Download Assisted Living and “Case Mix”

Medicaid Funding for
Assisted Living: A Case
Study
Brian D. Stever, BSN RN
Director of Health Informatics
And
Paul Taylor, MBA
Campus Administrator of the
Long Community at Highland
Overview
• Analyze how the existing Assisted Living ResidenceAssessment and Support Plan (ASP) can allow seniors
to remain independent longer
• Understand why expanding Medicaid funding is
possible in assisted living while it is not in personal
care
• Explore ways a “case mix” can be created using the
ASP tool and how it is applied to assisted living
communities
The cost of Long-Term Services
and Supports in Pennsylvania
• Based on a recently study released by Genworth, the state
median annual cost of a Long-Term Care semi-private room is
$108,847.
• The annual cost of an Assisted Living room is $43,200.
• This cost is less than half!
There are areas of the state where the cost is over triple for
Long-Term Care!
Genworth Cost of LTSS
Using the Assisted Living Assessment
and Support Plan to create an
individualized Service Model
• Pennsylvania created an item set for both Personal Care and
Assisted Living, the Resident Assessment-Support Plan or
RASP and the Assisted Living Residence Assessment-Support
Plan or ASP.
• Each is similar in nature, but the Assisted Living version has
the capability of scoring a resident for services that can be
provided by either community staff or by an outside provider
• This allows for a scoring process to be developed on the
document that can be converted to a “case mix”
Case Mix in Pennsylvania
• Case mix is the type or mix of persons treated by a particular location
or unit. The term is often used to describe the billing system of the
unit, since the "cost per item" of healthcare is based on the case mix
• We have had case mix in Pennsylvania Long-Term Care for over 20
years
• Each resident that requires Medicaid due to whatever reason, receives
a case mix classification which in turns assigns a specific number for
that resident
• Currently, Medicaid funds Long-Term Care only in the senior assistive
care settings
• The inception of the Managed Long-Term Services and Support process
may change that
What is Managed Long-Term Services
and Supports?
• Managed Long Term Services and Supports is the delivery of longterm services and supports (LTSS) through capitated Medicaid
managed care programs.
• It refers to an arrangement between Pennsylvania's Medicaid
programs and contractors. The contractors receive capitated
payments (flat, fixed fees per participant based on their aggregate
costs) for LTSS and are accountable for the health and welfare of
participants through the delivery of services and supports that
meet quality and other standards set in the contracts.
• The LTSS contracts were defined in an Request for Proposal, RFP,
that was released on March 1st
Community Health Choices Request
for Proposal Summary
Nursing Home Transition (NHT) is located in the Draft
Agreement, Section V: Program Requirements, L. Nursing Home
Transition
• NHT will also be absorbed as an administrative function of
CHC-MCOs. CHC-MCOs will have the option to contract with
existing NHT providers. This community is generally a less
expensive venue for services. CHC-MCOs have an inherent
interest to transition participants into the community.
• CHC-MCOs must provide Nursing Home Transition activities
for those residents in LTC that would like to transition back to
their homes or other community-based settings.
Assisted Living and “Case Mix”
• Currently there is no option for a resident that is in an Assisted
Living community if they require Medicaid
• They must leave their home and go to a Long Term Care community
which is a higher level of care than they may need as well as more
costly
• We are suggesting that Medicaid could cover a resident in an
Assisted Living environment
• In order to convert the current system of coding to a version that
will allow for scoring, we had to review the various codes
Assisted Living and “Case Mix”
• This can only work if you can convert the
current coding to a consistent reproducible
format and,
• The Assisted Living Assessment- Support Plan
will need an understandable process
The Scoring Codes
ASP
MDS
Score
Independent
=A
Prompting/Cueing
=B
Some Physical Assistance = C
Total Dependence
=D
Not Applicable
=E
0
1
2
3
0
0=
Independent
1=
Supervision
2 = Moderate Assistance
3=
Extensive Assistance
4=
Total Dependence
8 = Activity Did Not Occur
The Scoring of the ASP
• Similar to the MDS 3.0, the ASP can be
divided into Utilization Groups
• The areas recommended for scoring are
as follows;
– Daily Living Support
– Cognitive and Behavioral Support
– Medical Services Support
Case Mix in Assisted Living!
• It is possible, using the current required item set, to attain a
case mix on every resident in Assisted Living
• There only need be three levels of service;
– No/Low
– Moderate
rate)
– High/Waiver
Waiver allowed rate)
= 0 to 20
= 21 to 40
(basic MA rate)
(premium MA
= 41 to 52
(Add-on or
• The tool is being tested in an Assisted Living capable
community
• We are also attempting to test on higher functioning LongTerm Care residents
Why not Long Term Care
• There are many residents in the Long Term Care
setting that could qualify for this new process if there
was an Assisted Living environment available
• In the Long-Term Care setting we are required to ask
each resident if they would like to return to the
community (MDS 3.0, Section Q0550A)
• The focus on discharging residents to their highest
level of functioning is key
The Cost of Care…
Daily Living Support
• This coincides with the No/Low category in the Assisted Living
Case Mix
• This could be referenced as the “Reduced Physical
Function” categories found in Long Term Care
• This area focuses on the ADL/IADL areas
Daily Living Support
• ADL/IADL assistance and support
• Coordination with community providers
• Individualized supports
• Age in place with choice
Cognitive and
Behavioral Support
• This coincides with the Moderate category in the Assisted
Living Case Mix
• This could be referenced as the “Behavioral or
Cognitive Function” categories found in Long Term
Care
• This area focuses on the Cognitive and Behavioral areas and
lends itself well to the Individualized Service Model
Individualized Service Model
• Engagement of the whole person
– Resident Directed Care
• Choices developed by resident w/staff participation
– Dining developed with resident input
• All encompassing approach
– Purposeful Programming
• Meeting the needs of the individual
Medical Services
Support
• This coincides with the High/Waiver category in the Assisted
Living Case Mix
• This could be referenced as the “Clinically Complex” through
“Extensive Services” categories found in Long Term Care
• This area focuses on the medical diagnosis areas
• Coordination with community Waiver providers may be
needed
Medical Coordination of
Services
• Coordination with community providers
– Specialty and Ancillary Services
• Increased Control
– Availability to limit number of providers
• Natural Wake Time Medication Delivery
– Administration driven by resident preference
Aging with Choice
• Using the tool can provide flexibility in service to residents and
reduce transitions in care
• Areas of focus can be documented on a daily basis (as
indicated) for payment purposes
• Assisted Living communities that have clinical staff can provide
services as needed without need to requesting
accommodation which will ensure residents remain
Aging with Choice
– Flexibility to provide service and specialized care
on site to residents and reduce unnecessary and
unsettling transitions.
Obstacles to the process
• The ability to test the tool in a Long Term Care
community poses a bit more of a problem
– Not the same item set
– Permission to test
– Access to residents
Project to date…
• Electronically created in our EHR system
• Testing completed at Long Community
• Testing permission/information letter crafted
for Long-Term Care
What’s next?
•
•
•
•
Create a larger sample to include other communities
Validate findings
Meet with Pennsylvania State officials to discuss idea
Meet with the Managed Care Organizations that
have been approved for the MLTSS process in PA
• Creation of the electronic document in a consumable
format
Questions?