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Moving Forward with Transitional and Integrated Services: the Long-Term Services and Supports Providers’ Perspective

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Moving Forward with Transitional and Integrated Services: the Long-Term Services and Supports Providers’ Perspective Moving Forward with Transitional and Integrated Services: The Long-Term Services and Supports Providers’ Perspective Developed by the AAHSA Transitions and Integrated Services Taskforce Table of Contents Transitions and Integrated Services Taskforce Members Section I: Maureen Hewitt (Chair) Steve Hess Introduction....................................................................... 2 Chief Executive Officer Immanuel Health Systems Total Long Term Care Omaha, Nebraska Taskforce.and.Workgroups................................................ 2 Denver, Colorado Jerry Kuyoth Charge............................................................................. 3 Dan Brady, Ph.D. Chief Operating Officer, Section II: Executive Director, Home and Health Division Community-Based Services National Church Residence Recommendations.of.the.Transitions.. Miami Jewish Health System Columbus, Ohio and.Integrated.Services.Taskforce....................................... 3 Miami, Florida F. Michael Martin Section III: Rosemary Castillo Senior Vice-President Chief Executive Officer Riverside Health Systems Promising.Models.of.Transitional.and.Integrated.Care......... 4 Casa Bienvivir Newport News, Virginia El Paso, Texas Section IIIA: Rodney McBride Craig Connors Vice-President The.Affordable.Care.Act.................................................... 4 Executive Director, PACE Jon Knox Village Section IIIB: Riverside Health Systems Lee Summit, Missouri Newport News, Virginia Accountable.Care.Organizations........................................ 7 Jeff Petty Bev Dahan President & Chief Section IIIC: Total Long Term Care Executive Officer Denver, Colorado Wesley Enhanced Living Existing.Transitional.and.Integrated.Care.Models................ 9 Southampton, Pennsylvania Gina DeBlassie Section IIID: Executive Director Pat Sprigg Total Community Care President & Chief Housing.with.Services...................................................... 12 Albuquerque, New Mexico Executive Officer Section IIIE: Carol Woods Bob Edmondson Retirement Community Program.of.All-Inclusive.Care.for.the.Elderly..................... 16 Chief Executive Officer Chapel Hill, North Carolina On Lok Section IIIF: San Francisco, California Cheryl Wilson Chief Executive Officer Continuing.Care.Retirement.Communities.(CCRCs)........... 18 Peter Fitzgerald St. Paul’s Senior Homes Volunteers of America and Services Section IIIG: Alexandria, Virginia San Diego, California Service.Options.Using.Resources.in.. a.Community.Environment/Fee.For.Service....................... 22 Bibliography................................................................ 24 American Association of Homes and Services for the Aging 2519.Connecticut.Avenue,.NW. Washington,.DC.20008-1520. www.aahsa.org An AAHSA White Paper 1 Section I: Introduction from receiving the HCBS they need and deserve. In 2008, the most recent year for which figures are available, Today, people with chronic conditions must navigate a 393,000 people were on waiting lists for home and com- care system that is ill equipped to meet their needs. The munity-based services2. That number represents an human and economic toll is devastating. AAHSA members increase of more than 200,000 since 2002. are working on promising solutions to address the care needs of chronically ill people. The political will is needed Even a cursory review of the demographics of an aging to change clinical practices and policies in order to imple- American population and the prevalence of multiple ment evidence-based transitional and integrated care. chronic diseases should be enough to motivate us to implement transitional and integrated services for older At the most basic level, the care delivery system is frag- adults. Clearly, by sticking with the status quo, the mented nationwide, simply because each state has as much United States runs the risk of not being prepared to meet power as the federal government to determine reimburse- the complex needs of the future aging population. The ment for, and implementation of, long-term services and growth of this population cohort could have staggering supports. Acute care providers, primary care and specialty implications for providers and consumers of long-term care providers, and long-term services and support provid- services and supports. In July 2006, more than 37 million ers for years have provided services in their own care silos. Americans were 65 and older, a figure that represented This care vacuum leads to poor communication, mediocre a mere 12 percent of the nation’s population. By 2050, care, and high hospital re-admission rates. A recent New however, the over 65 population is projected to reach 86.7 England Journal of Medicine article reported that 20 per- million, or 21 percent of the population. The 85 and older cent of Medicare beneficiaries who were discharged from population, the population most likely to need long-term the hospital were readmitted within 30 days, and that 12 services and supports, is projected to increase from 4.2 1 percent of those re-admissions were preventable . It is million in 2000 to 8.9 million in 2030. during these transitional periods that older adults with chronic illnesses are most vulnerable. Medicare and Medicaid cost increases are not sustainable. The costliest 25 percent of Medicare beneficiaries account Within states, the lack of integration between the Medicare for 85 percent of cost, and 75 percent have at least one and Medicaid programs creates a dilemma for many older of seven chronic diseases. How will the nation meet the people. Often, these individuals do not have enough needs of this growing older population that is living lon- income to pay for home and community-based services ger and has more complex clinical needs? How will we (HCBS) out of their own pockets. Yet, many have too contain the skyrocketing care costs that lead to strained much income or too many assets to qualify for HCBS government budgets and assure consumer preferences under Medicaid. Other payment sources, such as Older to age in place? Members of AAHSA’s Transitions and American’s Act and Medicare funding provide only limit- Integrated Services Taskforce researched and discussed ed coverage for HCBS. Waiver programs that allow states these questions. to use Medicaid dollars for home and community-based skilled care often have long waiting lists and strict eligibili- ty requirements that prevent many Medicaid beneficiaries 1 Testimony of Assistant Attorney General Thomas E. Perez Before the Senate HELP Committee June 22, 2 Testimony of Assistant Attorney General Thomas E. Perez Before the Senate HELP Committee June 2010. Online at: http://www.prnewswire.com/news-releases/testimony-of-assistant-attorney-general- 22, 2010. Online at: http://www.prnewswire.com/news-releases/testimony-of-assistant-attorney- thomas-e-perez-before-the-senate-committee-on-health-education-labor-and-pensions-on-the-ada- general-thomas-e-perez-before-the-senate-committee-on-health-education-labor-and-pensions-on- and-olmstead-enforcement-96910054.html the-ada-and-olmstead-enforcement-96910054.html An AAHSA White Paper 2 Transitions and Integrated Services Taskforce Charge The Transitions and Integrated Services Taskforce was The AAHSA Transitions and convened by AAHSA leaders in 2010 and charged with Integrated Services Taskforce will: recommending to the AAHSA Board of Directors a plan • Help AAHSA understand the development of new that would improve care in transitional service settings, chronic care, transitional care, provider-based man- as well a plan to integrate all the services provided by aged care, and disease management models, and their care providers to assure quality and cost effectiveness of relationship to existing innovative models of long- care. term services and support that operate throughout the The taskforce focused on building programs with a com- continuum. prehensive focus rather than “boutique” programs that • Assist with the development of a state and federal have a narrow focus within our healthcare system. advocacy agenda that will facilitate the growth and sustainability of integrated programs that enable older Transitions and Integrated adults and persons with disabilities to age in place in a Services Taskforce Work Groups congregate housing setting. Members of the Transitions and Integrated Services Taskforce participated in four work groups that researched • Advise AAHSA about educational and other needs specific issues and formulated recommendations: of providers operating these programs, as well as members who want to expand into innovative care 1. The Housing with Services Work Group concentrated management services. on legislation and regulations that promote, or are barriers to, housing with services models, as well as • Provide input into AAHSA’s applied research agenda best practices in state government for housing with with an emphasis on developing pilot programs that services delivery. could be vehicles for members to be involved in future demonstration projects as part of healthcare reform. 2. The PACE Work Group examined how PACE uses an Develop a research agenda that includes evaluating effective integrated reimbursement system to assure existing programs for quality outcomes and cost con- quality of care during transitions from acute care to tainment. primary care to long term services and supports. 3. The CCRC Work Group focused on breaking down Section II: Recommendations the silos in care based on insurance coverage, specifi- The Transitions and Integrated
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