Transcript Long-term Care Consultation Expansion and Return to

Care Transitions:
What Can Senior LinkAge Line® Do for My
Clients?
Age & Disability Odyssey
June 17, 2013
• Stephanie Minor
– Senior LinkAge Line® Program Coordinator
• Minnesota Board on Aging
• Darci Buttke
– Return to Community Coordinator
• Minnesota Board on Aging
• Lori Vrolson
– Executive Director
• Central Minnesota Council on Aging
Agenda
• Background and Overview
• Senior LinkAge Line®
• First Contact
– Chisago County Pilot
– What is First Contact
– How it will affect you
• Return to Community
– Overview
– Update
IN THE NEWS
State Budget Cutbacks: A Job Market Drag?
Time Magazine (2011)
Aging Baby Boom Generation Will
Increase Demand and Burden on Federal
and State Budgets – Government
Accounting Office (2002)
Motivators for Change
• “Nearly two-thirds of people over age 65 will need long-term
care at home or through adult day health care, or care in an
assisted living facility or nursing home.
Source: Genworth Financial Cost of Care Survey 2010 and U.S. Department of Health and Human
Services National Clearinghouse for Long Term Care Information, 10/22/08.
Projected 2010-2020 Rate of Change in
Minnesota Elderly Medical Assistance Costs
Minnesota State Demographic Center projection with assistance of Mn Dept of Human Services
2007-09 Recession Permanently Reduced the
Base for Future Revenues
Nominal GDP
$ Billions
25,000
20,000
15,000
10,000
5,000
Feb 07
Jul 09
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Source: “But…What About Tomorrow?”, presentation to LCPFP Balanced Budget Subcommittee, October 2009.
Budget pressures will change -more 65+ than school age by 2020
1,400,000
1,200,000
1,000,000
18-24
65+
5-17
800,000
600,000
400,000
200,000
0
1950 1960 1970 1980 1990 2000 2010 2020 2030
Census counts & State Demographer projection, revised 2007
If State Health Care Costs Continue Their Current
Trend, State Spending On Other Services Can’t Grow
8.5%
Annual Ave Growth 2008-2033
9%
8%
7%
6%
5%
4%
3.9%
3%
2%
1%
0.2%
0%
Revenue
Health Care
Education & All
Other
General Fund Spending Outlook, presentation to the Budget Trends Commission,
August 2008, Dybdal, Reitan and Broat
Studies on Consumer Decision Making
The Right Service…
…at the Right Time…
• Consumers and family
members are not aware of the
cost of long term care services
• Available information is
underutilized and when it is, is
perceived as difficult to use
and unreliable
• There is a lot of information
available but consumers do not
seek it out
• Crisis decision making limits
choices
• Consumers are more satisfied
with care they choose
• Caregivers like to discuss
housing with family members
and friends but they prefer to
make the decisions
themselves
The Opportunity
• There is an increasing need for assistance from people who are
not on public programs who want to avoid spend down but have
few ideas on resources
• The counties have critical expertise in assisting high risk people
and managing the public programs
• MnChoices will provide a robust tool that will allow for more
robust assessment (more people are going to be assessed)
• The Linkage Lines have a robust call center model and are
experts in privately funded options and can provide a LITE
version
The Objective….
• We must manage the increasing volume of need for long term
care decision making from an increasing aging boomer
population,
• We need to significantly expand access to people who are
privately paying for services to offer decision making at the right
time (not in a crisis) and,
• We have to design something that meets this increasing
demand – its different then what we have now and must be
multi-media and multi-purpose (more than a static web site)
• We have 5 major initiatives from which we have learned these
lessons
Five major projects that reflect more
help for private pay individuals
• These models offer more intensive assistance at critical points
of access (on the critical pathway to long term care) that offers a
type of decision support and follow up that “lite”, available
immediately and is not as intensive as care coordination or case
management offer to publicly funded clients
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Chisago County First Contact Pilot
MnCHOICES
Live Well at Home Rapid Screen
Return to Community
Long Term Care Consultation Expansion
Bottom line – here is what we have learned
• There are opportunities to do some pieces of what we need to
do to meet the demand in a more efficient way (which we hope
will free up county resources to meet the higher demand/need).
This may include:
– Making it easier for people to find the place to call
– Increase marketing and outreach about the services
– Building in effective ways to manage care transitions and decision
support for consumers between systems
• Simple and easy screens can help us triage people effectively
• Better data tracking helps us more effectively design access
systems that meet peoples needs
The County LTCC Strengths
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Experts in public eligibility processes
Have the indepth expertise to perform needed face to face
assessments around complex medical concerns and frailty
Can identify the need for addressing safety concerns and also
preventative strategies for aging and living well in the home
Assists and supports relocations (familiar with various health care
systems and available transitional supports)
Connected with vulnerable adult systems
Connected to the county mental health authority
Connected to other social services which may impact across families
And they are LOCAL LOCAL LOCAL LOCAL LOCAL
The Senior LinkAge Line® Strengths
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Highly focused on private pay
Consumers/families looking at LTC financing options
– Long-term care insurance, reverse mortgages, annuities, LTC Partnership
•
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Caregivers who need support to avoid burnout
Medicare Counseling
– Including open enrollment: reviewing Part D options
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In-person assistance for applications
Consumer transitioning from skilled nursing facilities to the community
Consumers considering a transition to registered housing with services
Specialized concerns/hot topics = e.g. Hospital observation status issues
And they are regional
Senior LinkAge Line®
A One Stop Shop for Minnesota Seniors
•
•
Statewide service of the Minnesota Board on Aging in partnership with the Area
Agencies on Aging and sponsored by Lieutenant Governor Yvonne Prettner-Solon
Senior LinkAge Line® Implemented in 1993
– Transform access and assistance
– Meet the needs of the senior population
– Provides Long Term Care Options Counseling
•
•
Seven contact centers and many outreach sites
In 2012
– 159,666 contacts serving 80,384 people
– 87% of those served would recommend the Senior LinkAge Line®
– 31% are repeat callers
MinnesotaHelp Network™
Contact Center Locations
Credentials of Senior LinkAge Line® Specialists
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Senior LinkAge Line® specialists must have:
– Social work degree; or
– Nursing degree; or
– Other related college degree
Minnesota Board on Aging
– Provide monthly trainings
– Have established rigorous standards, assurances and protocols for
providing the Senior LinkAge Line® service statewide
– Boston University Certificate in Aging curriculum
County/AAA Partnership-Chisago County Pilot
First Contact Pilot
• Chisago County is a combined Health & Human
Services organization
• Long Term Care services have been administered
under the Public Health umbrella for many years
• Combination of nurses and social workers
• PHN supervises many social workers (and nurses)
• Aging & Disabilities (physical and intellectual) housed
in Public Health (except mental health) as are Adult
Protection, PCA assessments
First Contact Pilot
• Began the pilot in 2009
• Prior to the pilot Chisago County residents were very
low user of Senior Linkage Line
• Following the re-structuring of AAA’s in 2006, the
county was working on “mending” the relationship with
the AAA
• A way to offer a one caller, one call strategy for
streamlined access for clients and families to LTCC
• SLL also took over the actual authorization process for
nursing homes for Chisago County (Chisago County
still hold the legal authority)
First Contact Pilot
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Share a technology between County and SLL called Revation
Received a grant to implement this project through CSSD
Sharing technology did not come without challenges~!
Gave the opportunity to “map” out our processes to identify
strengths and gaps
Data Results
• In 12 months (2011), SLL received 1,531 calls from the Chisago
County Area (Routed via Revation Linklive).
• 32% increase in SLL calls from Chisago County Area
• 145 LTCC Referrals to Chisago County
• SLL completed 179 Level I OBRA Screenings on behalf of the
county
Wilder Foundation did an Evaluation and
here is what they learned
• Through Focus Groups, Key Informant Interviews, Observations
and Analysis of county and state records, they concluded:
– The changes to the services showed positive outcomes for both
consumers and project partners
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More information and assistance at the initial call
Services accessed more quickly
More comprehensive assistance in locating and arranging for services
Help in learning about options for paying for services
Testimonials …
• “The Senior LinkAge Line® representative was very
knowledgeable and capable in presenting the information and
help needed. Her input permitted us to make full use of the
information available online. It was a very useful and surprisingly
enjoyable meeting. I am very pleased to know this level of help
is available to me and the community at large.”
• “It has been extremely helpful to have the Senior LinkAge Line®
specialist and all the assistants that help take care of Dad. As
you may know, I moved in with my father to help care for him.
I’m not sure if I could continue doing this without the help your
services provide. Thank you.”
• “This service is a wonderful way to be informed about available
resources.”
There were benefits to the county
• Greater System Efficiencies
– More time to devote to completely long-term care
consultation activities
– Ability to project paperwork required for reimbursement in a
more complete and timely way
Impact on Data Submission (MMIS)
• Average number of days between preadmission
telephone screening and electronic submission of
data
– 12 months prior
• 95 days
– 12 months during pilot implementation
• 60 days
Impact on wait times
• Average number of days between initial referral* and
completion of in-person LTCC
– 12 months prior
• 63 days
– 12 months during pilot implementation
• 18 days
*The data that is used to look at response time between referral and assessment is frequently
not accurate for people who have had more than one LTCC service delivered over time. This
makes the average wait time appear longer than it actually is in most cases.
Benefits to Project Partners
• Cooperative and trusting working relationships established
among partners
• Better understanding of the functions and capacities of each
partner
• Increased knowledge about services available to older adults in
their community
• New technology for delivering more effective and efficient
services to consumers
Replicability of First Contact
Pilot Project
• Study results indicate that multiple components of the First
Contact Pilot are both replicable and worthy of replication in
other Minnesota counties.
• Keys to replication
– Initial and ongoing discussions to provide shared understanding of
the approach
– Embark on the technology enhancement (Revation Linklive Unified
Communication Technology) allows for:
• More efficient communication including live chat among the pilot staff
• Call handling that gives consumers quicker access to appropriate
service providers
• Secure transition and data sharing using encryption
Encrypted Instant Messaging
Lessons learned
• Increased upstream engagement with older adults
• Greater efficiencies in conducting long term care consultations
(MnCHOICES assessments)
• Benefits truly align with other reform initiatives of helping all
partners become more efficient and effective with the increasing
boomers that will need long term care supports
First Contact
Pre-Admission Screening Now
• Also known as PASRR or authorization for nursing home placement
• Federal requirement identifying those with MI or DD entering a
nursing facility
• In Minnesota
– Incorporates Level of Care
– Exemption for stays less than 30 days
– Primarily paper/fax/phone process between hospitals, nursing facilities
and lead agencies
Legislative Session 2013
• First Contact passed: Chapter 108, Article 2, Sections 3 – 10, 22-23
• Changes:
– Ends Long Term Care Consultation Allocation
– Pre-Admission Screening function moved to Senior LinkAge Line®
• Focus on OBRA Level I
– Removes 30 day exemption
– Creates efficiencies using online PAS request form
• Everything else remains the SAME!
What does this mean to you?
Hospitals
• All pre-admission screening requests to be made through online form
– Based on current hospital and health care home referral form for
consumers seeking Options Counseling from Senior LinkAge Line®
– Will be available at www.mnaging.org
– For all nursing home admissions regardless of length of stay or payer
source
– Required fields for efficiency
– Will contain Level of Care screening questions
– Ability to print and save form for documentation
What does this mean to you?
Lead Agencies
• Managed Care will retain pre-admission screening for enrollees
– Requests will still be submitted through online form
– Senior LinkAge Line® will triage to managed care plan contact
• Triage as appropriate to lead agency, including
– Face-to-face assessments required for under age 65 prior to day 40
or to determine level of care
– Face-to-face as requested by consumer
– OBRA Level II Referrals
– Waiver recipients not on managed care
– Individuals under 21 not on managed care
What does this mean to you?
Nursing Homes
• Strive for determinations within one business day
– May be longer if face-to-face is required
• Ensure pre-admission screening online form submitted
• Contact Senior LinkAge Line® if additional copy of form needed
• ALL admissions require a pre-admission screening
– Community admissions and emergency admissions do require a
pre-admission screening requested through online form
– Facility to facility transfers are still exempt
What does this mean to you?
Consumers and Caregivers
• Follow-up and Decision Support for Short Stays (<30 days)
– Senior LinkAge Line®: Age 60 and older
– Disability Linkage Line®: Under age 60
• Follow-up with permission from the consumer
• Completed after consumer has returned home
– Nursing facility provides discharge planning
– Linkage Lines ensures return home is successful
– Reduce risk of rehospitalization or readmission
Present vs. Future
• Present
– Paper/fax/phone
requests
– Exemption for stays <30
days
– Completed by lead
agency
– Exemptions for facility to
facility transfers
• Future
– Online form requests
– PAS required for all
admissions
– Completed by Senior
LinkAge Line®
– Referrals as needed
– Follow-up for short term
stays
– Exemptions for facility to
facility transfers
Next Steps
• Roadshows statewide throughout August
• DHS Bulletins
• AASD Videoconferences (Tentative)
– August 29, 2013
– September 26, 2013
Return to Community
What is the Return to Community Initiative?
•
Return to Community is a service of the statewide Senior LinkAge Line®
and provides in-person assistance for nursing home residents (who are
private pay) who would like to return to community setting.
•
Passed in 2009 by the legislature as a service of the Board on Aging.
•
It started in April 2010
– The protocols for the service were developed in partnership with nursing home
discharge planners.
– It is being evaluated by Dr. Greg Arling at the Center on Aging at Indiana
University in consultation with Dr. Robert Kane at the Center on Aging at the
University of Minnesota.
Targeting Criteria Developed by Researchers
• In working with the Centers on Aging at the U of M and Indiana University –
researchers determined that a group of people were more likely to return
home, but weren’t doing so.
• They created a profile:
• Prefer to return to the community and/or have a support person for
community care,
• Residents early in nursing home stays and still have community ties
• Fit a community discharge profile -- health, functional, or personal
characteristics indicating high probability of community discharge
Target Window: Persons Still in Facility
(49,895 NH Admissions Jan-Dec 2010)
50000
Number of Persons
45000
Targeting
Window
40000
35000
30000
25000
20000
15000
10000
5000
0
0
Slide 49
10
20
30
40
50
60
Days from Admission
70
80
90
RTCI Target Population
• Still in NH at 60 days after admission
• Prefers to return to the community (MDS Section Q)
• Fits community discharge profile
– Probability score
– Based on these characteristics from the MDS:
Female
No Mental Health/Alzheimer’s/Dementia Dx
Married
No Serious Behavioral Problems
Younger
No Diabetes
Medicare Admission
No End Stage Disease or Cancer
Hip Fracture
Lower Cognitive Impairment
RUG Extensive
Lower ADL Dependence
RUG Rehabilitation
No Serious Incontinence
Step by
Step
Why is this Service Unique?
•
It focuses on private pay individuals
– Targeting people who need help before they go on a public program
•
Intensive follow-up services are available for people assisted out of the
nursing home
– Also available for those we don’t specifically assist
•
It is being evaluated and has become an evidence-based practice that is
being disseminated to other states
How is Return to Community Related to MDS
Section Q Referrals?
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Senior LinkAge Line® is Minnesota’s designated local contact agency
for all Section Q referrals
If consumer requests in-person assistance and is not on Medicaid,
Senior LinkAge Line® Community Living Specialists will meet with
consumer to provide discharge assistance
MN had an advantage when MDS Section Q referrals started, as
Community Living Specialists had already been hired for the Return to
Community work
Experience to Date-Statewide
•
Over 760 consumers directly assisted by Senior LinkAge Line® who discharged
to community
•
Total discharged (naturally as well as by Senior LinkAge Line®) is over 4500
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Over 900 consumers receiving follow-up in community for 5 years
•
Referral Sources
– 44% Nursing Homes
– 38% MDS Profile List
– 5% MDS Section Q
Evaluation of MN Return to Community Initiative (RTCI)
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“Study of a State-Level Model for Transitioning Nursing Home Residents to the
Community”
Funded by Agency for Health Services Research and Quality
– Health Services and Research Demonstration and Dissemination Grants
Program (R18)
– Project Period: 1-Sep 2012 to 30-Aug-2015
Research Partnership
– Indiana University and University of Minnesota
– MN Department of Human Services and Board on Aging
Evaluation Aims
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Evaluate the Return to Community Initiative (RTCI) outcomes:
– Increasing community transitions
– Delaying Medicaid conversion
– Avoiding unintended consequences (e.g., hospital admissions or nursing home
readmissions)
– Achieving Medicaid savings.
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Assess the RTCI processes:
– ADRC staff counseling, transition planning, and follow-up;
– Nursing home engagement in the program;
– Transitioned residents and family caregiver experiences.
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Apply evaluation findings through rapid-cycle RTCI improvement.
Disseminate study findings to state Medicaid agencies, ADRCs, and nursing
facilities.
RTCI Impact
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Community discharge rates, NH utilization, and Medicaid expenditures
– Tracking of outcomes by resident and facility
– Before and after RTCI implementation (2008-2015)
– Comparisons between transitioned, targeted and non-targeted NH
residents
Three-year follow-up of transitioned individuals and their families
– Health, functioning, family caregiving and service use
– Baseline assessment at transition from the NH
– Follow-up assessments every 90 days thereafter
Evaluate RTCI Processes
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Interview with RTCI Community Living Specialists and Client
Services Center staff
– Daily activity and workflow
– Challenges and successes
– Ideas for improvement
Interviews with nursing home staff
– Opportunities and barriers for community discharge
– Attitudes toward RTCI and opportunities for collaboration
Case studies of transitioned residents and family caregivers
– Factors leading to successful and unsuccessful transitions
– Views of the transition process and current care arrangement
Preliminary Findings (September 2012 Report)
•
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Rate of community discharges for targeted residents increased
significantly from the period before and after implementation of the
RTCI
Transitioned residents had
– Only moderate functional dependency
– Mild to moderate cognitive impairment
– Good caregiver availability
•
Many targeted residents remaining in the NH appeared to have good
potential for community discharge
46% Increase (20-29%) in Community Discharge Rate During RTCI
Window (60-90 Days) for Residents Admitted from Acute Care and
Still in the NH at 60 Days
29%
Community Discharge
30%
24%
25%
20%
20%
15%
10%
5%
0%
Pre-RTC:
July 2008 March 2010
Slide 60
RTC-MDS
2.0: April
2010 - Sept
2010
RTC-MDS
3.0: Oct 2010
- April 2012
Preliminary Findings
– RTCI had a direct impact through resident transitions
– Probable indirect impact of RTCI
• Alerting facilities to residents who could return to
the community but have not done so
• Asking if residents would like transition assistance
• If not, facilities must provide a reason why not
Characteristics of Transitioned Residents
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Limited cognitive impairment – Only 25% were moderately cognitively
impaired and only 6% severely impaired.
Few symptoms of depression -- Only 9% reported moderate to severe
depressive symptoms (PHQ-9)
Independent in most Physical ADLs -- A majority could function
independently in eating (90%), bed mobility (80%), transferring (70%), using
the toilet (65%), and dressing (54%)
Dependent in most IADLs -- The majority needed assistance in multiple
IADLs
Caregiver Support –
– Most likely caregivers were adult child (36%) or spouse/partner (45%).
– 80% anticipated having a caregiver available each day throughout the day and
night; 8% part of each day, and 12% only on the weekends.
Questions?