DHS Responds to Questions about ALWPP

September 2005: DHS responds to Questions about the Assisted Living Waiver Pilot Program (ALWPP) From Connections

From:
Mark Mimnaugh, R.N., CCRN, M.P.A. (answers in italics)
Nurse Consultant III
DHS Home and Community-Based Services Branch Project Leader ALWPP
mmimnaug@dhs.ca.gov

To:
Jason Bloome (comments in blue) Connections Referral Service, Inc.
Good morning, Please find herewith the answers to your questions of August 26th. I am hopeful that these responses will provide you with the information that you requested. I would also suggest that you visit the website maintained by the contractor, NCB Development Corp., for additional details. The address for their website is: www.californiaassistedliving.org
1. What is DHS' estimate of hourly costs for intermittent visits by a nurse from a home health agency?

RCFE and HHA providers will be required to meet the skilled nursing needs of the ALWPP beneficiaries, so this rate is not a fixture in the ALWPP costs Intermittent visits by an HHA RN are a state plan benefit with a reimbursement rate of $74.86 per hour.
ALWPP providers are required to provide full or part time nurses (even for patients with identical care needs as current RCFE who do not require nurses) but are not reimbursed for nursing expenses. RCFEs will be reluctant to participate with ALWPP if they are obligated to provide services (nurses and private rooms) which are not covered by the tiered reimbursement rates. At $74.86/hour even the lowest cost RCFEs in Los Angeles (average cost $2,000-$3,500 for a private room) wil not be able to accept ALWPP participants if a nurse is required for more than 1 hour/week for Tier 1 patients, 2 hours/week for Tier 2 patients, 3 hours/week for Tier 3 patients, and 4 hours/week for Tier 4 patients.¹

2. What is the approximate minimum or maximum number of nursing hours required for patients at each tiered level of care? This is especially important for small providers who might only have 1 ALWPP participant but must have some idea as to the associated nursing costs for each level of care.

There is neither a minimum nor a maximum number of nursing care hours for patients. The stated obligation of the provider is to meet the skilled nursing needs of the clients. It is expected that clients at tier 3 or tier 4 would have more skilled nursing needs then clients at tier 1 or tier 2.

Providers are paid a fixed reimbursement rate but are expected to accept ALWPP participants without any guarantee as to nursing expenses associated at each tiered level of care.

3. Is it possible that some ALWPP participants will only need minimum nursing supervision and may not require a nurse visit for more than 1-3 hours/week?

The skilled nursing needs of the client are documented on the plan of care. It is possible that a client at tier 1 would not require frequent or scheduled skilled nursing interventions.

Current Title 22 standards which govern which patients can reside in RCFEs should have been considered when developing ALWPP guidelines. Since statute limits ALWPP participation to only patients who need nurses, the logical implementation would have been to only allow participation by patients with care needs (g-tubes, iv's, tracheotomies, etc.) currently prohibiited in RCFE settings. Instead, dueling standards between what the Department of Social Services, which licenses RCFEs, considers custodial care and what the Department of Health considers nursing care plagues ALWPP by forcing RCFE providers to have nurses even for patients with only custodial care needs. For example, according to the A LWPP Scoring Assessment tool a patient who is very confused and requires complete assistance with medicine, dressing, bathing and incontinence (Tier 3) requires a nurse even though a current RCFE resident with identical care needs does not.
4. Is a provider in any way obligated to keep an ALWPP participant if the costs of the nursing care hours exceeds the reimbursement rate?

Yes. Providers are required to meet the needs of the clients while they remain eligible for the ALWPP and to provide for the client across all four tiers of service. A provider may not restrict their participation to the lower tiers of service.

RCFEs will be reluctant to accept ALWPP participants when they are paid a fixed tiered reimbursement with no guarantee as to minimum or maximum number of nursing hours required at each level of care.
5. What is DHS's calculation for the cost of RCFE private rooms in the South Bay of Los Angeles?

The Department, through the contractor, did not calculate the cost of RCFEs by region. Reimbursement rates for waiver services do not vary within the state.

ALWPP arbitarily insists all providers provide private rooms even though the reimbursement rates have been developed without consideration for the costs of private rooms in pilot program site areas.
6. When DHS did the ALWPP market analysis what percentage of large RCFEs in the South Bay where found that accept residents who need a w/chair fulltime?

The Department, through the contractor, analyzed the relevant Medi-Cal usage and provider availability by county. It did not analyze data from the South Bay or other regions.
Market research may have revealed most large RCFEs in Los Angeles are not licensed to accept patients who are wheelchair dependent. Low income patients with wheelchairs may find it difficult to participate with ALWPP when most large settings cannot accept them and expensive new standards eliminate participation by small RCFE providers (usually licensed to accept wheelchairs).

7. For wanderers (with substantial physical care needs): what was the average cost for private rooms in RCFEs that have dementia units?

The Department, through the contractor, did not analyze the cost of RCFEs with and without dementia units. Dementia waivers are no longer required by CCL.

ALWPP fails to accommodate patients with dementia/Alzheimers who could wander when costs associated for most dementia units in larger settings (even for shared rooms) far exceed the ALWPP reimbursement rates.

8. What cities are considered as part of the ALWPP catchment area? For instance, can a home in Whittier participate?

Potential providers must be within the boundaries of one of the three target counties - Los Angeles, Sacramento, or San Joaquin. Whittier is in LA County.
9. How have potential providers been notified in pilot program site areas?

Public meetings were held in the three target counties. Announcements of the public meetings were distributed to the California Association of Health and Services for the Aging (CAHSA), California Association for Health California Advocates for Nursing Home Reform (CAHNR), and California Association for Health Service at Home (CAHSAH), etc. The Department has promoted these meetings and the ALWPP through presentations, articles and direct phone calls. In addition, information for potential providers is posted on the ALWPP website.

Most RCFEs (especially smaller settings) do not belong to CAHSA. Failing to notify potential RCFE providers in pilot program site areas (via letter) guarantees minimum RCFE participation.
10. Will DHS consider funding nurses to allow ALWPP participation for current RCFE residents who have identical care needs as incoming ALWPP participants?

No. To access the ALWPP waiver services, clients must be enrolled in the waiver. To qualify for the waiver, clients must have full-scope Medi-Cal or Medi-Cal with a Share of Cost, and be at the nursing home level of care. Current residents of RCFEs are not at the nursing home level of care, as RCFEs are prohibited from caring for clients at that level of care (Title 22, California Code of Regulations, §87582(c)(2)).

ALWPP is unfair to current Medi-cal eligiible RCFE residents who should be eligible for ALWPP accrording to the scoring assessment tool. ALWPP denies participation to current residents even though many may have higher care needs (see #3 above) than incoming ALWPP participants.

11. Are you aware of any other state measures to allow aging in place for current RCFE residents?

The question is somewhat unclear, however, I am not aware of other plans for current RCFE residents.

AB 499 (the bill authorizing ALWPP) specifically directs the state to promote "aging in place" in "home-like" RCFE settings. Olmstead reform in California is deeply flawed when ALWPP denies aging in place without any remedy for current RCFE residents forced into SNFs due to insufficient funds.
12. Any suggestion who I should contact to find out if the state conducts any exit analysis/SNF entrance interview to determine the care levels of IHSS patients who end up in SNFs? This is good data that can be used in nursing home diversion and nursing home transition. I am not aware of anyone who has done such an analysis. The best fiscal rationale for quickly adopting Olmstead is Medi-cal cost savings associated with nursing home transition. It is quite possible a survey of existing data on care levels of IHSS patients admitted to SNFs may reveal most have care needs identical to current RCFE residents.² ALWPP is illsuited for expansion when it promotes institutional bias by assuming all SNF residents require nurse assistance.



See ALWPP article for more information related to this topic. 1. In Los Angeles, RCFE private rooms range from $2,000-$3,500/month. Total ALWPP monthly provider reimbursement rate (see ALWPP scoring assessment tool) for Tier 2-4 is $2,430, $2,730, $3,000 and $3,300, respectively. This reimbursement rate will only meet the expenses of the lowest cost providers, but only if a nurse (state plan beneifit rate at $78/hour) is required for one hour/week: ($78/hour x 1 hour/week x 4 weeks= $314) = $2,314 (lowest cost to provider) at Level 1, two hours/week at Level 2 (78 x 2 x 4= 624) = $2,624, three hours/week at level 3 (78 x 3 x 4= 926) = $2,926 etc.
2. See Page 16 of 2002 California Department of Social Services, Research and Development Branch's publication titled IHSS: Keeping the Quality of Life at Home. According to the author of the report, Jon Sonma, (phone conversation, 2003) SNF admission records from 13,000 In Home Supportive Services (IHSS) patients seem to indicate 80% had care needs similar to patients currently residing in custodial care settings.