Letter to Sarah Steenhausen At DHS Re: Money Follows the Person
Hi Sarah,
I enjoyed participating at the Money Follows the Person (MFTP) discussion the other day and also believe, as Paula Acosta mentioned, the stars are beginning to align for Olmstead reform in California.
I am hopeful when you say MFTP will involve significant consumer stakeholder input. This was not the case with ALWPP. I think if you ask many senior advocates their opinion you'll find almost universal concern that ALWPP reflects an institutional bias, restricts provider participation and is poorly designed because it did not rely on adequate market research nor significant local stakeholder input. AB 499’s author and its lead sponsors have also expressed similar concerns. I do not believe your department fully understands the liabilities associated with ALWPP and I am quite concerned when you mention ALWPP will be related to future MFTP measures.
In Los Angeles, out of approximately 2,000 RCFEs, there are currently five participating with ALWPP. Most are non-profit, none are small providers and only one accepts patients who are wheelchair dependent or with Alzheimers. ALWPP does not reflect sound public policy when it is convoluted, bureaucratic, wastes medi-cal dollars and is based on unfunded mandates that thwart provider participation and restrict consumer choice.
Olmstead encompasses many issues, all of its goals are laudable, but specifically in regards to RCFEs I believe public policy is being developed in a vacuum. DHS does not license RCFEs and should not presume to be an expert for these settings. At the few meetings I have attended (usually by phone conference) I notice there is usually little or no participation by Community Care Licensing, RCFEs or advocacy groups related to these settings. Nowhere is this more evident than the complete lack of representation by these groups on the California Olmstead Advisory Panel.
RCFEs will be a critical component for MFTP patients wanting to transfer to these settings. In respect to the 2007 MFTP grant from CMS, I would suggest it prudent to solicit small provider opinion before developing any public policy that specifically involves these settings especially when ALWPP was never designed to accommodate small RCFEs.
In a week, our Los Angeles based coalition will host a meeting specifically devoted to this topic. Our city should be considered as one of the MFTP pilot program sites since we are a major metropolitan area with more RCFEs and nursing homes patients than any other city in California. And, since many of our RCFEs are affordable, having MFTP in our city would be an ideal way to show how medi-cal cost savings can be used to offset nursing home diversion expenses.
If we can devise a RCFE component for MFTP that is elegant, cost efficient and attractive to RCFEs would your department be receptive to using our template instead of ALWPP?
Call me anytime, if you would to discuss these issues further.
Kind regards,
Jason
The following individuals have pledged at www.carehomefinders.com/pledge.html to support the goals of the Olmstead Now Campaign. Their personal views do not necessarily reflect corporate or organization opinion.
The Olmstead Now Pledge:
I pledge to support California quickly implementing prudent, cost efficient Olmstead measures that will stop the low-income frail/disabled from being forced unnecessarily into SNFs.
I pledge to support Olmstead measures that do not perpetuate institutional bias, restrict choice, needlessly waste state resources and/or force the state to pay for nurses for patients who do not need nurses.
I pledge to support Olmstead rights for low income SNF patients with custodial care needs who would like to use their Medi-Cal dollars to receive care at home or in community based care settings, such as Residential Care Facilities (RCFEs).
Suggestions for MFTP implementation:
General components:
1. Departments responsible for MFTP should gather statistical information as to the percentage of skilled nursing facility (SNF) patients who could reside in community based care settings.
The state should conduct entrance interviews for all patients admitted to SNFs previously on IHSS to determine who have custodial care needs that could be met in community based care settings.
2. Departments responsible for MFTP should conduct local market analysis as to costs of residential care facilities for the elderly (RCFEs) vs. medi-cal reimbursed SNFs to determine approximate medi-cal costs savings for each patient who transfer to community based care settings.
3. Agencies responsible for developing MFTP should be free of institutional bias and recognize many patients end up in SNFs because they are low-income and because medi-cal does not currently for any other 24-hour care settings.
4. MFTP should not be a proprietary exercise by the Department of Health Services but should accommodate significant consumer stakeholder input and expertise by state departments currently responsible for the frail and disabled populations: e.g. the Department of Aging and Community Care Licensing.
5. MFTP should be cost efficient and designed so that medi-cal cost savings could be used to offset expenses associated with measures that involve new medi-cal dollars (e.g. nursing home diversion, aging in place).
6. Since the CMS 2007 MFTP grant specifically limits RCFE provider participation to settings with fewer than 4 beds, provisions should be made for California to submit to CMS an additional RCFE medi-cal waiver to allow participation by RCFEs that usually are licensed to accept 4-6 residents.
RCFE components:
1. MFTP should not use as a component for patients willing to transfer to residential care facilities for the elderly (RCFEs) the Assisted Living Waiver Pilot Program (ALWPP) which is opposed by many senior advocacy groups in the state including the American Parkinsons Association, the California Alzheimers Association, the Grey Panthers, the California Congress of Seniors, etc as well as by, Dion Aroner, author of the ALWPP’s enabling legislation (1999, AB 499).
2. RCFEs should not be converted to mini-nursing homes for SNF patients with custodial care needs wanting to transfer to these settings. Onerous new standards should not be imposed on RCFE providers willing to accept MFTP patients with identical care needs as current RCFE residents.
3. MFTP should be designed to allow easy participation by all RCFE providers including small (4-6) providers that have high staffing and frequently provide care for patients with wheelchairs or with dementia who could wander in cities (e.g. Los Angeles) where most large RCFEs are not licensed to accommodate this type of patient.
4. MFTP should only require RCFEs have nurses for participants with care conditions currently prohibited (g-tubes, i.v's, tracheotomies, ventilators, etc.) in RCFE settings.
5. MFTP should not create any unfunded mandates. For RCFEs willing to accept MFTP eligible patients, medi-cal reimbursement should incorporate a tiered base rate for custodial care and a supplemental payment for nursing expenses associated with patients who require these services. Should total patient expenses exceed total reimbursement (medi-cal and patient's SSI contribution), RCFE providers are not obligated to retain MFTP patients.
6. MFTP should take into consideration local market conditions and not mandate private rooms when share rooms are more affordable to state coffers and when many private paid RCFE residents do not enjoy this luxury.
7. MFTP participants should be allowed to use their medi-cal dollars to seek out shared or private rooms in the marketplace and not be restricted to only non-profit or low cost providers.
8. MFTP should incorporate sensible aging in place measures that do not obligate the state to upgrade RCFE residents in shared rooms to private rooms once they run out of money.
9. MFTP should be designed to facilitate participation by a large number of RCFE providers and provide maximum consumer choice. MFTP should not create unnecessary provider bottlenecks that would eliminate consumer choice.
10. Once fair, tiered reimbursement rates based on local market conditions have been developed, all RCFEs should be notified directly about MFTP and invited to participate.
11. All Olmstead public policy, including MFTP, should be transparent, open and allow for significant stakeholder contribution.
Suggestions for Rapid, Low-Cost Nursing Home Transition (according to the method used in Texas)
1. Send medi-cal SNF residents and their families’ letters informing them of nursing home transition options.
2. Send letters to all RCFE providers encouraging them to participate with nursing home transition.
3. Use existing state social workers/case managers to interview and determine eligibility of interested candidates.
4. Provide a list of community based care options for MFTP eligible patients who want to move home or to a community based care setting.
5. Provide state funding for one-time moving expense assistance.
6. Provide incentives for small RCFE providers to cater to specific populations (e.g. younger disabled people who cannot return home would most likely appreciate living in community based settings with peers of more or less of the same age).
7. Use existing state resources, e.g. Community Care Licensing, to monitor the status of patients who go to RCFEs who have only custodial care needs.
8. Work with the disabled rights advocacy groups to devise the best methods to allow MFTP patients to transfer back to their own home.
www.ajepartners.com
I am the author of AB 499 (statutes of 2000), which requires the State of California to develop a pilot program to permit Medi-Cal reimbursements for services provided in Residential Care Facilities for the Elderly (RCFEs).
Statute requires the state to develop a pilot program to allow eligible participants to live in the “least restrictive”, most “home-like” settings and to allow “aging in place” for current RCFE residents.
AB 499 statute is straightforward and consistent with the goals of the U.S. Supreme Court’s Olmstead decision that requires that individuals who could benefit from independent living services be offered them in the least restrictive setting possible. The court recognized the fact that many low-income patients end up in skilled nursing homes by default, not because they require nursing assistance. AB 499 requires participants be “medi-cal and nursing home eligible” but does not mandate the state restrict eligibility to only patients who need nurses.
AB 499’s eligibility requirements are consistent with standards used by the In Home Supportive Services (IHSS) program where recipients must be Medi-Cal eligible and at risk of pre-mature institutionalization but do not need nurses in order to receive state funding for care services at home.
The Department of Health misinterprets statute and defeats the spirit of AB 499 by developing a pilot program, called the Assisted Living Waiver Pilot Program (ALWPP), that restricts participant eligibility to only patients who need nurses and provider participation to only RCFEs that have nursing services.
Most RCFEs in California are small 4-6 bed settings that cannot afford to hire nurses. The proposed ALWPP eliminates from participation the most “home-like” and “least restrictive” of all care settings:-- small providers with the highest staff to resident ratio of any care setting in the state.
Limiting ALWPP provider participation to only settings that have nurses would eliminate the prospect of “aging in place” for current RCFE residents.
This faulty interpretation of statute reflects an institutional bias that creates rather than removes barriers to Olmstead reform in California: AB 499 was never intended to create mini-nursing homes out of community based care settings.
I request that the Assemblywoman request a legal opinion from either/both Legislative Counsel and the California Attorney General for the purpose of reviewing the statute and clarifying to DHS that AB 499’s intent is to allow “aging in place” for current RCFE residents and to permit participants to live in the “least restrictive” and most “home-like” setting--not obligate RCFE providers to have nurses nor restrict ALWPP participation to only patients who require nurse attention