• Case management/Care coordination;

   

• ADHC programs;

   

• IHSS;

   

• HCBS waivers (MSSP, NF/AH, AIDS, ALWPP, CCT);

   

• Independent Living Center Services;

   

• Accessible Transportation;

   

• Nutrition programs

   

• Respite and caregiver resources and supports

   

• Targeted Care Management;

   

• County mental health services;

   

• Medi-Cal home health;

   

• Durable Medical Equipment;

   

• Assistive technology;

   

• Home modifications;

   

• Pharmacy (including mental health); and/or,

   

• Alcohol and Substance Abuse Treatment.

   

C. Need to determine types of institutional care and levels of care to be included, such as:

• Nursing facilities;

   

• Rehabilitation facilities;

   

• Psychiatric NFs;

   

• ICF-MR facilities;

   

• Acute care hospitals; and

   

• Other types of institutions.

   

A. Need to establish philosophy and clear, expressed intent that home and community-based services are the preferred method of providing long-term care services in California. (Mollica report rec. 1).

B. Need for robust data-sharing and communications systems that guarantee continuous access to services, promote coordination of care across settings and permits statewide management of LTC and informed decision-making (CHCS at 2; Mollica report rec. 28).

C. Need to create “no wrong door” points of entry for access by beneficiaries (Mollica report rec. 22).

Need careful consideration and review of alternative models and successful efforts to date, in California and other states, including looking at:

• PACE programs;

   

• AB 1040 LTC Integration Pilot Studies;

   

• Cal Optima model (San Mateo and Orange Counties);

   

• Special Needs Plans for Dual Eligible Population (CHCS papers on integration of Medicaid/Medicare dual eligibles);

   

• ADHC programs;

   

• IHSS, including individual and consortium models;

   

• Independent Living Centers;

   

• Money follows the person efforts;

   

• California Community Transition project;

   

• California Community Choices project;

   

• Aging and Disabled Resource Centers;

   

• Regional Center model;

   

• Medical home models; and,

   

• Special Needs Plans under Medicare (targeting dual eligibles, beneficiaries requiring institutional care or with chronic conditions) (CHCS at 2).

   

5. California needs to promote consumer-driven choice regarding care options and providers in addition to individual, client-centered care planning. .

A.Consumers should be offered information in a language and form that they can understand (including Braille, ASL, and non-English written and spoken languages) so that they can actively participate in the planning process and make informed decisions about their needs and preferences. Consumer preferences must also drive service planning. Where possible and appropriate, consumers should be able to choose care providers (i.e., IHSS, primary care, etc.). (CCD Principles; DHC Principles; CHCS at 2).

B. People must be assessed prior to being moved into managed care and a care plan must be developed to address all their needs, with a preference/default for HCBS. The service plan should be determined by consumer preference, not provider reimbursement. (CalOptima/HPSM at 9).

C. Case management and care coordination are critical to any integrated system, regardless of the scope of services included in such a system. Care coordination to ensure that individuals are linked to, and actually receive, needed services must include: qualified, trained staff; development of a care plan that reflects the individual’s choice and participation; access to included services and those outside the scope of the plan; and accountability for following through on implementation of the plan. (Lewin Group report; CalOptima/HPSM at 7, 9).

D. Use of a multidisciplinary team for care planning and implementation that is structured to address the full range of beneficiaries needs (CHCS at 2).

E. Need for consumer protections that ensure access to providers and involve consumers in program design and governance (CHCS at 2; WCLP Paper).

A. There needs to be accountability to ensure that services identified in the care plan are actually provided.

B. Physical and programmatic accessibility and due process for consumers needs to be ensured (see WCLP paper on Consumer Protections).

C. Need to define home and community-based services (HCBS) in long-term care (LTC). HCBS for purposes of this discussion includes reference to all services that enable individuals with disabilities and elderly people to move to and live in the community homes of their choosing, including:

• Critical services which are necessary to meet individuals’ long-term care needs, in a sufficient frequency and amount. These services include, but are not limited to: IHSS, ADHC, ILC services, care management/coordination, accessible transportation, a medical system that is equipped and prepared to handle complex needs, adequate rates paid to providers, mental health services, pharmacy (including mental health pharmacy), home health, Durable Medical Equipment ,assistive technology and home modifications. (CalOptima/HPSM at 9).

   

• Services needed to sustain successful community living and quality of life. These include, but are not limited to: meals assistance (e.g., Meals on Wheels), non-medical day activities, family caregiver networks, advocacy assistance, assistance in managing finances, emergency response systems, and support to build a circle of support.

   

• Services needed to transition from an institutional setting, such as: case management to secure needed HCBS services and supports; transition services to ensure a smooth move (e.g., counseling, visits, accessible information, etc.); home modifications; home health, monetary assistance to pay for security deposits, installation of utilities, and rent during the transition process (if needed); critical and other supports to ensure health, safety, and independence.

   

• Services needed to avoid institutional placement when feasible, such as: case management in the acute hospital and/ or Independent Living Center transition services in the home setting to secure needed HCBS LTC services and supports; in and out-of-home respite care; home health; availability of critical and other supports necessary to ensure health, safety, and independence.

   

D. HCBS LTC must be available to people with all types of disabilities, needs, and preferences. An integrated HCBS LTC system cannot exclude, or “carve out” certain populations simply because of their diagnosis. While people with different diagnoses, or different ages, may be eligible for or entitled to services that remain outside of an integrated system (e.g., regional center services), a coordinated HCBS LTC system would ensure that such individuals have access to needed HCBS LTC services that complement other services received, and that they are linked to such specialty.

E. Services must include “gap-filling services” to increase options for staying in the community. These may include services or purchase of items not typically covered by Medi-Cal and/or expansion of or replication of HCBS and CCT waiver services, such as housing or board and care subsidies, habilitation, accessible transportation, respite, education and counseling about community living, assessment of interest and capacity to live in the community, location of housing, and development of a comprehensive services plan. (CalOptima/HPSM at 9).

F. Need to secure a comprehensive provider network for dual eligibles that meets the needs of the target population and supports the care coordination model (CHCS at 2).

A. There needs to be integrated/universal budgeting for both institutional care and HCBS, with a preference for HCBS; and managed care plans must be at risk for both institutional services and HCBS. (Mollica Report rec. 24; CalOptima/HPSM at 9).

B. Development of an integrated system must remove disincentives for the provision of HCBS LTC. (CalOptima/HPSM at 5-6).

C. Plans need to have financial flexibility to incur savings from acute and institutional care that will be used for HCBS, including financing strategies that improve the balance between community and institutional services. (Mollica report rec. No. 27; CalOptima/HPSM at 5-6; CCD Principles).

D. Any savings from moving to managed care and/or the waiver must be reinvested in the system to preserve, expand, and improve HCBS. (Mollica Report, Rec. No. 12; CalOptima/HPSM at 5-6; CCD Principles).

E. For dual eligibles, need for financial alignment that addresses fragmented systems of care through blended funding and/or shared gains and risks of providing services (CHCS at 2).

The inclusion of LTC home and community-based services as part of California’s managed care effort within the 1115 Waiver must be approached in a thoughtful manner which does not sacrifice consumer choice and independence, improved health outcomes, or the full range of home and community-based options necessary to prevent unnecessary institutionalization.

Sincerely,

Deborah Doctor Legislative Advocate Disability Rights California

Teresa Favuzzi, MSW California Foundation for Independent Living Centers

Executive Director Disability Rights Education and Defense Fund

Anita Shafer Aaron Executive Director World Institute on Disability