Managing Long Term Care Transitions Across Settings

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Information about Managing Long Term Care Transitions Across Settings

Published on October 19, 2007

Author: nashp



Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Ellie Shea Delaney

NASHP’s 20th Annual State Health Policy Conference October 16, 2007 Managing Long Term Care Transitions Across Settings Presented by: Eleanor Shea-Delaney, Acting Secretary Massachusetts Executive Office of Elder Affairs 1

Overview Massachusetts Profile  Population of just over 6.4 Million  856,000 people 65 and over (13.375%)  436 nursing homes that are Medicaid  certified for MassHealth payment 48,078 beds available  About 31,000 paid by MassHealth on any  given day About 26,000 elderly and 5,000 disabled  under 65 2

Overview (cont.) Approaches to Transition  SCO and PACE  CSSM  ASAP Services for Non-Medicaid  D/D Populations  3

Overview (cont.) SCO Integrated Medicare and Medicaid model for  dual eligibles Voluntary enrollment with three vendors  (Evercare, Senior Whole Health, Community Care Alliance) 8,276 current enrollees across all settings  and at all acuity levels More than half at Community Well level followed  by those in community at NF LOC 4

Senior Care Organizations (SCO) Key Features (continued)  Centralized enrollee record  Required interface with elder network  Accountability for health care outcomes  across all settings One set of coverage policies  Access to care management 24/7  5

SCO Managing Transitions (cont.):  Promote a flexible individualized response  Communication and team work are valued and  involve primary care, pharmacy, personal care, behavioral health, home health, transportation Rating categories recognize transitions and  reward community care Care coordination focuses on importance of  transitions 6

SCO All hospital, nursing facility, and community providers  are under contract to SCO/PACE (i.e. they are paid directly by SCO/PACE and are required to comply with contract requirements) Care management (Nurse Care Management for SCO;  Interdisciplinary Team for PACE) authorizes institutional care and monitors enrollees in all hospital and nursing facility settings every day, from admission forward Clinical professionals are available 24/7 to respond to  calls from institutions when changes in enrollee- caregiver circumstances call for a transition back to the community All services (including pharmacy, equipment,  transportation, personal care, etc.) are arranged through that one call by the institution to the SCO/PACE care manager 7

Program of All-Inclusive Care for the Elderly (PACE) Key Features:  Six current programs  Enrollment of about 1700 with all members at  nursing facility level of care Managing Transitions:  Utilize adult day health sites to coordinate  community care and support transition Extensive 11-member care coordination team  8

Comprehensive Service and Screening Model (CSSM) Effective January 2005, CSSM changed the way  Massachusetts evaluates, plans for services and screens individual who are entering or expected to access the MassHealth nursing facility benefit. Vision is for a coordinated person-centered  system that ensures the appropriate use of services and supports through a timely and comprehensive face-to-face needs assessment that identifies a menu of service options. 9

CSSM (cont.) Prior System  Strictly a pre-admission clinical eligibility screening process  for MassHealth members and applicants Determinations primarily conducted by Acute Inpatient  Hospitals and administratively reviewed by ASAPs No face-to-face contact with client – almost exclusively a  paper process Limited planning at nursing facility service planning involving  the ASAP/AAA network Payment Method: Unit Rate per Screen  Majority of Screenings were Short-Term Approvals after an  Acute Episode Offered limited Information regarding Community Service  Options 10

CSSM (cont.) Current Model  Expands the role beyond screening for payment  to include education, outreach and service planning Requires the use of an Interdisciplinary Team  composed at minimum of the ASAP Nurse, Case Manager, Nursing Facility and other professionals as applicable All reviews and assessments, except for a small  subset of individuals, are completed by the ASAP All reviews and assessment must be on-site with  the client; 11

CSSM (Cont.) Re-focuses the review on discharge potential, and  where appropriate, development of a community service plan; clinical eligibility is a secondary function Requires regular ASAP presence in nursing  facilities; and Requires ASAPs to work with and educate  members, families, nursing facilities, and other service providers on potential community options ASAPs follow up with people 60 and over at least  monthly for 90 days post-discharge 12

ASAP/AAA Approach to Non-Medicaid CSSM gives excellent opportunity to  identify candidates for transition Agencies provide intake,  assessment, service planning, and on-going case management, among other services, for eligible elders. 13

ASAP/AAA Approach to Non-Medicaid  Eligibility 60 years and over;  needs assistance with at least 2 ADLs or 6-10 ADLs  and IADLs; Has a critical unmet need;  Income approx. $10,100 for one person, $13,500  for two person family, with voluntary co-pay & cost-sharing sliding fees. Higher level clinical needs drive different programs  and more comprehensive service packages About 45,000 served and one-third are Medicaid  eligible 14

ASAP/AAA Approach to Non-Medicaid Care Management and Transitions  ASAPs provide on-going care management for all  clients; overarching goal: maintain elder in community setting as they desire. Care manager (CM) assesses needs, plans and  authorizes services, determines/re-determines eligibility, etc. CM coordinates services appropriate to needs and  maintaining elder in the community with emphasis on eligibility for higher acuity and higher dollar programs (Coming Home and Enhanced Community Options Program) CM assists with applications for MassHealth  (Medicaid) and Frail Elder waiver, as appropriate 15

ASAP/AAA Approach to Non-Medicaid Care Management and Transitions (Cont.)  Clients encouraged to contact CM with  questions, concerns; related directly to ASAP authorized services or not CM assists with referrals, community programs,  family conferences, caregiver support, etc. CM reports client self-neglect or abuse for review  and follow-up by Elder Protective staff 16

Special Populations (MR and DD) in Nursing Facilities Transition Management  Clients are assigned a DMR Service  Coordinator or for persons with DD a UMass Case Manager who works with the client, their family or legal guardian, nursing facility and ASAP on community transitional planning 17

Special Populations (MR and DD) in Nursing Facilities (cont.) Planning the Transition  Based upon the premise of informed choice.  Each individual is given a description of available  alternatives, provided opportunities to meet with other individuals and their families who have moved into the community from other facilities, he/she is provided with opportunities to visit the homes of people with similar needs who live in the community, and options for housing (houses, apartments and urban, rural, suburban) are presented. 18

Special Populations (MR and DD) in Nursing Facilities (cont.) Planning the Transition (Cont.)   Type of home and accessibility adaptations that may be necessary, and funding for housing and accommodations, such as rental subsidies, individual or trust purchase, provider purchase, use government funding for purchase, or local community development involvement.  Arrangement of paid supporters (live-in, shift staff, family support, shared living, home- sharing, PCA’s, home health aides, visiting nurses, etc.). 19

Special Populations (MR and DD) in Nursing Facilities (cont.) Planning the Transition (cont.)  Selection of a residential provider, the  mechanism for contracting, use of the consumer-directed request for response, staff- training requirements, Arrange for Day-Work-Vocational Program,  Clinical, and Transportation and search for new health care providers: primary medical doctors, specialists, dental, psychiatric, and pharmaceutical. 20

Special Populations (MR and DD) in Nursing Facilities (cont.) Budgeting and financial assistance: new  representative payee, conservator, change in banks, status of spending plan, room and board arrangements and arrangements for entitlement changes: SSI, social security, Mass Health. Individual safety assessment, emergency  evacuation and safety plan status. Continued involvement of family and  friends for whom safety of the individual is important. 21

Special Populations (MR and DD) in Nursing Facilities (cont.)  During the Transition  Gradual schedule of visits to the new home, including overnight stays when possible. That includes forming relationships with new housemates and paid supporters prior to the move.  Planning for the day of the move: how will belongings be moved, who will be responsible for arranging the move, how will items that are of special importance to the individual be protected.  Routine follow-up 22

Summary and a Look to the Future Variation by population and Medicaid status  Important factors for successful transitions  Consumer and family involvement  Communication  Cooperative relationships with facilities  Interdisciplinary approach  Proper financial incentives  Follow-up  Goal is to have more consistency in transitions  regardless of population Mechanism of an 1115 for about 1,000 people in  transition Working at better system coordination  23

Questions and Answers Additional Comments To: Eleanor Shea-Delaney, Acting Secretary Executive Office of Elder Affairs One Ashburton Place, 5th Floor Boston, MA 02108 E-mail: Phone: (617)222-7512 Fax: (617)727-9368 24

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