Self-Direction in Older Americans Act Programs
Illinois Governor’s Conference on Aging
December 8, 2011
Chicago, IL
Audience Questions
•How are you encouraging
consumer direction?
•How do you encourage
consumer choice?
2
Title I, Declaration of Objectives
for Older Americans – Sec. 101
• 10) Freedom, independence, and the free
exercise of individual initiative in planning
and managing their own lives, full
participation in the planning and operation
of community based services and programs
provided for their benefit, and protection
against abuse, neglect, and exploitation.
3
Brief Comparative History of LTC
Person Centered/Rebalancing
OAA
Medicaid
1995
Cash & Counseling (RWJF funded
demo with Medicaid)
2001
Real Choice Systems Change
Grants/New Freedom Initiative
2003
ADRC
2005
ADRC
DRA & Money Follows the Person
2006
Reauthorization – added
“self-directed care”
2007
Nursing Home Diversion
2009
Community Living, ADRC,
Care Transitions
ADRC, Care Transition
Title I, Definitions - Section 102
(46) The term ‘self-directed care’ means an approach to
providing services (including programs, benefits, supports, and
technology) under this Act intended to assist an individual with
activities of daily living, in which –
(A) such services (including the amount, duration, scope,
provider, and location of such services ) are planned,
budgeted, and purchased under the direction and control of
such individual;
(B) such individual is provided with such information and
assistance as are necessary and appropriate to enable such
individual to make informed decisions about the individual’s
care options;
(C) the needs, capabilities, and preferences of such individual
with respect to such services, and such individual’s ability to
direct and control the individual’s receipt of such services, are
assessed by the area agency on aging (or other agency
designated by the area a agency on aging) involved;
5
Title I, Definitions - Section 102, cont.
(D) based on the assessment made under subparagraph
(C), the area agency on aging (or other agency
designated by the area agency on aging) develops
together with such individual and the individual’s
family, caregiver (as defined in paragraph (18)(B)), or
legal representative –
(i) a plan of services for such individual that specifies
which services such individual will be responsible for
directing;
(ii) a determination of the role of family members (and
others whose participation is sought by such
individual) in providing services under such plan; and
(iii) a budget for such services; and
(E) the area agency on aging or State agency provides
for oversight of such individual’s self-directed receipt of
services, including steps to ensure the quality of services
provided and the appropriate use of funds under this
Act.
6
Basis for System Change
and Consumer Direction
• Olmstead, 1999 – right to services in least
restrictive environment
• Consumer direction research, e.g. cash and
counseling, show greater quality of life and
services
• States with increased use of HCBS have
decreased overall growth of long term care
costs
7
http://www.kff.org/medicaid/upload/2186-08.pdf,
accessed 11.14.11
Comparisons of Medicaid LTC HCBS Expenditures for A/D
Services and OAA Appropriations
$8,000,000,000
$7,000,000,000
$6,000,000,000
Medicaid LTC HCBS
Expenditures for A/D
Services
$5,000,000,000
$4,000,000,000
OAA Appropriations
$3,000,000,000
$2,000,000,000
$1,000,000,000
$2000
2003
2008
2010
What is the level of utilization of consumer direction?
IL
IN
MI
MN
OH
WI
Consumer
Direction
of Waiver
Services
Allowed?
Pilot programs in
parts of state
Attendant
Care is
available
statewide
via
consumer
direction
Yes for Home
Help
Services;
Four areas of
the state are
serving as
“pioneer
sites” for MI
Choice
consumer
directed
programs
Yes statewide
Four areas of
the state have
a level of
consumer
direction
(known as
“Choices”)
available
through the
PASSPORT
program
The COP-W
allows a level
of consumer
direction for
respite only.
Family Care
and WPP allow
for consumer
direction (IRIS)
Consumer
Direction
in OAA
Services
(1)?
•Title III Respite, in
portion of the state*
•CLP developed in 4
AAAs, building on
C&C program;
developing
VDHCBS programs
statewide
•CLP –
developing
pilots in 2
AAAs
•CLP in 10
AAAs,
VDHCBS
program in 9
AAAs, expect
to expand
both
•Title III
Respite &
Nutrition
•CLP –
screening
tool &
services
statewide,
developing
VDHCBS
site in 1
AAA
•CLP
developed in 1
AAA, expect to
develop
VDHCBS in
several AAAs
•CLP
beginning
development in
1 AAA, expect
to develop
VDHCBS
Data/info from SUA and/or CMS websites unless otherwise noted.
(1) http://www.nasua.org/resources/documents/StatePerspective2009_000.pdf,
accessed 5/10/10, * AW updates as of 5/12/10
10
FY 2009 Title III Expenditures, Regions V & VII
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Illinois
Indiana
Iowa
Kansas
Michigan
Minnesota
Missouri
Nebraska
Ohio
Wisconsin
50 States, DC, PR &
GU
$2,983,347.00
$1,308,495.00
$996,242.00
$1,087,663.00
$3,911,368.00
$798,787.00
$782,223.00
$632,346.00
$10,310,937.00
$1,981,230.00
$110,946,638.00
$276,061.00
$176,836.00
$188,717.00
$46,523.00
$971,193.00
$24,267.00
$162,623.00
$76,216.00
$60,790.00
$188,290.00
$10,524,272.00
$4,732,142.00
$806,619.00
$645,069.00
$761,615.00
$681,132.00
$1,201,411.00
$571,056.00
$269,499.00
$548,561.00
$543,818.00
$56,153,109.00
Title III Expenditures - Nutrition Education
$14,472.00
$11,224.00
$77,194.00
$71,474.00
$0.00
$77,570.00
$0.00
$45,209.00
$67,432.00
$21,706.00
$3,914,260.00
Title III Expenditures - Legal Assistance
$965,631.00
$267,990.00
$205,057.00
$262,530.00
$710,759.00
$592,600.00
$163,308.00
$174,496.00
$751,698.00
$934,605.00
$25,159,734.00
Title III Expenditures - Transportation
$1,626,706.00
$2,801,826.00
$504,709.00
$99,020.00
$465,748.00
$669,199.00
$1,954,158.00
$59,895.00
$3,543,241.00
$962,962.00
$68,731,182.00
$124,055.00
$39,251.00
$129,691.00
$0.00
$159,950.00
$40,359.00
$14,313.00
$11,323.00
$224,750.00
$103,910.00
$3,551,476.00
$0.00
$0.00
$1,560.00
$1,256.00
$984.00
$0.00
$0.00
$88,744.00
$0.00
$47,594.00
$1,368,863.00
Title III Expenditures - Congregate Meals
$10,080,111.00
$6,002,614.00
$4,601,366.00
$2,843,454.00
$7,767,289.00
$3,634,877.00
$4,283,321.00
$2,737,280.00
$6,217,708.00
$4,887,848.00
$263,999,422.00
Title III Expenditures - Case Management
$614,916.00
$489,157.00
$648,735.00
$127,548.00
$1,091,148.00
$0.00
$881,702.00
$103,015.00
$303,079.00
$54,441.00
$31,251,465.00
$128.00
$93,783.00
$128,937.00
$325.00
$0.00
$0.00
$80,194.00
$1,360.00
$634,114.00
$110,201.00
$11,720,327.00
$7,705,524.00
$6,518,004.00
$2,181,678.00
$1,675,917.00
$9,212,010.00
$1,989,079.00
$4,822,349.00
$1,109,716.00
$8,484,831.00
$4,262,041.00
$224,389,217.00
Title III Expenditures - Other
Title III Expenditures - Outreach
Title III Expenditures - Information & Assistance
Title III Expenditures - Assisted Transportation
Title III Expenditures - Nutrition Counseling
Title III Expenditures - Adult Day Care
Title III Expenditures - Home Delivered Meals
Title III Expenditures - Chore
$585,989.00
$51,685.00
$82,743.00
$0.00
$470,406.00
$598,272.00
$0.00
$227,397.00
$132,708.00
$69,053.00
$5,751,463.00
Title III Expenditures - Homemaker
$90,427.00
$727,324.00
$162,314.00
$598,969.00
$1,362,321.00
$81,424.00
$1,018,819.00
$498,947.00
$1,337,634.00
$105,365.00
$28,222,264.00
Title III Expenditures - Personal Care
$0.00
$502,111.00
$24,751.00
$192,841.00
$745,224.00
$0.00
$223,911.00
$106,042.00
$743,603.00
$157,637.00
$11,194,758.00
11
FY 2009 Total Expenditures, Regions V & VII
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Total Expenditures - Other
Total Expenditures - Outreach
Total Expenditures - Information & Assistance
Total Expenditures - Nutrition Education
Illinois
Indiana
Iowa
Kansas
Michigan
Minnesota
Missouri
Nebraska
Ohio
Wisconsin
50 States, DC, PR
& GU
$6,384,140.00
$4,350,817.00
$1,498,756.00
$1,395,744.00
$4,966,472.00
$2,007,177.00
$1,117,280.00
$3,697,360.00
$30,869,754.00
$3,786,133.00
$628,075,077.00
$509,209.00
$241,799.00
$225,108.00
$70,042.00
$1,489,350.00
$28,720.00
$188,740.00
$301,941.00
$115,058.00
$505,883.00
$23,870,848.00
$8,251,440.00
$1,814,461.00
$1,081,478.00
$909,176.00
$1,306,895.00
$1,596,647.00
$802,078.00
$840,794.00
$1,595,619.00
$2,402,397.00
$151,056,284.00
$30,144.00
$11,224.00
$140,454.00
$79,147.00
$0.00
$121,284.00
$0.00
$95,431.00
$77,357.00
$132,106.00
$6,819,614.00
Total Expenditures - Legal Assistance
$2,072,347.00
$470,513.00
$305,331.00
$323,509.00
$939,720.00
$1,283,777.00
$203,466.00
$344,036.00
$1,159,025.00
$3,452,978.00
$50,491,020.00
Total Expenditures - Transportation
$4,853,392.00
$5,340,646.00
$1,609,224.00
$336,621.00
$989,054.00
$2,552,243.00
$3,926,789.00
$1,332,671.00
$15,378,650.00
$5,393,923.00
$199,084,033.00
$463,667.00
$109,250.00
$692,689.00
$0.00
$199,890.00
$171,222.00
$34,160.00
$134,588.00
$645,625.00
$1,175,208.00
$15,143,273.00
$0.00
$0.00
$1,749.00
$1,256.00
$1,093.00
$0.00
$0.00
$110,256.00
$6,538.00
$168,154.00
$3,124,931.00
Total Expenditures - Congregate Meals
$21,518,762.00
$10,208,974.00
$9,980,575.00
$8,781,459.00
$16,107,182.00
$12,550,284.00
$14,055,206.00
$9,372,351.00
$15,628,439.00
$19,648,164.00
$643,914,615.00
Total Expenditures - Case Management
$9,443,080.00
$10,268,470.00
$2,575,862.00
$137,584.00
$10,325,608.00
$0.00
$1,056,260.00
$4,723,989.00
$3,843,261.00
$225,560.00
$264,708,055.00
$128.00
$1,463,427.00
$1,067,047.00
$325.00
$0.00
$0.00
$110,009.00
$1,360.00
$3,718,636.00
$925,624.00
$84,376,140.00
Total Expenditures - Home Delivered Meals
$36,016,912.00
$11,864,694.00
$8,395,500.00
$9,524,594.00
$34,877,479.00
$7,034,065.00
$29,876,166.00
$5,511,613.00
$35,273,240.00
$19,531,148.00
$790,488,569.00
Total Expenditures - Chore
Total Expenditures - Assisted Transportation
Total Expenditures - Nutrition Counseling
Total Expenditures - Adult Day Care
$1,195,096.00
$275,920.00
$323,831.00
$0.00
$708,221.00
$1,927,649.00
$0.00
$615,015.00
$860,451.00
$197,037.00
$21,061,577.00
Total Expenditures - Homemaker
$90,427.00
$5,664,352.00
$232,818.00
$678,957.00
$6,059,552.00
$297,007.00
$1,457,648.00
$1,297,481.00
$3,245,090.00
$150,463.00
$239,661,872.00
Total Expenditures - Personal Care
$0.00
$15,935,453.00
$38,013.00
$321,892.00
$4,537,402.00
$0.00
$265,848.00
$287,552.00
$3,739,903.00
$328,605.00
$270,336,077.00
12
How to implement self-direction in
OAA programs?
• Challenges:
– Reporting – need to report 3B, C1, C2, D and E
expenditures separately
– Service requirements: meals meet DRIs,
matching funds may be going to specific
providers, etc.
– Redirection of funds from existing
programs/models; will be able to sustain existing
programs/models?
– Paradigm shifts in case manager role,
approaches to risk, etc.
13
How to implement self-direction in
OAA programs?
• Opportunities
– Piggyback on already existing programs (e.g.,
Medicaid waiver/services for other populations)
– Look for other ways to increase consumer choice such
as Purchase of Service/All Willing & Qualified
(procurement v. certification) /Rolling Procurement
/Voucher models
– Look for other opportunities to implement self-direction
as way of controlling costs in tight budget times, with a
burgeoning aging population and while increasing
consumer satisfaction (consider doing a cost analysis to
help make your case and/or to see if you would
actually be able to serve more clients by moving
toward self-direction)
– Incremental approaches (look within 3B, C, D or E
programs); new SPR has Cash & Counseling
14
Steps toward self-direction
• Incremental approaches:
– Increasing choice of providers
– Increasing menu of services: may consider
“Flex Service” type of approach
– Increasing choice & control over when
services are delivered, etc. via use of
vouchers
15
45 CFR Part 92.36 relating to
procurement
• AoA does not “approve” procurement
methodologies
• Check with the governing sections of your state
laws and regulations and your state auditor
16
State &/or AAA Level Issues
• State Procurement standards, SUA guidance,
administrative rules, assessment & reporting
tools, abilities & requirements, etc.
• State & AAA – budgeting, intake, capacity,
quality assurance, staff training,
emergency/back-up plans
Note: New AoA SPR Reporting Requirements
being implemented to accommodate selfdirection – what does this mean for your
specific State or AAA level system?
17
Fiscal Management Services
• May be included as a OAA service (reported
as Title III-B, D or E – e.g., Under Other or
Supplemental Services in the SPR, depending
on the types of services associated with the
FMS)
• FMS may be provided directly by the AAA
(with SUA approval) or contracted/granted
out like any other Title III-B service
18
AoA Initiatives supporting consumerdirection
• CLP: This initiative encourages the Aging Services
Network to modernize and transform the funding
they receive under the Older Americans Act, or
other non-Medicaid sources, into flexible,
consumer-directed service dollars.
• VDHCBS: The VDHCBS program will provide veterans
the opportunity to self-direct their long-term
supports and services that enable them to avoid
institutionalization and continue to live
independently at home.
• May be elements in CIAIP, ADSSP and Lifespan
Respite grants
19
Resources
• National Resource Center for ParticipantDirected Services:
http://www.bc.edu/schools/gssw/nrcpds.ht
ml
– E.g., “Developing & Implementing Participant
Direction Programs & Policies: A Handbook”
• NASUAD Report - State of Aging: 2009 State
Perspectives on State Units on Aging Policies
and Practices:
http://www.nasuad.org/documentation/nas
uad_materials/StatePerspective2009_000.pdf
20
Contact Information
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES ADMINISTRATION ON AGING, Regions V & VII
Amy Wiatr-Rodriguez, Aging Services Program
Specialist
amy.wiatr@aoa.hhs.gov
312.886.8536
www.aoa.gov
State of Illinois
IDOA Perspectives on
Consumer-Direction in
Older Americans Act
Programs
Contact Information
Illinois Department on Aging
Betsy Creamer, Planning Supervisor
Betsy.Creamer@illinois.gov
217/524-7944
http://www.state.il.us/aging/
Consumer-Directed Respite
Experience of
Area Agency on Aging
of Southwestern Illinois
Consumer Directed Respite
Program Design
• Caregiver is assessed by a care manager
• $100 to Caregiver directly in reimbursement
• Caregiver hires whomever they want, as
long as they are over 18 and do not live in
the same house
• Flexible for case-by-case exceptions
• Area Agency handles administration
Program History
• Program began January 1, 2003
– December 2002 served 13 people, 132 hours @
$13.00 per hour
– January 2003 served 35 people, 350 hours @
$6.55 per hour (average)
– By September 2003, serving 84, 1,194 hours @
$6.35 per hour (average)
– In ten months
• Hours of utilization up 800%
• Cost per hour down 51%
• Increased service to 71 people, 546%
Caregivers
• 2002 – 39 (Prior to
Redesign)
• 2003 – 143
• 2011 - 162
Hours of Respite Provided
• 2002 – 969 (Prior to
Redesign)
• 2003 – 8,202
• 2011 – 15,920
Challenges and Surprises
Challenges
• Perceived Misuse
• Taxes
• Administration
• Budgeting
• Monitoring usage
• Caregiver calls about
payment
Surprises
• Not using the entire
$100
• Higher than expected
use of formal agencies
• High rate of and
reasons for attrition
– Death (52)
– Nursing home
placement (30)
Demographics of Caregivers
Age range of Caregivers 38-96
• 30% 38-59
• 8% 80+
• 62% between the ages of 60-79
Relationship of caregiver
• 52% Spouse
• 35% Daughter
• 13% Son
Unsolicited Caregiver Quotes
• “My husband has Parkinson’s and I’m able to afford an
extra day of day care every week. This is allowing him to
stay at home instead of going to a nursing home.”
• “Thanks again, very much. I’m able to do the honey-do list,
that my honey isn’t able to do. I have enjoyed being able
to visit with my girls, instead of running every time they
come or giving them lists to do.”
• “My mother, Agnes, passed away on January 21, I want to
thank you for the respite service. The program gave me
some time I needed and even help here the last few days
Mom had here at home. Thank you.”
83% of caregivers using respite said in a
survey the program allowed them to care
for their loved one at home instead of
Nursing Home placement
Contact Information
Area Agency on Aging of Southwestern Illinois
Joy Paeth, CEO
jpaeth@answersonaging.com
1-800-326-3221
www.answersonaging.com
Questions?