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State agency seeking changes to keep poor elderly and disabled at home and out of institutions

There was a time when most Minnesotans with developmental disabilities lived in state hospitals and most ill elderly in nursing homes.

Lucinda Jesson
MinnPost/James Nord
Lucinda Jesson

However, for the last many years, there's been a trending away from institutional care, including the closing of state hospitals and the downsizing in the number of nursing home beds. Institutional care has become more the exception rather than the norm. Home and community-based services have proliferated in Minnesota, helping people stay out of institutions and in their own homes.

All of which helps explain why Human Services Commissioner Lucinda Jesson and her department are busy these days trying to turn Medical Assistance — Minnesota's version of the federal Medicaid health-care program for the poor elderly and the disabled — on its head.

The department will be asking the federal government for changes — a "global waiver" — which, if approved, would change how the state can spend federal human-services funds. The redesigned MA approach, supported by the Legislature as well, takes a more flexible approach.  

Loren Colman
Loren Colman

The waiver request would ensure nursing-home care for persons with the "greatest needs,'' while more easily providing home or community-based services to persons with "lower care needs,'' according to DHS.

Also according to the department, in fiscal year 2009, 557,000 Minnesotans received Medical Assistance, the state's Medicaid program for low-income seniors, children and parents and people with disabilities.

The current system is unwieldy. "What we have ended up with now is a system that no one in their right mind would ever design. It is a system by exception," says Jesson.

"We want the right amount of government services going to the individual at the right time in the right setting, instead of one-size-fits all," explains Loren Colman, assistant commissioner and a department veteran.

"We've been a leader in developing these services," he says, adding that in 1995 only 30 percent of the disabled under age 65 and receiving publicly funded care lived in the community. Now 94 percent of that group do. "Now what we want to do is make community-based care the standard," depending on an individual's choice as well as safety concerns, Colman says.   

Click on chart to enlarge.

MinnPost talked with Jesson for details:
 
MinnPost: Minnesota wants to reform Medical Assistance, Minnesota's version of the federal Medicaid program that is funded jointly by state and federal governments, and to do that the state has to apply to the feds for a waiver.  What is this about?

Lucinda Jesson: What we're trying to say to the federal government is, "Look, we want a waiver to basically redesign the whole thing, from start to finish. Basically, what we'd like to do is to shift the paradigm. Right now Medicaid pays for institutional care and we'd like to basically turn that on its head and say we'd like Medicaid to pay for home and community-based services [first]...because that's what we think people want, to stay in their homes and communities.   

MP: According to the "MA Reform Overview" released by your department this month, this means a "redesign of home and community-based services to better meet the needs of older people and those with disabilities who would otherwise be in nursing homes, hospitals or other institutional settings."

LJ: Now, Medicaid pays for institutional care or it pays for home services through five different waiver programs. Originally Medicaid rules wouldn't pay to keep you out of a nursing home, so, basically Minnesota asked for waivers from the federal requirement that only pays for nursing homes.

MP: Is that a problem?

LJ: We have a series of exceptions for different populations…that have gone into place over the course of the last 20 or 25 years. What we have ended up with now is a system that no one in their right mind would ever design. It is a system by exception. Right now we have five exception programs and they are incredibly complex. I'm a lawyer and I find it hard to know which programs covers which population. What we're trying to do is step back and say, "How would we create a system that's easier to access and better serves our people in Minnesota today?"

Click on chart to enlarge.

MP: This would be a Minnesota plan?

LJ: Yes. Minnesota is ahead of most states. Right now the way it works, to get into a waiver program, you have basically to get on a waiting list. Basically, what we would like to propose is enabling more people to be served at their level of need, to save the intensive services for those who need them the most, to have more services available for those who need them in homes and the community. Ultimately we think this may save us money.

MP: What are some of the home and community-based services you are talking about?

LJ: It's everything we do to keep people in their homes, people at risk otherwise to be in an institution. For example, for seniors, doing Meals on Wheels, or having someone help do chores or having personal care attendants. For individuals with disabilities, it may also mean supported work to help them have appropriate jobs. It includes respite services for care providers. If you think of all the things, if someone is in precarious health, what do we need to keep them at home rather than put in an institution? Generally it costs three times as much to have someone in a nursing home than to have them cared for in their home.    

MP: Why do this?

LJ: We think this is the right thing to do because we can serve people better. We think we can also potentially save money. But we know we can serve people in a fair, more equitable way.

MP: Do you have some specific examples, some people stories?

LJ: I was talking to a family with a young adult son with a disability. They were taking care of him at home and wanted to take care of him but he got into a program [that enabled him to] go out and get a job and maybe get into a place of his own. The parents were relieved. They want to be involved in their son's life but realize they're not going to live forever [and didn't want him institutionalized].

MP: What's the time line on this proposal to the federal government?

LJ:  People in long-term care in the community have been working on this for several years, involving stakeholders and families. We hope to have a proposal for the federal government in early 2012. It's a tight timeline. It would be hard if we hadn't had a lot of work on this already.

(She said the public will also be invited to comment later this fall.)

MP: How long will it take the federal government to respond?

LJ: We will urge the federal government to move quickly on the things they can move quickly on. I would hope it's completed within a year.    

MP: What about accountability and supervision of these programs, which would be based in the community or homes rather than in nursing homes or hospitals, for instance?

LJ: That is a very serious concern. We are addressing this. We just created an Office of Inspector General. That person's primary job is to prevent and detect health care fraud and abuse. We don't think the answer is to stop doing home-based services.   

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Comments (4)

Very nice to see support for the elderly who want to remain in their homes. My mother is disabled, but she's able to remain at home thanks to a wonderful homecare agency. They utilize ClearCare's care management software, which gives me such peace of mind. I can check on my mom anytime by logging onto ClearCare's website. I get real-time updates when my mom receives her meals and medication, and also get alerted if the caregiver isn't at her house on time. I'm a firm believer the elderly do better at home so hopefully more states will follow your example!

A fine idea which should be applied nationally; disability advocates have been fighting for this for years through proposed legislation called the Community Choice Act:

http://www.adapt.org/cca

Unfortunately, they have not yet been successful. I do not understand why anyone would be against improving a system so that it both saves money AND provides better services. It's completely illogical.

This system would be wonderful and could already be in place in Minnesota but for health plans such as UCare and BluePlus. These companies direct the care of many of our seniors from their desks in the metro area. For the most part service providers doing home health care have the best interest of the elderly in mind and have the goal of keeping the senior out of the nursing home,if it is a safe environment that they live. Health Plans on the other hand would rather save the money that could be paid to the health care provider to pad their own pockets. If the dollars that the State pays the Health Plans to provide the service,to the senior citizen, went for their care at home, the Health Plans would not be having to return those premiums to the state, as they are now. Many times in our agency we are denied in providing services by a person who has never been in this persons home nor has any idea of the circumstances of the elderly persons life.
I do hope that if we go to this "New Medical Assistance" changes really do assist the elderly in remaining in their own home and that is not just a sound good program.

Amen, Pat Stewart (#3).

The right way to do this would be for this to be a public program with the State as the only payer/insurer, with all payouts made to the actual providers of care. Otherwise, the HMOs will attempt to place their profits (oh, sorry, their reserves and exec. compensation) above the purposes of the program, with their reserve funds continuing to grow and provide investment income FAR beyond any possible need.

We do not need intermediaries and would save billions upon billions by dispensing with them.