversight of Medicaid programs; program data & info; benefits to clients· Waiver and State Plan

Development & Compliance· Research-Planning & Rates· Quality Assurance· Federal Reporting· Medicare Modernization Act

(MMA)/ Medicare Services· Information Systems

coordination· Provider Payments· Disability Determination

Services· Rule & Policy Development

Field· Disability

Determination Services

Provides management & oversight of programs to persons w/developmental disabilities. Activities include:· Comprehensive Services· In-Home Supports· Staley Agreement Implementation· Housing Supports· Rule & Policy Development· Technical Assistance· Development Disabilities (DD)

County Relations· Children & Family Supports· State Operated Group Homes· Contract Administration· Provider Development & Monitoring· Quality Assurance· Case Management

Field· Community

Developmental Disabilities Programs

· Brokerages· State Operated Group

Homes

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APD services

Seniors and People with Physical Disabilities Eligibility for Medicaid, food stamps Case management services Older American Act services In-home services Community-based facility and nursing facility services Disability determination services

(SSA Title II and XVI)

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Who receives APD services

Seniors and People with Physical Disabilities 18,000 individuals age 65 and older receive long-term

services under Medicaid 26,500 individuals (including people with physical

disabilities) receive long-term services under Medicaid monthly

76,200 seniors and people with disabilities receive medical coverage and/or food stamps

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DD services

People with developmental disabilities Eligibility for developmental disabilities services Case management for children and adults Family support for children Support services for adults Community-based care services for children and

adults

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Who receives DD services

People with developmental disabilities 17,300 children and adults with developmental

disabilities receive case management services 6,100 children and adults with developmental

disabilities receive comprehensive services 6,100 adults with developmental disabilities receive

in-home support services 1,400 children with developmental disabilities receive

family support services

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SPD licensing

SPD and its partners license: 1,847 relative adult foster homes, consisting of 79

percent Medicaid 1,713 commercial adult foster homes, consisting of

7,174 beds, 38 percent Medicaid 205 assisted living facilities, consisting of 13,790 beds,

28 percent Medicaid 229 residential care facilities, consisting of 8,622 beds,

26 percent Medicaid 141 nursing facilities, consisting of 12,462 beds, 40

percent Medicaid

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SPD licensingSPD and its partners license and certify: 574 residential sites (24-hour) 31 children’s residential sites (24-hour) 86 employment and alternative-to-employment agencies 56 supported living agencies 6 proctor foster agencies 719 adult foster care providers 248 child foster care providers 118 agencies in Oregon that are licensed or certified to

provide services to individuals with developmental disabilities

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Growing need for APD services By 2010 – 13 percent of Oregon’s population will be

65 or older By 2030 – 20 percent of Oregon’s population will be

65 or older By 2010 – 76,000 Oregonians will have reached age 85,

and by 2030 the number is expected to reach 120,000 25 percent need assistance with ADLs from family or

paid caregivers 20 percent need assistance with three or more ADLs Many “spend down” their assets and cannot afford long-

term services Many rely on Medicaid for their long-term services

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Challenges facing APD The state’s changing demographics Lack of provider capacity Decrease in Medicaid capacity in community settings The need to realign Medicaid services to allow

individuals with significant needs to be served in community settings

Continued need to provide protection for vulnerable adults

Recruitment and retention of a long-term care workforce

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Growing need for DD services Today there are more than 17,000 adults and children

with DD enrolled in case management services During 1998 there were 2,700 individuals with DD

receiving home and community-based waiver services In-home services expanded as part of the Staley

agreement Now nearly 12,000 adults with DD receive support or

comprehensive services The number of Oregonians with DD needs such as

autism, alcohol- and drug-related causes is growing The Centers for Disease Control estimates 1 in 100

children is diagnosed with autism The need for DD services has grown by 800 every year

for the last four years for both children and adults

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Challenges facing DD

Supporting children and families Provider stability County stability Rate setting and assessments Final implementation of the Staley settlement

agreement

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SPD continuous quality improvement efforts

DHS Transformation Initiative Fundamentally changing the way business is done SPD already is producing early results SPD is being challenged to do business better within

existing resources

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SPD continuous quality improvement efforts

Efforts of quality improvements have included:– Financial eligibility intake process

(SPD/AAA field and central offices)– Presumptive Medical Disability Determination Team

process improvement– Developmental disability contract administration– Corrective Action Unit

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Major caseload and budget drivers The economy Demographics Population changes Federal policy and funding

– Automatic Verification System (AVS) – Federal Stimulus (ARRA) limitations

Medicare services– Medicare Improvement for Patients and Providers

Act (MIPPA)

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Aged and Physically Disabled caseload trends

76,877

79,104

82,000

74,000

75,000

76,000

77,000

78,000

79,000

80,000

81,000

82,000

83,000

2005-07

07-09 Fall Fcst 08

09-11 Fall Fcst 08

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Forecast changes to EBL2005-2007 2007-09 2009-11 2007-09

Fall 08 Fall 08 2009-11

Forecast Forecast Y/Y Pct Chg

In-Home Program

In-Home Hourly 9,951 9,296 9,194 -1.1%

In-Home Live-In 1,193 1,062 1,019 -4.0%

In-Home Spousal 131 130 132 1.5%

11,275 10,488 10,345 -1.4%

Community Based Care

Relative Adult Foster Care 1,547 1,475 1,399 -5.2%

Commerical Adult Foster Care 2,496 2,482 2,510 1.1%

Regular Residential Care 1,000 962 968 0.6%

Contract Residential Care 1,116 1,106 1,099 -0.6%

Assisted Living Facilities 3,816 3,672 3,657 -0.4%

Specialized Living 161 164 165 0.6%

ElderPlace (PACE) 635 674 750 11.3%

10,771 10,535 10,548 0.1%

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Forecast changes to EBL2005-2007 2007-09 2009-11 2007-09

2005-07 07-09 Fall Fcst 08 09-11 Fall Fcst 08 2009-11

Forecast Forecast Y/Y Pct Chg

Nursing Facilities

NF Basic 4,532 4,594 4,668 1.6%

NF Complex Medical 350 378 361 -4.5%

NF Pediatrics 61 55 56 1.8%

NF Extended Care 78 83 80 -3.6%

NF Enhanced Care 58 59 60 1.7%

NF Post-Hospital Care 2 5 6 20.0%

5,081 5,174 5,231 1.1%

Oregon Supplemental Income Program

Aid to the Blind 596 611 638 4.4%

Aid to the Disabled 38,841 40,673 42,300 4.0%

Old Age Assistance 10,313 11,623 12,938 11.3%

49,750 52,907 55,876 5.6%

Total Caseloads- APD 76,877 79,104 82,000 3.7%

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Aged and Physically Disabled by care settings

Seniors and People with Physical Disabilities Long-Term Care Clients 2001-2008

Nursing Facility

In-Home

Residential Care Facilities

Assisted Living Facilities

Adult Foster Homes

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

2001 2002 2003 2004 2005 2006 2007 2008

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Developmental Disabilities caseload trends

5,289 5,684 6,178 6,658

15,64416,98817,274

18,350

6,695 7,200

5,4986,200

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

2003-2005 2005-2007 2007-2009 2009-2011

ComprehensiveServicesCase ManagementServicesSupport Services

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Developmental Disabilities by care settings

People with Developmental Disabilities by Care Setting

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

6000

6500

7000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Residential Services

In-Home Services

Foster Care

Medically Fragile/Behavior ChildrenEOTC

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Caseload model looked only at the number of cases to determine staff need

The new workload model looks at the actual activity (time) required for the job

The workload models were developed by Public Knowledge and McKinsey

Future budget documents and rebalance displays will rely on the more accurate workload/staffing comparisons

Workload staffing gap

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2009-11 Caseload Staffing Compared to Workload Staffing

Standards

1,417

1,630

1,348

-

500

1,000

1,500

2,000

Positions Authorized

Positions Earned (Caseload)

Positions Earned (Workload)

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Position Type as of December 2008

Positions Currently Authorized

Positions Earned (Caseload)

Percent of earned (Caseload)

Positions Earned (Workload)

Percent of earned (Workload)

Difference (Current to Workload)

Compliance Specialist 2 5 8 160% 8 100% 0Adult Protective Services 101 106 105% 139 76% -33Eligibility Specialist 267 269 101% 327 82% -58Support Staff 282 282 100% 295 96% -13Supervisors 105 105 100% 121 87% -16Case managers 509 509 100% 575 89% -66Paraprofessional CM 59 64 92% -5Quality Assurance 6 6 100% 15 40% -9Training & Development 13 0% -13Disability Analyst 10 10 100% 10 100% 0PAS Screeners 30 30 100% 30 100% 0Diversion-Transition 33 33 100% 33 100% 0

Totals 1,348 1,417 1,630 (213)

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SPD MEBL program budget2009-11 GRB Base to Modified Essential Budget Level

Seniors and People with Disabilities Divisionby Program

$3,541 million

Aged and Physically Disabled $1,884 53.2%

Developmentally Disabled $1,303 36.8%

Program Support and Administration

$355 10.0%

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SPD 2009-2011 base budget to MEBLGeneral Funds Other Funds Federal Funds Total Funds Pos FTE

Base Budget 1,021,330,254 172,038,223 1,727,428,903 2,920,797,380 2,010 1,974.68

Essential Packages: - 10 - Vacany Factor/Non-PICS 474,332 70,077 (53,030) 491,379 - - 21 - Phase Ins 28,384,390 14,777 44,242,029 72,641,196 - - 22 - Phase Outs (189,090) 175,522 - (13,568) - - 30 - Inflation and CPI 29,153,738 480,169 49,742,817 79,376,724 - - 40 - Mandated Caseload 77,650,878 12,274,947 138,556,956 228,482,781 31 27.52 50 - Fund Shift (21,987,440) (166,084) 22,147,524 (6,000) - - 60 - Technical Adjustments 100,670,829 202,345 144,789,225 245,662,399 - - Total Essential Budget Level (EBL) 1,235,487,891 185,089,976 2,126,854,424 3,547,432,291 2,041 2,002.20

70 - Revenue Shortfall - (6,710,095) - (6,710,095) - - Total Modified EBL: 1,235,487,891 178,379,881 2,126,854,424 3,540,722,196 2,041 2,002.20

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SPD MEBL by fund type2009-11 GRB Base to Modified Essential Budget Level

Seniors and People with Disabilities Divisionby Fund Type$3,541 million

Federal Funds $2,127 60.1%

Other Funds $178 5.0%

General Funds $1,235 34.9%

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SPD MEBL Federal Funds2009-11 GRB Base to Modified Essential Budget Level

Major Sources of Federal Funds$2,127 million

Medicaid-MAP $1,883 88.5%

Other Sources $12

0.5%

Food Stamp Administration $13

0.6%

Social Security Administration (DDS)

$48 2.2%

Medicaid-Admin $140 6.6%

Older Americans Act $31

1.5%

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SPD MEBL Other Funds2009-11 GRB Base to Modified Essential Budget Level

Major Sources of Other Funds$178 million

Provider Taxes $89

49.9%

Other Sources $11

5.9%

Oregon Project Independence $8

4.4%

DD Housing Trust Fund $6

3.5%

County Local Match $10

5.7%

DD Other (Care State Wards, SS, Settlements)

$21 12.0%

Estate Recoveries $19

10.5%

Client Contributions $14

8.1%

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General Funds Other Funds Federal Funds Total Funds

Base Budget 421,894,309 129,744,780 860,369,948 1,412,009,037

Essential Packages: - 10 - Vacancy Factor/Non-PICS - - - - 21 - Phase Ins 14,221,647 - 22,698,515 36,920,162 22 - Phase Outs - 364,612 - 364,612 30 - Inflation and CPI 15,272,724 27,362 30,114,038 45,414,124 40 - Mandated Caseload 46,676,192 6,769,734 96,382,311 149,828,237 50 - Fund Shift (18,357,483) (166,084) 18,517,567 (6,000) 60 - Technical Adjustments 100,696,530 - 144,580,260 245,276,790 Total Essential Budget Level (EBL) 580,403,919 136,740,404 1,172,662,639 1,889,806,962

70 - Revenue Shortfall - (5,613,644) - (5,613,644) Total Modified EBL: 580,403,919 131,126,760 1,172,662,639 1,884,193,318

APD Total

Services to Seniors and People with Physical Disabilities (DD)

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2009-2011 APD budget comparisons

$422

$130

$830

$693

$132

$1,303

$580

$131

$1,188

$396

$129

$856

$-

$500

$1,000

$1,500

$2,000

$2,500

2007-09 LAB after December2008 Rebalance

2009-11 ARB 2009-11 MEBL 2009-11 GRB

2009-11 SPD Aged and Physically DisabledBudget Comparison by Fund (in million dollars)

Federal Fund

Other Fund

General Fund

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Base Budget 420,945,450 23,791,331 613,911,930 1,058,648,711

Essential Packages:10 - Vacancy Factor/Non-PICS (124,948) 708 (210,191) (334,431) 21 - Phase Ins 13,933,275 14,777 21,314,910 35,262,962 22 - Phase Outs (189,090) (189,090) - (378,180) 30 - Inflation and CPI 10,754,046 239,912 15,523,579 26,517,537 40 - Mandated Caseload 26,865,871 5,505,213 38,732,249 71,103,333 50 - Fund Shift (6,763,971) - 6,763,971 - 60 - Technical Adjustments 48,482,807 3,339,683 59,254,716 111,077,206 Total Essential Budget Level (EBL) 513,903,440 32,702,534 755,291,164 1,301,897,138

70 - Revenue Shortfall - - - - Total Modified EBL: 513,903,440 32,702,534 755,291,164 1,301,897,138

DD Total

Services to People with Developmental Disabilities (DD)

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2009-2011 DD budget comparisons

$421

$24

$609

$515

$27

$768

$514

$33

$755

$471

$43

$710

$-

$200

$400

$600

$800

$1,000

$1,200

$1,400


2009-11 ARB 2009-11 MEBL 2009-11 GRB

2009-11 SPD Developementally DisabledBudget Comparison by Fund (in million dollars)

Federal Fund

Other Fund

General Fund

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Program Support


Base Budget 178,490,495 18,502,112 253,147,025 450,139,632

Essential Packages:10 - Vacancy Factor/Non-PICS 599,280 69,369 157,161 825,810 21 - Phase Ins 229,468 - 228,604 458,072 22 - Phase Outs - - - - 30 - Inflation and CPI 3,126,968 212,895 4,105,200 7,445,063 40 - Mandated Caseload 4,108,815 - 3,442,396 7,551,211 50 - Fund Shift 3,134,014 - (3,134,014) - 60 - Technical Adjustments (48,508,508) (3,137,338) (59,045,751) (110,691,597) Total Essential Budget Level (EBL) 141,180,532 15,647,038 198,900,621 355,728,191

70 - Revenue Shortfall - (1,096,451) - (1,096,451) Total Modified EBL: 141,180,532 14,550,587 198,900,621 354,631,740

Program Support & Central Administration Total

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$178

$18

$242

$142

$15

$200

$141

$15

$200

$133

$14

$193

$-

$50

$100

$150

$200

$250

$300

$350

$400

$450


2009-11 ARB 2009-11 MEBL 2009-11 GRB

2009-11 SPD Program Support and AdministrationBudget Comparison by Fund (in million dollars)

Federal Fund

Other Fund

General Fund

2009-2011 Program Support budget comparisons

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Governor’s Recommended BudgetGeneralFunds

OtherFunds

FederalFunds

TotalFunds

POS FTE

Base Budget 1,021,330,254 172,038,223 1,727,428,903 2,920,797,380 2,010 1,974.68

Revised Essential Packages:

10- Vacancy Factor/Non PICS 474,332 70,077 (53,030) 491,379 - -

21- Phase In 28,384,390 14,777 44,242,029 72,641,196 - -

22- Phase Out (189,090) (189,090) - (378,180) - -

30- Inflation and CPI 29,393,844 844,781 49,742,817 79,981,442 - -

40- Mandated Caseload 77,650,878 12,274,947 138,556,956 228,482,781 31 27.52

50- Fund Shift (21,987,440) (166,084) 22,147,524 (6,000) - -

60- Technical Adjustments 100,430,723 202,345 144,789,225 245,422,293 - -

70- Revenue Shortfalls - (6,710,095) - (6,710,095) - -

84- December 2008 E-Board (1,790,574) 8,776,574 1,138,107 8,124,107 (11) (10.06)

90- Analyst Adjustments (Reductions) (234,294,539) (1,681,504) (368,964,693) (604,940,736) (12) (12.33) Total Revised Essential Packages: (21,927,476) 13,436,728 31,598,935 23,108,187 8 5.13

GeneralFunds

OtherFunds

FederalFunds

TotalFunds

POS FTE

Policy Packages included in the Governor's Recommended Budget:

123- Improving Quality of Long Term Care - 267,560 267,544 535,104 4 3.00

143- Expedited Trustee Fund - 200,000 - 200,000 - - Total Policy Packages: - 467,560.00 267,544.00 735,104.00 4.00 3.00

Governor's Recommended Budget 999,402,778 185,942,511 1,759,295,382 2,944,640,671 2,022 1,982.81

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GRB – Proposed investmentsPolicy Option Package 123: Improving Quality of Long-Term Care This POP creates a Long-Term Care Quality Fund separate from

the General Fund. Funds are appropriated for the purpose of regulatory compliance, enforcement and providing technical assistance for nursing facilities, residential care facilities, residential training facilities and residential training homes.

Increases state civil penalties collected from LTC facilities not in compliance and places state civil penalties into the Long-Term Quality Care Fund dedicated for use for regulatory and compliance or enforcement activities.

Increases annual licensing fees for long-term care facilities to fund the Long-Term Care Quality Fund.

Increases compliance monitoring staff by four positions.

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GRB – Proposed investmentsPolicy Option Package 143: Expedited Trustee Fund This POP enhances the tool used to protect residents in facilities

by modifying the grounds for the court to order appointment of a temporary trustee when residents are at risk and in order to prevent immediate evacuation of residents.

Increases the amount of current assessments to nursing facilities and community-based care facilities to increase the current Facilities Trust Fund account balance from $300,000 to $500,000. Funds are used to pay for trustee services and continue paying for operating expenditures such as electrical, heat, water, supplies and food services.

Current statute allows for a trustee to be requested and appointed when the health and welfare of residents in a facility are in jeopardy, but court appointment of trustees can take several days to weeks. This allows DHS to petition for the expedited appointment of a trustee in emergency situations. This will strengthen the department’s ability to respond quickly when faced with emergency situations and will allow the department to take over management of troubled facilities.

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Outstanding Federal Funds issuesOregon stimulus package update 2007-2009: Stimulus $88 million 2009-2011: Stimulus $218 million December 2010: Stimulus expires SPD GF fund shift FMAP changes

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2007-2009 investments

CBC rate increase– $260 per month, April 2009– Memory care contracted rates

DD provider rates– 14 percent rate increase to DD providers– 10 percent increase to employment– $260 per month to DD adult foster homes

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2007-2009 investments

Grants: Money Follows the Person – Oregon “On the Move” CMS Real Choices-Hospital Discharge planning/ADRC Restructuring, budget, assessment and rates (ReBAR) AOA grants

– Chronic disease management– Nutrition, healthy living, exercise

NF Diversion and Transition (management action) DD county infrastructure, APS, eligibility EOTC fund transfer (SIS – ReBAR) CNA staffing

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Governor’s Recommended Budget

Reductions – APD ($ 3.0) million GF reduces 4 percent personal services,

six month hiring freeze ($ .4) million GF reduces 2 percent services and

supplies and Attorney General fees ($26.0) million GF eliminates all inflation ($ 2.5) million GF reduces HCW training and HUBB

overpayment for HCW health insurance reserve ($23.0) million GF reduces in-home care less than 80

hours

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Governor’s Recommended Budget Reductions – APD ($ 6.3) million GF eliminates HCW health insurance for

less than 30-hour work week, 120 hours per month ($ .3) million GF eliminates RSVP – Retired Senior

Volunteer Program ($ .8) million GF eliminates SHIBA – Senior Health

Insurance Program ($39.0) million GF reduces NF reimbursement via cost

containment ($ 3.5) million GF savings from NF diversion to

community care settings ($99.0) million GF implements “i” state plan amendment,

eligibility changes

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Governor’s Recommended Budget Reductions – DD ($ 2.5) million GF reduces support for DD Housing

development and maintenance ($ 3.0) million GF reduces DD Employment Community

Inclusion Program ($ 1.5) million GF savings from JPSRB secured facilities

development ($ 0.5) million GF savings in DD children’s in-home

services ($ 1.6) million GF reduces DD NF special services and

special projects

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Governor’s Recommended Budget Reductions – DD ($ 6.0) million GF reduces DD Family Support Program ($ 9.0) million GF reduces DD CDDP comprehensive

24/7 services for 130 clients and local administration ($ 6.0) million GF reduces DD brokerage community-

based support services for 700 clients and local administration

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SPD major programs

Services to Seniors and People with Disabilities (APD)

Services to People with Developmental Disabilities Program Support and Administration

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Seniors and People with Disabilities (APD) Overview


April 2009

51

APD services

Services to Seniors and People with Physical Disabilities Older Americans Act Direct financial support In-home services Community-based care facilities Nursing facilities Money Follows the Person (MFP)

52

Older Americans Act services Federal program targeted to people 60 years and older Approximately 323,000 Oregonians have been served Local Area Agencies on Aging (AAAs) provide a variety

of services:– Family caregiver supports– Nutrition via group settings and home-delivered meals– Senior employment– Legal services– Elder abuse prevention

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Direct financial support

SPD determines eligibility for Medicaid food stamps, and provides financial support and services to low-income seniors and people with disabilities– Supplemental cash payments– Medicare buy-in programs– Medicare savings programs – Medicare Part D pharmacy benefit

54

Direct financial supportService delivery Eligibility and case management services are

delivered statewide by SPD and AAA employees ORS Chapter 410 allows the AAAs options about

which populations they wish to serve In areas for which AAAs do not provide Medicaid

services, SPD has offices SPD provides administrative funds to the AAAs to

administer these programs

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Who receives Medicaid services

Approximately 27,000 aged and physically disabled Oregonians use Medicaid long-term services

Federal law requires each state to develop criteria for access to nursing facility services

Criteria must include financial (and asset test) and service eligibility criteria

Oregon created Service Priority Levels (SPL) to prioritize services

Today Oregon serves individuals in SPL levels 1 - 13

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How Medicaid services are delivered Eligibility and case management services are

delivered statewide by SPD and AAA employees ORS Chapter 410 allows AAAs to determine which

populations they wish to serve SPD has offices to serve seniors and people with

disabilities in areas where AAA offices do not provide Medicaid

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Significance of services to Oregonians

Since 1981 Oregon has provided home and community-based services

These services are an alternative to nursing facilities Services emphasize independence, dignity and

choice, and are provided at much lower costs than nursing facilities

58

Medicaid long-term care balancing Percent of 2001 Medicaid LTC Expenditures going to HCBS

Percent of 2006 Medicaid LTC Expenditures going to HCBS

All Medicaid Beneficiaries

Older People & Adults with

Physical Disabilities




State

Percent Rank Percent Rank Percent Rank Percent Rank Oregon 67% 1 51% 1 72% 1 55% 1 New Mexico 55% 2 34% 4 67% 2 54% 2 Washington 47% 6 42% 3 60% 4 54% 3 Alaska 54% 3 32% 7 63% 3 51% 4 California 47% 7 43% 2 51% 9 47% 5 Texas 33% 22 34% 5 40% 18 42% 6 Minnesota 40% 12 19% 17 60% 5 40% 7 North Carolina 35% 16 33% 6 41% 16 39% 8 Idaho 28% 27 26% 9 42% 14 38% 9 Kansas 43% 9 26% 10 53% 7 34% 10 Nevada 22% 35 14% 24 42% 13 32% 11 Missouri 33% 21 24% 11 39% 21 30% 12 Wisconsin 34% 17 23% 14 44% 10 27% 13 New York 32% 23 23% 13 39% 19 26% 14 Montana 38% 14 29% 8 42% 15 25% 15 Oklahoma 33% 19 15% 21 41% 17 25% 16 Maine 39% 13 13% 26 52% 8 24% 17 Dist. of Columbia 1% 50 1% 48 22% 47 23% 18 Virginia 29% 26 17% 20 36% 28 23% 19 Massachusetts 30% 24 15% 22 39% 23 22% 20 Arkansas 25% 30 23% 12 26% 40 21% 21 Colorado 46% 8 17% 19 43% 12 21% 22 New J ersey 20% 37 14% 23 34% 29 19% 23 Illinois 15% 44 10% 31 28% 35 19% 24 South Carolina 29% 25 20% 15 32% 31 18% 25 West Virginia 33% 18 19% 18 37% 25 18% 26 AARP Public Policy Institute: A Balancing Act: State Long-Term Care Reform; #2008-10, J uly, 2008, page 127

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Medicaid long-term care balancing Percent of 2001 Medicaid LTC Expenditures going to HCBS

Percent of 2006 Medicaid LTC Expenditures going to HCBS







State

Percent Rank Percent Rank Percent Rank Percent Rank Hawaii 25% 33 13% 25 37% 26 17% 27 Ohio 13% 47 11% 29 26% 39 17% 28 Nebraska 25% 29 9% 34 33% 30 16% 29 Michigan 25% 32 12% 28 31% 34 15% 30 Louisiana 14% 46 2% 47 26% 41 15% 31 Wyoming 50% 5 0% 50 54% 6 13% 32 Iowa 16% 43 5% 42 32% 33 13% 33 New Hampshire 40% 11 9% 33 39% 22 12% 34 Maryland 24% 34 5% 40 38% 24 11% 35 Georgia 17% 42 11% 30 23% 45 11% 36 Mississippi 8% 49 8% 36 11% 49 11% 37 Rhode Island 41% 10 10% 32 44% 11 11% 38 Pennsylvania 18% 40 3% 45 27% 38 10% 39 Delaware 25% 31 8% 35 32% 32 9% 40 Florida 22% 36 7% 37 27% 37 9% 41 Connecticut 26% 28 6% 39 27% 36 8% 42 Kentucky 19% 39 12% 27 22% 46 8% 43 Alabama 17% 41 7% 38 25% 43 7% 44 South Dakota 33% 20 4% 43 36% 27 6% 45 North Dakota 20% 38 3% 44 24% 44 5% 46 Utah 38% 15 5% 41 39% 20 4% 47 Indiana 11% 48 2% 46 18% 48 2% 48 Tennessee 15% 45 1% 49 25% 42 1% 49 Arizona * * * * Vermont 53% 4 20% 16 * * United States 29% 19% 37% 25% Notes: Because of lack of comparable data between 2001 and 2006, U.S. totals exclude Arizona and Vermont. 2000 nursing home data are used instead of 2001 for Iowa, Kansas, Louisiana, Missouri, new J ersey, Oregon, and South Dakota. *Data omitted because of lack of comparable data to the rest of the states. AARP Public Policy Institute: A Balancing Act: State Long-Term Care Reform; #2008-10, J uly, 2008, page 128

60

APD long-term clients, 2001-2008

Seniors and People with Physical Disabilities Long-Term Care Clients 2001-2008

Nursing Facility

In-Home

Residential Care Facilities


Adult Foster Homes

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

2001 2002 2003 2004 2005 2006 2007 2008

61

APD clients by service settingSeniors and People with Disabilities

Clients by Service Setting, June, 2008

Community Based Facilities, 10,648

Nursing Facilities, 5,160

In-Home, 10,955

62

In-home services Client-employed home care workers In-home agency services Medicaid Independent Choices Medicaid adult day services Medicaid home-delivered meals Medicaid personal care services Medicaid specialized living services Oregon Project Independence

63

In-home services Cornerstone of Oregon’s community-based care system Supports an individual’s goal to remain at home by

providing assistance with ADLs SPD and AAAs provide authorized services for

approximately 10,500 individuals statewide Services are provided by home care workers and in-

home agencies Individuals who want more self-direction receive a cash

benefit based on their assessed needs

64

Oregon Project Independence

100 percent state-funded in-home service program administered statewide by AAAs

Serves 3,000 Oregonians 60 years of age and older or with a dementia-related disorder who meet SPLs 1-18

Services include home care and personal assistance, case management, adult day services, respite, chore, transportation, home repair, home delivered meals

Average monthly cost per case is $140

65


34 percent have incomes at or below the federal poverty level (FPL) ($867) and receive services at no charge

59 percent have incomes between 100-200 percent of the FPL ($868 - $1734) and pay for services based on a sliding fee scale

7 percent have incomes above 200 percent of the FPL ($1734+) and are assessed the full hourly cost of direct services

66

Community-based facilities

24-hour care settings and services for seniors and people with physical disabilities that provide an alternative to nursing facilities

Services include assistance with:– ADLs– medication oversight– social activities – nursing and behavioral supports to meet complex

needs Facilities must meet extensive state and federal

guidelines related to health and safety

67

Community-based care settings

Adult foster homes Residential care facilities Enhanced care services Assisted living facilities Program of All-Inclusive Care for the Elderly (PACE)

68

APD clients by SPL and settingSTATEWIDESeniors and People with Physical Disabilities

Clients in Personal Care are not included in these numbers

June, 2008SPL Non Relative Relative Assisted Nursing In-Home In-Home Residential Contract Specialized Spousal

Foster Foster Living Facility Hourly Live In Care Residential Living PayHome Home Care

1 174 81 7 512 79 37 15 66 0 122 3 2 1 4 1 0 0 0 0 13 1,420 499 1,052 3,143 1,576 517 538 885 101 1354 171 75 108 346 242 55 37 37 7 55 87 121 168 215 519 101 38 16 4 06 17 20 80 16 121 5 8 3 2 07 311 418 1,073 680 3,025 297 130 48 13 08 13 13 25 17 46 1 3 3 0 09 14 7 18 17 19 0 9 9 1 010 125 155 729 92 2,043 43 86 11 29 011 82 68 272 82 586 2 38 18 4 012 11 6 41 5 68 0 5 1 1 013 74 28 175 31 1,211 3 31 24 4 0

Total 2,502 1,493 3,749 5,160 9,536 1,061 938 1,121 166 153

69

Nursing facilities Institutional services provide individuals with:

– Skilled nursing services– Housing – Related services and ongoing assistance with ADLs

Currently, approximately 5,100 individuals live in

nursing facilities

70

Major initiatives Money Follows the Person – “On the Move”

– Five-year demonstration grant from Centers for Medicare and Medicaid Services (CMS)

– Rebalance initiative to move individuals from nursing facilities to community settings

– Oregon’s goal is to move 1,000 individuals by 2011

Diversion and transition – Management action to reduce nursing facility caseload

71

Quality and efficiency improvements Waiver quality assurance activities Program efficiency and quality

– Continuous Quality Improvement– Automatic Verification System (AVS)– Payment Error Rate Measurement (PERM)– CCMU Culture Change Initiative– Long-term care facility quality

72

Long-range plan Current long-term services system is responsive only

to the poorest of the poor– Older Americans Act funds are flat, aging

demographics continue to grow– Budget cuts during 2003-2005 reduced available

services to impaired Medicaid-eligible clients– Oregon Project Independence funds reduced or

eliminated

73

Long-range plan Approximately 3.9 percent of Oregonians ages 65 or

older receive Medicaid services today Today 18,000 seniors receive Medicaid-funded

services; without intervention the number will rise to more than 34,000 by 2030

Today 27,000 seniors and people with disabilities receive Medicaid services; without intervention the number will rise to more than 44,000 by 2030

74

HB 1061 HB 1061 required SPD to report on the long-range plan

and the following recommendations:– Aging and Disability Resource Centers– Medicaid waiver options– Medicaid provider capacity– Acuity-based reimbursement– Cost projections for other services

75

Oregon’s aging population, 2010-2030Oregon Population Estimates for Individuals 65 and Older

0

100,000

200,000

300,000

400,000

500,000

600,000

2010 2015 2020 2025 2030

65-74

75-84

85 or older

76

Oregon’s expected Medicaid caseloadExpected Medicaid Caseload

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

2010 2015 2020 2025 2030

Seniors

People w/ Disabilities

Total Caseload

77

Medicaid long-term caseload, 1989-2008

The bars in this chart represent actual nursing facility (NF) and community-based care (ALF, RCF, AFH) caseloads from 1989 through 2008. The lines represent projected nursing facility (NF) caseloads assuming 3 percent and 5 percent annual growth, respectively.

78

2009 Long Term Services Model

NF

Waivered Services

1915c

Prevention – Early Intervention

Non Medicaid - OPI- OAA Services

State Plan Options

79

2020 Long Term Services Model

NF

Optional Waivers

“I” ,1915c

Waiver Services

State Plan Services

Independent Choices

Prevention – Early Intervention

Aging & Disability Resource Centers

Older Americans Act Services


80

Aging and Disability Resource Centers

Aging and Disability Resource Centers Non-Medicaid services system includes three major

components:– Central information center– Network of local assistance centers– Expanded direct services and resources

Purpose is to assist members of the target populations remain independent, healthy, safe and active

81

Medicaid waiver options Expanding access to in-home services Expanding housing with services Expanding community-based service options 1915(1) State Plan Option Acute and long-term care service options

82

Community-based careCapacity update and recommendations for revitalizing Oregon’s reimbursement system

Problem: Decreased Medicaid access to community-based care

facilities leads to increased use of more expensive nursing facility care

As of December 31, 2008, the average community-based care rate is $1,696, while the average nursing facility rate is $6,265

83

Accomplishments

Increased awareness of Medicaid access crisis $260 rate adjustment funded by 2008 Oregon

Legislature Passage of SB 1061 by 2008 Oregon Legislature

84

Accomplishments

Monthly rate adjustment per Medicaid client for adult foster home, residential care facility, assisted living facility and specialized providers implemented July 1, 2008

License moratorium lifted and rules for new license applications implemented January 1, 2009

Acuity-Based Rates Workgroup completed Assessment and on-going monitoring of CBC capacity

85

HB 3626 (15)Directed DHS to assess the capacity of residential care facilities and adult foster homes as of January 1, 2008.

Benchmark

1-1-08/ Update

12-31-08

Residential Care Facilities (non-ACU)

RCF-Alzheimer’s Care Units


Adult Foster Homes-

Commercial

Adult Foster Homes-

Relative

# Licensed Facilities

129/150 102/102 204/205 1735/1719

1615/1847

# Facilities in Medicaid

87/106 68/68 176/178 1217/1255

1442/1464

# Medicaid

Clients

1092/1206 1045/1054 3857/3921 2654/2705

1542/1554

# Gradual Withdrawal Contracts

2/4 10/8 30/30 NA NA

86

In process

Assessing Medicaid contract options for providers to better manage payer mix

Staff dedicated to provider development Capacity needs assessment Plan for development of specialty providers

87

SB 1061

SB 1061 directed SPD to propose a reimbursement structure that ensures access to services while controlling costs and maintaining quality care by: Re-examining client acuity and appropriate service

priority level designations Developing reimbursement rates that are reasonably

competitive with rates paid by private payers Creating incentives for providers to participate in the

state medical assistance program Addressing geographic differentials

88

Stakeholder involvement

SPD central office Oregon Health Care Association Oregon Alliance on Senior Services Service Employees International Union Independent Foster Home Association

89

Reimbursement system principles

Rate structure should: Secure access to community-based care for Medicaid

clients Provide a predictable revenue stream for the provider

community Support high Medicaid census business model Be simple to understand and administer for both field

staff and providers

90

Reimbursement system principles

Core services rate should cover a majority of individuals in community-based care facilities, regardless of setting (assisted living facilities, residential care facilities, adult foster homes)

Add-on rates should be meaningful and provide adequate compensation for extra services provided

Exceptions should remain available in limited circumstances

91

Proposed rate scheduleCategory Service Rate

Base Service Rate $2,034

Enhanced Payment for facilities with 60% Medicaid occupancy and history of substantial regulatory compliance.

$450

Behavior/ Cognition- Level 1 $640

Behavior/ Cognition- Level 2 $1,280

Medical $960

Intense Activities of Daily Living $640

92

Cost of implementing new rate methodology

Proposed before additional Stimulus funding: GF: $41.8 million FF: $71.3 million TF: $113.1 million

Proposed after additional Stimulus funding: GF: $33.9 million FF: $79.2 million TF: $113.1 million

93

Challenges and opportunities

Oregon’s changing demographics Provider capacity Medicaid capacity in community settings Protection of vulnerable adults Recruitment and retention of the long-term care

workforce

94

Services to People with Developmental Disabilities (DD) Overview


April 2009

95

Services to People with Developmental Disabilities (DD)

Comprehensive services Support services

96

Who receives services

More than 17,000 Oregonians with developmental disabilities accessed services in 2008

Individuals eligible for services must have a developmental disability that impedes their ability to function independently

Most individuals meet Medicaid financial eligibility requirements (300 percent of SSI $2,022)

Services are administered under federal Medicaid waivers

97

How services are delivered

SPD delegates authority for developmental disability programs to community developmental disability programs (CDDPs), usually operated by counties

CDDPs deliver case management, evaluation and coordination of services, protective services, provider recruitment, contracting, and quality assurance services

98

Significance of services to Oregonians

Since 1981 Oregon has provided lower cost alternatives to institutional care through Intermediate Care Facility for the Mentally Retarded (ICFMR)

Services to individuals emphasize:– Independence, dignity and choice in the least

restrictive setting possible The Staley settlement creates entitlement for support

services for adults

99

People with DD by care setting

People with Developmental Disabilities by Care Setting

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

6000

6500

7000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Residential Services

In-Home Services

Foster Care

Medically Fragile/Behavior ChildrenEOTC

100

People with DDPeople with Developmental Disabilities

38

5,433

4,818

2,128

0

672

1,357

3,128

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

5,500

6,000

EOTC Comprehensive Support Services Case ManagementOnly

Adults Children

101

Key programs Adults with DD may be eligible for services ranging from

supports to help the individual live at home to 24-hour comprehensive services

Settings include:– Group homes– Foster homes– State-operated community programs (SOCP)

Children with DD may be eligible for services ranging from family support to out-of-home placements

Settings include– Proctor care– Foster care– Residential settings

102

Comprehensive services Approximately 6,100 individuals receive comprehensive

services Services are provided to both adults and children Needed 24-hour supports are provided either at home

or in a community setting Services include:

– Assistance with meeting critical daily needs such as bathing, dressing and eating

– Assistance with limitations in self-direction, self-sufficiency and learning

103

Service types

Adult residential programs Children’s residential care Children’s intensive in-home services Comprehensive in-home support services for adults Supported living services Vocational services including training, support and

employment Foster care (non-relative) State-operated community programs Eastern Oregon Training Center (EOTC)

104

Comprehensive services

Additional services for individuals receiving comprehensive services include: Diversion/crisis and short-term services:

– Additional in-home supports– Respite– Out-of-home placements

Transportation services: – Transportation providers help individuals participate

in employment and other services when public transportation is not available

105

Support services Approximately 5,300 adults receive support services Services are provided by individuals or community-

based organizations hired by the client with the assistance of a personal agent

Personal agents help the individual: – Develop plans of care – Develop and maintain service budgets– Identify service providers– Monitor the quality of services

Individual service plans cannot exceed $21,562 per year These services are a result of a lawsuit and settlement

agreement reached in 2000 (Staley v. Kitzhaber)

106

Family supports for children

Flexible program to support families of children 17 years of age and younger

Assists families so the child can remain at home Annual cap of $1,500 Funds can be used to purchase goods or services such

as:– Respite care, delegated nursing, one-time purchase

of adaptive equipment, home modifications, family training behavioral supports

107

Caseload and demographics National and Oregon numbers are growing for people

with DD-related needs such as autism and drug- and alcohol-related causes

Increasing number of people with co-occurring mental health and/or corrections needs who need services

6 percent increase in children and adults requesting new services

Caseloads are increasing, but access to existing resources is declining due to longer life spans

New services are being developed for people in crisis, individuals with medical needs or behavioral and mental health supports

108

Quality and efficiency improvementsRestructuring, Budget, Assessments and Rates Project (ReBAR) $2.4 million, five-year Real Choice Systems Change

grant from CMS Designed, developed and implementing a new system

for funding comprehensive services Goal is to replace a 25-year-old “slot-based” system New system will establish individual budgets for 3,000

individuals and will:– Standardize rates– Standardize assessment tool to better identify

support needs

109

Quality and efficiency improvementsStaley settlement agreement In-home services for 5,300 adults including in-home

supports, job supports, respite community involvement and specialized equipment

Allows a capped benefit for all adults with DD, thereby avoiding more costly 24-hour services

High level of satisfaction

110

Quality and efficiency improvementsModel waivers for children SPD has three model waivers for children to remain in

their family homes:– Medically-fragile conditions – nursing and

vulnerable care– Behaviors dangerous to self or others, often

combined with autism– Medically involved

Waivers provide:– Staffing with nurses and personal assistants,

supplies, and respite care

111

Challenges and opportunities

Supporting children and families Provider stability County stability Rate setting and assessments Final implementation of the Staley agreement

112

Program Support and Central Administration Overview


April 2009

113

Program Support and Central Administration

This program area includes: Direct service staff Office of Senior and Disability Services Office of Licensing and Quality of Care Office of Federal Resource and Financial Eligibility Office of Developmental Disability Services Central Administration

114


115


Provides the basic organization structure Allows SPD to effectively serve seniors and people

with physical and developmental disabilities Provides direct client services

116

Direct service staff Disability determination services (DDS) Presumptive Medicaid Disability Determination Team Medicare Support Team Support to Area Agencies on Aging to operate the

Medicaid programs Children’s intensive in-home services Children’s residential services Client Care Monitoring Units

117

SPD office structure Office of Senior and Disability Services Office of Licensing and Quality of Care Office of Federal Resource and Financial Eligibility Office of Developmental Disability Services

118

Office of Senior and Disability ServicesProvides management and oversight of programs to seniors and people with disabilities In-home supports Home Care Worker Program Oregon Project Independence State Unit on Aging APD Field Services Case management Home Care Commission Rule and policy development Technical staff training

119

Office of Licensing and Quality of CareMonitors and enforces standards of care and quality in long-term care settings Quality assurance Provider training and technical assistance Provider contract management Licensing and certification of long-term care facilities

and programs Policy development Protective services Community nursing Establishment of standards of care in adult foster

homes, residential care facilities, assisted living and nursing facilities

120

Office of Federal Resource and Financial Eligibility

Provides oversight of Medicaid programs, program data and information, benefits to clients Waiver and State Plan development and compliance Research, planning and rates Quality assurance Federal reporting Medicare Modernization Act (MMA), Medicare services Information systems coordination Provider payments Disability determination services Rule and policy development

121

Office of Developmental Disability Services

Provides management and oversight of programs to persons with developmental disabilities Comprehensive services In-home supports Staley agreement implementation Housing supports Rule and policy development Development Disabilities (DD) county relations Children and family supports State-operated group homes Contract administration Quality assurance EOTC

122

SPD quality and efficiency improvements

Staffing study– Public Knowledge– McKinsey– SPD continuing analysis

Transformation– Financial eligibility intake process (SPD/AAA field

and central offices)– Presumptive Medical Disability Determination Team

process improvement– Developmental disability contract amendment– Corrective Action Unit

123

Central Administration Provides overall policy direction Program planning Resource development Standards setting Technical assistance Monitoring and evaluation of programs Works directly with federal agencies including:

– Centers for Medicare and Medicaid Services– Administration on Aging– Social Security Administration

124

Councils, Boards and Commissions Provides support to a variety of organizations:

– Oregon Developmental Disabilities Council– Governor’s Commission on Senior Services– Oregon Disabilities Commission– Medicaid Long-Term Care Quality and

Reimbursement Council– Continuing Care Retirement Center Advisory

Council– Local Disability Services Advisory Councils

125


Thank You!

Questions?

Seniors and People with Disabilities Division James Toews, Director April 2009

Documents

Transcript of Seniors and People with Disabilities Division James Toews, Director April 2009