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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?