The delivery and financing of long-term services and supports (LTSS) differ considerably from state to state. Although Medicaid is the single largest public funding source, it does not require a uniform national delivery system. In many states, LTSS services, functions, and operations are dispersed across many state government agencies and departments. The result is often confusion for both consumers and providers. Many policymakers and state officials believe that strategies to improve coordination should begin with consolidation of LTSS programs, policies, and budgets within one state agency.
Such “single entry points” make it easier for consumers to access LTSS. At a single local or regional location, they can get information and assistance, including needs assessment, care planning, and, in some systems, service authorization. Single entry points differ from state to state in the populations they serve and the services they provide. Some states’ single entry points are actually multiple sites that are coordinated and standardized.
Aging and Disability Resource Centers ( ADRCsAll states now operate Aging and Disability Resource Centers (ADRCs) as a single source of information and assistance about services for older adults and people with disabilities, regardless of their income or type of disability. A critical function of ADRCs is conflict-free care management… ) or No Wrong Door systems offer one-stop, single-entry access to LTSS. ADRCs’ staff can provide information on public and private services, assistance with obtaining services, needs assessment, conflict-free care management services, and determination of eligibility for public programs.
Access to home- and community-based services can be expedited through single entry points that determine both financial and functional eligibility, or that coordinate that process. Yet most single entry points do not determine both areas of eligibility.
One mechanism for ensuring that LTSS clients receive the most appropriate mix of services is care management or care coordination. Conflict-free care management emphasizes individual choice and control and helps people find and coordinate community LTSS. 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 acute-care needs benefit from care coordinators/care managers helping them to navigate their care across settings and providers.
Steps to Improve Long-Term Services and Supports Coordination: 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 and, when appropriate and feasible, help coordinate activities among LTSS agencies and agencies that otherwise serve people who use LTSS—for example, agencies dealing with income support and housing (see Chapter 9, Livable Communities, for more information on housing).
Conflict-free care management should be an essential part of any LTSS system because it can address the fragmentation of present delivery systems and help ensure that clients’ needs are met cost-effectively.
Characteristics of consolidated LTSS agencies
States should consolidate LTSS agencies.
The model structure includes the state agency on aging with its Older Americans Act (OAA) programs. A centralized state LTSS organization should integrate programs supported by OAA funds.
The consolidated agency should have responsibility for LTSS administration, policy, and funding. This includes Medicaid-funded institutional care and community-based programs such as personal care, home- and community-based services (HCBS) 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 people’s financial eligibility for Medicaid and for 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
A centralized state LTSS administrative body should have a single entry point for people seeking publicly or privately funded LTSS, such as an Aging and Disability Resource Centers (ADRC).
The entry point should provide comprehensive, conflict-free, consumer-friendly counseling at critical decision points (including at home and within hospitals); conveniently located offices in neutral settings; an 800 number to assist in finding the nearest office; and comprehensive information on care options and funding sources.
States should conduct an assessment of and devise care plans based on consumer needs and preferences, and 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.
A single LTSS agency should have global budgeting, with flexibility and authority to fund an array of LTSS, whether institutional or HCBS. (Global budgeting allocates a set level of funds within which providers must operate, whether the funds are applied at the federal, state, or institutional level.)
Global budgets must be based on the projected needs of the population and anticipated changes in LTSS delivery and must be adjusted for expected inflation.
A centralized state LTSS agency should eliminate unnecessary paperwork and other inefficiencies through administrative and systems reform to help contain costs and streamline the process for people covered by more than one program.
Providers should use standard, simple terms and billing forms, including electronic billing.
Current data on nursing facility charges and all other LTSS providers should be available to the public.
Setting fees for service providers
A centralized state LTSS agency should have fair rate-setting and contracting processes for service providers.
A state LTSS agency should have a structure and process for ensuring quality oversight and outcomes throughout the system.
Uniformity in assessing LTSS needs
A state LTSS agency should determine beneficiaries’ LTSS needs through a comprehensive uniform assessment.
The federal government should assist states in developing uniform eligibility criteria, assessment and data collection instruments, quality control standards, and outcome measures.
Assessments should take into account the different needs of people with different conditions and should focus on the individual’s current care needs and potential ability to live in the community with appropriate LTSS.
When a care plan includes (or involves) a family caregiver, the family caregiver’s own needs and preference should also be assessed and addressed with the family caregiver (see this chapter’s section on Supporting Family Caregivers).
Availability of conflict-free care management
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). Conflict-free assessment, counseling, and assistance shall be afforded to the individual (and family) prior to entering any type of LTSS, or at any time, regardless of locus or level of care, at the request of the individual or family.
Training and professionalism of care managers
States should require competency-based training, annual continuing education, and supervision for care managers to ensure high-quality service plans that meet client needs and program 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.
Focus on the consumer
States should ensure that a person- and family-centered planning process reflects people’s preferences and goals. This planning should empower older adults and people with disabilities by recognizing that the person receiving services is the expert in his or her own care. Individuals should be active in their own planning and may include other people of their choosing, 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, and consumers should sign off on their care plan as equal partners.
States should require care management agencies to be conflict-free and have strong consumer representation on their boards, particularly of consumers who use LTSS.
States should ensure that individual care plans are based on clients’ LTSS needs.