During this first meeting on May 11, 2012, work group leaders provided an overview of vision for the delivery of the In-Home Supportive Services (IHSS) program in the duals demonstration. Panelists summarized the IHSS intake process and the managed care intake process and then there was a discussion around the “touch points” between the two existing systems.
View the materials used in the meeting below:
CA IHSS INTEGRATION—WHY NOT YEAR 3?
First Draft—4-29-12
Background
The required transparent stakeholder process in California to develop the Medicare-Medicaid Demonstration, left stakeholders believing IHSS and Behavioral Health services and funding would be integrated with all other health and social services for improved consumer outcomes and well-being. Yet, when the draft State proposal to CMS was published for 30 day input, both IHSS and Behavioral Health were again carved out, with the requirement that health plans would coordinate with these two programs.
Essential questions remain for stakeholders and health plans:
• Health plans could coordinate now, but without resources and authority, won’t the result be the same as now—coordination based on the willingness of other program staff to be cooperative or not?
• Without eliminating the IHSS bureaucracy at the State and local level (California’s biggest LTC program expenditure), how will health plans get a high enough cap rate to provide meaningful case management?
• How will health plans provide integrated services to Behavioral Health patients who identify their primary physician as a psychiatric provider and get LTSS from the County Specialty Mental Health System, without the authority and resources to be effective?
• How will health plans begin to pay for the huge unmet mental health needs of seniors who never become a part of the local system as they go to the hospital under Medicare for a diagnosis other than mental health to assure reimbursement? (This is a very serious problem as evidenced by the highest rate of suicide victims being among seniors.)
• Where is the money to assess, train and support all caregivers as needed (the State Department of Mental Health has taken away the bulk of resources from Caregiver Resource Centers, which still only serve family caregivers with cognitively impaired loved ones) to improve transitions and care plan compliance of this most expensive population?
• Will consumers with a health plan case manager who need IHSS and Behavioral health services now need a case manager for the 3 case managers and 3 assessments and 3 care plans of the 3 continued silos?
Idea for IHSS Integration
#1. The consumer:
IHSS needs to be eliminated as a stand-alone program. It has been over-litigated and over-regulated with minutes assigned to each task a person needs. It has not evolved to protect the consumer’s quality of life, but to protect the State and Counties from lawsuits. Consumers may be afraid to change IHSS as some depend on it to get out of and into bed, to eat, or be able to work. They need to be reassured (which Medicare and Medicaid appeals and grievance procedures can do) that they not only would get necessary personal assistance, but whatever else was deemed necessary for their health and well-being under a fully integrated program. They need one case manager to contact when they are in crisis. They need one assessment to be able to help develop a care plan that meets their need for independence with the appropriate services and supports.
#2. The State IHSS Program:
IHSS has been such a liability to big bureaucracies that legislation was written to create the Public Authorities to keep the program at arm’s length in terms of liability. The State receives 50% of the cost of the program from CMS and funds all but 17.5% which comes out of “Realignment” resources at the local level (these are State tax dollars returned at a certain percentage to the Counties where the taxes were collected). The formulae used to divvy up Realignment is so complicated at the State level that staff and legislators shy away from any change to it. With good will and actuarial assistance, it is possible to parse those funds and add the State and Federalportions to the health plan cap rate.
#3. The County IHSS Programs:
The Counties use the Realignment resources to fund 17.5% of the local IHSS program costs. County administrators see the Realignment dollars as “theirs”, able to shift it to several categories of County-funded services, such as Behavioral Health, Children’s Services, and IHSS. Thus, they do not want to lose any Realignment dollars. However, many support “smaller government”. Perhaps a deal can be made for health plans to receive the majority of the County realignment funds from IHSS as the stand-alone program is eliminated in Demonstration Year 3. Maybe the County would negotiate to keep 5% of Year 2 IHSS costs in their coffers to give up the program and allow health plans to fully integrate health and social services for the “duals”. IHSS case workers could be hired by health plans and exchange the very narrow focus of the IHSS assessment and service package for an interdisciplinary assessment and a broad scope of home and community-based services to support the overall well-being of the consumer.
#4. The Health Plans:
A capitated rate developed without integrating IHSS and Behavioral Health funding will most likely be a non-starter for health plans. The State and CMS required savings from the point of start-up while providing and coordinating of health, social services, and any other thing needed for well-being. Yet this is known to be the most expensive, needy, and high utilizing group of public beneficiaries. The experience of Medicaid Waiver programs(like California’s Multipurpose Senior Services Program) and national integration models (e.g., Texas StarPlus, Massachusetts Senior Care Options) all show first year costs to manage health and social services for this group are higher due to stabilizing the individual in the home setting. (The consultants may do well to consider recruiting individuals with experience or knowledge of these programs for the IHSS Workgroup.) During Year 1, glasses, dentures, specialty visits, preventive care, chronic care education, and caregiver supports are integral and more expensive than the former sporadic health care when a chronic condition exacerbates.
Moreover, health plans will need IHSS resources to provide case management to every dually eligible member. Assessment will include need for personal care as well as all other necessary services. The health plan care manager will rely on contracted providers, monitor quality of and satisfaction with care, and change the care plan as needed to maintain consumer well-being. Health plans will contract with more than one provider to insure competition and consumer choice. Personal care then will be one of the many LTSS resources in the case manager’s tool box to meet the unique needs of the individual.
Health Plans will need Behavioral Health dollars to be able to support the needs of those who are seriously mentally impaired as well as to prevent so many of these individuals from depression and isolation. (put in % of duals w/multiple chronic conditions here). The two biggest predictors of depression in the elderly are functional dependencies and a history of low level depression, not addressed by the current Behavioral Health System.
#5. Public Authorities:
Legislative changes could be made to allow Public Authorities to contract with health plans as a required local provider of personal care services. Public Authorities could become more robust by negotiating rates that allow for administration, supervision, training, a career ladder for paid caregivers, and benefits for those who work full-time. Caregivers with extra training, providing care to high need individuals, would be paid a higher hourly wage. Public Authorities would establish their own Board of Directors, independent of County supports or authority.
Paper prepared by Louis Frick and Evalyn Greb
Louis Frick
• Served as Executive Director of Access to Independence since November 2003
• Suffered a spinal cord injury in 1977 and uses a power wheelchair for mobility
• Has over 15 years of senior level management experience including finance, strategic planning, business operations, consulting, education, and health care
• Has served as on executive committee of The CA Foundation for Independent Living, the State Independent Living Council, and the Board of Directors of the National Council on Independent Living
• Has been recognized by AoA, CMS, and the Office of Disability for ILC innovations.
Evalyn Greb
• Started two of California’s first Adult Day Health Care Centers in 1973
• Organized and administered a hospital social work department, including development of home health, emergency room response program, and San Diego’s first in-patient hospice unit
• Worked for the County of San Diego for 28 ½ years:
o procured funding for and administered eight case management programs with 96 staff for elderly and disabled persons over 20 years
o was lead staff person for the Long Term Care Integration Project (Medicare and Medicaid Integration) for balance of time
• Established private consulting business with public programs, foundations, and private agencies
• Is CA Licensed Clinical Social Worker with small practice specializing in working with caregivers.