Although Medicaid is the single largest public funding source for long-term services and supports (LTSS), the U.S. does not have a uniform national delivery system. The financing and delivery of LTSS differ considerably from state to state. In many states, LTSS program administration is dispersed across several 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 the consolidation of LTSS programs, policies, and budgets within one state agency.
Another strategy to improve coordination is the establishment of single-entry points where individuals can get information about all the LTSS in a given geographic area, have their needs assessed, and eligibility for public programs determined, as well as, in some systems, receive service authorization. A single-entry point is a one-stop shop concept; states can have multiple locations that serve this same comprehensive service. Aging and Disability Resource Centers or No Wrong Door systems are examples of how this can work. Person- and family-centered practice is at the heart of a No Wrong Door system, which requires an interactive process directed by individuals and family members to support decision-making about LTSS. This type of options counseling facilitates the development of a plan that accounts for a person’s and family’s strengths, preferences, needs, and values. The use of conflict-free care management also improves service 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.
IMPROVING COORDINATION OF LONG-TERM SERVICES AND SUPPORTS: Policy
Ensuring coordination among long-term services and supports providers
All federal and state agencies with a key role in financing or delivering long-term services and supports (LTSS) should coordinate their efforts and, when appropriate and feasible, help coordinate activities among LTSS agencies and agencies that serve people who use LTSS such as those dealing with income support and housing.
Establishing a consolidated long-term services and supports agency
States should consolidate agencies responsible for LTSS, including Medicaid, state-funded programs, Older Americans Act programs, and the state agency on aging. The consolidated agency should have responsibility for policy, funding, administration, and oversight of LTSS programs that serve both older and younger people with disabilities. Its responsibilities should include 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 people’s 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.
Ensuring a single-entry point for long-term services and supports
All states have a single-entry point for people seeking publicly or privately funded LTSS, such as an Aging and Disability Resource Center (ADRC). Single-entry points can help consumers and their families access these services regardless of which organization they contact. However, the operations and functions of each organization in an ADRC model vary greatly, with improvements needed in streamlining eligibility for programs, moving toward person- and family-centered care, and increasing public outreach, so consumers know about these important information resources.
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 assessments 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.
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.
Streamlining administration through a centralized state agency
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; 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 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.
Ensuring accuracy and appropriateness when assessing long-term services and supports needs
States should use a comprehensive uniform assessment instrument to determine individual needs and to develop a service plan.
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 needs of people with different conditions and 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 preferences should also be assessed and addressed with the family caregiver (see also this chapter’s section on Supporting Family Caregivers).
Ensuring conflict-free care management/Training care managers
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 individual needs are met cost-effectively. States should ensure that conflict-free care management is available through a community organization (such as an Aging and Disability Resource Center) 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.
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.
States should require care management agencies to be conflict-free and have strong consumer representation on their boards, particularly of consumers who use LTSS.
Ensuring a consumer focus
States should ensure that all LTSS programs use a person- and family-centered (when desired) service planning process that reflects individuals’ 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 be conflict-free and have strong consumer representation on their boards, particularly of consumers who use LTSS.