California has a high level of bipartisan support as called for by the U.S. Dept of Health and Human Services’ Real Choices Systems Transformation solicitation. In addition, the state has a champion for reform in Kim Belshé, Secretary, California Health and Human Services Agency (CHHSA). Much of the re-conceptualization necessary to accomplish systems transformation in this area is reflected in the examples of state leadership below and creates the necessary foundation for building our Strategic Planning process.
Governor Arnold Schwarzenegger has shown a high level of leadership in and dedication to increasing the availability of home and community-based services. He continues to act on his resolve to reform the long-term care system to help seniors and people with disabilities remain in the community and avoid institutionalization. On September 27, 2004, the Governor signed Executive Order S-18-04 affirming California's commitment to provide services to people with disabilities in the least restrictive and most integrated settings possible. The Order also assigned certain responsibilities to the CHHSA and established the Olmstead Advisory Committee, which is responsible for providing input to CHHSA on its efforts to implement the California Olmstead Plan, for recommending actions to improve California's long-term care system, and for identifying opportunities to support people with disabilities in the community.
The Governor’s Fiscal Year 2006/07 Budget and May Revision contain numerous proposed initiatives and funding increases dedicated to assist systems transformation and promote home and community-based services. Specifically, Governor Schwarzenegger’s 2006–07 proposed Budget included initiatives designed to promote community-based alternatives to institutionalization, and to coordinate consumer needs with appropriate services. The proposed Budget outlined an initiative for integrating the acute and long-term care services and improving continuity of care across the long-term care continuum.
In addition, Governor Schwarzenegger’s 2006–07 proposed Budget included an initiative to develop a coordinated assessment tool (Community Options and Assessment Protocol) for use across long-term care programs in order to better coordinate services for consumers. The proposed 2006-07 Budget also included a Coordinated Care Management pilot project that would target high-end users of the Medi-Cal program (California’s Medicaid Program) by offering case management services in order to more efficiently manage service delivery and improve healthcare outcomes. Governor Schwarzenegger’s proposed budget also included resources to implement the Assisted Living Waiver Pilot Project, and test the provision of assisted living as a Medi-Cal benefit. Finally, the Governor’s proposed Budget included resources to expand the number of slots by 500 for the Nursing Facility A/B waiver, thereby increasing the capacity of a Home and Community-Based Services (HCBS) Waiver program that provides a skilled nursing level of care to people in the community.
In May of 2006, Governor Schwarzenegger released the “May Revise,” representing his revised spending plan for the proposed 2006–07 Budget. The May Revise is based on such factors such as updated revenue estimates and the latest projections of enrollment, caseload, and population. The May Revise included proposals that further demonstrate the Governor’s commitment to long-term care systems transformation. The May Revision also included language that would, under specified circumstances, allow individuals in nursing homes to voluntarily move into a community setting and still receive the same amount of funding for services. This Budget language provides the state the ability to move forward with a Money Follows the Person Demonstration when released later this year. In addition, the May Revision also proposed a $2 million funding increase for the Alzheimer’s Disease and Research Program. This increase, the first since 1998–99, will enhance the program's ability to provide state-of-the-art diagnostic and treatment services, caregiver training, and caregiver support services; and to evaluate the most complex cases of dementia of Alzheimer's-related disorders. In addition, the funds will be used to expand Alzheimer's disease research.
Additionally, the May Revise included spending increases for In-Home Supportive Services (IHSS), California’s publicly funded personal care assistant program. This line item included an increase of $25 million during 2005–2007 to continue funding costs associated with applying Medi-Cal share-of-cost rules to certain IHSS consumers in order to protect their access to services under the recent federal waiver. Finally, the May Revise proposed a total increase of $26.5 million from 2005–2007 for 15 counties, increasing the IHSS wages and/or health benefits for direct service providers since the January Governor's Budget. All of these efforts show that the Schwarzenegger Administration is committed to providing sufficient funding for home and community based services. Overall, the Governor’s actions show a commitment to move toward the goals of this grant.
Key Legislative Officials, including both California State Senate and Assembly Members, also demonstrate a strong commitment to support seniors and individuals with disabilities in the community as long as possible, as evidenced by authoring legislation and participating on select committees. The Assembly has a standing committee on Aging and Long-Term Care, whereas the Senate has a Subcommittee on Aging and Long-Term Care. The Senate also has a Select Committee on Developmental Disabilities and Mental Health. The Legislature has established additional committees, councils, and commissions to address long-term care issues, including the Assembly Select Committee on Olmstead Implementation and the Expert Panel to Review California Department of Aging Structure. The Assembly Committee on Aging and Long-Term Care recently convened a Committee to Advance an Aging Agenda for the 21st Century, which sought to develop recommendations for how the state should proceed in planning for the aging baby boomers. On December 14, 2005 Assembly Members Patty Berg and Lynn Daucher held an information hearing entitled “Bridging the Gaps in California’s Fractured Long-Term Care System”. Consumers and providers presented compelling perspectives on the urgency of need; and committee members also solicited best practices and recommendations from other states for addressing this concern.
An abundance of legislation in the current session focuses on long-term care reform (see Appendix A.4.). Two bills are Schwarzenegger Administration-sponsored, including AB 3019 (Daucher) and AB 2979 (Richman). AB 3019 requires the CHHSA, in consultation with specified entities, to develop and test the Community Options and Assessment Protocol (COAP) to minimize duplication and redundancy of multiple assessments for home and community-based services and to connect consumers under the Medi-Cal program. AB 2979 develops two integrated care models. Demonstrating a consistency of commitment, Chair of the Senate Budget Committee, Wes Chesbro, and Assemblywoman Patty Berg have written letters of endorsement for this grant application.
Executive and Administrative Leaders also support long-term care systems transformation. Mike Genest, Budget Director, is responsible for ensuring the fiscal health of the State now and in the future. The Department of Finance has supported numerous initiatives that have moved California to a ranking of eleventh in the nation in the percent of funding spent on HCBS compared to institutional care. The budget director specifically demonstrated his commitment when he provided financial assistance during the closure of the Agnews Developmental Center, with the ultimate goal of transitioning residents into alternative, community-based living situations. He has made funds available to maintain staffing levels for transition assistance and to develop community-based housing for displaced residents. This was the first time California dedicated funding specifically for the creation of alternative, community-based housing with necessary support services.
State Medicaid Director, Stan Rosenstein, is a tremendous asset to California’s systems change efforts. His leadership enables California’s Medicaid program (Medi-Cal) to rank eleventh in the nation in percentage of Medicaid long-term care services spent on HCBS. Since its grass-roots inception in 1973, personal care services became a Medicaid state plan service; in August of 2004, California was awarded $340 million annually in new federal assistance over the next five years to support in-home care for Californians who are aged, blind, and disabled. The approval of the IHSS+ waiver allows for federal Medicaid support of in-home care for the aged, blind and disabled by caregivers who are relatives. In addition to these efforts, the state Medicaid Director supported the established provisions for HCBS, including (1) the Multipurpose Senior Services Program; (2) a proposed expansion of Medi-Cal Managed Care for seniors and individuals with disabilities; and (3) long-term care integration proposals and the Money Follows the Person pilot project operated by the Department of Health Services’ Office of Long-Term Care. See Section III – Required Letters of Endorsement from State Medicaid Director Stan Rosenstein.
California’s Departments of Aging, Developmental Services, Rehabilitation, Mental Health, Social Services, and Veterans Affairs, and the Office of Statewide Health Planning and Development are also engaged in and have pursued and implemented several waiver and grant-funded demonstrations relating directly to systems change to improve access to and choice of HCBS and related community supports. More on these initiatives in Questions 8 and 11.
Consensus and Decision-Making in the Budget and Policy Process. In every two year Legislative session, hundreds of bills are introduced and only a percentage are passed and subsequently signed. The Legislative process allows for extensive public comment from stakeholders and for consensus-building between the Administration and the Legislature. The Budget process also provides a forum for debate and discussion of budget initiatives proposed in the Governor’s proposed budget, as well as consideration of additional budget proposals brought forward by the Legislature. At times, the Governor will propose an initiative in the Budget, but the Legislature feels it is best debated in the policy arena. For example, the Governor’s Budget proposals for acute and long-term care integration, and development of a coordinated assessment tool were taken out of the Budget process and put into legislative vehicles [AB 2979 (Richman) and AB 3029 (Daucher), respectively]. At this time, the Administration continues to work with the legislature on these initiatives, as part of the policy process.
See Appendix A: A.1. Olmstead Executive Order S-18-04; A.2. Budget Proposals of Interest to the Olmstead Advisory Committee, A.3. May Revise Summary to the Olmstead Committee A.4. Olmstead-Related Legislation: 2nd Year 2005-06 Session; A.5. Report on the Plan for the Closure of Agnews Developmental Center, Executive Summary, May 2006; A.6. California Medicaid Waiver Matrix
Within California, there are many strong and active stakeholder groups with a history of initiating change around a set of core principles of independent living. Begun in Berkeley, California, the Independent Living Movement coined the phrase “Nothing about us, without us.” This captures the sentiment that consumers hold the key to what most benefits them. A strong advocate base combined with strong laws governing “sunshine requirements” for policy development and open meetings of policy-making bodies results in a well-informed decision making process. This section addresses the degree of interactive involvement and support by stakeholders in this effort, including how points of concern are mediated. Following are just a few examples of stakeholder participation and influence.
The State’s Olmstead Advisory Committee is established by Governor’s Executive Order to advise the Secretary of the CHHSA on matters related to the avoidance of institutionalization and the support of seniors and persons with disabilities in their homes/communities. The committee consists of a strong and diverse representation of consumers, as well as members of advocacy groups, provider associations and private organizations. The committee provides a forum to discuss policy issues and create solutions to Olmstead implementation together with the Secretary of CHHSA, Kim Belshé, a member of the governor’s cabinet. CHHSA and staff from multiple state departments, including Mental Health, Developmental Services, Health Services and Rehabilitation, update the Committee, review data, discuss progress, and receive feedback from this body. The Committee offers input on CHHSA’s efforts to evaluate, revise, implement, and monitor the Olmstead Plan and recommends actions to improve the long-term care system.
The Olmstead Advisory Committee provides a forum for stakeholders and the Administration to communicate. Committee members and public stakeholders are encouraged to highlight issues that inform the Administration’s understanding of the long-term care system and its transformation needs. The full committee meets once every three months and operates in three work groups that bring recommendations forward to the Secretary; all meetings are publicly noticed. In addition, the committee engages the Secretary of CHHSA on several budgetary and legislative items and on implementing long-term care initiatives. For example, the committee’s recommendations for developing both an integrated acute and long-term care system and a uniform assessment tool led to budget proposals in the 2006–07 Budget. Some members of the committee, however, voice concern over various issues, including budget savings proposals that were introduced in the 2006-07 Budget. In addition, the committee monitors the State’s implementation of the California Pathways pilot project and recently discussed barriers the program has encountered related to transitioning individuals out of nursing homes. The committee is currently focusing on opportunities provided by the Federal Deficit Reduction Act specifically related to provision of HCBS as part of the State Medicaid Plan and the Money Follows the Person federal demonstration program.
Consensus-building is required to help usher the numerous long-term care initiatives brought forward on behalf of the Administration and the Legislature. For example, the Governor’s proposed budget initiative to integrate the acute and long-term care continuum (AB 2979, Richman) has been a very contentious policy issue. The proposal seeks to develop a system that better integrates the services and funding in order to provide a more coordinated system of long-term care services. While many Olmstead Advisory Committee members are in strong support of developing a more coordinated system of care, others have expressed concerns. Some stakeholders fear that blending funding systems and shifting control for programs to health plans may end up jeopardizing access to long-term care programs. The Administration continues to work with the stakeholders to build consensus in developing an integrated acute and long-term care system.
Specifically relating to people with developmental disabilities, the Department of Developmental Services convenes a Consumer Advisory Committee comprised solely of consumer members who advise DDS on important issues that affect consumers with developmental disabilities. In 2002 the Committee interviewed 400 people with developmental disabilities throughout California about the choices they make in their lives today, and the choices they would like to make. From these conversations, a book was developed and published on self-direction and consumer choice, entitled Community Conversations with People with Developmental Disabilities in California.
Although there is no formal mediation system established, the Olmstead Advisory Committee and the Department of Developmental Services’ Consumer Advisory Committee exemplify the state’s commitment to seeking informed discussions with those who know the issues including those who may be affected by the decisions made by the Secretary. For example, in 2004 when the disability community voiced strong concerns about mandating Medi-Cal managed care for certain populations, Secretary Belshé sponsored a statewide meeting with teleconference capacity to discuss the concerns directly with stakeholders. In response to stakeholder concerns, Governor Schwarzenegger proposed in the 2006-07 Budget to phase-in statewide implementation and revise its proposal for mandatory managed care and is pursuing development of a demonstration pilot to test mandatory managed care for seniors and persons with disabilities in two areas of the state. In addition, the Administration commissioned research through the California Health Care Foundation on the development of plan readiness standards for managed care plans serving seniors and persons with disabilities (California Health Care Foundation, 2005). The Department of Health Services is building off the recommendations of the California Health Care Foundation and will soon release its readiness standards for managed care entities serving seniors and persons with disabilities.
See Appendix B: B.1. Olmstead Advisory Committee Roster; B.2. Olmstead Meeting Minutes December 12, 2005; B.3. California State Council on Developmental Disabilities State Plan 2002-2006
While the state does not currently have a formal shared vision statement for systems transformation, there is a shared vision of service coordination in California’s Olmstead Plan, expressed in the following goal: “Implement a comprehensive service coordination system that will improve the long-term care system so that California residents, regardless of disability, will have available an array of community service options that allow them to avoid unnecessary institutionalization.”
The Olmstead Advisory Committee has also recently developed a shared policy vision that describes the objectives and values the committee uses to advise the state on implementing Olmstead. To briefly summarize, those objectives include providing opportunities for self-direction, independence, and economic self-sufficiency; holding the state responsible to protect against unnecessary institutionalization; supporting quality of life, cost-effectiveness, community inclusiveness and respect for diversity as a result of community-based care and services; and ensuring that consumers and their chosen representatives are actively involved in the development and implementation of services designed to a support people in community-based settings.
Values for achieving these objectives involve self-determination, consumer choice, integration into all aspects of community life, and culturally competent and accessible community-based services.
The California Community CHOICES will use the Harvard University model of strategic planning to organize in the first nine months of the grant period. This model calls for the creation of a mission and vision statement, each with a defined purpose and format. Although the Olmstead Plan’s vision and policy statements will be used as a starting point, it will be within the strategic planning process that California Community CHOICES’s Advisory Group can develop the state’s first truly shared comprehensive vision statement for systems transformation. As exemplified by California’s past inclusiveness of the consumer voice, the grant’s advisory committee will include consumer members representing a variety of groups (i.e., diversity among cultures, seniors, adults with disabilities, family members).
See Appendix C: C.1. Olmstead Advisory Committee Policy Statement
California has a number of initiatives designed to improve access to services for seniors and persons with disabilities in a coordinated or one-stop fashion. The State demonstrates transformation preparedness through its commitment to seeing to completion a long-range vision and making multiple changes over several years.
The state continues to support the Senior Care Action Network (SCAN), a “Medicare Advantage” HMO that serves the needs of over 70,000 seniors in approved zip codes within four Southern California counties: Los Angeles, San Bernardino, Riverside, and Orange. SCAN offers a combination of in-home personal care services, with comprehensive medical benefits, to enable older adults to remain independent and avoid nursing home care. The federal demonstration of the social HMO model is phasing out, but California will continue the successful SCAN model. Governor Schwarzenegger proposed as part of the 2006-07 Budget to integrate acute and long-term care systems through two new types of Medi-Cal managed care plans: Medicare HMO Wraparound and Integration Plus Community Choices (this proposal is currently being considered in legislation AB 2979, Richman).
Both types of plans will coordinate Medi-Cal and Medicare benefits to improve the continuity of acute care, primary care, and long term care; and to simplify health care access for enrollees. Coordination of the IHSS program with plan benefits will be required. This coordination will allow IHSS recipients to enroll in an Integration Plus Community Choices plan and still receive services through the existing IHSS program and through the IHSS provider(s) of their choice. In addition, the plans will not include California Children’s Services, county mental health services, regional center services for people with developmental disabilities, or Intermediate Care Facilities for the Developmentally Disabled. Instead, the department will require memoranda of understanding with each of these programs to coordinate services for enrollees. Integration Plus Community Choices will include home and community-based services, in addition to Medicare and Medi-Cal benefits. Existing successful models of coordinated care and community-based services, such as the Programs of All Inclusive Care for the Elderly (PACE) plans, will not be impacted.
The PACE model of care can be traced to the early 1970s, when the Chinatown-North Beach community of San Francisco, along with other community leaders, formed a nonprofit corporation, On Lok Senior Health Services, to create a community-based system of care. This was one of the earliest Adult Day Centers in the nation. The U.S. Department of Health and Human Services funded On Lok through a four-year grant to develop a consolidated model of delivering care to persons with long-term care needs in 1979 and in 1983 allowed them to pilot new funding structure. In 1986, federal legislation extended On Lok’s new financing system, allowing ten additional organizations to replicate On Lok’s service delivery and funding model in other parts of the country. By 1990 the first Programs of All Inclusive Care for the Elderly received Medicare and Medicaid waivers, and by 1997 the Balanced Budget Act of 1997 established PACE as a permanently recognized provider under both Medicare and Medicaid. California has four plan providers serving areas with high need.
To better coordinate access to care for consumers, California is piloting two Aging and Disability Resource Centers through a Real Choice Systems Change grant from CMS. Resource Centers are up and running in rural, northern Del Norte County and urban, southern San Diego County, in partnership with the local Area Agencies on Aging, to simplify access to long-term care services. The Resource Centers have identified systems improvements related to access and continue to conduct public awareness activities, target outreach to underserved or hard-to reach populations, and partner with physicians who will link with social services. Through California Community CHOICES, we intend to expand the one-stop “no-wrong door” service system by funding two additional centers: Community Link Resource Centers, in major metropolitan statistical areas in southern and northern California. We describe an initial design to connect the four centers in a community of practice, and for them to work with the state to test technological solutions to making the CalCareNet website useful to consumers and providers.
The CalCareNet website supports the State’s One-Stop system by making available comprehensive information on long-term support for both providers and consumers. More detail on the background of this website is provided in Question 7. California Community CHOICES will expand and improve the use-ability of CalCareNet to be inclusive of a full array of home and community-based services through preliminary strategies discussed in Part III, Goal 4.
See Appendix D: D.1. Senior Care Action Network (SCAN) History and Vision; D.2. AB 2979, Richman, Active; D.3. On Lok Senior Health Fact Sheet; D.4. Report: Aging and Disability Resource Center Development in California: A Work in Progress
The cornerstone of self-directed services in California is the In-Home Supportive Services (IHSS) program. California’s IHSS program has played a significant role in helping people remain at home and avoid institutionalization, as well as in developing a model system of self-directed services. IHSS provides personal care and domestic services to more than 355,778 aged, blind, or disabled individuals in their own homes. The purpose of the program is to allow these individuals to live safely at home rather than in costly and less desirable out-of-home placement facilities. This is an entitlement program with no cap on its growth; and it must serve any interested individual who meets the eligibility criteria. While IHSS regulations determine the range of services, it is the consumer who drives the program. The consumer decides how, when, and in what manner IHSS services will be provided. To this end, consumers can access the Advance Pay Option and are responsible for hiring, training, and supervising providers. In addition to being consumer-driven, IHSS is unique among programs in California’s long-term care system in the types of services it provides. This is because IHSS employs a social model rather than a medical model. Services are determined by a social worker assessment rather than medical criteria. The social model focuses on activities of daily living and the IHSS consumer’s ability to function in his or her own home. The medical model assesses clients based on medical deficits.
In addition, there are many promising activities now moving forward for the community of individuals with developmental disabilities. Three self-determination pilot projects, started in 1999 for California’s residents, created a new service delivery model within Regional Centers. They allow participants to control an individual budget to purchase services and supports identified in their Individual Placement Plan (developed through a comprehensive person-centered planning process). Based on findings from the pilot projects, The Department of Developmental Services 2002–2006 State Plan has prioritized the statewide expansion of self-determination programs in all Regional Centers.
Other programs in California offer strong consumer-directed components that have been active for a number of years, including Independent Living Centers and Social Security’s Plans for Achieving Self-Support (PASS).
Although not necessarily a “funding stream” in the traditional sense, one of the longest-lived examples of consumer-directed programs is Independent Living Centers. Their philosophy focuses on individualized, person-centered planning. In centers across the state, consumers receive such services as peer counseling, independent living skills training, individual advocacy, and assistive technology; all of which, either directly or indirectly, assist people with disabilities in understanding their rights and advocating for what they need.
Outside of Medi-Cal, through Social Security Administration (SSA) funds, many Californians increase their ability to manage and direct the services they need to become and remain self-sufficient through Plans for Achieving Self-Support. This program allows people on Supplemental Security Income (SSI) to set aside either earned or unearned income while maintaining an established level of cash aid in order to achieve goals related to employment and ultimate self-sufficiency. A 2005 report released by SSA shows that California generates a large share of PASS program use by beneficiaries: out of 1582 people with disabilities nationwide who have approved Plans for Achieving Self Support, 414—over 25 percent—are Californians.
As exemplified by the planned actions and programs mentioned above, California has adopted successful models of consumer-directed services. However, we also see a need to enhance access to information and tools that facilitate planning and self-direction. Further opportunities for self-directed services through the use of information technology are identified in Goal Four of California Community CHOICES projects.
See Appendix E: E.1: Table: SSA, Other Work Incentive Participants by State
California has recent initiatives that center on developing and implementing quality management systems for long-term care. For example, in August of 2004 the Department of Social Services initiated the development of a comprehensive statewide Quality Assurance initiative (SB 1104) as part of the governor’s Fiscal Year 2004–2005 Budget. This effort is one of several measures designed to improve the integrity of the assessment process in the IHSS program. In order to standardize program operation throughout the state, the initiative includes requirements for the State and counties to create and maintain an IHSS “quality and integrity program.” The principal activities to be carried out through the program include the following: establishing a formal statewide training for all IHSS social workers, establishing formal quality review units at the state and county levels, budgeting for additional social workers at the county level, creating certain statewide forms to be used by all counties (e.g. protective supervision certification and provider enrollment forms), reviewing and updating IHSS regulations, developing hourly task guidelines, establishing routine error studies and data matches, establishing methodologies to ensure recipients are receiving services, and establishing procedures to detect fraud and recoup overpayments.
The Bay Area Quality Enhancement Initiative, funded in 2003 through a Real Choice Systems Change Grant, is developing a model and corresponding plan to implement a quality management system to provide person-centered quality services in Regional Centers for people with developmental disabilities. The quality management system will be piloted in three regional centers, as well as with all consumers affected by the closure of the Agnews Developmental Center. A systematic approach to measuring consumers’ satisfaction with services and supports at important intervals will be taken, including consumer and family satisfaction surveys and interviews, a provider certification process, provider performance expectations, a quality assurance review commission, and database systems that drive decision making and inform continuous quality assurance efforts. The Department of Developmental Services intends to use the lessons learned from project activities to make statewide system reforms. This project is discussed further in response to Question 11.
Finally, should consumers of any program remain dissatisfied with the services they receive (or don’t receive), California has a built-in safety net for quality assurance by providing opportunities for individual-level appeals processes within the Medi-Cal, Social Services, Social Security and Developmental Services systems.
See Appendix F: F.1. All County Letter Number I-69-04, Summarizing SB1104
California has two large-scale initiatives involving information technology to support the transformation of the long-term care system. In the first example, state, federal and charitable foundation funds have together supported a vision of a leading community-based disability organization to use a Web portal to get “the right information, in the right hands, at the right time.” The right information in this case refers to health and benefits planning, work, and self-sufficiency. In the second example, the CHHSA has sought private funds to enhance access to information on health and long-term care options for seniors and people with disabilities.
The World Institute on Disability in Oakland, California, has developed a webportal—disabilitybenefits101.org—through funding partners, including the State Department of Rehabilitation, the Employment Development Department, California Health Incentives Improvement Project (a Medicaid Infrastructure Grant), the California Endowment and other charitable foundations. The portal is expanding to include an interactive benefits calculator, funded over two years by the Social Security Administration. Disabilitybenefits101.org was conceived and developed in the disability community and helps workers, job seekers, and service providers and employers understand the connections between work and benefits. It brings together rules for health coverage, benefits, and employment programs that people with disabilities frequently use—programs that may be administered by the state, the federal government, or private organizations. The value of the website is that all related programs can be found in one location; and each is discussed in plain language. This website’s purpose is to take a broad, customer-centered view, focusing on the linkages among programs, while not attempting to replace or compete with existing Web resources on these topics.
The philosophy behind disabilitybenefits101.org is that the disability experience is different for each individual, and each program affects that experience in a different way. With planning, people with disabilities can take control of finding the programs and jobs that meet their needs. For service providers and program managers, sharing this information helps everyone understand how the programs interact with and support each other.
Another statewide Web resource locator, www.calcarenet.gov, is sponsored by the Health and Human Services Agency (HHSA). It provides consumer information on the long-term care system. This website has been effective in providing resources in licensed care facilities and services, but not inclusive of home and community-based service information. Toward that end, the CHHSA launched the CalCareNet Portal Enhancement Project in May 2005 through funding by the California Wellness Foundation. The CalCareNet Portal Enhancement Project Steering and Advisory Committees provide oversight and feedback on project deliverables. A baseline report has identifies the business needs of customers: Aging and Long-Term Care Integrated Information Systems: A Summary Report for California. This report includes the results of both consumer and provider surveys on CalCareNet’s usefulness and use-ability, generally speaking, as well as analysis of similar Web resources developed through local initiatives of Area Agencies on Aging and other state models such as Michigan’s MiSeniors.
California has a strong model in the disabilitybenefits101.org Web portal. The state is hoping to transform CalCareNet into a Web portal that provides information and resources to seniors, individuals with disabilities, family members, providers, healthcare organizations, program operators, and others on services available for long-term care needs in the community, as well as through facilities.
See Appendix G: G.1.WID press release; G.2. Aging and Long Term Care Integration Information Systems: A Summary Report for California
A recent analysis of California’s long-term care program caseloads and costs conducted by the non-partisan Legislative Analyst’s Office (LAO) found that while spending in general on long-term care services has grown significantly over the last five years ($10.3+ billion in 2001-02 vs. $14 billion in 2005-06) an increasing portion of California’s long-term care spending is for home and community-based services over institutional care (LAO, 2006-07: C-25). According to the Legislative Analyst’s 2005-06 report, spending for community-based services has increased by 6% (from 55% to 61%) over institutional care since it was last examined in 2000-01. Interestingly, over the past decade the number of Medi-Cal paid nursing facility days has stayed virtually the same (a 1.7% increase), despite the fact that the number of people eligible for Medi-Cal over age 65 has increased almost 25% (USC/UCLA 2003). The availability of California’s In Home Supportive Services program, home and community-based waiver programs, home health, adult day health care and other community-based services have helped reduce average utilization from almost 44 days per eligible Medi-Cal person over age 65 in 1991 to just over 36 days in 2001 (ibid). California’s seven HCBS waivers are an important component to the community-based care system and have helped rebalance funding. They are summarized below and in Appendix A.6.
1) Persons with Acquired Immune Deficiency Syndrome: This waiver provides HCBS to persons diagnosed with symptomatic HIV disease or AIDS with symptoms related to HIV disease as an alternative to nursing facility or hospital care. Currently 2449 enrollees; Cap is 3,410 in CY 2006.
2) Assisted Living Waiver: Provides HCBS as an alternative to long-term nursing facility placement to Medi-Cal beneficiaries over the age of 21 in either of two settings: in a residential care facility for the elderly; or in publicly subsidized housing with a home health agency providing services. Since January 2006, 14 enrollees; Cap is 200 in CY 2006.
3) Persons who are developmentally disabled: This waiver specifically provides HCBS to people with developmental disabilities who are regional center consumers and reside in the community as an alternative to care provided in an intermediate care facility. The current number of enrollees is 61,964; the cap on enrollees is 70,000 in WY 05/06.
4) Persons with disabilities requiring in-home medical care: This waiver provides HCBS to people with disabilities who also have a catastrophic illness, who may be technologically dependent, who have a risk for life-threatening incidences, and who would otherwise require care in an acute care facility for a minimum of 90 days. Currently 67 enrollees; Cap is 350 in WY 06/07.
5) Persons who are age 65 or older and medically needy: The Multipurpose Senior Services Program provides HCBS to Medi-Cal beneficiaries who are 65 or over and are medically needy. This allows the individuals to live independently in their homes; without this waiver, the persons served would require care in a nursing facility. Currently 11,789 enrollees; Cap is 16,335 for each year of the waiver. The MSSP waiver is operating under capacity due to flat funding rates that have made it difficult for providers to have the capacity to fill all allotted slots. MSSP has had one funding increase since its inception in 1983. An ever-increasing number of elders served by MSSP have very complex medical and psychosocial needs requiring an intense level of service. The Administration is currently considering a proposal to augment the MSSP budget by $6 million (50% FMAP) in order to address provider capacity issues.
6) Medi-Cal beneficiaries with disabilities meeting Nursing Facility A or B criteria: The Nursing Facility A/B waiver provides HCBS to people with disabilities who are also Medi-Cal beneficiaries and who meet the Nursing Facility A or B level of care criteria for 365 consecutive days or more. The current number of enrollees is 890; the cap on enrollees is 890 in CY 05/06. Since late 2004, the Nursing Facility A/B Waiver has established a waiting list. Last year, the Schwarzenegger Administration worked with the Legislature to add 500 slots to the Nursing Facility A/B Waiver (SB 643, Chesbro, Statutes of 2005).
7) Medi-Cal beneficiaries with disabilities meeting Nursing Facility Sub-Acute criteria: This waiver provides HCBS to people with disabilities who are also Medi-Cal beneficiaries and who meet the Nursing Facility Sub-acute level of care criteria for 180 consecutive days or more. The current number of enrollees is 600; the cap on enrollees is 1005 in WY 07/08. As is noted by these numbers, this waiver is operating under capacity. The State anticipates that this is due in part to the high level of need required for enrollment into the waiver, and also a lack of awareness about the waiver for people who may benefit from its services.
Other Initiatives: In 2006, Governor Schwarzenegger proposed a number of initiatives to promote community-based alternatives to institutionalization, while also helping to rebalance the long-term care funding system. Descriptions of each are included in Appendix A.2. Olmstead-related budget proposals and are summarized here. To begin with, there is the Advancing Community Options through Integration proposed project, which would provide $1.1 million to establish Medicare/Medi-Cal pilot projects that will coordinate services to improve continuity of care across acute and long-term care settings and simplify access to HCBS for consumers. A second proposal involves the enrollment of California’s seniors and people with disabilities into managed care in order to improve their access to health care and their health outcomes, while reducing the state costs associated with fragmented care. The state will increase its outreach efforts to raise the voluntary enrollment numbers of seniors and people with disabilities in all managed care counties. A third proposal is the Coordinated Care Management Pilot Projects. The program’s goal is to maintain access to medically necessary and appropriate services, improve health outcomes, and provide care for seniors and people with disabilities who have chronic conditions.
While the state has made progress in rebalancing its funding system, there remains a need to examine the laws and regulations that impact the funding of the long-term care system and determine how to better structure the system to promote access to long-term care services, as identified in Goal 5 of the California Community CHOICES.
See Appendix H: H.1. ALWPP; H.2. Coordinated Care Management Pilot Project
There are currently two large-scale joint initiatives working towards increasing the availability of housing for persons with disabilities and seniors. In recognition of the fact that chronic homelessness is almost always inextricably tied with mental illness, the Governor’s Initiative to End Chronic Homelessness serves to provide housing, in addition to supportive services, to ensure tenants stay off the streets. As part of the initiative, Governor Schwarzenegger directed the Department of Housing and Community Development, the California Housing Finance Agency, and the Department of Mental Health to provide an integrated package of funding for the development of permanent supportive housing for persons with severe mental illness who are chronically homeless. These housing development funds are to be complemented by Mental Health Services Act (MHSA) funds from counties to support the creation of 400 to 500 units of permanent housing during Phase I of the initiative. The May Revision proposes to continue this interagency collaboration for Phase II by providing up to $75 million in MHSA funding each year. It is expected that these resources will be leveraged to secure an estimated $4.5 billion in other funding sources to support construction of more than 10,000 new housing units. As a condition of receiving these funds, counties will be required to provide the supportive services necessary to maintain individuals in their homes.
In an effort to increase the availability of low-income accessible housing for seniors and persons with disabilities, a joint initiative was created between the Department of Housing and Community Development and local housing entities. There were $195 million in state bond funds allocated specifically for supportive housing under the Multifamily Housing Program portion of Proposition 46. The Multifamily Housing Program provides assistance with the new construction, rehabilitation, and preservation of permanent and transitional rental housing for lower income households. The Department of Housing and Community Development made housing for persons with disabilities a priority for the $779 million available under the “General” component of Multifamily Housing Program.
In addition, the State is proceeding with plans to transition people with developmental disabilities out of institutional residence at the Agnews Developmental Center by June 2008. The Agnews Developmental Center Closure Plan and the Bay Area Housing Plan include partnerships between Regional Centers, several non-profit housing corporations, and the Department of Developmental Services. These partners are working to ensure the smooth transition of Agnews residents into the community with access to services through the development of Individual Placement Plans, family teaching homes, and specialized residential homes. Community housing funded through this initiative are required to be built or modified using universal design standards for accessibility. See Appendix A.5 for progress detail.
See Appendix I: I.1. Initiative to End Chronic Homelessness; I.2. Summary of Proposition 46
California has made great strides in interagency and intra-agency collaboration—and has some significant remaining challenges. Examples of the current status of these collaborations and the progress made to date follow.
The Governor’s Chronic Homeless Initiative: The passage of Proposition 63, the Mental Health Services Act, provides an opportunity for collaboration between the California Health and Human Services Agency and the Business, Transportation, and Housing Agency to reduce chronic homelessness among the mentally ill. The May Revision of the proposed 2006/07 Budget intends to continue this interagency collaboration for Phase II by providing up to $75 million in MHSA funding each year. It is expected that these resources will be leveraged to secure an estimated $4.5 billion in other funding sources to support construction of more than 10,000 new housing units.
California Department of Transportation (CalTrans) and Health and Human Services Agency: These two agencies have partnered to implement California’s United We Ride grant from The Federal Transit Administration. This grant will coordinate transportation services for people with disabilities, older adults and individuals with lower incomes. The goal is to help improve transportation coordination and to remove the barriers between transit and human service programs.
The Department of Rehabilitation (DOR) Interagency Agreements with Department of Mental Health (DMH): Currently DOR and DMH have three interagency agreements, including Systems of Care, supporting service providers; Traumatic Brain Injury, for employment services; and Long-Term Care programs, for vocational rehabilitation services to individuals leaving state hospitals.
Interagency agreements between DOR and the State Independent Living Council: DOR also works in collaboration with the State Independent Living Council, a separate state agency, in developing policy and making budget decisions.
The Department of Health Services Interagency Agreements with Department of Developmental Services and Department of Aging: These three agencies work together to implement and operate HCBS Waiver programs. See descriptions of these programs in the Medicaid Waiver Matrix, Appendix A.6.
The Department of Developmental Disabilities collaborative work with the State Council on Developmental Disabilities: These two agencies have collaborated in numerous policy areas, most recently in planning the closure of developmental centers and arranging transition for residents into community placements. It’s important to note that this large-scale redirection of persons with disabilities into the community is not being conducted as a stand-alone, single action but as a test of a variety of approaches to expanding HCBS, housing, and transportation services to take community living to scale.
Sonoma State University Memoranda of Understanding with Department of Health Services and the Employment Development Department: This collaborative was created to implement a Medicaid Infrastructure Grant expanding employment and self-sufficiency for people with disabilities. The two state agencies are providing office space and equipment to house the California Health Incentives Improvement Project staff. Staff work to integrate relevant health and employment service policy discussions on employment, independence and self-sufficiency for people with disabilities.
All State Departments: A one-stop shop database for grants, “GetGrants,” was developed as an inter-agency effort among all state departments. This easily accessible website lists the most current funding available from state government agencies at http://getgrants.ca.gov.
Despite California’s progress in collaborating across agencies, challenges still remain. Foremost among these is the fact that state departments and agencies are still required, through federal and state funding streams/laws/initiatives, to operate primarily on the basis of serving distinct populations. While interagency agreements help coordinate, each department must still support and respond to separate reporting requirements, separate performance requirements, and separate fiscal management requirements.
Appendix J: J.1. United We Ride Interagency Description
The following projects reflect all RCSC grants awarded to date and documents progress in and barriers to achieving grant goals.
State of California Department of Mental Health - California Study on New Medi-Cal Respite Benefit for Caregivers of Adults with Cognitive Impairment
$100,000 per year operating since 2003. Goal: Develop a plan for expanding respite services to caregivers of persons with adult-onset cognitive impairments. Provide recommendations on ways California can implement and evaluate a new respite benefit under Medicaid. An advisory committee will identify the target population, project service use, analyze the potential impact of expanding respite services with the current infrastructure, identify protocols and procedures in existing state programs and outcome methodology currently in use in California and elsewhere, and establish procedures for data collection and evaluation of respite services to measure satisfaction, outcomes, cost, and utilization. Progress: Project work is completed and a draft final report has been compiled. Barriers: Barriers to this project included change in Administration and state priorities in the first year of the project; deficit budgets in the state through FY 2005–06 and the resulting environment of tempering discussion of adding new services to the Medi-Cal package of services. Additional barriers include the lack of uniform definition and eligibility for respite services across programs and lack of consistency in collecting and formatting usable data by state departments and contractors.
Goal: To transition consumers (Native Americans and Hispanic individuals with cognitive, mental/emotional, physical, hearing, vision and multiple disabilities, families, and health clinics statewide) from nursing homes to the community. Progress: Working with 27 skilled nursing facilities (SNF), 35 people transitioned from nursing homes, three people were diverted, and 38 individuals developed Independent Living Plans. The program also developed an outreach brochure and conducted presentations to 38 SNFs and three hospitals. The program matched consumers with peer support members. A PSMT facilitator group is now initiating a new training program with 6 interested potential peer supporters. Project Director Nancy Hall was appointed to the California Olmstead Advisory Committee, March 2005 and attends quarterly meetings and is a member of the Assessments Subcommittee and monitors issues including “Money Follows the Person.” Barriers: Availability of appropriate, low-cost, accessible, subsidized housing. Staff work with the City, County, builders and various other housing groups and progress has been slow.
$750,000 federal funding over three years. Currently in Year Three. (The state will likely request a no-cost extension that will enable 12 additional months of work under the grant funding.) Goal: To develop and field test a model for a uniform assessment and transition protocol that would enable nursing facility residents to exercise informed choice of home and community-based services and to provide case encounter and cost data that provide the basis for policy recommendations for Money Follows the Person initiatives in California. Project Status: (1) The project team has field-tested a preference assessment tool that systematically interviews nursing facility residents regarding their preference to return to community living. The preference survey is a brief screening interview that has been tested in eight nursing facilities. Analysis of data is in progress. (2) The project team has identified existing Medi-Cal home and community-based waivers and existing Medi-Cal programs and services that could support those who will transition from nursing facilities under the project; for example, Multipurpose Senior Services Program, IHSS, Independent Living Centers and others. (3) The Department has required the project have input from stakeholders, including program experts, potential consumers, advocacy group representatives, the CHHSA Olmstead Committee and other stakeholders.
The University of California Los Angeles/Borun Center and the University of Southern California (USC) and the project team will produce the following outcomes by the end of the grant period: Recommendations for a nursing facility transition assessment tool and protocol; a small pilot project that tests a transition protocol that can be used in various nursing facilities and by a variety of care planners; cost and encounter data that form the basis for one or more financing model(s) that demonstrates that the money follows the person; a uniform transition care planning protocol that enables nursing facility residents to exercise interest and informed choice of care options and services in a community setting; cost and other information regarding ongoing or one-time services needed by nursing facility residents in order to transition to community living. Barriers: The project team has encountered issues regarding limited access to on-going care management and waiver services and affordable, accessible housing. These issues will impact the availability of community-based services to support those persons who will transition from nursing facilities under the project.
$800,000 federal funding from Centers of Medicare and Medicaid Services and the Administration on Aging over three years. The grant is currently in year two of the three-year grant period. Goal: To develop effective Resource Centers providing the public with easily accessible information, counseling and/or assistance, and program linkage on the following areas: Aging and long term support options; Benefits counseling; long term care planning; Health promotion; and Home and community-based supports. This initiative involves a “one-stop” approach to the services provided at the Resource Centers, simplifying not only the number of places, but also eligibility and assessment processes. Project Status: San Diego and Del Norte are the two counties developing Resource Centers. Both have secured lead staff and have formed local advisory groups that include consumers. Both pilot counties have identified baseline assessments and activities to address the problems noted. San Diego has contracted with the Network of Care developer to work with Center staff to design and install fixes; developed a second targeted community survey; conducted formal survey sessions with care management and Call Center staff of the principle service providers; held stakeholder advisory group meetings; developed a continuous quality improvement model focused on Web support tool development; and held focus groups with physicians re: their needs for Web support tools. Del Norte progress includes upgrading their Management Information System to improve capability for reporting, supervision and client intake management; began work on a Web-based resource directory for consumers, caregivers and providers; met with hospital discharge staff and local nursing facilities regarding ADRC development; plans for co-location with a health clinic serving most community residents; held Medicare Part D and ADRC outreach and education sessions at a multitude of public events and through radio and flyer distribution. Barriers: The San Diego Resource Center experienced some delays in negotiating with Trilogy Software, Inc. over enhancements to the Network of Care website. Del Norte/Humboldt experienced staff changes as well as a change in the proposed partnership for the Wellness Center one stop.
State of California Department of Social Services In-Home Supportive Services (IHSS) Enhancement Initiative Real Choice Systems Change. $1,385,000 for three years received in 2002. Project serves approximately 360,000 Medicaid-eligible aged, blind, and disabled individuals in the IHSS program, as well as roughly 280,000 care providers. Goals: (1) Develop training, educational materials, and other methods of support to aid IHSS program consumers to better understand IHSS and to develop the skills required to self-direct their care; and (2) identify training and other support needs of IHSS providers and create materials, tools, and work aids that will enable those providers to improve the quality of care they render to the consumer. Progress: CDSS has contracted with California State University, Sacramento (CSUS). CSUS has completed all data collection activities. These data collection activities included telephone interviews with consumers and providers in 18 counties and focus groups in three counties. The focus groups were conducted with IHSS program staff, IHSS public authority staff, elderly and disabled consumers, family care providers, non-family care providers, and Service Employees International Union and United Domestic Workers staff. In addition to the telephone interviews and focus groups, CSUS completed an inventory of existing training material available through the counties, public authorities, unions, and other agencies. The needs assessment report and inventory of existing educational material has been completed. Topics were prioritized for material development. CSUS has drafted the final training material, which is currently under review by CDSS. After this material is approved, CSUS will present training to county IHSS and public authority staff. Grant activities are scheduled to end 9-29-05. Barriers: None known
$499,844/year and operating since 2003 serving individuals with developmental disabilities. Goals: Design a model and corresponding plans to implement a Quality Services Network to provide person-centered and person-directed quality services and supports to people served within the Bay Area; adopt a systematic approach to measure consumers’ satisfaction with services and supports in meaningful ways at important intervals to guide system improvement efforts; apply the “lessons learned” from the project activities to make statewide system reforms.
Progress: (1) The model for the Quality Services Network, renamed the “Bay Area Quality Management System (QMS)” has been developed. Implementation plans have created with specific focus on component: A draft certification process for providers; Provider Performance Expectations; the Quality Assurance Review Commission; the database systems that will drive decision making and continuous quality assurance efforts. (2) The grant’s Steering Committee decided upon using the National Core Indicators (NCI) Consumer and Family Satisfaction surveys. The consumer sample includes a random sample of adults 18 years and over drawn from the population of Medicaid Waiver consumers, as well as individuals who have transitioned into the community from Agnews Developmental Center since 2003. Approximately 220 consumers have been interviewed - 770 still in process. The family survey was recently sent to a random sample of 2000 families of Medicaid Waiver consumers from the three regional centers. (3) QMS is working in collaboration with closure of Agnews Developmental Center. Individuals who have transitioned into the community from Agnews Center since 2003 is the target population of the Bay Area QMS. Barriers: (1) Collaborate efforts require many hours spent in meetings, which is a challenge in terms of scheduling and workload impact. Working around the logistics of this has created some time delays in terms of the grant’s original time goals and affected when the products could be presented to the stakeholders. (2) The NCI has two written sections that are completed prior to each interview. Each of these sections is to be filled out by the case manager of the individual consumer to be interviewed. Given our sample population of approximately 990 consumers, this requirement has created a very large workload for case managers and other regional center staff.
See Appendix K: K.1. Real Choice Systems Change Grant Fact Sheet
A major statewide system reform grant awarded to date is the California Health Incentives Improvement Project (CHIIP), a multi-agency collaborative effort targeting barriers to the gainful employment of people with disabilities, particularly health care and personal assistance barriers, initiated in 2002 with Medicaid Infrastructure Grant from CMS. Assembly Bill 925, Chapter 1088, Statutes of 2002, aligned CHIIP with the Governor’s Committee on Employment of People with Disabilities to foster better collaborative efforts across workforce development, healthcare, and disability support services. The project provides outreach and training for consumers and others in two areas: (1) the Medi-Cal 250% Working Disabled Program, a Medicaid Buy-In program allowing individuals with disabilities to earn income and maintain healthcare benefits by buying into Medi-Cal with a monthly premium; and (2) the provisions of IHSS that allow individuals to use personal assistant services in the workplace as well as at home. Progress and barriers: In 2005, CHIIP and the California Governor’s Committee on Employment of People with Disabilities worked together to write the Comprehensive Employment Strategy for Employment of Persons with Disabilities. The strategy is the culmination of grassroots advocacy, legislative leadership, and departmental support across the California Labor and Workforce Development and California Health and Human Services agencies beginning in 2000. The Strategy, approved January 2006 by the Committee, sets the course for project activities as well as coordinated efforts of state departments serving Californians with disabilities. Since May 2005, the rate of enrollment in the Medi-Cal Working Disabled program has increased by 67%. Still, while usage of these work incentive initiatives has grown over the last two years, many consumers with disabilities are not aware of these incentives. The CHIIP continues to build communication and outreach through multiple strategies and has had continued support from the Department of Health Services and the Employment Development Department.
Appendix L: L.1. SSU/CIHS Annual Report 2005 – CHIIP summary; L.2. California Comprehensive Strategy for the Employment of People with Disabilities
California’s size, geography, and demographics create unique challenges for long-term care systems transformation. Specific barriers to transformation include:
The One-Stop Model, coupled with enhanced access to information through use of technology, can help address the above-mentioned barriers. Expanding the one-stop model into two additional areas in the state that are major metropolitan areas will help span some of the geographic challenges and further address challenges of the sheer size of our population. To make a one-stop system viable statewide, a "No Wrong Door" principle must be applied - as it is unlikely in a state the size of California that consumers will all use the same place of entry into the long-term care system. Consumers should not be turned away if they happen to enter the "wrong" door into the long term care system. To this end, consumers need access through multiple locations that are likely "entry points" into the long-term care system - whether an Independent Living Center, a physician's office, a senior center, an Area Agency on Aging or a human services agency. Each location must be able to provide the consumer with the information s/he needs, using information technology through web interface in the form of "kiosks" to help consumers access consistent and accurate information about long-term care services in their community. The one-stop center can be the hub of resources and information, and can work within the community to ensure that all entry points have a core of information to provide consumers, including information on how to access one-stop services.
At the policy level, systems transformation will require extensive consensus building among multiple stakeholders. Whole scale systems change in California is often hampered by competing interests that feel threatened by a change in the status quo. For example, while no one would argue that California's fragmented system of care benefits the consumer, it is difficult to come to agreement on HOW to develop a more integrated continuum of care. The Administration has sought for years to implement an integrated acute and long-term care system, but some stakeholders have feared that this systems change could compromise individual program quality.
The Administration recognizes the importance of working closely with stakeholders to achieve consensus and implement change, and each year, incremental progress is made in developing a more integrated system of care. The California Community CHOICES project anticipates similar struggles and stands ready to work with stakeholders in achieving consensus to transform the long-term care system.
Appendix M: M.1: California’s Long Range Strategic Plan for Aging
Staffing for the California Community CHOICES project will be achieved through a combination of State Civil Service positions (new hiring as well as in-kind support) and contracted staff. The CHHSA is requesting the addition of one additional personnel year to their staff level for grant management purposes and will additionally support the project administration and deliverables through highly qualified existing staff who support the Agency’s Olmstead related activities. The appropriate control agency has already received this request in the process of reviewing this application and has advised that a mid-year budget adjustment will be processed upon award.
CHHSA is partnering with Sonoma State University (SSU), the California Institute on Human Services to ensure additional staff and technical assistance resources will be secured as, and when needed. The SSU/CIHS has a strong track record with existing staff expertise in the field of human services and disability, has an excellent history of reaching out to community leaders as consultants, and has proven a successful partner with the State in administering the Medicaid Infrastructure Grant. This partnership brings together a strong and diverse set of people with specific experience and individual qualifications at appropriate state administration and program policy levels, expertise in project management, knowledge of IT systems, successful strategic planning, and an ability to provide or contract for technical assistance.
Appendix N: N.1. CHIIP role in working with the Governor’s Committee, briefing paper.
California has one of the most comprehensive Medicaid packages in the nation, with as many as 30 different programs serving approximately 6.5 million Californians. Over the years, there have been multiple increases in Medicaid State Plan Options, Home/Community Based Waivers, and covered populations. The most recent increases are briefly summarized below.
The Assisted Living Waiver was established in 2006 to provide HCBS to Medi-Cal beneficiaries over the age of 21 who would otherwise be placed into a nursing facility. Waiver participants will be provided care in one of two settings: a residential care facility or in publicly subsidized housing with a home health agency providing the personal care services. This waiver is particularly important as it is the first to provide the availability of HCBS as an alternative to nursing facility placement to persons under the age of 65. Just established in January this year in three counties, 14 individuals have transitioned out of nursing homes through the program. See Appendix H.1. for more information on this program.
Multipurpose Senior Services program was established in 2004 to provide HCBS to Medi-Cal beneficiaries aged 65 and over who are medically needy and would otherwise be referred to or remain in a nursing home. Benefiting both nursing home diversion and transition efforts, this program currently serves 11,789 seniors in their homes. Also in 2004, the Governor secured an IHSS Independence Plus 1115 waiver authorizing federal financial participation for parent and spouse providers, advance pay, and an array of personal assistance services.
In February 2003, the CMS approved an increase to the annual caps on enrollment for the Developmentally Disabled waiver, applied retroactively to October 2002. This action permits enrollments to grow at a higher rate annually, culminating in the fifth year with 70,000 persons, ~19,200 more individuals than initially approved, and greatly assists the State’s goal of transitioning individuals out of state-run developmental centers to homes in the community.
The Department of Developmental Services’ (DDS) Home and Community-Based waiver was amended to include “specialized therapeutic services” and vouchered respite. DDS also has approved a State Plan Amendment for Targeted Case Management.
Although not initiated by the State, the Medicare Modernization Act creates a reduction in the type of service provided to individuals eligible for both Medicare and Medicaid as prescription drug costs are covered through Medicare plans. This may have an impact on the population currently enrolled in Medi-Cal through the Medically-Needy, Share of Cost program.
See Appendix O: O.1. In-Home Supportive Services Waiver Announcement; O.2. Table: May 2006 Estimated Average of Certified Medi-Cal Eligibles
California has demonstrated a commitment to implementing changes to improve the health, safety and independence of its population in several ways over many years. As discussed in Question 8, California has one of the most extensive package of Medicaid services in the Nation. We were the first state to create a program to provide In Home Supportive Services as an alternative to nursing home institutionalization, which pre-dated personal assistance as a Medicaid service. Along that same theme, we have successfully expanded the use of personal assistance services to the workplace through a State Plan Amendment. And similarly, the State has created work incentives, or eliminated work disincentives, by establishing the Medi-Cal Working Disabled program, which allows Californians with disability to access and maintain Medi-Cal coverage if they go to work with earnings up to 250% of the federal poverty level. These are all statewide changes that require(d) an extensive amount of outreach and education amongst county eligibility staff, social workers and other front-line staff such as rehabilitation counselors, and people with disabilities themselves.
Part of the State’s success in implementing full-scale rollouts is our commitment to working together with advocates, providers and others who will be affected by a statewide change as was described in Question 2. California has strong capacity in leadership, stakeholder involvement, and a commitment that spans multi-step implementations.
Appendix P: P.1. AB 925, Aroner, Chapter 1088, 2002 – Workforce Inclusion Act, Personal Assistance Services at Work; P.2. AB 155, Migden, Chapter 820, 1999, Medi-Cal Buy-In
Many more laws and regulations have been implemented to further systems change in California than can be meaningfully addressed here. A few of the laws in the last ten years are listed below.
Assembly Bill (AB 155 Chapter 820, Statutes of 1999) created the Medi-Cal 250% Working Disabled Program, which provides Medi-Cal to certain working disabled individuals.
The Workforce Inclusion Act (AB 925, Chapter 1088, Statutes of 2002) established personal assistance services at work through the In-Home Supportive Services program and intergovernmental collaboration to increase employment of people with disabilities.
AB 499 (Statutes of 2000 Chapter 557) to test the efficacy of providing assisted living as a Medi-Cal benefit and as an alternative to long-term placement in a nursing facility.
Legislation in 1998 (AB 2583) authorized 10 new sites for the Program of All-Inclusive Care for the Elderly program, AB 798 in 2003 enabled this program to be made permanent.
SB 643, Chesbro, Statutes 2005, to expand the Nursing Facility A/B Waiver
SB 520, Chesbro, Chapter 671, Statutes of 2001, amended housing element law and Government Code to require localities to include accessibility requirements in preparation and adoption of a housing element.
AB 1040, Bates, Chapter 875, Statutes of 1995, which established the long-term care integration pilot program.
Ab 2787, Aroner, Chapter 726, 2002 calling for universal design standards in housing.
Proposition 63, by the People of California, 2004, The Mental Health Services Act (MHSA) provides for a comprehensive approach to the development of community-based mental health services and supports for the residents of California.
See Appendices P& Q for legislation cited above.
Continue to Part 2 of California Community Choices Grant Application Narrative