Bumps in the Road
August 2006
After waiting for more than
three years consumer groups are gratified to see the rollout of Senate
Enrolled Act 493, the long term care reform law, finally get
underway. In June, The Generations
Project joined Steve Smith, the director of the Indiana Division of
Aging, in announcing the start of the Options initiative (in
effect, SEA 493). At that time the
income eligibility standard for home and community based services (HCBS)
through Medicaid waivers was equalized with the standard used for
Medicaid funded nursing home care.
This long overdue action is critical to the success of
re-balancing Indiana’s long term care system from
one that is based on nursing homes to a new system driven by consumer choice.
The Options initiative has
the potential to transform Indiana’s long term care system from
one that spends 75 percent of its dollars on nursing home care to a new
system, as established by SEA 493, that spends
the majority of its federal and state funds on HCBS. Since Indiana has an annual Medicaid
budget of $1.6 billion for long term care making the transformation to a
consumer driven system based on HCBS represents fundamental change. It is a change that is very achievable. Many other states have already done so
in order to save money and to provide better care for their citizens.
Unfortunately, in the rush to
implement Options the Indiana Division of Aging has recently run into
some serious bumps in the road of its own making. These include making commitments to
spend huge and unnecessary sums to “buy out” nursing home beds as a means
to accelerate the process of transforming the long term care system. Fiscally and legally buying out
licensed Medicaid beds is not necessary in order to reduce the
utilization of nursing home care.
Other states have avoided doing this, but in Indiana the state administration has
decided bed buy outs are necessary in the LTC re-balancing process. Consumer groups fear the buy outs will
consume dollars that can best be used to build HCBS capacity. (Bed buy outs are examined in more
detail in the July 2006 edition of this website series.)
Another costly bump is the
undue pressure brought to bear on the area agencies on aging (AAAs) by
the Division of Aging and its parent agency, the Indiana Family and
Social Services Administration (FSSA).
The AAAs have been forced to submit to the state huge and ill
defined planning reports in addition to their normal reporting requirements
that have sapped the time and the morale of the agencies. AAAs budgets have been reduced by the
state for SFY 2007. That has
produced cuts in senior staff and critical case managers at a time when
their budgets should be increased in order to meet the challenges of
implementing SEA 493. The state
has inexplicably taken senior citizen employment programs from the AAAs
and is threatening the viability of their senior nutrition programs. Good nutrition is the canary in the
mine when it comes to the health of senior citizens. The AAA nutrition programs receive high
marks and should be left alone.
The combined impact of these actions by the state against the AAAs
places the delivery of critical nutrition and home care services for
seniors and persons with disabilities at risk.
The administrative and
budgetary actions directed at the AAAs do not appear related to the
improvement of AAA operations. A
March 2005 management briefing paper prepared by The Generations Project at
the request of FSSA has largely been ignored by the Division of
Aging. Under SEA 493, the 1987
CHOICE home care law, and the federal Older Americans Act the area
agencies on aging are central to the administration of home and community
based services. With the rollout
of SEA 493 the Division should be building a partnership with the AAAs in
order to optimize the benefits of that law. Taken as a whole, Indiana’s private not-for-profit
AAAs have a proven track record of success and a positive national
reputation. They are successful
enterprises that are trusted by senior citizens. Taking positive steps to improve the
AAAs and to establish uniform business practices would be a far better
course for the state to follow.
The Generations Project, AARP, and the AAAs have all offered to
participate in a process to develop and improve management practices and
cooperation among the AAAs with the Division of Aging. So far there has not been a response to
that offer.
The Division and FSSA can and
do engage in productive partnering with the AAAs. They have announced their intention to
work with all sixteen area agencies on aging to establish aging and
disability resource centers (ADRCs). ADRCs are
designed to be state of the art information, outreach and marketing
centers for HCBS and other services for senior citizens, persons with disabilities,
and their families. Two AAAs have
already established ADRCs and two more have the
process underway.
The state is also pitching
the enrollment of providers for services, such as adult foster care
(AFC), in a manner that could result in care that places consumers at
risk. This is a bump that could
become a real hole for consumers and the state. Instead of carefully recruiting
families to provide homes for seniors and persons with disabilities the
state is aggressively marketing adult foster care as an entrepreneurial
opportunity. Other states, such as
Oregon, have discovered the latter approach can
produce harmful outcomes for the vulnerable people who must use AFC.
Concurrent with the above
actions the state has taken a series of steps that will harm the CHOICE
program. Specifically, provider
rates have been reduced below Medicaid waiver levels. CHOICE will remain a necessary home
health care program in the future for persons who will still need
publicly funded care but who will not qualify for the new Medicaid
waivers under SEA 493. Under that
law CHOICE is supposed to set the care standard for Medicaid waiver
services. So even though fewer people will be using the CHOICE program in
the future their care should not be compromised. Degrading CHOICE will
only serve to prematurely drive persons into nursing homes.
Despite the aforementioned
bumps, The Generations Project continues to take every opportunity to
work with the state, consumer organizations, AAAs, professionals, and
business to improve home and community based services and to re-balance
the overall long term care system.
Recently, this has resulted in a productive dialogue to establish
a new system of long term rehabilitation for persons with traumatic brain
injuries. The objective of these
discussions is the restoration of independence for TBI individuals. Consumer groups, the Project, and
providers are working with Steve Smith and the Division of Aging to make
this dramatic and wonderful new development a reality.
In order to fulfill its
mission of establishing a LTC system based on true consumer choice, The
Generations Project is obligated to report on the entire journey
including the bumps in the road.
To re-balance Indiana’s system of long term care
in a manner that produces better care outcomes while serving more people
and saving public dollars is a huge challenge. The positive and the counterproductive
elements must all be fairly evaluated and vetted. It is a challenge that requires the
state to be an active, positive and transparent partner with
organizations that represent the bottom line of any healthy LTC
system: the consumer. If our collective efforts do less than
that we will produce higher costs, poorer care and needlessly jeopardize
individuals and their families.
