Background
Medicaid is the single largest public funding source for long-term services and supports (LTSS). It is a combined federal-state program. Some Medicaid services are federally mandated. Others are optional at the states' discretion. Thus, state Medicaid programs can vary considerably regarding the services covered and how the program is administered. Many states also operate LTSS programs for individuals who need services but do not meet Medicaid's stringent eligibility criteria. States also operate programs with federal grant funding, for example, through the Older Americans Act. Consequently, in many states, LTSS program administration is dispersed across several agencies and departments. As a result, consumers frequently have difficulty identifying the programs for which they are eligible and obtaining the services they need.
Many policymakers and state officials believe that strategies to improve coordination between and among LTSS programs should begin with the consolidation of LTSS program administration, policies, and budgets within one state agency. Using a global budget for all publicly funded LTSS would allow individuals a choice of where to receive services. Another strategy to improve coordination is to establish single-entry points for all LTSS. The term means that an individual seeking LTSS can obtain comprehensive information and apply for services through multiple programs at the same time.
All states have a single-entry point for people seeking publicly or privately funded LTSS, such as an Aging and Disability Resource Center (ADRC) or a No Wrong Door system. Single-entry points enable individuals to obtain information about all LTSS in a given geographic area. They can have their needs assessed and their eligibility for public programs determined. Some states have set up their systems to authorize services as well. ADRCs can also provide information about affordable housing options.
States often use different assessment instruments to determine eligibility for each LTSS program and develop service plans. When this is the case, individuals applying to several programs are assessed multiple times. A comprehensive uniform assessment instrument would eliminate this costly and time-consuming process. It would streamline eligibility determinations for multiple programs. Some states have developed such instruments. Conflict-free care management can also improve service coordination. In conflict-free care management, the person providing service assessment, making decisions about which services will be provided and by whom, and providing service coordination is not affiliated with a service provider. The goal of conflict-free care management is to promote individual choice and independence. Many publicly funded state programs use care managers or care coordinators to assess a person's need for LTSS and organize service delivery. Evidence shows that people with multiple chronic conditions and those who have both LTSS and health care needs benefit from the services of care coordinators/care managers. These professionals can help them coordinate their care across multiple settings and providers.
COORDINATION OF LONG-TERM SERVICES AND SUPPORTS: Policy
COORDINATION OF LONG-TERM SERVICES AND SUPPORTS: Policy
Coordination among long-term services and supports (LTSS) providers
All federal and state agencies with a key role in financing or delivering LTSS should coordinate their efforts. When appropriate and feasible, they should help coordinate activities among LTSS agencies and other agencies that serve people who use LTSS, such as those dealing with income support and housing.
Consolidated or coordination of LTSS agencies
States should consolidate or coordinate agencies responsible for LTSS, including Medicaid, state-funded programs, Older Americans Act programs, and the state agency on aging. These consolidated or coordinated agencies should have responsibility for policy, funding, administration, and oversight of LTSS programs that serve both older and younger people with disabilities. These responsibilities should include the determination of eligibility for public programs.
This includes Medicaid-funded institutional care and community-based programs such as personal care, home- and community-based services waiver programs, managed LTSS programs (including Programs of All-Inclusive Care for the Elderly), and state-funded LTSS programs. The consolidated agency also should have responsibility for determining financial eligibility for Medicaid and LTSS quality management. It should cover all populations of older adults and people with disabilities: older people, other adults with physical disabilities, and people with developmental disabilities.
Single-entry point for LTSS
The operations and functions of each organization in an Aging and Disability Resource Center (ADRC) model vary greatly. States should streamline eligibility determinations for LTSS programs. They should move toward person- and family-centered care and increase public outreach so consumers know about these valuable information resources.
Entry points should provide comprehensive, conflict-free, consumer-friendly counseling at critical decision points. This should include—at home, in hospitals, and at conveniently located offices in neutral settings—an 800 number to assist in finding the nearest office and comprehensive information on service options and funding sources.
States should conduct assessments of, and devise service plans based on, consumer needs and preferences. They should promptly determine functional and financial eligibility for all publicly funded services.
The assessment of LTSS needs and the delivery of services and support should be conflict-free.
Global budgets should be based on the projected needs of the population and anticipated changes in LTSS delivery and must be adjusted for expected inflation.
Centralized administration
A centralized state LTSS agency or coordinated agencies should:
- eliminate unnecessary paperwork and other inefficiencies through administrative and systems reform to help contain costs,
- streamline the process for people covered by more than one program, and
- have a global budget with authority to allocate funding among an array of LTSS, including both institutional and home- and community-based services.
The agency or agencies should also:
- have fair rate-setting and contracting processes for service providers;
- have a structure and process for ensuring quality oversight and outcomes throughout the system;
- direct providers to use standard, simple terms and billing forms, including electronic billing; and
- make current data on nursing facility charges and all other LTSS providers available to the public.
Conflict-free care management
Conflict-free care management should be an essential part of any LTSS system. It can address the fragmentation of present delivery systems and help ensure that individual needs are met cost-effectively. States should ensure that conflict-free care management is available through a community organization (such as an ADRC) that does not directly provide LTSS. This would not apply to people in managed care programs. At the request of an individual or family member, conflict-free assessment, counseling, and assistance should be provided prior to entering any type of LTSS facility. It should be available at any time, regardless of location or level of care.
States should require competency-based training, annual continuing education, and supervision for care managers. This can ensure high-quality service plans that meet consumers' needs and programs' cost constraints.
States should require care managers to practice according to professional standards and norms, which include attention to recommended safe and manageable caseload limits.
States should ensure that public and private geriatric care managers can demonstrate competency as required by the state.
States should require care-management agencies to be conflict-free and have strong consumer representation on their boards, particularly LTSS consumers.
Consumer focus
States should ensure all LTSS programs use a person- and family-centered service planning process that reflects individuals' preferences and goals. This planning should empower older adults and people with disabilities. It should recognize that the person receiving services is the expert on their own care. Individuals should be active in service planning. They may include other people of their choice, such as family caregivers.
Consumers should be guaranteed a choice of care managers and the ability to change care managers.
Care managers should inform consumers about the costs of service options. Consumers should sign off on their service plan as equal partners.