Transcript Illinois LTCOP

Home Care Ombudsman Expansion
Lyle VanDeventer, Deputy State Home Care Ombudsman
Legislative Action
Adult Protective Services
On July 1, 2013, legislation was signed into
law to expand the Department’s Elder
Abuse and Neglect Program (now Adult
Protective Services Program - APS)
 APS was expanded to prevent abuse,
neglect and financial exploitation of
people with disabilities between the ages
of 18-59 living in the community.

Move to Service Integration
February 22, 2013, the Centers for
Medicare and Medicaid Services (CMS)
and the State of Illinois entered into a
Memorandum of Understanding
 Intent was to provide integrated benefits
to Medicare-Medicaid enrollees in
targeted geographic areas in Illinois
 Project will alleviate fragmentation and
improve service coordination

Expansion of Long-term Care
Ombudsman Program

On August 16, 2013 the Illinois Act on the
Aging was amended to expand the
LTCOP to cover seniors and adults with
disabilities who are:
- on a medical assistance waiver
administered by the State; and/or
- served by a managed care organization
providing care coordination and other
services.
Home Care Ombudsman Coverage
Expansion of the LTCOP now makes it
possible to bring ombudsman advocacy
services to consumers of Home and
Community Based Services (HCBS)
 HC Ombudsman services will remain
essentially the same as provided to
nursing home residents

Who is a Home Care Ombudsman
Participant?
An older person, or an adult with
disabilities ages 18-59 who is eligible for
services under a state medical assistance
waiver program for the delivery of longterm care services and supports in the
home and community or managed care
organizations.
 A projected 137,734 individuals are
included in this population.

Managed Care and Waivers
Medicaid-Medicare Alignment
Initiative (MMAI)
Medicaid-Medicare Alignment Initiative
makes it possible for individuals who are
eligible for both Medicaid and Medicare
to receive managed care services.
 Dually-eligible (MMAI) recipients receive
healthcare services, and may get extra
benefits by enrolling in this program.

Managed Care Coverage
Department of Healthcare and Family
Services (HFS) selected eight health plans
to serve MMAI clients
 Coverage:
- Chicago and Cook County
- Quad Cities to Vermilion County
- Metro East St. Louis

Home and Community Based
Services (Medicaid Waivers)
Medicaid waivers are federal/state funded
home care programs for Medicaid
recipients.
 Waivers provide a variety of supports to
enable the individual to remain at home.
 In order to be eligible for waiver services,
individuals must be at risk of nursing
home placement, but also can be safely
served at home with proper supports.

Home Care Participants
 18-59
years of age
and disabled
 60+ years of age
 Living in the home
Home and Community Participants
Adults and Seniors Enrolled in Medicaid Waivers:
 Aging
- Community Care Program
 Department of Human Services
- Disability
- Brain Injury
- HIV/AIDS
- Developmental
Disabilities
MMAI and Waivers

Some participants may be enrolled in
both a Medicaid waiver and an MMAI
managed care plan.
Participants vs. Residents
 Individuals
in nursing
homes are still
identified as
“residents”
 The home care
population group are
labeled as
“participants”
Home Care Ombudsman Role
Home Care Ombudsmen
 Home
Care
Ombudsmen will
maintain the
continuum of care by
advocating for
residents and
participants alike.
Home Care Ombudsman


Home Care Ombudsmen are professional
problem solvers and advocates, whose
primary role is to investigate complaints
from residents of long‐term care facilities,
and more recently, individuals living at home
in the community.
Home Care Ombudsmen draw on strong
problem solving skills, knowledge of the
relevant rights and regulations, and effective
relationships with consumers, service
providers, and other agencies.
Home Care Ombudsman
Responsibilities
 Response
to inquiries
 Identification,
investigation & attempts
to resolve complaints for
or on behalf of
participants
 Access to participants
and their records with
permission
Home Care Ombudsmen
Responsibilities (cont.)
Educating consumers and stakeholders
 Advocating and investigating complaints
on behalf of enrollees
 Collecting complaint data and outcomes
 Identifying and reporting systematic
problems
 Making policy recommendations to
improve the delivery of integrated care to
enrollees

Home Care Bill of Rights (1)

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Have assistance to help you to understand your rights;
Be treated with dignity and respect at all times;
Be free from harm. This includes physical, sexual, verbal or
mental abuse, neglect and exploitation, including if someone
steals your money or Social Security check;
Receive respect for your personal property by your home
care provider, and request an investigation if there is theft or
loss of that property;
Receive treatment and services to help you live at home and
support your independence;
Home Care Bill of Rights (2)
Receive care from properly trained staff that have the
education, experience and proper license or certification to
carry out the services for which they are responsible;
 Get help, if you need it, using the Medicare and Medicaid
complaint and appeal processes, and exercising your civil and
other legal rights;
 Be protected against discrimination. No one can discriminate
against you or mistreat you because of your race, color,
religion, sex, national origin, ancestry, age, marital status,
citizenship status, genetic information, sexual orientation,
military status, physical or mental disability or source of
payment for your health care (for example, Medicare or
Medicaid);

Home Care Bill of Rights (3)
Get correct, easy to understand information and have
someone help you make informed health care decisions;
 Have someone help you if you have difficulty with language
or communication so you can understand all information
given to you;
 Access information about available home care services
provided in your community, and choose from those
services;
 Choose your own primary care physician and, if needed,
specialists within your managed care organization (MCO)
network;

Home Care Bill of Rights (4)
Fully participate in all treatment decisions related to your
health care. If you cannot fully participate in your treatment
decisions, and you want to have someone you trust help you,
you have the right to choose that person;
 Have all treatment options explained to you in a language
you understand before being treated and be fully informed of
your health status and how well you are doing;
 Refuse services, treatments or medications. If you choose
not to get a service or treatment or take your medication,
you must be told how it will affect your health;
 Participate in making and carrying out your plan of care to
help you live at home and support your independence;

Home Care Bill of Rights (5)
Be informed of the cost of services prior to getting those
services, whether the cost of those services is covered under
health insurance or other private or public programs, and
any charges you will be expected to pay and be given
advance notice of any changes to those costs or services;
 Talk with health care providers in private and have all your
personal, financial and medical information kept private as
protected under state and federal laws;
 Have access to your medical records, and be given copies
upon request, at a charge determined by the medical
provider;
 Request changes to your medical records;

Home Care Bill of Rights (6)

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Receive information on advance directives and receive
assistance to help you make an advance directive. An advance
directive is a written document that says how you want medical
decisions to be made in case you cannot speak for yourself;
A full explanation of the complaint and appeals process, and
who you may contact in order to have those complaints
addressed in an proper and timely manner;
Complain about the services or treatment you receive, or that
you need and do not receive, the quality of care, number of
service hours or any other concerns or problems you have;
Be encouraged, and helped, to freely explain your complaints to
persons of your choice.You must not be harmed in any way for
telling someone your concerns. This includes being punished,
threatened or discriminated against; and
To know the name and address of the state agency to contact
for additional information or assistance.
Complaint Process
Participant call to Senior Help Line
 State Home Care Ombudsman

◦ Enter case in OmbudsManager
◦ Refer to region

Regional Ombudsman
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Call, possible home visit
OmbudsManager update
30-day follow-up
Closure
CTM Process
Case Scenarios

Examples of possible inquiries and
complaints
Related State Activities
Duals Demonstration Grant
Effective 12/2/2013, the Department on
Aging was awarded a three-year
demonstration grant from the federal
Department of Health and Human
Services to expand the LTCOP to cover
MMAI.
 Project period: 12/2/2013 - 11/30/2016.
 Total grant award = $939,124
 First year funds = $267, 556.

Project Purpose
Department on Aging will approve grants
to provide expanded ombudsman
services to individuals served by managed
care (MMAI)
 Additional funds will be utilized to ensure
expanded coverage for individuals in
Medicaid waivers

Illinois Grant Activities
FY14: 10 MMAI demonstration
ombudsman grants - MMAI recipients
 FY15: 18 MMAI demonstration
ombudsman grants - MMAI and Waiver
recipients
 FY15: 13 MFP grants (PSAs) – transition
of nursing home residents to the
community, sub-granted to 17 regional
programs

National Collaboration
LTCOP staff are working closely with
federal agencies including the Health and
Human Services - Administration for
Community Living, and the Centers for
Medicare and Medicaid Services
 LTCOP have been collaborating with
other state LTCOPs
 State LTCOP MMAI demonstration
grantees will meet in Washington D.C. in
September for collaboration

Training
New staff have begun to receive training
for Levels One and Two ombudsman
certification.
 Training was provided to ombudsmen
during the Adult Protection and Advocacy
Conference in Oakbrook Hills.
 OmbudsManager training webinars have
been provided.
 Level Three ombudsman training being
developed for home care ombudsmen.

Public Awareness
A pamphlet is being produced that
highlights the home care expansion
 A “bill of rights” brochure is being
produced that describes the rights of
individuals residing in the home and
receiving home care/MMAI
 An informational video is being developed
that promotes the availability of the
ombudsman program in community
settings

Discussion