California can best be described as a state currently at a level of mid-range transformation. While reform has occurred in several agencies and for multiple populations, these efforts have largely been targeted to specific improvements, rather than to whole scale systems reform. California operates several successful HCBS programs, including the IHSS program, the nation’s oldest and largest personal assistance services program. California’s dedication to the adult and aging population is further exemplified through expansion of HCBS availability in order to keep up with vast increases in our aging population; and sound state and community planning for transition services from institutionalization to community living. However, these efforts and others described in the Systems Readiness Assessment tend to have a population-specific focus and overall have not translated into a systems rebalancing and transformation.
California is poised and ready for the planning and actions to establish true systems transformation. Eiken’s 2004 report, “Common Factors of Systems Change,” identifies preparedness for systems transformation in eight areas. California’s current status strongly reflects four of these areas: need to respond to a swell in the aging baby-boomer population, consumer involvement, collaborative state-agency leadership and a strong political long-term care champion, and the institution of multiple changes over several years.
California must plan for the needs of our greatly increasing population of senior and adults with disabilities. According to the California Department of Aging, between 1950 and 1990, California’s elderly population grew from 1.6 million to 4.2 million, an increase of 157 percent. By 2010, one in five Californians will be 60 years of age or older. Not only will California experience a swell in its older population, but the elderly population itself has and will continue to become “older.” As discussed in Part I, Readiness Assessment, Assembly and Senate committees and subcommittees recognize the importance of planning for this change. Plans such as those completed within California Department of Aging and Department of Developmental Services each look at population estimates from their service perspective. Plans such as the Olmstead Plan and what will be developed by California Community CHOICES address necessary systems change reforms as well.
California is committed to the inclusion of consumer input in decision-making and legislative processes that encompass long-term care issues. Legislative hearings and committee meetings are open to the public and inclusive of comments from stakeholders. Consumers and advocates are active in policy and budget hearings and have consistently been successful in maintaining budgetary support for quality systems of care, specifically IHSS. Prior to implementation of the IHSS Plus waiver (2004), which expanded federal financial participation for IHSS components that had previously been state-funded only, IHSS consumers routinely testified to protect funding for family member providers during budget reduction proposals. Consumers, care providers and family members also advocate for quality care measures, including increasing worker wages. In addition, consumers are well represented on the Olmstead Advisory Committee. Members exemplify a strong cross section of seniors and people with disabilities, advocates, community-based providers, health systems, and legislative representatives.
California possesses strong leaders in the area of long-term care; including Secretary, Kim Belshé who heads the applicant agency, CHHSA, with oversight responsibility for 11 state departments, and one state board. In addition, Secretary Belshé oversees the Olmstead Advisory Committee and appoints active, knowledgeable, and committed members to help inform CHHSA projects and policies for maintaining access to essential health and human services for California’s most disadvantaged and at-risk residents, while pursuing ways to better manage and control costs over the long-term. The Schwarzenegger Administration supports the availability of HCBS, as evidenced by existing Real Choice Systems Change grantees, including the Departments of Developmental Services, Social Services, Health Services, Mental Health, and Aging. There is additional support for this effort from State Senator Wesley Chesbro, Assemblywoman Petty Berg, the Congress of California Seniors, California Foundation for Independent Living Centers, California Caregiver Resource Centers, California Association for Health Services at Home, and Sutter Health, to name just a few. Letters of support are included in Appendix R.
By instituting multiple changes over the past few years, CHHSA has made progress in moving towards overall transformation and the needed infrastructure changes. These changes have been outlined in Part I: Systems Readiness, including seven 1915(c) HCBS waivers serving approximately 78,000 individuals; the recently established Assisted Living Waiver providing HCBS as an alternate to nursing facility placement for individuals aged 21 and older; and the Multipurpose Senior Services Program for individuals over the age of 65. California has also had great success in supporting people with developmental disabilities in the community and transferring those persons from institutions into the community by creating new community living arrangements and developing new assessment and individual service planning procedures and quality assurance systems. The state is working aggressively pursuing to close its own state-run developmental centers.
The acute and long-term care system in California remains fragmented for people with long-term health care needs and disabilities. While there has been an evident lack of coordination between medical and social systems of care, and a lack of consumer access, awareness, and understanding of home and community-based options, the state has realized some success in managing multiple funding streams to facilitate HCBS options over institutionalization among its seniors.
Because California does not currently have a coordinated mechanism for developing a statewide infrastructure for long-term care, California Community CHOICES is critical to addressing the barriers and making progress in systems transformation. Specifically, CHHSA seeks to develop solutions that address the barriers summarized above by building, enhancing and connecting infrastructures among multiple agencies and departments by using information technology, building on the one-stop system to connect consumers to services, and developing and implementing more flexible payment methodologies for home and community-based services.
Lead Agency/Applicant
The California Health and Human Services Agency (CHHSA) is the lead applicant for the Community CHOICES project. CHHSA administers state and federal programs for health care (including Medi-Cal, California’s Medicaid program), long-term care, social services, public assistance, and rehabilitation. Specifically, CHHSA has oversight responsibility for eleven departments and one board in California, including the departments of Health Services (DHS), Rehabilitation (DOR), Mental Health (DMH), Developmental Disabilities (DDS), Social Services (DSS), and Aging (CDA). As lead agency for this project, CHHSA will coordinate across the various state departments both within and external to it, as well as with local organizations, stakeholder groups, and existing one-stops; and it will ensure integration of this systems transformation project with other initiatives already occurring in the state. Upon grant award, CHHSA will hire the project director who will be responsible for overall project management and for ensuring completion of project goals on time and within budget, as well as supervising all personnel, monitoring all subcontractors, and serving a liaison between CHHSA and CMS/AoA. The project director will be required to have a working knowledge of and extensive experience with California’s long-term care system, strong relationships with stakeholder groups, the ability to work with complex and conflicting interests, and project management skills.
Project Partners/Subcontractors
The State agencies listed above are important Community CHOICES project partners who will provide state and local staff support, as well as in-kind support and expertise to the project. A letter of endorsement from each of these California agencies is located in the Appendix. Other partners and subcontractors include the California Institute on Human Services at Sonoma State University (SSU/CIHS). SSU/CIHS will be responsible for: 1) conducting the strategic planning process, 2) providing technical assistance through outside specialists when specific expertise is needed; 3) developing and maintaining some Web-based resources; and 4) advising CHHSA on the competitive processes to select other subcontractors. SSU/CIHS has already established excellent working relationships with CHHSA and DHS (California’s Medicaid agency) through its administration of California’s Medicaid Infrastructure Grant, the California Health Incentives Improvement Project (CHIIP), first funded by CMS in 2003.
The Olmstead Advisory Committee, described on page four, will work with the key project partners and staff to identify a project advisory group comprised of consumers, advocates, providers, and other groups. The advisory group will be a key partner throughout the term of the project and will meet on a regular basis with the project director, subcontractors, and external evaluators. Specifically, the advisory group will be responsible for providing ongoing input and feedback regarding the three project areas, reviewing data and products, and providing recommendations for changes/adjustments in the project’s implementation plan for continuous improvement.
Other project partners and subcontracts to be retained after a competitive process include:
In addition, individual consultants with specific expertise will be retained as needed to provide technical assistance to existing and new one-stops on systems change, to increase local capacity, improve information technology systems, and to conduct a long-term care financing study.
For the Community CHOICES project, CHHSA has chosen transformation goals:
#1: Improve Access to Long-term Support Services: Development of One-Stop System;
#4: Transform Information Technology to Support System Change; and
#5: Create a System that More Effectively Manages the Funding for Long-term Supports that Promote Community Living Options.
These three goals represent the elements most needed for reform in order to achieve coherent systems management and a consumer-directed system in California. The strategies and activities for each will focus on building upon the existing one-stop system; and improving and building infrastructure for a more integrated, coordinated, accessible long-term support system for individuals with disabilities or chronic illness, regardless of income. Systems transformation in these areas will help California meet the challenges that lay ahead as a result of its large, aging population.
"Persons at significant risk of needing long-term care services in the near future often lack the knowledge they need on how to access services... Absent an understanding of what services are available and how to access and finance them, these individuals might make less-than-optimal long-term care decisions— especially if they do so at a time of crisis, when there is little opportunity to investigate alternatives. Doing so could lead to reduced quality of life, unnecessary health problems, and greater caregiver burden.”
---William Black and Randall Brown, Mathematica Policy Research, Inc. 2004
Rationale for choosing this goal and California’s readiness for reform through development of the one-stop system.
As set out in the Systems Readiness Assessment section, California has a number of home and community-based services (HCBS) programs; but the state continues to confront a number of challenges in the service system. First, the services operate under multiple funding streams through various state departments, leading to fragmentation in service delivery. Second, community-based alternatives to long-term care are relatively unknown and often misunderstood by consumers. Third, consumers and caregivers often cannot access the necessary services and supports that promote community living, resulting in premature or unnecessary institutionalization; and finally, individuals often cannot access these linkage services in times of crisis, particularly after an acute care episode. Without connection to critical HCBS after an acute care episode, an individual is more likely to be placed in a nursing home. Or, for individuals who are admitted to nursing homes for a short-term stay, it is critical that there be timely access to and awareness of necessary HCBS services upon returning to the home and community. California needs to provide consumers with more information and flexibility so consumers can exercise more choice and take advantage of the services available outside of institutions. The expansion and improvement of California’s one-stop system model can help address these issues.
Barriers. Barriers to systems transformation through building on the existing one-stop system include the challenges presented by the size of the state’s population and funding constraints. However, there are more specific challenges already experienced by the existing one-stops or ADRCs as set out in a recent evaluation report prepared for the state Department on Aging (see, ADRC Development in California 2006).
In San Diego, the ADRC initiative is an approach that supports an integrated information and communication system that builds upon the county’s existing Network of Care (NOC) website (www.sandiego.networkofcare.org) and Call Center at Aging & Independence Services. The NOC website is being used as the foundation for the ADRC. The Web-based approach was adopted to complement and enhance existing Call Center functions, develop the “one stop shop” concept, and ultimately provide the entire San Diego community with more seamless, accessible, long-term care information, assistance, and support. However, the program has encountered issues in updating the NOC website to meet consumer satisfaction. Specifically:
In Del Norte County, the ADRC initiative is an approach that seeks to enhance the ability of existing programs of the Info Center (Senior Information & Assistance, HICAP, Volunteer Center & RSVP) through streamlining access to long-term care services for seniors, determine what is needed to better serve the disability program, and improve the Del Norte InfoCenter Web access program all co-located with the ADRC in Crescent City. A computerized database is being used as the foundation to build resource information for all populations targeted by the ADRC initiative. Work is underway to develop a Web-based resource directory so that consumers, caregivers, and providers may go directly to the website for resources if desired.
Assets. CHHSA chose this transformation goal because the state, through the leadership of Governor Schwarzenegger, has demonstrated a commitment to addressing the issues that plague the long-term care system and to developing more innovative approaches to service delivery; state readiness for this reform is an asset. With Executive Order S-18-04, Governor Schwarzenegger set a priority for the identification of (1) Californians who could be served successfully in non-institutional settings and (2) the barriers in the existing system that might prevent those individuals from moving out of, or avoiding admittance to, institutional long-term care facilities (see, Readiness Assessment, Question 1). The State has taken steps to address these issues, demonstrating a political will and readiness to advance a viable one-stop approach. The Olmstead Advisory Committee Strategic Plan identified the fragmentation of the current long-term care system and the lack of consumer education regarding HCBS options as two of its top priorities for statewide improvement (See Part II - Level of Transformation). In addition, California’s two existing ADRC sites in San Diego and Humboldt Counties are assets to California Community CHOICES and will participate in our strategic planning process.
California wishes to expand and improve its existing ADRC model by creating two additional one-stops in other areas of the state, to be called “CommunityLink Resource Centers (CLRC).” Expanding the development of the one-stop system, these ADRC/CLRC projects will improve access to comprehensive information, assistance, and long-term support services for individuals of all ages who have chronic health issues and disabilities. Together with the existing ADRCs, the new CLRCs will address issues of system fragmentation and the need for greater access to information related to home and community-based long-term care services as alternatives to nursing home care and institutionalization. The CLRCs will seek to increase awareness of the availability of HCBS services, as well as provide information and assistance to consumers. The CLRCs will offer a comprehensive program that includes a range of screening, assessment, counseling, and eligibility determination/enrollment services. In short, the CLRCs will be responsible for providing both intake and referral services, as needed, and assessments and short-term case management, as needed, together with education and community outreach.
Philosophy: The CommunityLink Resource Centers will focus on empowering adults with disabilities and seniors to have greater control over their lives by improving their ability to make informed choices (See, Lutzky 2004).
Mission Statement: The CommunityLink Resource Centers will improve access to information and linkages to long-term supports and chronic care services for the elderly and persons with disabilities in specified regions of California. Although CLRCs will have a special focus on providing access to home and community-based services for persons at risk of institutionalization, they will provide information, counseling, and assessment to anyone, regardless of level of need, because early intervention will likely result in better outcomes for the individual and more efficient delivery of services (See, Lutzky 2004).
In the 2006-07 proposed Budget, the Administration proposed development of the Community Options and Care Protocol (COAP), a tool that will provide an assessment protocol for persons needing both health and social long-term care supportive services (proposal currently being considered in AB 3019, Daucher). This tool, when developed, represents another asset that will help lead to successful system change. The tool will enable health and social services programs to share information about an individual trying to access community-based services instead of entering a nursing home. This will streamline the assessment process for consumers at ADRCs. The coordinated assessment tool will provide a mechanism through which to connect consumers with long-term care programs (LAO, 2005-06, C-28).
Integration of this goal with California’s other chosen goals
Each of the Community CHOICES project goals is dependent upon the other. CHHSA has long been committed to long-term care systems transformation by addressing access issues and helping consumers navigate services; developing information technology to empower consumers with the information they need to remain at home and avoid institutionalization; and finally, effectively managing the funding for long-term care systems to enable greater access to community-based services. By more effectively managing long-term care funding (Goal 5), the system will build its HCBS capacity, thereby making more services available. The One Stops will be critical to connecting consumers to HCBS system (Goal 1). Goal 4 (use of IT) strategies will use information technology to increase consumer knowledge of—and therefore access to— community-based services (goal 1). The use of information technology to increase consumer choice and lead to a more consumer-directed system is especially important to a state the size of California where an ADRC in each community may not occur for many years in the future. Therefore, goal 4 (use of IT) will also serve to meet the objectives of goal 1.
Goal 1, Objective 1, Provide Awareness, Information, and Assistance
While several entities in California, including Independent Living Centers, Area Agencies on Aging, Benefits Planning Assistance and Outreach, and the existing ADRC sites, seek to increase awareness of services and provide access to information, not all consumers can access services in a seamless manner. Some consumers may not know where to go for help, and others may go to one entity that can only connect them to a narrow scope of services. Although much of this is due to fragmented funding streams (addressed by goal 5), it is also the result of a lack of consumer awareness of programs and a lack of consistent information that connects consumers across programs. To make consumers aware of the existence of the one-stop system and help consumers understand their choices for HCBS, California’s preliminary strategies include ADRC and CLRC capacity building. As noted above on page 7, a 2006 review and evaluation of California’s two recently developed ADRCs reveal that, among other things, the information systems need improvement to allow the Resource Centers to better assist consumers in making a long-term care choices (ADRC Development in California 2006).
Goal 1, Objective 1, Preliminary Strategy: Build Capacity of Information and Referral Systems: Pilot CalCareNet website for use in CommunityLink Resource Centers (CLRC) to provide consistently updated information and referral services to consumers.
From the experience of the two ADRCs in California, information systems have been critical to program efforts and have the potential to impact the ability of consumers to access needed information to remain at home and in the community. Information systems are often the key in supplying appropriate information and referral to consumers. At present, the ADRCs are operating with separate and different information systems. Therefore, the core component to an effective one-stop system in California is the development of the state-level information system, referred to as the CalCareNet Web Portal (www.calcarenet.ca.gov). Work has already begun to create a prototype for the one-stop portal. Once constructed, CalCareNet will enable consumers and providers at the one-stop centers, as well as in other programs, consistent access to accurate and comprehensive information about HCBS and institutional care.
While the use of IT to improve HCBS access is detailed in goal 4, it is also intricately connected to the delivery of services through the one-stop system. The enhanced CalCareNet Web portal will be piloted and field tested through the two new CLRCs to provide information on medical, social, housing, and supportive services needed by individuals with chronic diseases and disabilities. Once CalCareNet has been updated, improved, evaluated, and revised, CLRC staff will be able to use the site to quickly help consumers assess needs, develop a plan of care, and link to services in the community.
Preliminary implementation steps to be refined through the strategic planning process include:
1. Conduct a solicitation process to select community-based organization(s) to operate two new one-stops or CLRCs to reach more Californians needing long-term care information, planning and services;
2. Identify 2–3 counties/regions to locate the CLRCs in two major metropolitan statistical areas where they can broadly address consumer needs;
3. Build upon the ADRC model to improve capacity for information and referral;
4. Expand/enhance the one-stop system in areas with existing local Web-based long-term care information database;
5. Prioritize one-stop expansion to those committed to working with CalCareNet in order to inform design, populate database, and test programming and user interface;
6. Participate as requested with Project and CMS evaluators;
7. Provide appropriate cross-program training statewide on CalCareNet;
8. Pilot and field test CalCareNet at selected one-stops;
9. Revise CalCareNet in accordance with field test/pilot feedback from staff/consumers; and
10. Conduct presentations and other outreach to community-based and health organizations to make consumers aware of availability of one-stops and CalCareNet, as described below.
Project staff will oversee all implementation activities, but individuals with specific expertise in capacity building, cross-program planning, information and referral training, information systems, and systems change will provide technical assistance to the ADRCs and CLRCs.
Goal 1, Objective 1, Preliminary Strategy: Improving communication and collaboration among long-term care service providers to facilitate access to long-term care services and information by allowing consumers to enter the long-term care system through multiple channels in the community
This strategy has three separate components to develop local-level collaborations between the CLRCs and the long-term care providers, create community kiosks, and develop a collaborative learning center for the existing ADRCs and CLRCs to share and develop best practices.
Establishing Community Connections and Collaboration: CLRC staff will be responsible for raising community awareness on the availability of services offered through the CLRCs. As the primary gateway to home and community-based, long-term care services the CLRCs will conduct outreach and training for providers that serve as the major pathways to long-term care on the services available through the CLRCs. Doctors, hospitals, long-term care planners, home health providers, caregiver organizations, programs serving seniors and persons with disabilities, advocacy organizations, and others serving persons who are in need of HCBS will be targeted for outreach and training. The training will focus on increasing awareness of one-stop services, increasing awareness of available HCBS, and encouraging consumer referral to the one-stops.
Community Kiosks: As an outreach strategy, the CLRCs will use community kiosks to provide a presence for the CLRCs outside of their physical location. The use of community kiosks is based upon The Lewin Group’s ADRC-TAE Issue Brief Entitled “Electronic Kiosks,” by Madison Sloan, published May 15, 2006. Community kiosks will be established in locations where people currently seek HCBS information, including hospitals, senior centers, Area Agencies on Aging, Independent Living Centers, physician offices, libraries, and other designated community locations. The kiosks will enable consumers to access information on HCBS by providing printed and electronic materials and information accessed through computers at the kiosk site. Using the kiosk, consumers will be able to perform an informal self-assessment of long-term care needs, addressing issues that include activities of daily living, caregiver and familial supports, health care needs, financial needs, and long-term care service needs. The consumer will have the option of either contacting the CLRC for additional support, or working on their own with the information provided at the kiosk. To further increase consumer awareness of the availability of the one-stops, foster community relationships, and facilitate connections, the ADRCs/CLRCs will maintain regular communications via email and listserv, with all programs serving long-term care consumers.
Establishing an ADRC/CLRC Coalition: The ADRCs and CLRCs will establish a coalition and will meet regularly, both in-person and via internet interface, to develop a shared repertoire of resources, including experiences, tools, and ways of addressing recurring problems encountered through the one-stop experience. By building relationships and sharing learning across sites, the ADRC model can continually be improved and updated. The Community CHOICES project director will lead and provide technical assistance to this ongoing activity.
Goal 1, Objective 1, Preliminary Strategy: Screening
The provision of brief screenings to establish/review needs, determine current service needs, and analyze potential eligibility for HCBS is a critical part of the information and referral/follow-up system. Research (see, for example, Home Health Care Services Quarterly, 2001) has shown that providing this type of inclusive information and referral/follow-up service regarding long-term care options can improve an individual’s ability to live in the community and reduce the need for institutional care when coordinated across multiple service programs.
A relatively brief screening when an individual first enters the system allows for rapid and accurate referral to long-term supports that allow the individual to live in a home environment. Follow-up by professional staff assists individuals in accessing services, such as scheduling medical appoints, respite care, and arranging transportation (Long, 2001).
A preliminary screening strategy, to be refined through the strategic planning process, will entail ADRCs/CLRCs sharing existing screening mechanisms and protocols and examining common elements in individual screening tools. This process will help plan for the use of a common intake screening tool to be used in coordination with the COAP assessment tool. A common screening tool at the beginning of the process will help direct consumers to the right services, since case workers, or consumers working online, will be screening for all needed long-term care services, not just those in a particular program area.
Goal 1, Objective 2: Streamline the Multiple Eligibility Processes
Currently, intake procedures vary considerably from program to program in California and can include an extensive services eligibility structure for programs such as Medi-Cal, IHSS, housing assistance, and transportation services, among others. Persons in acute care or long-term care facilities generally cannot access intake for these services without a particularly savvy and persistent advocate. Indeed, individuals and family members facing crisis-time decisions about acute care after-treatment frequently only learn about and consider institutional care options and feel ill-equipped to investigate HCBS. CHHSA wants to establish the infrastructure necessary to increase consumer awareness, enhance access to information and assistance, and streamline eligibility.
As mentioned on page 26, the coordinated assessment tool to be developed by the COAP project will not only connect consumers to HCBS by identifying core assessment elements used by most programs, but it will also streamline the multiple eligibility processes for consumers. Community CHOICES and the CLRCs will work with the COAP project to establish program cross-referral protocols that build on assessment procedures currently used by California’s home and community-based programs and will provide important feedback on the new screening tool’s effectiveness in streamlining the multiple eligibility processes for the one-stops.
Goal 1, Objective 2, Preliminary Strategy: Intake Process Development
The preliminary CLRC service design calls for CLRC staff to conduct an initial intake screening. When a CLRC is contacted via telephone, office visit, email, fax, postal mail, or TTY with a request for assistance the call will be transferred for intake and referral. (This follows a process developed by the Eastern Agency on Aging’s Community Services Department.) A CLRC staff person will be responsible for conducting telephone or in-person screenings to help consumers understand the type of information and assistance they need and the services for which they may be eligible. The CLRC will ask for the person’s name and contact information, will ascertain whether the caller is asking for information for themselves or a loved one, and to determine the basis of their request. At this point, the CLRC will work with the consumer to determine whether a formal intake and assessment is necessary. (Lutzky, S. 2004). The purpose of this step is to quickly and efficiently route the consumer to the most appropriate information source or type of service (Lutzky, S. 2004). After conducting the initial screening, the CLRC staff person will collect any additional information that will be helpful, such as Medicare and Medi-Cal eligibility or income/assets information. Upon receipt of the information, and verbal permission to make a referral, the CLRC staff person will explain the referral process to the consumer. This includes a brief, simple explanation of the referral agency intake process and the option for a more formal assessment. Upon referral to other programs and services, the CLRC staff person will be responsible for following up with the consumer/family to ascertain whether appropriate connections to services were facilitated. Staff will keep records to evaluate success or needed improvements in streamlining the intake process and facilitating service delivery.
Goal 1, Objective 2, Preliminary Strategy: Formal Assessment
In coordination with the state effort to develop a coordinated assessment tool, the CLRCs will pilot and field test the COAP tool in California Community CHOICES project out years. The Resource Centers will provide valuable feedback on the tool’s usefulness in minimizing duplication and redundancy of multiple assessments for home and community-based services and in connecting consumers with appropriate program services under the protocol. Working in partnership with community stakeholders, project staff will explore opportunities to use the coordinated assessment tool in other settings.
Many one-stop consumers may not require an in-depth formal assessment and may only need information and brief assistance. For those consumers who require additional services, ADRC/CLRC staff will conduct a formal assessment, using the COAP—with consumer permission. During the formal assessment process, CLRC staff will gather information relating to long-term care needs, functional eligibility determinations, supporting resources assessment and perform an initial programmatic and financial eligibility determination, as outlined in the COAP. The CLRC staff will conduct in-person, written or electronic assessments, using the coordinated assessment tool once developed. The assessments will be designed to collect background information, discover current health and functional status, and review available resources and the current care level to arrive at a determination of appropriate, available services and supports to assist individual consumers. In addition, CLRC staff will determine whether the consumer meets the level of care criteria for all publicly funded, long-term supports, including Medicaid HCBS waiver programs, In Home Support Services, Adult Day Health Care, services provided by the Independent Living Centers, and other programs operating under the Older Americans Act.
The project’s intent is to ensure coordination with the county Medi-Cal offices and other HCBS at the local level. This coordination will involve the provision of common information to all potential service providers to eliminate or reduce lengthy individual financial determinations. HCBS agencies conducting financial eligibility determinations will then be able to begin the process by stating: “We have your information relating to _____ and just need a bit more detail to complete the process.” A CLRC Intake and Referral Specialist will be responsible for streamlining eligibility determinations, connecting consumers/advocates with local HCBS programs.
Goal 1, Objective 2, Preliminary Strategy: Comprehensive Care Plans
The CLRC staff will provide both benefit counseling to ensure that individuals receive information about and assistance in applying for public and private benefits for which they are eligible, as well as and long-term care options counseling to develop the consumer’s plan of care (Lutzky, S. 2004). CLRC staff will be trained in providing counseling for long-term care options, a service designed to allow the client to determine the best choice for long-term care and support services based on the results of the long-term care needs and resources assessment, the financial eligibility screen, and the professional expertise of the CLRC staff person. Once the consumer has worked with CLRC staff to identify benefits and long-term care options, a plan of care will be developed. The CLRC staff will work with consumers to develop a service package that provides the needed supports in the least restrictive and most timely manner possible.
Providing follow-up or short-term case management is also an important part of protecting consumer choice in long-term care. As Wisconsin found in its ADRC system, short-term case management is an essential part of ADRC services, as it offers consumers information about and access to long-term supports and services in order to minimize confusion, enhance individual choice, and support informed decision-making (Fact Sheet on Short-Term Case Management for ADRCs 2005). Short-term case management is often the critical link that helps prevent premature institutionalization and often serves as a bridge to formal or informal long-term case management. Longer-term case management can be delivered through the MSSP waiver program, local or state- funded programs, or private agencies and usually involves intensive, on-going relationships with consumers. CLRC counselors will perform short-term case management and help connect consumers to the services outlined in their plan of care.
Goal 1, Objective 2, Preliminary Strategy: Service Authorization for Services by Outside Agencies
The provision of services to support community living is the last step in the process after screening, intake, assessment, eligibility determination, and individual comprehensive care plan development. As previously noted, California does not seek to change the current systems of service authorization but instead to make it easier for consumers to link those programs, create a more seamless intake/eligibility/authorization process, and assist consumers/families, as needed, to complete the assessment and authorization. The CLRC counselor will work through connections at hospitals and local community programs such as Independent Living Centers, Area Agencies on Aging, senior centers, and other resources to educate consumers/families about services available in the community, empower them to access information, assist them with service authorization, and develop a plan of care, as needed.
Goal 1, Objective 3, Preliminary Strategy: Target Individuals Who Are at Imminent Risk for Admission to an Institution
Individuals often cannot access home and community-based services in times of crisis, particularly after an acute care episode. Without connection to critical home and community-based services and without short-term case management, individuals are more likely to be placed in a nursing home. Individuals and family members facing crisis-time decisions about acute care after-treatment frequently only learn of the details of institutional services and feel ill-equipped to investigate home and community-based services. Therefore, the CLRCs will focus on building relationships with hospitals, nursing homes, and other providers in the long-term care critical pathway to ensure that consumers avoid unnecessary institutionalization in times of crisis.
The CLRCs will be responsible for conducting outreach to and developing relationships with local hospitals, physicians, hospital discharge planners, nursing homes, and developing processes to link consumers who are at risk for institutionalization to CLRCs resources. CLRC staff will work directly with doctors, discharge planners, and other hospital staff to explore viable community service options based on consumer preferences for an alternative to nursing home care. To protect client privacy, the CLRCs will work with hospital and skilled nursing facility staff to identify individuals who are interested in HCBS as an option. Hospital discharge planning staff will initially approach individuals at imminent risk of institutionalization to assess interest in receiving assistance exploring HCBS options. If interested, the individual will be asked to sign a form indicating approval for a CLRC counselor to meet with him/her and have access to confidential information, such as medical records, discharge plans and financial information. Skilled nursing facility staff will follow the same process.
In addition to providing information and referral/follow-up for HCBS, the CLRC counselors will provide assistance and information for individuals and their families on often-difficult local transportation and housing options. This will include mobility training to familiarize and instruct individuals on using various public and private transportation options. If an individual does not currently have housing or has recently lost housing due to his/her hospital stay, the CLRC counselors will work with the consumer and family/advocate to locate available affordable, accessible housing and to find roommates, if desired by the consumer.
The CLRCs will provide a single point of contact for individuals at risk of nursing home placement and will provide connections to and assistance with eligibility and enrollment for various home and community-based services programs. The CLRCs will work primarily with hospital discharge planners to target individuals who are at risk of nursing home placement, but could also act as an educational resource for the local communities to provide information and referrals on home and community-based services before a crisis situation occurs. The CLRCs will also target the population of consumers placed in nursing homes for a short-term stay. They will consult with local HCBS program staff to form a larger “community network” of experts working to reduce the number of individuals who are placed in nursing homes by default after an acute health crisis.
Goal 1, Objective 3, Preliminary Strategy: Triage System
As discussed in the Readiness Section, Question 8, California has several Medi-Cal waiver programs that provide community-based services for people at risk of institutionalization. The Multipurpose Senior Services Program can serve Seniors age 65 and older who are medically needy. The Nursing Facility A/B Waiver provides community based services to people with physical disabilities who meet specified levels of needed care for at least one year. And the In-Home Medical Care Waiver serves people with disabilities who also have a catastrophic illness, or other acute care needs for at least 90 days. These programs provide necessary services and do serve to divert people away from institutional care, but they are not designed as systems change initiatives that broadly serve Californians. (See Appendix A.6.) California Community CHOICES plans to demonstrate diversion strategies through the CLRCs that will reach people who do not need the level of care for the waiver programs, but who need information and support services to remain safely in a community setting.
Summary of Anticipated Project Accomplishments at the end of 5 years
The follow evaluation questions to apply to Goal 1, Community Link Resource Centers:
Evaluation Question 1: Is the one-stop system developed effective?
Potential quantitative outcomes looking at effectiveness of the CLRCs include:
(1) A percentage increase in the number of individuals who are served through the CLRCs, comparing year 1 to year 4 numbers served;
(2) A percentage increase in the appropriate use of home and community-based services among the individuals assisted by the CLRCs; and
(3) Consumer and stakeholder satisfaction.
Data to be collected and analysis methodology for each sub-objective is described below.
This data will reflect the effectiveness of the program in gaining local buy-in, as well as the trust of the hospital staff for the first priority individuals and the skilled nursing facility and other institutional staff for the second priority consumers.
This objective gets to the heart of the program in ascertaining to what extent the CLRCs have effectively increased consumer choice often resulting in the use of HCBS instead of institutionalization. Because direct measurement is virtually impossible, grant staff will compare the numbers of consumers served by various HCBS before the program is initiated compared to the numbers served 4 years later. The data will provide a trend picture, rather than a numerically accurate one. The project evaluator will work with local hospitals to determine if discharge data can be accessed to help triangulate data sources. The evaluator will also contact local HCBS to determine how their data is collected, validated, and reported to ensure accuracy of the final assessment.
Grant staff will work with the project evaluator to first develop the definition of “providing service,” that is, the amount of effort constitutes providing service to a consumer or family. They will also create the definitions for “at imminent risk of placement in an institution” and for the various categories for disaggregating data, including race/ethnicity, type of disability if any, previous living arrangement, etc. The project evaluator will then provide training for CLRC staff in data collection, as well as follow-up and periodic oversight to ensure data accuracy.
This objective will be handled directly by the project evaluator. S/he will create a satisfaction survey, after conferring with the Olmstead Advisory Group and project staff. This survey will be sent out quarterly to consumers and family members/advocates and annually to HCBS providers and hospital/skilled nursing facility staff. The evaluator will provide the data validation, analysis, and results.
Evaluation Question 2: Is the one-stop that has been developed efficient?
Potential quantitative outcomes looking at CLRC efficiency include:
(1) Consumer satisfaction measures for the ease in navigating the intake and eligibility aspects of HCBS.
(2) The process to access services has been streamlined, decreasing the average number of steps it takes to access HCBS and decreasing the number of people involved in facilitating consumer access to services, including Medicaid waivers, measured by comparing the process in 2006-07 to the process at the close of the grant period.
(3) The total amount of time it takes for consumers to access services will decrease as measured by the time from application to approval comparing a baseline time period to average elapsed time at the close of the grant period.
Evaluation Question 3: Is the one-stop visible, accessible, and approached with trust?
Potential quantitative outcomes looking at CLRC efficiency include:
(1) Consumer satisfaction measures for accessibility, helpfulness, value of information, and cultural competency.
Key stakeholders necessary to achieve a foundation of support to accomplish this goal
Key stakeholders in the design of an expanded one-stop system include the consumers and families who depend on it; case managers, hospital discharge planners, and others who assist consumers and families, often in times of a health crisis, to access HCBS or nursing facility care; the Olmstead Advisory Committee responsible for making policy recommendations to the state for reform of California’s long-term care system and other consumer advocate groups; the various state departments under applicant CHHSA who all play a part in administering long-term care programs, and of all direct service providers and the existing one-stops or ADRCs. The Community CHOICES strategic planning process will allow California to bring together representatives from each group of key stakeholders to carefully review and refine project strategies and projected outcomes.
The desired expansion and improvements to the CalCareNet Web portal are driven by consumer feedback and widespread support from consumers, providers, and policy-makers for moving the state closer to an integrated, comprehensive Web-based information and referral system. Together with highly visible, efficient and effective one-stops this virtual, no wrong door one-stop once completed will benefit all Californians.
To ensure that the CLRCs are responsive to and representative of local/regional needs and desires, each CLRC will convene a local stakeholder advisory group. The CLRC stakeholder advisory groups will advise project and CLRC staff on building Resource Center infrastructure, policies, practices, training, tools, and all matters that effect the consumer’s experience in accessing information, referral, or assistance through the one-stops. Likely members drawn from the local community for each CLRC include, representatives from Independent Living Centers, Area Agencies on Aging and other providers and consumer advocates, hospital boards, and other institutional care providers.
Rationale for choosing this goal and California’s readiness for reform through enhancement of IT Systems in support of HCBS
Technology, in its many forms, is quickly becoming integrated into everyday life in the 21st Century. In order to efficiently serve older adults, persons with disabilities, and their families, public and private agencies are turning to various technology applications. The success of these technology systems is increasingly contingent on the interdependency of systems, Web accessibility, consumer privacy protections, and outcomes that support continuous quality improvement. While some states have made bold planning moves by integrating information technologies for consumers (front-end) and providers (back-end), most states currently provide separate information systems for each. Consumer-based information technologies typically focus on providing easily accessible information about available services and products, the costs, eligibility criteria, and accommodations for persons with different needs. Some also offer the option of completing a brief needs assessment, or self-assessment, to assist consumers in determining their resource and information needs. By contrast, provider-based information systems address provider data requirements and generally include some form of a client/service data tracking system. This goal was selected to address California’s dissonant consumer and provider long-term care information technology systems by building upon a current information technology prototype that focuses on promoting consumer awareness, access and choice.
As was previously noted, California has a wide array of publicly funded long-term support programs and services administered by numerous state departments, primarily under the CHHSA umbrella. Each department has a unique set of eligibility requirements, services, and target populations challenging efforts at coordinating aging and long-term support services for the state. Each department also hosts an informational website for consumers providing relevant information about the department’s programs, services, eligibility, etc. In addition to these state-sponsored aging and long-term care information technologies, CHHSA hosts the CalCareNet website (www.calcarenet.ca.gov), introduced in Goal 1, Objective 1 on page 27, an internet application designed to enable Californians to go to a single website to find help for adults in need of care or services from a licensed care facility.
Continue to Part 3 of California Community Choices Grant Application Narrative