ExploringMissouri’sLevelofCare(LOC)EligibilityProcessandCriteria

May5,2018

• QUESTION–WhenthinkingaboutthecurrentLOCprocessandcriteria,whatarethethreetofivemostsignificantchallengesorissuesexperiencedbythepopulaFonsyouserve?

• Writeoneideapernotecard• Nolessthan3cards• Nomorethan5cards• Pleasewritelegibly

AcEvity:IdenEfyChallenges

ReportOut

• MedicaidundertheLTSSprogrampays63%ofallinsFtuFonalcareforthestateofMissouri• MOspendsaround58%towardsHCBS• 50%increaseinelderlyneedsinapproximatelythenext15years• Hostofotherconcernslikefromnotecards

Missouri’sNeedforTechnicalAssistance

OverarchingGoal:CreateanewLevelofCare(LOC)modelthat:

1.  EnsureaccesstocareformostinneedofHCBSprovidingleastrestricEvecommunityseYngaslongassafelypossible

2.  UselimitedstateresourcesonthosemostinneedofHCBS

comparedtomorecostlyfacilityplacement.3.  Ensureindividualsabletoliveinthecommunityarenot

inappropriatelyplacedinamorerestricFveseYng.

BeginwiththeEndinMind

1.  NaFonallandscapescan• Deeperdivesintospecificstatesofinterest

2.  Stakeholderengagement3.  Co-createthenewmodel4.  SummarizekeylearningsandbestpracFces

TechnicalAssistance(TA)Scope

• CentersforMedicaidandMedicare(CMS)issinglelargestpayerofhealthcareintheU.S.

• LOCmandatedbyCMS,butstateshavelaFtudewhatspecificeligibilitycriteriashouldbe• CoversbothinsFtuFonalcareandHCBS

LOCRefresher

• ConductanaFonalscanofexisFngLOCresearch•  Evaluatemethodology,tools,andprocessesinallthestates

•  LOCeligibilitycriteria•  FuncFonalassessmenttypesused•  Assessors/Determinersofservicesandsupports•  Scoringsystems

• Researchstrategy•  Phonecalls,reviewofstatutes/regulaFons,publishedreportsandfindings,websitescan

• Provideda50-statelibraryofLOCeligibilitycriteria

NaEonalLandscapeFindings

OverallDiscoveries

• Lengthanddepthoffindingsvariedsignificantlyamongstates• Nocommonnomenclature• Everyoneis“unique”• Apprehensiveofjudgmentoroversight• Lackofevidence-basedpracFceorresearch• Eligibilitycriteriahadshared“buckets”withagreatdegreeofvariability

• IniFal,SpecializedandCross-CuYngtools• Toolsincludehomegrowntools(LOCET),naFonalassessments(interRAI),orcustomizedtool(ArPath)•  interRAImostcommonlyusedtoolinU.S.andbeyond•  Trendingupwards,reportsofmanystatesexploring/transiFoning

• Lengthandcomplexityoftoolusedvariedsignificantly• Paper,electronic/onlineform,web-basedsogware

WhatToolsAreLeveraged?

• SixSharedBuckets1.  ADLs–Commonlyincludesacrossallstates2.  IADLs–Halfofstatesinclude3.  Clinical–Two-thirdofstatesinclude4.  Medical–NotmedicaFondriven5.  Safety–Onequarteruse,trendingupwards6.  CogniFon–Majorityseparatementalhealth,

demenFa,IDD

WhataretheCriteriaBuckets?

•  Transfers•  LocomoFon• Bedmobility• Upperdressing•  Lowerdressing•  EaFng•  ToileFng• Personalcare• Bathing

AcEviEesofDailyLivingIndicators

IntellectualAcEviEesofDailyLivingIndicators

• Groceryshopping•  Laundry•  Lighthousework• MealpreparaFon• MedicaFonmanagement• Moneymanagement

•  TransportaFon• Usingphonetoaccomplishtasks• Billpaying•  Schedulingmedicalappointments• Othershoppingtasks

• AssisFvedevices• Treatmentsandprocedures

•  MOusesthislabelfor“rehabilitaFve”below

• RehabilitaFveservices(long-termneeds)•  Tubefeeding• Woundcare• VenFlatorcare

ClinicalIndicators

• Medicalhistory• Mentalhealthhistory• Diagnoses• Vitalsigns• MedicalcondiFons•  Specialtreatments

MedicalIndicators

• Environmentalfactors/problems• LivingcondiFons• Riskevidence• “Butfor”factorandimpactonLOC

SafetyIndicators

• Behavior• CommunicaFon• SensoryorientaFon• AssessmentofsocialsituaFon• Expression

CogniEonIndicators

Assessorsinclude:

•  AreaAgenciesonAgingandDisability(AAADs)•  AgingandDisabilityResourceCenters(ADRCs)•  ManagedCareOrganizaFons(MCOs)•  Nursingfacility/hospitalcasemanagers•  Stateemployees•  Independentcontractors•  CerFfiedassessors

Determinersinclude:•  Physicians•  Registerednurses•  CerFfiedassessors

WhoAssessesandWhoDetermines?

FourTypicalScoringSystems• Points• Doorway• Algorithm-based• Blended

HowDoesSomeoneMeetEligibility?

59%27%

12%2%

TYPEOFSYSTEMS

Pointssystem Doorwaysystem Algorithmbasedsystem Blendedsystem

QuesEonsonNaEonalScan?

AcEvity:TheFutureState

Ifyoucouldwiggleyournoseandmakeitmagicallyhappen,whatchangeswouldyouliketoseeimplementedintheLOCprocessinMissouri?

ReportOut

BucketChallenge

Havethoughtsyouhaven’tshared?

WritedownyourideaorsuggesEonforimprovementandplaceitintheappropriatecriteriabucket.

• IdenFfiedfivestatesfor“deepdives”• Arkansas,Indiana,Louisiana,NorthCarolina,Wisconsin•  “Trusteddiscovery”

• ConFnuestakeholderengagement•  SummermeeFngstoexplorenewLOCmodels

• Co-createnewmodelbasedonfeedbackandfindings• ProjectcompletebyNovember2018

Wrap-Up&NextSteps

ContactinformaEon

charla@golongconsulFng.com melissa@golongconsulFng.com

AnA_er-Thought