Tuesday, October 6, 2015

Getting Help with Long Term Care Planning

A care manager can be an invaluable resource for a family struggling to meet the long term care needs of an older adult.
Care managers are professionals who have expertise in the aging process and in both health care and social service systems. A care manager may be a social worker, nurse or other professional with experience in long term care. Many care managers are knowledgeable about Medicare, Medicaid, PACE, and other programs that can help seniors get and pay for the care they need. 
Care managers provide families with expert information and guidance about local resources and supports. And they can act as health care advocates for their clients, working to ensure that the client receives the best care possible whether at home or in a nursing facility.
A care manager’s work typically begins with a comprehensive assessment. In addition to evaluating the client’s physical, functional, and emotional situation and current living arrangements, the care manager can identify and recommend community and private resources that might be helpful. Thereafter they can provide ongoing monitoring and regular reporting to family members.
The services provided by a care manager can help an older adult stay home for as long as possible. And the care manager can serve as your experienced representative and advocate if you need care in a nursing home or other residential facility. For example, a care manager can:
  • Link you to the best resources available in the community to provide you with services you need you live independently at home;
  • Coordinate the services you receive in the home such as unpaid and paid caregivers, medical equipment and home modifications.
  • Help you find ways to pay for the care you need in the most financially sound manner.
  • Help you transition as health and functional changes take place.
  • Arrange for respite care for your unpaid caregivers – every caregiver deserves a break.
  • Serve as the local representative and information source for your distant family members.
  • Provide advocacy and support in your dealings with health care providers. This can include critically important representation at care conferences if you are in a nursing home.
  • Arrange for expert estate planning including financial planning for Medicaid qualification, powers of attorney, wills and trusts through an experienced elder law attorney.
  • Provide assistance with stress and conflicts that can easily arise among family members and coordinate family caregiving.
  • Provide regular visits to monitor care and recommend adjustments to the care plan.
  • Guide you to the best choice for facility care if care at home is no long appropriate.
  • Help families make the best decisions in support of their loved one.
If nursing home care becomes necessary, the care manager can help families solve the many problems that can be encountered. They help ensure that the resident receives appropriate and high quality services that are tailored to the resident’s individual preferences and needs. They serve as health care advocates, attend care planning meetings and work with the resident’s doctors, family and nursing home staff to help create a personalized care plan, resolve problems and conflicts with the facility, and make sure all providers, services and treatments work together to optimize the resident’s health and well-being.
If you live in Northcentral or Northeastern Pennsylvania, within 40 miles of one of the cities of Williamsport, State College, Wilkes-Barre, and Scranton, it’s easy to find a quality professional care manager – just contact one of the care managers at Marshall, Parker and Weber.
If you reside elsewhere, here are some tips for locating the care management help you need. To find a care manager, ask people who are involved in the long term care network. Hospital discharge planners, Alzheimer’s and other support groups, elder law attorneys, and physicians and other health professionals all may be able to refer you to a quality professional care manager in your geographic location.
Care managers will often work closely with an elder law attorney. This is a powerful combination that can help you successfully address a full range of legal, medical, financial, social and family issues. The lawyer and care manager work together to find the best outcomes for families facing a long term care crisis. 
Some law firms, such as Marshall, Parker & Weber offer professional care management as a compliment to their legal services. Such law firms are sometimes referred to as “Life Care Planning” firms. You can find a listing of law firms that belong to the Life Care Planning Law Firm Association here.

Friday, October 2, 2015

GAO Issues Disappointing Report on Hospital Value-Based Purchasing

Under the Affordable Care Act the federal government uses Medicare payment incentives to try to raise the quality of hospital care received by Medicare beneficiaries. Medicare payments to hospitals now vary based on the quality of care they provide, not just the quantity of procedures they perform. Hospitals are rewarded based on how closely they follow best clinical practices and how well hospitals enhance patients’ experiences of care. The thinking is that when hospitals follow proven best practices, patients receive higher quality care and see better outcomes.
The Hospital Value-Based Purchasing (HVBP) program, which the Centers for Medicare & Medicaid Services (CMS) administers, annually evaluates individual hospital performance on a designated set of quality measures related to inpatient hospital services and, based on those results, adjusts Medicare payments to hospitals in the form of bonuses and penalties. The HVBP program was enacted in 2010 as part of the Patient Protection and Affordable Care Ac (ACA).
The payment incentive approach makes a lot of common sense. But does it work in practice?
On Thursday, the Government Accountability Office (GAO) issued a report evaluating the results of HVBP. The first HVBP payment adjustments occurred in fiscal year 2013. ACA included a provision for GAO to assess the HVBP program’s impact on Medicare quality and expenditures, including the HVBP program’s effects on small rural, small urban, and safety net hospitals. The GAO report evaluates the initial effects of the HVBP program on: (1) Medicare payments to hospitals, (2) quality of care provided by hospitals, and (3) selected hospitals’ quality improvement efforts.
Here is a Kaiser Health News summary of the GAO report. It is reprinted with permission. Kaiser Health News is a nonprofit national health policy news service.
By Jordan Rau October 2, 2015
Medicare’s quality incentive program for hospitals, which provides bonuses and penalties based on performance, has not led to demonstrated improvements in its first three years, according to a federal report released Thursday.
The Government Accountability Office examined the Hospital Value-Based Purchasing Program, one of the federal health law’s initiatives to tie payment to quality of care. Earlier this year Medicare gave bonuses to 1,700 hospitals and reduced payments to 1,360 hospitals based on their mortality rates, patient reviews, degree of improvement and other measurements.
While the payments to a majority of the nation’s hospitals have been affected each year, the audit found the financial effect has been minimal. Most hospitals saw their Medicare payments increase or drop by less than half a percentage point.  In the fiscal year that ended Sept. 30, 74 percent of hospitals fell within that range, with a median bonus of $39,000 and a median penalty of $56,000, according to the analysis.
Safety-net hospitals, which serve more poor patients, tended to do worse than hospitals overall, but that difference has decreased over the life of the program, the report said. Hospitals with the strongest balance sheets tended to do better than other hospitals, the report found:  Those with a net income margin more than 5 percent received average bonuses of 0.23 percent, while hospitals basically breaking even financially on average did not earn any extra payments.
The Centers for Medicare & Medicaid Services did not respond to the report. Officials have previously stressed that financial incentives like these will have a long-term effect by focusing hospitals more on quality.
The report said that even before the program began in October 2012, hospitals had been improving in how consistently they followed basic clinical guidelines, such as performing blood cultures before giving patients antibiotics. That improvement continued but did not increase with the advent of the financial incentives. The same was true for patient ratings, on such items as the quality of communication from doctors and nurses, and for mortality rates for heart attack patients. Heart failure and pneumonia death rates stayed roughly the same.
“Our analysis found no apparent shift in … quality measure trends during the initial years of the program, but such shifts could emerge over time as the program implements planned changes,” the GAO wrote.
The report noted patient readmission rates began to decline in 2010, when the health law was passed. It said that might be due to a separate Medicare penalty program, also created by the health law, which focuses only on readmission rates. Those penalties  will hit 2,592 hospitals over the next 12 months, with the worst performers losing 3 percent of their regular Medicare payments for each patient stay.
“The conjunction of the drop in hospital readmission rates and the introduction of a financial incentive program targeting those rates provide some additional indication that financial incentives … may, under certain circumstances, promote enhanced quality of care,” the report said.
KHN’s coverage of aging and long-term care issues is supported in part by a grant from The SCAN Foundation.

Monday, September 28, 2015

Pass the Special Needs Trust Fairness Act

The Special Needs Trust Fairness Act was approved by the US Senate on September 9th and is now under consideration by the House of Representatives. The Act corrects an error in existing law that creates needless delay and legal expenses for many people with disabilities.
Disabled individuals who want to live active lives can face extraordinary costs to pay for what others are able to accomplish as a matter of course – from getting out of bed, taking a bath, or feeding or clothing oneself – to more complicated tasks – travel, reading and writing, or working productively. While Medicaid benefits may cover some medical and remedial costs there are many more expenses incurred during everyday living. And Medicaid has strict limits on the amount of assets that a beneficiary can own that can prevent an individual from saving for these non-covered expenses.
Congress recognized the limits of Medicaid in 1993, when it authorized two types of special needs trusts that allow funds to be set aside to pay for the supplemental care and non-medical needs of disabled individuals without jeopardizing their Medicaid eligibility. But that law requires that an individual special needs trust “must be established by a parent, grandparent, legal guardian of the individual, or a court.” 42 USC §(d)(4)(A). By leaving out the words “the individual” it fails to allow competent individuals from establishing their own special needs trust.
While this was likely just an error in drafting, it suggests that Congress believes that ALL persons with disabilities do not have the mental capacity to handle their own affairs. It results in unnecessary legal and court fees for those who wish to establish a special needs trust but do not have parents or grandparents to help them set up these trusts. In these instances, the individual is forced to petition the court to set up the trust.
H.R. 670, the Special Needs Trust Fairness Act is a commonsense fix. This bi-partisan legislation was introduced by Pennsylvania’s Glenn ‘GT’ Thompson (PA-5) and Frank Pallone, Jr. (D-NJ). A hearing was held on September 17th before the House Energy and Commerce Subcommittee on Health.
In a statement submitted to the Committee, Representative Thompson noted:  
This simple, bipartisan, bicameral measure would eliminate a current prohibition on a disabled individual from creating his or her own Special Needs Trust, or SNT. These trusts enable assets to be saved on behalf of disabled individuals while protecting their eligibility for means- tested benefits.
Under current law, individuals who are or become disabled must have a parent, guardian, or the courts create their SNT. This places an undue monetary and logistical burden upon individuals who are seeking to secure their financial future, and runs counter to what has already been established by Congress. Individuals with disabilities have always been able to set up their own pooled trust accounts (created by Congress in 1993 and administered by non-profit organizations) and can create their own tax-free savings accounts under the recently passed ABLE Act. . . .
The perspectives of those directly impacted by this legal discrepancy coupled with my experience as a certified recreational therapist, a hospital manager and licensed nursing home administration has solidified my stance on this matter. I have had the honor of working with a number of individuals as they set out to rehabilitate their level of functioning and independence following an accident or illness. As a result, it is hard for me to find a palpable reason why we should continue to complicate their journey to self-sustainability.
As I previously mentioned, the Special Needs Trust Fairness Act of 2015 is a largely bipartisan initiative. For that I thank my colleague and ranking member, Representative Frank Pallone, who has continued to partner with me on this issue. He has consistently acknowledged that individuals facing life changing diseases or disabilities are not being treated fairly and has sought to correct this legal inequity.
In conjunction with Mr. Pallone, I respectfully ask for the support of the Committee of jurisdiction as we approach an opportunity to enable individuals living with a disability to stabilize their financial future, by advancing H.R. 670 through the legislative process, so these individuals facing disability can be treated equally under the law.
Credit to Representatives Thompson and Pallone for recognizing that after 22 years it is time for Congress to finally correct this demeaning and costly drafting error. Please contact your Congressional Representative and express your support for H.R. 670. Directions on how to contact your Representative can be found here.  

Friday, September 18, 2015

Details of Change to Managed Care for Medicaid LTSS

In February 2015, Pennsylvania Governor Wolf directed the Departments of Human Services (DHS) and Aging to develop a plan to shift Pennsylvania’s method of administering Medicaid Long Term Services and Supports (LTSS) to a managed care model. This means that the Pennsylvania will soon begin to hire private insurers (managed care organizations or “MCOs”) to administer the state’s Medicaid funded long term care services.
Medicaid is a federal and state funded benefit program which can pay for the cost of nursing home care and other long term care services if level of care and financial requirements are met. Medicaid is a primary source of public funding of nursing home and other long term care services for older adults.
On September 16th the Commonwealth issued a “Concept Paper” which describes the features of the new managed care approach – to be called “Community HealthChoices” (CHC). The plan represents a significant change that will impact an estimated 450,000 Pennsylvanians including 130,000 older persons and adults with physical disabilities who are currently receiving LTSS in the community and in nursing facilities. It is hoped that the managed care approach will result in reduced long term care costs while adding coordination to the current fragmented system and allowing more participants to receive services in more independent home and community based (HCBS) settings.
The new program will roll out in three phases over three years, beginning in January 2017.
The Concept Paper states the goals of CHC as follows:
1. Enhance opportunities for community-based living. There will be improved person-centered service planning and, as more community-based living options become available, the ability to honor participant preferences to live and work in the community will expand. Performance incentives built into the program’s quality oversight and payment policies will stimulate a wider and deeper array of HCBS options.
2. Strengthen coordination of LTSS and other types of health care, including all Medicare and Medicaid services for dual eligible individuals. Better coordination of Medicare and Medicaid health services and LTSS will make the system easier to use and will result in better quality of life, health, safety and well-being.
3. Enhance quality and accountability. CHC-MCOs will be accountable for outcomes for the target population, responsible for the overall health and long-term support for the whole person. Quality of life and quality of care will be measured and published, giving participants the information they need to make informed decisions.
4. Advance program innovation. Greater creativity and innovation afforded in the program will help to increase community housing options, enhance the LTSS direct care workforce, expand the use of technology, and expand employment among participants who have employment goals.
5. Increase efficiency and effectiveness. The program will increase the efficiency of health care and LTSS by reducing preventable admissions to hospitals, emergency departments, nursing facilities and other high-cost services, and by increasing the use of health promotion, primary care and HCBS.
The CHC population will include the following:
  • Adults age 21 or older who require Medicaid LTSS (whether in the community or in private or county nursing facilities) because they need the level of care provided by a nursing facility or an intermediate care facility for individuals with other related conditions (ICF/ORC);
  • Current participants of DHS Office of Long Term Living (OLTL) waiver programs who are 18 to 21 years old; and
  • Dual eligibles [qualified for both Medicare and Medicaid] age 21 or older whether or not they need or receive LTSS.
Persons included in the CHC population will be required to enroll in CHC. However, persons who are eligible for the LIFE program will not be enrolled into CHC unless they specifically ask to be enrolled.
CHC-MCOs will be accountable for most Medicaid-covered services, including preventive services, primary and acute care, LTSS (home and community-based services and nursing facilities), prescription drugs, and dental services.
Participants who have both Medicaid and Medicare coverage (dual eligible participants) will have the option to have their Medicaid and Medicare services coordinated by the same MCO. 
The estimated total statewide enrollment of dual eligibles, older persons, and adults 21 and older with physical disabilities for CHC is 450,000. The CHC population will include individuals with Medicaid-only coverage who receive or need LTSS, and individuals with full Medicare and Medicaid coverage (dual eligible), including those with and without LTSS needs. The CHC population will not include Act 150 program participants, individuals receiving their services through the lottery-funded Options program, persons with intellectual/developmental disabilities (ID/DD) who receive services through the DHS Office of Developmental Programs, or residents of state-operated nursing facilities, including the State Veterans’ Homes.
This shift to managed care is a work in progress. The state is actively seeking comments from participants, advocacy organizations, providers, managed care organizations, care coordination agencies, legislators, family members, and other interested members of the public. Feedback received will be used to finalize the program design and issue a Request for Proposals (RFP) in November 2015.
Feedback is due by 5:00 p.m. on Friday, October 16, 2015.
Please submit your written feedback by mail or e-mail.
By mail, please address to:
April Leonhard Office of Long-Term Living Bureau of Policy and Regulatory Management P.O. Box 8025 Harrisburg, PA 17105-8025
By e-mail, please send your comments to:
RA-MLTSS@pa.gov and include “Community HealthChoices” in the subject line.