Home and Community-Based Long-Term Care: Recommendations to Improve Access for Californians

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Home and Community-Based

Long-Term Care:

Recommendations to Improve

Access for Californians

Prepared for:
California Community Choices

California Health and Human Services Agency

Submitted by:
Robert Mollica, Ed.D.

National Academy for State Health Policy

Leslie Hendrickson, Ph.D.

Hendrickson Development

November 2009

This document was developed under Grant CFDA 93.779 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents of this report do not necessarily represent the policy of the U.S. Department of Health and Human Services or the California Health and Human Services Agency and you should not assume endorsement by the Federal Government or State of California.


Click page numbers to access contents

Contents 3

List of Tables 8

List of Figures 14

Acknowledgements and About the Authors 15

About the Authors 15

Denika Boardman, Central Coast Center for Independent Living 17

Ann Guerra, Nevada Sierra Regional IHSS Public Authority 17

Lisa Jackson, Association of Regional Center Agencies 17

Eileen Koons, Huntington Hospital Senior Care Network/MSSP Site Association 17

Deborah Miller, SCAN Health Plan 17

Robert Sessler, Retired-former Contra Costa Aging and Adult Services 17

Executive Summary i

General Findings ii

System Design iv

In-Home Supportive Services (IHSS) v

Home and Community-Based Services (HCBS) Waiver Programs v

Department of Developmental Services vi

Adult Day Health Care (ADHC) vii

Mental Health vii

Nursing Facilities viii

Transition Programs ix

Summary of the Recommendations x

Recommendation by Category xiii

Introduction, Purpose and Scope 1

California Community Choices 2

Methodology 2

Organization of the Report 3

Section 1: Overview 5

Strategic Plan 7

Section 2: Demographics 9

Disability Prevalence in California 10

Level of Care Criteria Considerations 14

Section 3: Program Trends 17

In-Home Supportive Services (IHSS) 17

IHSS Eligibility 18

IHSS Expenditure Analysis 19

Number of Persons Receiving IHSS 19

The Cost per Hour for IHSS 21

Number of Hours of IHSS Services Provided 21

IHSS Expenditures 22

IHSS Functional Index 23

Medi-Cal Home and Community-Based Services (HCBS) Waiver Programs 27

Acquired Immune Deficiency Syndrome (AIDS) Waiver 29

Multipurpose Senior Services Program (MSSP) Waiver 32

Developmentally Disabled (DD) Waiver 36

Assisted Living Waiver Pilot Project (ALWPP) 45

Discontinued Waivers 47

The In-Home Medical Care (IHMC) Waiver 47

Nursing Facility Subacute (NF/SA) Waiver 50

Nursing Facility A/B (NF/AB) Waiver 52

In-Home Operations (IHO) Waiver 55

Nursing Facility/Acute Hospital (NF/AH) Waiver 57

Persons with Traumatic Brain Injuries 60

Adult Day Health Care 60

National Comparisons 66

Section 4: Developmental Services 73

National Comparisons 73

Regional Centers 74

Individual Program Plans (IPP) 76

Community Placement Plan (CPP) 77

Controlling Growth 78

Closing Developmental Centers 81

Nonstate-Operated Intermediate Care Facilities (ICFs) and Skilled Nursing Facilities (SNFs) 85

Downsizing Initiatives 86

Department of Developmental Services (DDS) Summary 90

Section 5: Mental Health Services 93

Money Follows the Person (MFP) Rebalancing Demonstration 95

Section 6: Nursing Facility Trends 99

Background 99

Cost and Utilization Trends 101

California Nursing Facility Trends Compared to National Trends 101

Nursing Facility Use 103

California Long-Term Care Institutional Spending Compared to HCBS Spending 105

Older Adults and Adults with Physical Disabilities 105

Persons with Developmental Disabilities 106

Institutional and HCBS Population Groups 107


Section 7: Nursing Facility Reimbursement and Rate Setting 122

AB 1629 Rate Setting 122

Liability Insurance 123

Caregiver Training 124

Fair Rental Value System 124

Other Rate Comments 124

Quality Assurance Fee 124

Use of Benchmarks 125

Labor-Driven Operating Allocation 130

Case-Mix Reimbursement 131

Section 8: Home and Community-Based Services (HCBS) Expenditures, Reimbursement and Rate Setting 134

Acquired Immune Deficiency Syndrome (AIDS) Waiver 134

Multipurpose Senior Services Program (MSSP) Waiver 135

Developmental Services Programs 136

In-Home Supportive Services (IHSS) 140

Nursing Facility/Acute Hospital (NF/AH) Waiver 144

Assisted Living Waiver Pilot Project (ALWPP) 146

In-Home Operations (IHO) Waiver 148

Cost-Effectiveness of HCBS and the “Woodwork Effect” 150

Cost Avoidance from Lower Utilization of Medi-Cal Nursing Facility Services 152

The Cost-Effectiveness of California 1915(c) Waivers 154

Break Even Analysis 160

Studies of Cost-Effectiveness Using California Data 161

Other Cost-Effectiveness Studies 162

Section 9: Fiscal Incentives Affecting Institutions and Home and Community-Based Services (HCBS) 167

Potential Impact of Budget Reductions Due to Declining Revenues 167

Potential Impact of Provider Fees as a Fiscal Incentive to Promote Home and Community-Based Care 168

Potential Impact of State Efforts to Work with Long-Term Care Providers 169

Section 10: Transitioning from Institutions 173

Cost-Effectiveness of Transition Programs 178

Access to Affordable Housing 179

Section 11: California Community Choices Forum and Survey Results 182

Section 12: Findings 186

General Findings 186

System Design 188

In-Home Supportive Services (IHHS) 188

Home and Community-Based Services (HCBS) Waiver Programs 189

Department of Developmental Services (DDS) 190

Adult Day Health Care (ADHC) 190

Mental Health 191

Nursing Facilities 191

Transition Programs 193

Section 13: Recommendations for Improving the Management of Funding for Home and Community-Based (HCBS) Services 194

Reduce Institutional Bias 194

1. Establish the Philosophy and Legislative Intent 196

2. Develop a Strategic Plan 200

Balanced Long-Term Care Systems 201

Short-Term Recommendations 204

3. Add a Special Income Level Eligibility Group 204

4. Increase the Home Maintenance Income Exemption 205

5. Maintain the Supplemental Security Income/State Supplement Program (SSI/SSP) Medi-Cal Eligibility Status 207

6. Adopt a Case-Mix Reimbursement System for Nursing Facilities 207

7. Establish a Nursing Facility Occupancy Provision 208

8. Convert the Labor Driven Operating Allocation to an Incentive to Promote Discharge Planning or Increased Quality of Care 208

9. Review Department of Developmental Services (DDS) Regional Centers Rates for Nonresidential Services 208

10. Conduct a Study of Need for Waiver Expansion 209

Medium-Range Recommendations 209

11. Establish a Statewide Institutional Transition Program 209

12. Reinvest Savings from Institutional Care in HCBS 211

13. Promote Diversion through Preadmission Screening/Options Counseling about Community Alternatives through Single Entry Points and Aging and Disability Resource Connections (ADRCs) and by Working with Hospitals 213

14. Expand Coverage of Residential Options Statewide to Offer More Service Alternatives for Older Adults 216

15. Increase the Use of Provider Fees for HCBS Providers 218

16. Explore Converting a Portion of State Supplement Program (SSP) Payments to Provide Services in Residential Settings 219

17. Create a Temporary Rental Assistance Housing Subsidy 221

18. Allow Presumptive Medi-Cal Eligibility for HCBS Waiver Applicants 223

19. Develop HCBS That Address Individuals with Mental Illness 225

20. Create Rate and Other Incentives to Reduce Nursing Facility Capacity 226

Longer-Term Recommendations 226

21. Create a Department of Long-Term Services and Supports 227

22. Create Single Entry Points (SEPs) to Access Services for Aged and Disabled Beneficiaries 228

23. Co-locate Medi-Cal Financial Eligibility Workers in Single Entry Points/ADRCs 231

24. Create a Unified Long-Term Care Budget 232

25. Create a Standardized Rate Structure for HCBS Based on the Acuity of Persons Receiving Services 233

26. Create Incentives for HCBS through Managed Long-Term Care and Capitation 236

27. Create Financing Strategies That Improve the Balance between Community and Institutional Services 239

28. Develop a Long-Term Care Database 243

Conclusion 245

Appendices 247

Appendix A: Related Reports and Articles 247

Appendix B: Glossary and Acronyms 253

Glossary 253

Acronyms 262


Appendix D: State Plan Home and Community-Based Services Option - §1915(i) 275

Appendix E: Pennsylvania Incentives to Reduce Nursing Facility Capacity 277

Appendix G: State and National Statistics on Nursing Facilities and RCFEs 293

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