Estimated Savings from Early Intervention

September 10, 2013

Lisa Alecxih, Senior Vice President

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ACL Commissioned Study • National and state-specific estimates of costs and benefits of a

Return to Community type program implemented across the U.S.

• Steve Kaye, UCSF Institute for Health & Aging and The Lewin Group

• Initial estimates based on published and secondary data sources – Pre-MFP (prior to 90th day in a nursing facility) Medicare post-acute

target group

• Refined estimates based on Medicare and Medicaid claims, plus MDS assessments available in CMS Chronic Condition Warehouse (CCW) – Various target group explored

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Intervention Costs: Key Assumptions Intervention Costs

– Screening costs will be included in administrative costs and based on Minnesota’s electronic screening tool and secure referral system

– Assessment costs assume 2 hours staff time and overhead at $108 per assessment, based on Minnesota experience

– Care Planning, Activation and Short-Term Intensive Follow-Up, assumes 20 hrs staff time and overhead at $1,080/participant, based on Minnesota experience

Participation – 30% of individuals screened will be identified as being at high-risk of a long-term SNF

stay and having the potential to transitioned, and will be assessed to confirm their possible transition, based on S. Kaye analysis of 2004 NNHS.

– 20% of those assessed will be transitioned, based on the Kansas 5-year tracking study (R. Chapin, 2002).

Preliminary Estimates

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Intervention Savings: Key Assumptions

Service Costs – Total per participant annual service costs will be $15,000, based on ¾ of Money

Follows the Person costs; on average, $10,000 of the costs will be covered out-of-pocket by participants, with the demo covering $5,000, based on S. Kaye analysis of 2004 NNHS

Medicaid Savings – 50% of the transitions will be “successful” (i.e., the participant will remain in or die in

the community) and most of these individuals will not spend down to Medicaid; based on the Kansas 5-year tracking study (R. Chapin, 2002) and Minnesota’s 3-year experience.

– Medicaid will save $40,100 annually for every successful transition, which is the average annual cost to Medicaid for all Medicare-only beneficiaries who enter nursing facilities on the Post-Acute SNF benefit and experience a length of stay longer than 60 days

Medicare Savings - TBD

Preliminary Estimates

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Projected National Annual Targets

Assess 499,400 of Beneficiaries Screened

(30% of total screened)

Serve 99,880 Beneficiaries at High Risk of Long-Term SNF

Stays (20% of total assessed)

Divert 49,940 Beneficiaries from Long-Term SNF Stays

(10 % of those identified at-risk)

49,940 Beneficiaries not served due to

NH readmission, and not included in Savings Estimates

Preliminary Estimates

Serve Assess Outcomes

•Includes only FFS Medicare beneficiaries. Sources: Medicare and Medicaid Research Review/2011 & 2012 Statistical Supplements; MEDPAC, Report to Congress: Medicare Payment Policy, March 2012; Jencks (2009); and, 2004 National Nursing Home Survey. All numbers are preliminary; further refinements and precision in identifying target population will be developed in the coming weeks with data from the CMS Data Warehouse.

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Intervention Savings Applied Nationally Projected Savings to Medicaid ($31.9B)

** National First and 10 Year estimates include a 1% cost for national administration, and 10 Year costs are inflated by 2.5% annually.

Preliminary Estimates

Costs/Savings Over 10 Years**

Building Pre-MFP Nursing Home Transition Programs into “High

Performing” ADRC/NWD Systems

John Wren Deputy Administrator for Disability and Aging Policy

U.S. Administration for Community Living HCBS Conference, September 10, 2013

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A Niche Transition Population

2

Hospital

Home/Community

Skilled Nursing

Facility

Medicaid Eligible Residents Post 90 Days

The Pre-MFP Nursing Home Population

Money Follows the Person Demonstration

CCTP, QIO 10th Scope, HENs Care Transitions

Demo to Reduce Avoidable Hospitalizations for Dual Eligible Long-Term SNF Stay Residents

Nursing Home

Long-Stay Residents

(22% of post-acute

admissions)

Private Home 26%

Nursing Home, Rehab Facility

8%

Hospital or Hospital SNF

58%

Assisted Living, Group Home

6%

Other 2%

Home 67%

Elsewhere 33%

The Transition from Hospital to SNFs is the Main Pathway to Long-

Term Stays in Nursing Homes for Medicare Beneficiaries

Data source: 2004 National Nursing Home Survey 3

Nearly Two-Thirds of Long-Stay Nursing Home Residents Admitted Under Medicare End Up on Medicaid within 1 Year

4 * Private resources that could be used for community services

*

*

Length of stay at time of interview

Data source: 2004 National Nursing Home Survey

Nearly Two-Thirds of Long-Term SNF Residents Admitted Under Medicare End Up on Medicaid within 1 Year

5

*

* Private resources that could be used for community services

Length of stay at time of interview

Data source: 2004 National Nursing Home Survey

Experience Transitioning People Out of Nursing Homes CMS Money Follows the Person Demonstration

Enacted in 2007, targets Medicaid beneficiaries in Nursing Homes longer than 3 months (originally longer than 6 months).

Over the first 5 years, 31 states have transitioned over 26,000 people out of NHs, and have gained experience developing the infrastructure, tools, techniques and service strategies needed to help NH residents return to and live in the community.

The program has served large numbers of elderly, younger people with physical disabilities, and people with intellectual disabilities, and has documented the transition and services costs for these different groups; annual average cost for elderly = $23,725.

Most MFP transitions to date have had moderate to high impairment levels, and involved people who have been in the Nursing Home more than 1 year.

Performance varies by state: from 2010 – 2011, 6 states increased new MFP transitions by 50% and another 13 states by 20% or more, with the remaining states showing modest gains or declines.

Source: Money Follows the Person 2011 Annual Evaluation Report, Oct. 2012, Mathematica Policy Research; Institutional Level of Care Among MFP Participants, Oct. 2012, Mathematica Policy Research; Post-Institutional Services of MFP Participants: Use and Costs of Community Services and Supports, Feb 2012, Mathematica Policy Research

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Experience Diverting People from Nursing Homes Kansas Client Assessment Referral and Evaluation Program

Program Design - State requires all individuals applying for NH placement to have their needs

assessed and be counseled about community alternatives Key Outcomes from 5-Year Tracking Study - Of 2,882 individuals applying for NH placement in 1999-2000, 20% (599 )

were successfully diverted, and after 5 years, 57 % of those diverted were still in the community or had died in the community

- Service use was most intensive in the first month, then sporadic, often following acute episodes; with average monthly state cost of services being $367 in 2003

Source: Residential Outcomes for Nursing Facility Applicants Who have Been Diverted: Where Are They 5 Years Later?, R. Chapin, et al, The Gerontologist

2009, and unpublished reports.

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The Vast Majority of Kansas Diversions Who Stayed in the Community Did Not Enroll in Medicaid

Funding Source for Services for People Still Living in the Community by Length of Time in the Community

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16.8% 13.9%

Source: The Community Tenure Study: Community Tenure Status of CARE Assessment Customers 60 Months After Diversion, R. Chapin, et al, University of Kansas, 2007.

Experience Transitioning “Pre-MFP” Population from Nursing Homes

The MN Return to Community Program

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Nationwide Infrastructure for Scaling A Pre-MFP Transition Program

ACL/CMS have been funding Aging and Disability Resource Center (ADRC) Programs since 2003, and the CMS Balancing Incentive Program now requires states to develop No Wrong Door Systems to receive the enhanced match.

ADRC/NWD programs are managed by states help consumers and their families understand their options and navigate the LTSS system.

Currently, 50 state ADRC programs cover over 70% of the U.S. population

42 state ADRC programs have counselors doing MFP transitions, and have also been designated by their state Medicaid agency to serve as a Local Contact Agency for SNF residents who have expressed a desire during the MDS assessment process to transition back to the community; the ADRC is the only designated Local Contact Agency in 12 states.

ACL, CMS and VHA are currently investing in the development of “High Performing” NWD Systems in 8 states to serve “All Payers and All Populations” and become financially sustainable. This includes a National Training and Certification Program for NWD Counselors and new National Standards for NWD Systems. 10

No Wrong Door System

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Option Counselor Core Job Duties

Slide 1

ACL: Return to the Community: The Aging & Disability Network Role in Developing

Nursing Home Transitions

Presenter: Krista Boston, Director–Consumer Assistance Programs

Minnesota Board on Aging

Slide 2

Background - Return To Community Initiative • The research that led to the proposal

• Review of fiscal impact (savings forecasted)

• Relationship to the MinnesotaHelp Network™ (ADRC)

• Characteristics of the target population

Slide 3

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

0 10 20 30 40 50 60 70 80 90

Num

ber o

f Per

sons

Days from Admission

Target Window: Persons Still in Facility (49,895 NH Admissions Jan-Dec 2010)

Targeting Window

Slide 3

Slide 4

Implementation Approach • Business process modeling • Comprehensive Assessment Process and tools • Evaluation • Communications Strategy focused on high level of transparency and stakeholder

engagement – Road Shows (initial and update) – Booklet for consumers – Brochures – Webinars, booths and conferences presentations at annual industry

conferences – Dashboards

• Use of Data to complete target profiling

Slide 5

Step by Step

Slide 6

Program Continuous Quality Improvement • Regular conference calls with state unit lead staff • Site visits • Specialized training and discussions with Dr. Arling about

professional experience and need for changes in the tool • Dashboards and data collection reports generated and sent

out monthly to directors and senior management team • Also, tracked at the department level as part of DHS

Dashboard

Slide 7

Sample Dashboard Metrics

Slide 8

Expanding The Reach • ADRC becomes local contact agency

for MDS Section Q • MDS Screen is done for people of all

ages in the target population beginning 60 days regardless of payor status

• MFP has adopted the Return to Community protocol becomes basis for follow up strategy for all populations.

• Referrals now come in from three main places

Slide 9

Evaluation of MN Return to Community Initiative (RTCI) • “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

Slide 10

Evaluation Aims • Evaluate the Return to Community Initiative (RTCI) outcomes:

– Increasing resident transitions to the community – Delaying Medicaid conversion – Avoiding unintended consequences (e.g., increased hospital admissions or

nursing home readmissions) – Achieving Medicaid savings.

• Assess the RTCI processes: – ADRC staff counseling, transition planning, and follow-up; – Nursing home engagement in the program; – Transitioned residents and family caregiver experiences.

• Apply evaluation findings through rapid-cycle RTCI improvement. • Disseminate study findings to state Medicaid agencies, ADRCs, and nursing

facilities.

Slide 11

Evaluate RTCI Impact • Examine trends in community discharge rates, NH utilization, Medicaid

expenditures and other outcomes – Monthly and quarterly tracking of outcomes at the resident and

facility level – Before and after RTCI implementation (2008-2015) – Comparisons between transitioned, targeted and non-targeted NH

residents • Conduct as multiyear follow-up of transitioned individuals and their

families – Assessments of health, functioning, family caregiving and service

use – Baseline assessment at transition from the NH – Follow-up assessments every 90 days thereafter

NH Admissions with LOS <= 60 days

(46,242)

NH Admissions with Stays > 60 Days*

(15,002)

Meet RTCI Target Criteria or NH

Referral or MDS Q (4,321)

Remain in NH > 90 Days

(2,538)

MA [Possible

MFP] (1,414)

Not MA [Pre-Dual]

(1,124)

Community Discharge 61-

89 Days (1,513)

RTCI Transitioned

(339)

Unassisted Not MA

(770)

Unassisted MA

(404)

Other Discharge 61-89 Days (270)

Not Meet RTCI Target Criteria

(10,681)

Remain in NH > 90

Days (8,747)

MA [Possible

MFP] (4,535)

Not MA [Pre-Dual]

(4,212)

Community Discharge

61-89 Days (1,004)

Other Discharge

61-89 Days (930)

Annual NH Admission Cohort (N=61,244, Calendar Year 2012) DRAFT 9-Sep-2013

* Includes 138 RTCI Referrals or Section Q with LOS < 60 days

Slide 13

Evaluate RTCI Processes • Based on interviews and case studies conducted annually • Interview with RTCI Community Living Specialists and Client Services

Center (90 Day Follow Ups) – Description of 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

• Interviews and case studies of transitioned residents and family caregivers – Comparison of successful and unsuccessful transitions – Views of the transition process and current care arrangement – Factors leading to success or posing challenges

Slide 14

Characteristics of Transitioned Residents • 18% were moderately cognitively impaired and only 6% severely impaired. • Only 6% reported moderate to severe depressive symptoms (PHQ-9) • A majority could function independently in eating (92%), bed mobility (83%),

transferring (73%), using the toilet (70%), and dressing (54%) • The majority needed assistance in multiple IADLs • Most likely caregivers were adult child (40%) or spouse/partner (34%). • 80% anticipated having a caregiver available each day throughout the day

and night; 8% part of each day, and 12% only on the weekends.

Slide 15

RTCI Challenge and Opportunity: Targeted Residents Remaining in the Nursing Home

• 59% of targeted residents remained in the nursing home at 90 days • Targeted residents still in NH at 90 days

– At admission • Differed very little in health and functional status from targeted residents

discharged to the community – Between admission and 90 days

• Improvement in ADLs and overall health status • Small decline in cognitive status and continence

– At 90 days • 23% would not have met proposed state minimum Level of Care criteria (lowest 2

RUG groups)

Slide 16

Impact

• Almost 900 consumers directly assisted by Senior LinkAge Line® who discharged to community

• Total discharged (naturally as well as by Senior LinkAge Line®) is almost 5300 • Over 900 consumers receiving follow-up in community for 5 years

• Reasons why people don’t discharge:

– 36% Health status declined – 28% Personal choice

Slide 17

Next Steps

• 2011 Changes for ADRC – Focus on Assisted Living (Registered Housing with Services)

• Addition of Hospital and Health Care Home Referrals • Pre-Admission Screening • RTCI Expansion proposal (Waiver Reform 2020)

Slide 18

First Contact Proposal Expanding Access to Return to Community Two new target groups

1. Nursing home residents who discharge within 30 days and return to nursing home for 2nd admit in same calendar year • Uses existing service protocol including follow-up in community

2. Consumers who are considering a move to assisted living/housing with services but decide to stay at home

• Decision obtained during 10 day follow-up conducted by SLL – Consumer/caregiver will be offered in person assistance for support planning

• Ongoing follow-up in the community

Slide 19

Timelines for Roll Out and Roles • New Community Living Specialists (CLS) to be hired: Late Fall • Launch: January 1st • Nursing home role: Notify Senior LinkAge Line® of short-term stay discharges

for purposes of follow-up • Senior LinkAge Line® role

– Follows up with consumer offering community living consultation and follow-up for up to 5 years based on consumer preference

– People who choose to remain in their home after long term care options counseling conversation will be offered CLS supports through the initial LTCCE consultation phone call

– CLS follows Return to Community protocol (5 years follow-up) • Lead agency role – Will receive referrals for in-home MnCHOICES assessment

and eligibility determination for publically funded long term care programs

Slide 20

Questions?