Olmstead Now Primer
What is the Supreme Court Olmstead decision?
What is the Olmstead Now Campaign II? 
What is the current state of Olmstead reform in California in regards to allowing low income seniors who require 24-hour custodial care the choice to reside in a RCFE or assisted living setting vs. a skilled nursing home?
What is the Assisted Living Waiver program? (ALW)?
What are the primary goals of the Olmstead Now Campaign? Take the pledge here.
Commonsense Olmstead: Fixing ALWPP
DHS Reponds to Questons about ALWPP
Summary of Fixes for ALWPP
Dion Aroner's (author of ALWPP's enabling legislation) letter in oppositon to ALWPP
What is nursing home transition or Money Follows the Person (MFTP)?
What is the MFTP plan advocated by the Olmstead Now Coalition?
What is the percentage of patients in Skilled Nursing Facilities (SNFs) who may be eligible for nursing home transition?
How much does medi-cal reimburse SNFs in California?
What is the average cost of Residential Care Facilities for the Elderly (RCFEs) in Los Angeles and surrounding counties?
What are the barriers to Olmstead Implementation in California?
What is the Supreme Court Olmstead decision?
In Olmstead v. L.C., 527 U.S. 581 (1999) (the "Olmstead decision"), the Supreme Court construed Title II of the ADA to require States to place qualified individuals in community settings, rather than in institutions, whenever treatment professionals determine that such placement is appropriate, the affected persons do not oppose such placement, and the State can reasonably accommodate the placement, taking into account the resources available to the State and the needs of others with disabilities.
Many Olmstead measures are implemented by submitting waivers to the federal government that would allow medicaid dollars to be used to provide care services either at home or in community based care settings.
Total costs for individual patients covered by these waivers cannot cost more than what the state currently pays for that patient to be in a SNF.
What is the Olmstead Now Campaign?
An on-line petition used to coordinate legislative efforts to urge lawmakers to enact prudent, cost-efficient Olmstead measures that stop the forced institutionalization of the low income frail/disabled and permit nursing home transition for current skilled nursing facility residents who choose not to reside in these settings.
What is the current state of Olmstead reform in California in regards to allowing low income seniors who require 24-hour care the choice to reside in a RCFE or assisted living setting vs. a skilled nursing home?
California has enacted the ALW program (see below).
What is the California Assisted Living Waiver program (ALW)?
ALW allows 1000 qualified individuals to use medi-cal funding to receive care in assisted living settings and publicly subsidized housing sites. ALW participation is quite limited due to the small number of available waiver slots.
Eligible patients are anyone 21 years of age or older who is eligible for Medi-Cal without a share of cost and who has been determined to need the level of care provided in a skilled nursing or intermediate care facility. In some instances, ALW will remove barriers which currently prevent patients with certain conditions (eg. g-tubes, tracheotomies, etc.) from living in RCFE or public housing settings.
ALW is a byproduct of the Assisted Living Waiver Pilot Program (ALWPP) which was opposed by many senior advocacy groups and, according to the author of the enabling legislation (Aroner, AB 499, statutes of 2000), “reflects an institutional bias that creates rather than removes barriers to Olmstead reform in California". Most RCFEs find it difficult to participate as a ALW provider. For more information, see ALWPP articles at publications.
What are the primary goals of the Olmstead Now Campaign?
We support:
1. The Olmstead Now Campaign's Money Follows the Person (MFTP) (see below).
2. MFTP public policy that is open and transparent and developed with significant stakeholder and RCFE contribution.
3. MFTP measures that are prudent, cost-efficient and which allow for maximum consumer choice and RCFE participation.
4. A state-wide standard uniform assessment tool that distinguishes between SNF patients who require nurses vs. custodial care patients who could reside at home or in RCFE settings without nurse supervision.
5. Olmstead policies that are not related to the Assisted Living Waiver Pilot Program (ALWPP) opposed by many senior advocacy groups. ALWPP wastes medi-cal dollars, restricts provider participation, limits consumer choice and, according to the author of the enabling legislation (Aroner, AB 499, statutes of 2000), “reflects an institutional bias that creates rather than removes barriers to Olmstead reform in California".
6. Olmstead measures that do not create any unfunded mandates. For RCFEs willing to accept MFTP eligible patients, medi-cal reimbursement should include a tiered base rate for custodial care and a supplemental payment for nursing expenses associated with patients who require these services.
7. An Olmstead medi-cal global budgeting system where MFTP cost savings could be used to offset new medi-cal dollars needed to allow nursing home diversion and aging in place.
8. California's adoption of an up-to-date webpage specifically devoted to Olmstead Reform in California for easy access by state and consumer stakeholders.
What is nursing home transition or Money Follows the Person (MFTP)?
Money Follows the Person (MFTP) is a progressive Olmstead measure that allows eligible individuals to move with their medi-cal dollars from institutional settings to home and community based care settings. For some background information, see Nursing Home Transition under publications.
MFTP does not involve new medi-cal dollars and holds the best promise for extending Olmstead relief to the most participants in California. If implemented properly, it could save the state millions of medi-cal dollars a years (since home and community based care is usually far more affordable than institutional care) and help fund portions of Olmstead that involve new medi-cal dollars: nursing home transition and aging in place.
A previous California Pathways Grant helped establish some of the protocol for recognizing patients willing to transfer from nursing homes. Unfortunately, California has established no other critieria other than ALWPP to allow for transfer of MFTP patients to RCFE settings.
What is the MFTP plan advocated by the Olmstead Now Coalition?
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.
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).
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 should not be 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.
What is the percentage of patients in Skilled Nursing Facilities who may be eligible for nursing home transition?
Medi-cal pays for about 2/3 of SNF patients (there are approximately 240,000 SNF beds in California.). About 90% of these patients are elderly.
California does not currently assess how many SNF patients on medi-cal could be in lower level care settings. Although some SNF patients have g-tubes, iv's, tracheostomies, ventilators, open wounds, etc., and need nurse supervision, many have identical care needs as private paid RCFE residents with only custodial care needs (eg. help with dressing, bathing, help out of bed, etc.).
The California Little Hoover Commission estimates at least 30% of the residents in SNFs have only custodial care needs. Many senior care professionals feel the true percentage is far higher.
Initial results from the Money Follows the Person Preference Interview Draft Report (January, 2005) indicate in surveyed SNFs up to 56% of the medi-cal eligible partients interviewed where interested in nursing home transition.
How much does medi-cal reimburse SNFs in California?
In California, each facility has its own rates based on its costs and the AB 1629 rate scheme.
AB 1629 (Frommer, 2004) replaced the existing flat rate medi-cal payment system for freestanding skilled nursing facilities with individualized rates for each facility. Under the flat rate system, Medi-Cal rates ranged from $107 to $139 per day depending on location and facility size. The new individualized rates are based on each facility's costs, plus a profit component. Many nursing homes are getting rate increases of $20 - $70 per day; about 200 skilled nursing facilities have tentative daily rates ranging from $160 to $211 per day. Some nursing home rates have increased so much that they have raised private pay rates to keep pace.
A nursing home's interest in admitting Medi-Cal applicants is connected to its new rate. Rate increases vary substantially by facility.
What is the average cost of Residential Care Facilities for the Elderly (RCFEs) in Los Angeles and surrounding counties?
Average costs for RCFEs in Los Angeles and surrounding counties range from $1400-2300/month for a shared room.
What are the barriers to Olmstead Implementation in California?
Lack of will, state inefficiency, bureaucracy and, perhaps, lobbying influence. See the Los Angeles Times article under publications about these issues.
Other barriers:
For younger and disabled people who would like to live at home who could receive enough care within funding limits:
According to the California Federation for Independent Living Centers problems include:
"State and local decision makers will need to address many complex municipal and community service issues, such as housing and transportation to provide the social infrastructure that supports community-based care.
"Many persons with persons with disabilities living in the community complain of "funding silos" which are covered in red tape and are difficult to access. These limited funding streams don't allow for much flexibility, let alone choice.
"The continued failure of society to improve access to municipal services and community-based support options (affordable/ accessible housing, transportation, healthcare) are also barriers that the Olmstead decision requires us to overcome."
For younger and older disabled people who would like to live at home who need 24-hour care:
Insufficient medi-cal funding (see above) for patients with advanced care needs who need 24-hour care.
For current RCFE residents who run out money who would like to age in place and for current SNF residents with only custodial care needs who would like to transition to RCFEs:
Current medi-cal law does not allow funding for RCFEs for patients with only custodial care needs.
