proposed new models of long term care · family care, partnership, iris, or remain in medicaid fee...
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PROPOSED NEW MODELS OFPROPOSED NEW MODELS OFLONG TERM CARELONG TERM CARE
Calumet, Outagamie, and Waupaca CountiesCalumet, Outagamie, and Waupaca Counties
October, 2008October, 2008
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CommunityCommunity--Based Care inBased Care inWisconsin A Historical ViewWisconsin A Historical View
Wisconsin has been viewed as a leader among states in establishing community-based, long-term care for many years.
Began state-funded, county-based community services in 1974.
Community Options Program (COP) in 1981.
Community Integration Program (CIP) for persons with developmental disabilities in 1983.
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Why did the State of WisconsinWhy did the State of Wisconsinwant to change the current LTCwant to change the current LTCsystem?system?
Contain Statewide Cost Growth
Expand Consumer Choice (Nursing Home vs. Waitlist)
Simplify Access to LTC Services
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What were the Goals for LongWhat were the Goals for Long--Term Term Care Reform?Care Reform? Purchase better consumer outcomes, not services
or processes.
Allow consumers and care managers flexibility to respond to individuals’ needs, preferences, and resources.
Enable individuals to live in the most integrated setting suited to their needs and preferences.
Reduce reliance on institutional and residential care.
Include and support informal caregivers.
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How Does the Current SystemHow Does the Current SystemCompare to the New?Compare to the New?
Current SystemCurrent System
Entitlement to nursing Entitlement to nursing home care: wait list home care: wait list for community carefor community care
Specific types of Specific types of service availableservice available
Many different federal, Many different federal, state and county state and county funding streamsfunding streams
Proposed ModelProposed Model Entitlement to both Entitlement to both
communitycommunity--based and based and nursing home carenursing home care
Single, expanded, Single, expanded, flexible benefit flexible benefit packagepackage
One primary funding One primary funding streamstream
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Comparing SystemsComparing Systems
Current SystemCurrent System No $ incentive for No $ incentive for
intervention & intervention & preventionprevention--person person automatically enters automatically enters nursing homenursing home
Service authorization Service authorization limited by available limited by available funds, or by state prior funds, or by state prior authorizationauthorization
Proposed ModelProposed Model Intervention and Intervention and
prevention in care prevention in care plans; must provide plans; must provide services if condition services if condition deterioratesdeteriorates
Service authorization Service authorization by local teams with by local teams with access to needed access to needed fundingfunding
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Current LongCurrent Long--Term Care Reform Term Care Reform AlternativesAlternatives
Family Care: Family Care: System that arranges and manages longSystem that arranges and manages long--term term care and works closely with acute and primary health care care and works closely with acute and primary health care providers to better coordinate care and services.providers to better coordinate care and services.
Currently available in Fond du Lac, La Crosse, Portage, RichlandCurrently available in Fond du Lac, La Crosse, Portage, Richland, , Milwaukee, Racine, Kenosha, Sheboygan, Ozaukee, Washington, Milwaukee, Racine, Kenosha, Sheboygan, Ozaukee, Washington, Waukesha, Dodge, Jefferson, Columbia, Green Lake, Waushara, St. Waukesha, Dodge, Jefferson, Columbia, Green Lake, Waushara, St. Croix, Croix, Pierce, and Marquette counties.Pierce, and Marquette counties.
Partnership: Partnership: System that delivers longSystem that delivers long--term care and term care and integrates acute and primary care that integrates acute and primary care that includesincludes medical care.medical care.
Currently available in Chippewa, Dunn & Eau Claire; Milwaukee, RCurrently available in Chippewa, Dunn & Eau Claire; Milwaukee, Racine, acine, Kenosha; Dane, Columbia, Pierce, and St. Croix counties.Kenosha; Dane, Columbia, Pierce, and St. Croix counties.
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What is Family Care?What is Family Care?
Comprehensive, flexible longComprehensive, flexible long--
term care program to fosterterm care program to foster
independence and quality of lifeindependence and quality of life
for the elderly and people withfor the elderly and people with
disabilities in Wisconsindisabilities in Wisconsin
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Who is Eligible for FamilyWho is Eligible for FamilyCare?Care?
FINANCIAL • Be Medicaid-eligible,
FUNCTIONAL
TARGET GROUP
• Be otherwise eligible to receive services in a nursing home.
• Be one of the following:- 65 years or older- 18+ years with a physical disability- 18+ years with a developmental
disability
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What does Family Care Offer toWhat does Family Care Offer toConsumers?Consumers? Comprehensive AssessmentComprehensive Assessment Interdisciplinary Team (including Interdisciplinary Team (including
consumer)consumer) Identification of appropriate longIdentification of appropriate long--term term
care outcomescare outcomes Identification of natural and paid Identification of natural and paid
supports to help consumers attain supports to help consumers attain outcomesoutcomes
A network of qualified service A network of qualified service providersproviders
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Family Care TeamFamily Care Team
Manages servicesManages services Ensures consumer’s outcomes and Ensures consumer’s outcomes and
needs are addressed as needs changeneeds are addressed as needs changeThe Team includes:The Team includes: MemberMember Care ManagerCare Manager Nurse Care ManagerNurse Care Manager Others Others (i.e. other professionals, guardian, (i.e. other professionals, guardian,
relatives, friend)relatives, friend)
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What Services are in theWhat Services are in theBenefit Package?Benefit Package?
XXXXXXTransportationTransportationXXXXXX
Supportive Home CareSupportive Home CareXXXXXXCase ManagementCase ManagementXXXXXXResidential CareResidential CareXXXXXXHome ModificationsHome ModificationsXXXXXXHome Delivered MealsHome Delivered MealsXXXXXX
Day Service or RespiteDay Service or RespiteCardCardXXXXNursing Home CareNursing Home CareCardCardXXXXPhysical, Speech, OTPhysical, Speech, OTCardCardXXXX
Home Health, Personal Home Health, Personal CareCare
CardCardXXXXDME/DMSDME/DMSCardCardCardCardXXMedicationsMedicationsCardCardCardCardXX
Physician/Hospital Physician/Hospital ServicesServices
Current MA Current MA WaiverWaiverFamily CareFamily CarePartnershipPartnershipCovered ServicesCovered Services
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Does Family Care Save Money?Does Family Care Save Money?
Independent assessment of four of the five Independent assessment of four of the five original Family Care Pilots found:original Family Care Pilots found:
Average savings of $452 per monthAverage savings of $452 per month
Reduced use of nursing homesReduced use of nursing homes
Persons maintained Health and functioningPersons maintained Health and functioning
Assembly Committee of Medicaid ReformAssembly Committee of Medicaid Reform
Department of Health and Family ServicesDepartment of Health and Family Services
February 8, 2006February 8, 2006
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How Money is Saved?How Money is Saved?
Reduced hospital costsReduced hospital costs
Reduced nursing home useReduced nursing home use
Focus on outcomes; needs Focus on outcomes; needs vsvs wantswants
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What is the Family CareWhat is the Family CarePartnership Program?Partnership Program?
Combines health and longCombines health and long--
term care services for elderlyterm care services for elderly
and people with disabilities.and people with disabilities.
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Who is Eligible for Partnership?Who is Eligible for Partnership?
FINANCIAL • Be Medicaid-eligible,
FUNCTIONAL
TARGET GROUP
• Be otherwise eligible to receive services in a nursing home.
• Be one of the following:- 65 years or older- 18+ years with a physical disability- 18+ years with a developmental
disability
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Partnership TeamPartnership Team
Partnership Team includesPartnership Team includes-- Primary Care PhysicianPrimary Care Physician-- Nurse PractitionerNurse Practitioner-- Registered NurseRegistered Nurse-- Licensed Social WorkerLicensed Social Worker-- Member, Significant OthersMember, Significant Others
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How Does PartnershipHow Does PartnershipWork?Work?
Team provides or arranges all servicesTeam provides or arranges all services
-- Goal: To assist participant in living in the Goal: To assist participant in living in the community for as long as possiblecommunity for as long as possible
Medical CareMedical Care-- Medical care is includedMedical care is included-- Member contacts Team to make appointments for Member contacts Team to make appointments for
routine, urgent and outroutine, urgent and out--ofof--area carearea careException: Emergency careException: Emergency care
-- Primary Care Provider makes referrals to network Primary Care Provider makes referrals to network specialists when neededspecialists when needed
-- Members present their ID card to network Members present their ID card to network providers to receive servicesproviders to receive services
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Family Care is a better fit when:Family Care is a better fit when: Member prefers control over convenienceMember prefers control over convenience
-- Member maintains greater responsibility in Member maintains greater responsibility in coordinating own carecoordinating own care
One stop shop for all services One stop shop for all services –– longlong--term term care care andand medical care medical care –– is less importantis less important-- Retaining existing physician(s) is importantRetaining existing physician(s) is important-- Physicians who have agreed to contract with Physicians who have agreed to contract with
the MCO are not those the member would like the MCO are not those the member would like to seeto see
Absence of chronic, complex diseaseAbsence of chronic, complex disease Medication management is not indicatedMedication management is not indicated
Why Choose One or The Other?
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Partnership is a better fitPartnership is a better fitwhen:when:
Participant prefers convenience over Participant prefers convenience over controlcontrol-- Participant maintains less responsibility in Participant maintains less responsibility in
coordinating carecoordinating care
One stop shop of all services One stop shop of all services –– longlong--term term care care andand medical care medical care –– is importantis important-- Retaining existing physician(s) is not as Retaining existing physician(s) is not as
importantimportant-- Physicians who are willing to contract with the Physicians who are willing to contract with the
MCO are acceptableMCO are acceptable
Presence of chronic, complex diseasePresence of chronic, complex disease Medication management is indicatedMedication management is indicated
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What about SelfWhat about SelfDirected Supports?Directed Supports?
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SelfSelf--Directed Supports OptionDirected Supports Option
Option available for all Community Care Option available for all Community Care programs (Family Care & Partnership)programs (Family Care & Partnership)
-- Empowers you to arrange, purchase and direct Empowers you to arrange, purchase and direct some of your own longsome of your own long--term care servicesterm care services
-- Gives you greater control and flexibilityGives you greater control and flexibility
Option available through state wide Self Option available through state wide Self Directed Supports program called IRIS Directed Supports program called IRIS (Include, Respect, I Self(Include, Respect, I Self--Direct)Direct)-- Empowers you to arrange, purchase, and direct Empowers you to arrange, purchase, and direct
allall of your long term care servicesof your long term care services
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In order for Family Care or In order for Family Care or
Partnership to be offered in an Partnership to be offered in an
area, there must first be an area, there must first be an
operating Aging and Disability operating Aging and Disability
Resource Center (ADRC)Resource Center (ADRC)
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Aging & Disability Resource Centers Aging & Disability Resource Centers and Longand Long--Term Care ReformTerm Care Reform
A single sourceA single source for the general public to get for the general public to get objective and reliable information about a broad objective and reliable information about a broad range of community resources of interest to range of community resources of interest to elderly people and people with disabilities.elderly people and people with disabilities.
Service is provided at no costService is provided at no cost and without regard and without regard to income and assets.to income and assets.
Help people conserveHelp people conserve their personal resources, their personal resources, health and independence.health and independence.
Reduce the demandReduce the demand for public funding for long for public funding for long term care by delaying or preventing the need.term care by delaying or preventing the need.
Growth of aging and disabled populationGrowth of aging and disabled population means means that more people will need assistance.that more people will need assistance.
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Aging & Disability Resource Center Serving Aging & Disability Resource Center Serving Calumet, Outagamie and Waupaca countiesCalumet, Outagamie and Waupaca counties
Go ToGo Towww.www.youradrcresourceyouradrcresource.org.org
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Aging & Disability Resource Center Serving Aging & Disability Resource Center Serving Calumet, Outagamie and Waupaca CountiesCalumet, Outagamie and Waupaca Counties
Waupaca CountyWaupaca County
BranchBranch
811 Harding Street811 Harding Street
Waupaca, WI 54981Waupaca, WI 54981
715715--258258--64006400
11--866866--739739--23722372
www.co.waupaca.wi.uswww.co.waupaca.wi.us
Outagamie CountyOutagamie County
BranchBranch
401 S. Elm Street401 S. Elm Street
Appleton, WI 54911Appleton, WI 54911
920920--832832--51785178
11--866866--739739--23722372
www.co.outagamie.wi.uswww.co.outagamie.wi.us
Calumet CountyCalumet County
BranchBranch
206 Court Street206 Court Street
Chilton, WI 53014Chilton, WI 53014
920920--849849--14511451
11--866866--739739--23722372
www.co.calumet.wi.uswww.co.calumet.wi.us
WWW.yourADRCresource.org
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The ADRC serves people in Calumet, The ADRC serves people in Calumet, Outagamie, and Waupaca Counties who Outagamie, and Waupaca Counties who meet one or more of the following:meet one or more of the following:
Are over age 60Are over age 60
Have a developmental disabilityHave a developmental disability
Have a physical disabilityHave a physical disability
Have mental health issuesHave mental health issues
Have substance abuse issuesHave substance abuse issues
Are young adults with disabilities who are transitioning to Are young adults with disabilities who are transitioning to
adulthood and related servicesadulthood and related services
Are families, caregivers, or advocates for any of these Are families, caregivers, or advocates for any of these
individualsindividuals
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What does the ADRC do?What does the ADRC do?ADRC helps to:ADRC helps to: Sort out issues and answer questionsSort out issues and answer questions Identify options to make choices and maximize Identify options to make choices and maximize
independenceindependence Identify informal supports and location of gapsIdentify informal supports and location of gaps Determine eligibility for public fundingDetermine eligibility for public funding Explain programs and services that are available in their Explain programs and services that are available in their
own communitiesown communities
ADRC will assist with:ADRC will assist with: Applications for public benefitsApplications for public benefits Signing up for government programsSigning up for government programs
For those with greater needs, ADRC will help to encourage an For those with greater needs, ADRC will help to encourage an even more ineven more in--depth interview to help identify care and other depth interview to help identify care and other support needs.support needs.
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Plan for the FuturePlan for the Future
Transition from individualTransition from individualCountyCounty Managed ProgramsManaged Programs
totoManaged Care OrganizationManaged Care OrganizationCovering Several CountiesCovering Several Counties
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Role of the Managed CareRole of the Managed CareOrganization (MCO)Organization (MCO)
Partners with counties in dayPartners with counties in day--toto--day day provision of longprovision of long--term care servicesterm care services
Tailors the delivery of care to eligible Tailors the delivery of care to eligible recipients based on their needsrecipients based on their needs
Contracts with quality providers of serviceContracts with quality providers of service Contracts with the state to provide Contracts with the state to provide
consistent level of long term careconsistent level of long term care Bears financial riskBears financial risk
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Role of the State ofRole of the State ofWisconsinWisconsin
Provides statewide fiscal, regulatory Provides statewide fiscal, regulatory and quality oversightand quality oversight-- Managed Care OrganizationManaged Care Organization
-- ADRCsADRCs
Legislative changes to accommodate Legislative changes to accommodate reform reform -- FundingFunding-- Statutory changesStatutory changes
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Role of CountiesRole of Counties
Provides local oversight through the Provides local oversight through the ADRC Consortia Advisory Committee, ADRC Consortia Advisory Committee, regional Long Term Care Council, regional Long Term Care Council, Operations Council, and local Advisory Operations Council, and local Advisory CommitteeCommittee
Operates Aging and Disability Resource Operates Aging and Disability Resource Centers (Centers (ADRCsADRCs))
Encourages crossEncourages cross--county collaboration county collaboration for efficiencies and best practicesfor efficiencies and best practices
County Boards must approve County Boards must approve participation in redesigned systemparticipation in redesigned system
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Calumet, Outagamie & Waupaca Counties Calumet, Outagamie & Waupaca Counties have partnered with Community Care have partnered with Community Care
to work toward becoming the MCO in this areato work toward becoming the MCO in this area
Community Care isCommunity Care is-- A pioneer in communityA pioneer in community--based longbased long--term careterm care
-- Nationally recognized for model of integrated careNationally recognized for model of integrated care
-- A nonA non--profit organization with over 30 years of profit organization with over 30 years of experience in experience in caring for atcaring for at--risk Wisconsin residentsrisk Wisconsin residents
-- Currently serving more than 4000 adults with longCurrently serving more than 4000 adults with long--term term care needscare needs
-- An agency with a high degree of member satisfactionAn agency with a high degree of member satisfaction
FFamiliar places. amiliar places. CCaring faces.aring faces.
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Our shared goalsOur shared goals
To empower adults with health and longTo empower adults with health and long--term term care needs to remain independent as long as care needs to remain independent as long as possiblepossible
To improve the quality of life for all people in our To improve the quality of life for all people in our communitiescommunities
To work together to end waiting lists for longTo work together to end waiting lists for long--term care servicesterm care services
To ensure that people understand their choices To ensure that people understand their choices and are matched with the best program for them and are matched with the best program for them (Family Care, Family Care Partnership, IRIS, or (Family Care, Family Care Partnership, IRIS, or Medicaid fee for service)Medicaid fee for service)
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KEY ELEMENTS OF PROPOSEDKEY ELEMENTS OF PROPOSEDMODELMODEL
Community Care is MCO with state contractCommunity Care is MCO with state contract
Community Care provides Partnership & Community Care provides Partnership & Family CareFamily Care
Representative of each county on Representative of each county on Community Care BoardCommunity Care Board
Local input through Advisory Committees Local input through Advisory Committees and Operations Counciland Operations Council
Counties may contract for care Counties may contract for care management and/or other key servicesmanagement and/or other key services
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Who Will be Impacted ByWho Will be Impacted ByImplementation of ProposedImplementation of Proposed
Model?Model? ConsumersConsumers
-- Current COP, CIP recipients will be offered the opportunity to sCurrent COP, CIP recipients will be offered the opportunity to select elect Family Care, Partnership, IRIS, or remain in Medicaid fee for seFamily Care, Partnership, IRIS, or remain in Medicaid fee for servicervice
-- For those counties with wait lists, the wait lists will be gone For those counties with wait lists, the wait lists will be gone in 24 in 24 monthsmonths
ProvidersProviders-- Current providers will be offered the opportunity to contract wiCurrent providers will be offered the opportunity to contract with th
Community Care to continue to provide servicesCommunity Care to continue to provide services
CountiesCounties-- After the transition period, counties will no longer offer long After the transition period, counties will no longer offer long term term
support programs; COP & CIP will go awaysupport programs; COP & CIP will go away-- Counties will continue to sponsor the ADRC, mental health Counties will continue to sponsor the ADRC, mental health
programs, adult protective services, and programs for childrenprograms, adult protective services, and programs for children
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What can you do toWhat can you do toensure success?ensure success?
Get InformedGet InformedProvide inputProvide inputProvide feedbackProvide feedbackStay informedStay informed