Patti Cullen's Blog

Musings on the Level of Care Changes

by Patti on Thursday, December 01, 2011 11:15 AM

In October I wrote a blog about the Medicaid Reform Waiver and the Home and Community-Based Services Redesign that passed during the 2011 Special Session.

Every week Association staff has been participating in a variety of workgroup meetings designed to provide input and develop recommendations on some of the waiver reform project directives from the 2011 legislation. While the details are not yet “ripe” for many of the provisions, there is enough information available now on the level of care changes to provide some fuel for comment.

In the November 2011 State Register, the Department of Human Services (DHS) provides a notice of intent to submit a request to the federal government to waive the federal maintenance of effort provisions in order to adopt a modified nursing facility level of care standard on July 1, 2012. (View documents for the Long-Term Care Realignment Section 115 Waiver Proposal and Appendix V Potential Impacts of Revised NF LOC on Medicaid Eligibility in Minnesota.)

Since the introduction of this level of care concept in 2009, Association staff have consistently expressed concerns about the “soft landing” needed for those who would no longer be eligible to receive nursing facility and/or home and community-based waiver services once the level of care “switch” was turned on. We also expressed some cynicism about the “fall back” position known as “Essential Community Supports.”

Most individuals who will no longer meet the revised nursing facility level of care will lose Medical Assistance payment for nursing facility care and home and community-based waiver services, but they will retain eligibility for Medical Assistance coverage. This means they could receive Medical Assistance state plan benefits such as personal care assistant, rehabilitation and/or home health services. However, some seniors will not qualify for state plan benefits even though they have an assessed need for one or more of the services provided through the program. In these circumstances, they will be eligible for essential community supports. Essential community supports will provide care coordination and one or more of the following four services, all for $400 per month or less: personal emergency response system, homemaker services, chore services, caregiver support and education, and service coordination. (Although likely most of that $400 will be “eaten up” by the care coordination fees that currently run in the $200–$300 range.) (Note, we are still confused about who will ultimately be eligible for essential community supports given that it appears DHS is asking for a federal match for this program — we don’t think there is a federal match for non-Medicaid programs.)

While this all looks well thought-out on paper, and even makes sense conceptually, it is important to note that this change in level of care criteria is projected to save the state tens of millions of dollars. Those numbers cannot be reached without some significant disruption in the lives of those seniors who will no longer be able to live in the place they call home.

Yes, we believe that those with the greatest need should be served “first,” and that when budgets get stretched, again, those with the greatest need should be taken care of. However, the projected change in monthly caseload if this level of care change is implemented is significant — when fully implemented, the caseload would be reduced by nearly 300 in nursing facilities; 3,260 in the Elderly Waiver (EW) program; and 541 in the Community Alternatives for Disabled Individuals (CADI) program. There are names, faces and life stories for each and every one of the over 4,000 who will no longer be eligible for public funding for some of the long-term care services in their communities. While there is a transition “plan” that reduces the immediate impact of the revised level of care for the longer stay residents (90 days), there will still be seniors caught in the trap. And for some, especially those living in assisted living or nursing homes in small towns where alternative services are non-existent, this change will be devastating.

I don’t have any ability to make up the fiscal savings for some of the proposals that are made by the state agencies and adopted by the Legislature. If I did I would question so many aspects of this proposal, and the overall system savings that are projected. We know there are seniors in our settings who stay well because of the interventions we provide them — whether it is reminders to eat, assessments of condition changes, medication management, or personal hygiene. Yet some of these same customers will no longer be eligible to receive nursing facility and/or waiver services. We know there are “orphan” seniors without family supports, and without a family home to return to. Without supports, we know some of these seniors will end up requiring more expensive health care services — doctor visits, urgent care visits and hospitalization episodes. Money may be saved in the long-term care side of the ledger, but the net costs for health care are sure to outweigh the savings in some cases.

How would I have done this differently? First, I would make the change prospective so there would be no implications on current recipients of services. Secondly, I would take the restrictions off of the $400 for the essential community supports — too much of the money will go toward care coordination, leaving little to nothing for services. Thirdly, I would create the ability for exceptions — for seniors in rural communities who have no housing and/or family support, there should be an exception. Fourthly, I would make sure that it is easy and quick for seniors to move back into the “system” — we serve a population with declining health conditions, so as a customer falls back under the revised level of care criteria, we need to be able to quickly respond to their new service needs. Finally, and most importantly, I would not have proposed these changes at all in this rapidly changing environment — walk through the nursing facilities today and tell me which folks don’t need our services.


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