State Initiatives
Introduction
What follows is information about initiatives taken by other states across the U.S. to develop entry point systems and also to develop integrated care systems. While the NY ANSWERS program is geared more heavily toward the creation of a single point of entry, it seems useless to even attempt to implement a point of entry without some form of integrated care system in place upon which to build. The presence of an integrated care system plays into the main functions identified by NY ANSWERS for a point of entry system to serve, most notably care and service coordination. By investigating integrated care systems in addition to entry point systems, one can gain insight into how states have gone about increasing coordination of services through the use things such as patient assessments, case managers, and community outreach.
A. Entry Point Systems
1. Colorado: Options for Long-Term Care
What is Options for Long-Term Care?
Options is a single entry point that provides a statewide network of case management agencies serving one or multiple counties that contract with the state to perform level of care assessments, care planning, and case management. The program, which is overseen by Aging and Adult Services, was originally implemented in 1995 and as of December 2004, there are 25 entry points covering all 64 counties in Colorado.
How was the program implemented?
The program was implemented during a 2-year phase in period. According to state staff, the transition to the single entry point system did not increase the state’s expenditures fur home and community based service program administration. Instead, Colorado was able to reallocate funds already in use and the state conducted planning for the program within available resources. County officials then determine which organization will conduct the entry point functions. The cost to the state is approximately $14 million per year and it serves approximately 16,000 each year.
What agencies are involved in the Options program?
A variety of organizations are involved in the options program. Out of the 25 total agencies, over half (13) are housed in county Social/Human Services Departments. Seven are held within county Nursing Services/Health Departments. Two points each are within the Area Agencies on Aging and private nonprofit agencies. The final agency involved in Options is a private for-profit agency. The agencies are not allowed to provide services unless they have been approved by Colorado’s Department of Health Care Policy and Financing, or there is either a lack of providers of the type of service in the district or sub-region of the district. Lastly, the agency should also be able to provide services more cost effectively.
What is the purpose of the single point of entry?
The entry point was developed to simply access to the long-term care information and services for consumers, reduce fragmentation of coverage and services, and eliminate the need for duplicate assessment and duplicate administrative costs.
What activities are covered by the Options point of entry?
The point of entry covers intake, client assessment, referrals, case management, resource development, and care planning. All Medicaid recipients go through this assessment system.
How is eligibility determined?
Eligibility is based on a person’s functional capacity score determined by an assessment. As part of the assessment a case manager looks at activities of daily living, instrumental activities of daily living, and cognitive measures. The individual must need services for their impairments at least five days a week. In addition, the individual’s need for skilled treatments, therapies and rehabilitation is considered. Once completed, the case manager’s assessment is sent to the Colorado Foundation for Medical Care, which will then determine the appropriate level of care for the individual.
What services are provided under the Options program?
The Options program authorizes home and community based waiver services such as personal care, homemaker services, home modification, electronic monitoring, respite care, non-medical transport, and alternative care facilities like assisted living. Options also provides Medicaid long-term home health services. Services also include adult foster care and services available under Home Care Allowance. The entry point can either develop a care plan for the beneficiary or refer individuals to other resources such as programs financed by the Older Americans Act, private grant funding, or faith based organizations.
What is Home Care Allowance?
Home Care Allowance (HCA) is a state funded program that provides funding to purchase non-skilled assistance for activities of daily living, instrumental activities of daily living, supportive services such as medicine management, appointment management, money management, access to resources and help with phone usage. The individual’s ability to access HCA services is dependent upon his/her score on the initial care assessment, which will also determine the amount of HCA funds to be approved by the single point of entry.
How is care coordination handled under the Options program?
The key to the coordination under the Options program is a standardized assessment instrument. The beneficiary’s physician completes a medical assessment and compiles all necessary medical information including things like diagnosis, prescriptions, last hospital admission, etc. In addition to a medical history, a case manager will perform a functional assessment of the beneficiary and then will contract the primary care physician whenever he/she notes changes in the client’s condition or has concerns about the care plan. Completed assessments are submitted to a Utilization Review Contractor who will determine whether an individual meets the nursing home level of care criteria. Once approved, the individual will be enrolled and the case manager will develop and implement a care plan for the beneficiary who is determined to be eligible for home and community based services and HCA. On average, the caseload for each case manager is 63 individuals.
How is training of case managers approached?
Case managers are trained in the single point entry system and will receive additional training every fiscal year on health and medical issues. Training may be provided by single entry point nurses. In addition, the Department of Health Care Policy and Financing also conducts 1 to 2 sessions per year. Training topics are determined through the use of a survey of single entry point agencies, but will always include medical topics.
What sort of funding is provided to the agencies?
Each agency receives $855 per client per month for case management and administrative costs. The actual services provided to the clients are reimbursed separately from case management services. If the agency is maintaining an entry point that is serving multiple counties, they will receive an additional $8000 per county per year to support the additional costs that are anticipated for coordination with the other counties.
What sort of impact has the entry point had?
State officials have reported that since the implementation of the program, the number of individuals housed in nursing facilities has remained constant. However, utilization of home and community based services has grown from 5,000 to 17,000 per year.
2. Massachusetts: Aging Services Access Points (ASAPs)
What is ASAPs?
ASAPs is a pilot project to establish formal collaborations between physicians and elder service organizations. It is being jointly supported by the Division of Medical Assistance, the state Medicaid office, and the Executive Office of Elder Affairs. The program is funded by state general revenues and Medicaid home and community based service waivers.
What is the planned function for ASAPs?
ASAPs are intended to function as single entry point for long-term care services. They are designed to serve distinct geographic areas and coordinate a wide variety of home and community based services.
What are the goals of ASAPs?
The developers of ASAPs set forth four distinct goals for the program. First, the ASAPs are designed to support and enable elderly individuals to remain in the community for as long as possible before needing to seek institutionalized care. The ASAPs are also intended to improve coordination of primary, acute and community long-term care services. ASAPs are geared to introduce new strategies to maintain optimal functional status of individuals in the community. Lastly, ASAPs hope to increase access to preventive and primary care services.
What services are available from ASAPs?
ASAPs provide access to a full menu of Medicaid state plan services and home and community based services.
Who is eligible for service?
ASAPs service is open to Medicaid and dually eligible individuals who are medically stable yet qualify for nursing home admission and meet the state determined “high risk” criteria. Currently, the ASAPs serve seniors aged 60 and older.
How is care coordination achieved?
ASAP staff work closely with home health agencies to conduct risk management activities and improve coordination. Program staff and beneficiaries’ physicians communicate monthly to exchange client information. Such information that is exchanged includes the client’s health status, social supports, and environmental and housing circumstances. ASAP staff are on call to alert the physician to any changes in the client’s condition so that the individual’s care plan can be adjusted to meet the changing needs of the client.
3. New Jersey: New Jersey Easy Access, Single Entry (NJ EASE)
What is NJ EASE?
NJ EASE is a statewide system that allows elderly individuals and their families to learn about and obtain local services with a single phone call to the single access point in the form of a nationwide toll-free phone number (1-877-222-3737). It aims to provide information regarding long-term care services for the elderly. The program was implemented over a five-year period originating with each county identify a lead agency for the service, most of which were identified as the Area Agencies on Aging.
What kind of information does NJ EASE provide?
Individuals who call NJ EASE get county-specific information on a range of services for older individuals. In addition, the individual can receive counseling about available public benefits, arrange for assistance, or make changes to services that the enrollee is currently getting. If the counselor is unable to provide answers to the caller’s questions, then a referral is made. If needed, three way calling is available so that the caller and the counselor can assure that the referral is appropriate and that all necessary information is being transferred. Callers also have the opportunity to get assistance with completing application for services.
How does NJ EASE work?
Within New Jersey, when an individual calls the number, the system automatically recognizes the country from which the person is calling and transfers the caller to the single entry point office for that specific county. The phone number provides the caller with a live individual to speak with weekdays from 8:30 am to 4:30 pm. If a person tries calling outside of the working hours, the person will get a recording listing the hours of operation and directions for what steps to take for emergency services.
What happens when NJ EASE isn’t enough?
Situations arise when the phone system is unable to provide the information that the caller needs. If a caller needs intensive assistance, he/she can arrange for an in-home comprehensive assessment to determine the appropriate level of long-term support services that the individual needs. Following the assessment, a care manager will work with the individual to identify and arrange for services to assist the person to remain living in the community.
How is NJ EASE funded?
NJ EASE was developed with grants from the Robert Wood Johnson Foundation, which were matched by state funds and in-kind contributions. The program was then able to expand after receiving a grant from the Administration of Aging as part of the National Family Caregiver Support Program.
What sort of impact has NJ EASE had?
County program managers have indicated that NJ EASE has resulted in elderly individuals being made aware of more choice in terms of available care. This is due to counselors being trained to be more familiar with the range of services available under the various enrollment and benefit programs. It has been indicated that NJ EASE has resulted in counties becoming more aware of the need for services for older people and has resulted in the development of waiting lists for care management programs. It is important to note, however, the New Jersey has a relatively low number of counties (21), and this kind of system may not be appropriate for states with a larger number of counties. In such situations, it may be better to look at developing regional referral offices and information services.
4. Wisconsin: Aging and Disability Resource Centers
What are the purposes of the Resource Centers (RCs)?
The RCs were developed to offer information to the general public about community supports available to the elderly and disabled individuals. They are organized to give in-depth advice about long-term care service and support options available. The RCs provide a single entry point for individuals seeking access to Wisconsin’s home and community based service programs, and recommendations regarding publicly financed support in nursing facilities, residential settings, and adult family homes. In addition, the RCs are organized to be able to enroll individuals in the state’s publicly funded programs.
How does an individual access the RCs?
The RCs are operational in 9 counties across Wisconsin, representing a range from rural to urban counties. Individuals can contact the RCs either in person or through a 24-hour telephone number. In addition, RC staff is available for in-home visits if requested by individuals. The RCs are also equipped to respond to urgent situations if needed, such as the sudden death of a care giver.
What does the RC staff do?
The RC staff is trained to offer counseling on factors for individuals to consider when making long-term care decisions. Staff can also provide preadmission consultation to individuals entering nursing homes, community based residential facilities, and adult family homes. They also provide advice on the publicly funded home and community based services available to individuals. Staff is also prepared to be able to determine eligibility for Medicaid home and community based services, integrated health plans, and long-term care programs (PACE and Wisconsin Partnership Program). Staff can provide information on preventative and community social services for people with disabilities and elderly. In addition, they assist individuals to access entitlements like Medicare, Medicaid, and SSI.