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Vermont puts long-term care on level playing ground
Vermont Medicaid has been able to make some important changes to the delivery of long-term care services, thanks to its unique Choices for Care waiver.
The 1115 Long-Term Care Medicaid Waiver is "a first in the country," according to Brendan Hogan, MSA, deputy commissioner of the Agency of Human Services' Department of Disabilities, Aging, and Independent Living. "We have equalized the entitlement to both nursing home and home and community-based options for individuals who are eligible for our waiver program." One result is that more people are being cared for in the community as opposed to nursing homes.
Prior to Choices for Care, a 1915(c) waiver was in place, as in many states, to provide services under home and community-based services. Starting in 2005, though, the budgets for home and community-based services and nursing homes were combined. If an individual is eligible for the waiver, he or she is now given the choice of which setting to obtain long-term care.
"So, what we have now is a global budget to cover all long-term care in Medicaid," says Mr. Hogan. "And that is something that is unique to Vermont. We are the only state in the country that equalizes long-term care under Medicaid services. This levels the playing ground. Since the budgets are combined, the access to services is opened up, hence the reason for the name of the waiver, 'Choices for Care.' We believe it's been successful for several reasons."
For one thing, the number of people waiting for home and community-based services was reduced from several hundred to fewer than 100. "We still have a financial safety valve, for lack of a better term, that allows us to control access based on the different eligibility groups we have," Mr. Hogan reports.
The arrangement took several years of planning and coordination with other departments to achieve, along with negotiations with both regional and national Centers for Medicare & Medicaid (CMS) offices. "But they were very willing to work out all of the details. We have recently submitted our request to extend our waiver for an additional three years," says Mr. Hogan.
The approach of combining long-term care funding into a single budget is likely to be adopted by other state Medicaid programs in the near future. "I believe there are other states looking at this. There are certainly discussions in long-term care and health care reform that speak to this type of arrangement," says Mr. Hogan. "We have been contacted by other states to ask us about some of the challenges."
Since the budgets are no longer separate, a global look is taken in terms of what is paid out for care, whether it is provided in nursing homes or the community. "We look at it as one budget. Because it's a 1115 waiver, we are provided the flexibility to do that," says Mr. Hogan. "Frankly, we found the cost of care servicing people in the community tends to be about half what it would be in a nursing home. By virtue of combining the budgets together and with less people served in the nursing homes, we have been able to stay within budget neutrality."
In order to be eligible for long-term care under Medicaid, an individual must be both clinically and financially eligible, so a two-step process is required. In Vermont, a three-tiered system for clinical eligibility is used, consisting of highest-, high-, and moderate-need groups.
The highest-need group consists of individuals who clearly require a nursing home level of care. "The high need are also a nursing home level of care, but as part of our waiver, it's the group that we are allowed to have a waiting list on. Currently, there are approximately 80 of this group on the waiting lists. There may be more people who may be eligible, but we have limited funds," says Mr. Hogan.
In the past, individuals were automatically eligible to get into a nursing home, and the waiting list was only used for home and community-based services. "The wait would depend on funding, similar to what we have now, but it also depended on the turnover rate. Like many other 1915(c) waivers around the country, the turnover rate in terms of people enrolled tends to be about two years," says Mr. Hogan. "So, there are a lot of people who would have to wait until money was freed up by somebody leaving the waiver." Now the same waiting list is used for either setting.
The moderate-needs group is a smaller expansion group, whose members are not eligible for full long-term care Medicaid services. "For that group, we are providing people a certain amount of services but not the full amount. We hope to prevent them from needing the full array of services," says Mr. Hogan. The theory is that if an individual is able to access benefits such as case management, adult day services, and personal care services on a limited basis, the need for full long-term care services will be delayed.
Most of the individuals eligible for long-term care in Vermont Medicaid are now opting for home- and community-based care, including residential care homes, as opposed to nursing homes.
"We have had some nursing home diversion grants from CMS. There has been some ability to move some people out of nursing homes. But for the most part, it is more a sense of now that community services is an option and we are able to make it work, they are choosing it," says Mr. Hogan.
Medicaid is working with its providers on the community-based side, such as adult day centers and residential care centers. "One part of our waiver involves consumer-directed and surrogate-directed care. Under that, we have a contract that allows people to hire their own personal care workers," says Mr. Hogan. "We have seen a lot of growth in that area."
Since the agency has had difficulty finding enough qualified individuals to hire, individuals were given the option of hiring their own. To help them do so, a direct care worker registry was developed, with names listed on an electronic registry for participants to access.
"People may need hands-on care. They have to be able to access someone to help. At the same time, we are also working closely with nursing homes. There will always be a need for nursing home care," says Mr. Hogan. "We are trying to work as hard as we can to balance both sides of the system."
Contact Mr. Hogan at (802) 241-2326 or firstname.lastname@example.org.