Rebalancing under Money Follows the Person
In his mid-term budget, Governor Malloy continues his support of the Money Follows the Person (MFP)
Rebalancing Demonstration. Under MFP, the federal government encourages states to reduce their
reliance on institutional care for Medicaid recipients by transitioning individuals out of institutional
settings and into community settings with appropriate supports. DSS receives enhanced federal
Medicaid reimbursement for the first year of an individual’s transition. Last year, Governor Malloy
proposed a significant increase in the number of transitions under MFP, from the original goal of 700
transitions to over 5,200 transitions by 2016. This year, the Governor is proposing a number of
initiatives to further strengthen the rebalancing efforts under MFP.
Governor Malloy recognizes the need to move away from past practice of over-reliance on institutional
long-term care settings and create a system that better supports consumers’ informed choice. By
aligning long-term services and supports with consumer choice and control, the state will not only
improve the quality of life for Medicaid participants by providing options but also reduce unnecessary
expenses and institutionalization.
For the six month period ending December 2010, Connecticut accounted for 30% of the total cases
nationally that did not result in transitions to the community because care plan costs exceeded the
individual’s institutional costs under MFP. While the cost of medication administration is not the only
cost driver, it is one of the primary cost drivers and one of the primary barriers to community
placement. Governor Malloy’s budget includes four initiatives that will strengthen the state’s
rebalancing efforts by reducing the high cost of medication administration and aligning the state’s
medication administration policy with the principles of person-centered planning and consumer choice.
These initiatives will result in savings of $20.5 million in FY 2013 by: (1) reducing the reimbursement
rate for medication administration, (2) allowing agency-based personal care assistants (PCAs) to
administer medications in the home, similar to the PCAs under the PCA waiver where the care is selfdirected, (3) permitting nurses at home health agencies to delegate administration of medication to
home health aides, and (4) allowing clients to gain a higher level of independence at less cost by utilizing
assistive technology such as medication reminders and automatic pill dispensers when it is costeffective. In addition, waiver provider staff will be cross-trained so that providers can serve all
consumers of long-term services and supports and statewide training on informed choice and personcentered planning will be developed and implemented for long-term services and supports staff.
The Governor’s budget reflects the addition of Adult Family Living under the Connecticut Home Care
Program for Elders and the Personal Care Assistance (PCA) waiver. The addition of this service will help
strengthen the state’s rebalancing efforts by providing a cost effective alternative to clients, who are
institutionalized or at risk of nursing home placement, and in need of care and/or supervision on a 24hour basis. The budget also reflects the addition of Independent Support Broker to the menu of services
available under the PCA waiver, which will allow more persons under the age of 65 to have access to
long-term services and supports in the community. These individuals will have the opportunity to
experience a higher quality of life in the community while also reducing the state’s costs since these
individuals will be served at a lower cost than if they were to remain institutionalized.
The Governor’s budget also includes $300,000 to create a standardized level of care -process across
long-term services and supports. Funds will support the design, development and implementation of
the new standardized process, which will include the development of an automated needs assessment
tool, pre-screening tool and care plan budget methodology. Needs assessments will be coordinated
with institutional settings and the "Minimum Data Set" (MDS) assessment, which is part of the federally
mandated process for the comprehensive assessment of all nursing home residents. Greater
standardization of long-term care assessments will promote greater administrative efficiencies and
increased equity.
For the state to be successful in meeting its rebalancing goals, additional efforts in the area of workforce
development need to be undertaken. To ensure that the number of direct care workers is sufficient to
meet the anticipated demand for services, the long-term services and supports workforce needs to be
sustainable, valued, and skilled. To strengthen the state’s direct care workforce, the Governor’s budget
includes $400,000 to (1) develop a marketing plan to increase awareness of the opportunities for direct
care workers; (2) provide job assistance and re-training; (3) fund training programs at community
colleges; and (4) create incentives tied with marketing to attract potential workers to direct care.
Governor Malloy recognizes the importance of housing in allowing individuals to transition back to the
community and in keeping individuals in the community in the first place. The Governor’s budget
includes $1.0 million in bond funds for modifications of existing housing. These funds, administered by
DECD, will create additional accessible housing, allowing individuals who are institutionalized to
transition to their family homes or apartments which are not currently accessible.
Consistent with the goals of rebalancing but not directly part of the MFP initiative are several other
initiatives, the Governor is including in the budget. The Governor is recommending $12.5 million in
capital funding to re-invigorate the state’s congregate housing program, which has been successful in
promoting aging in place and preventing premature institutionalization of the growing elderly
population in the state. Unfortunately, there has been no new state funding for congregate facilities in
Connecticut for eleven years. The $12.5 million capital investment proposed by the Governor will
provide grants or loans for the development of approximately 50 new units of congregate housing for
frail elderly persons. In addition to the capital funding, the Governor proposes $405,000 in operating
subsidies for the new congregate units to provide rental assistance for those tenants who pay no more
than 30% of their adjusted gross income toward rent and for core services such as one main meal a day,
housekeeping services, and a 24-hour emergency service to enable semi-independent living in a
residential setting. The Governor’s proposal to expand the state’s congregate living program will allow
elderly residents to age comfortably in their homes and prevent many of them from premature
placement in a nursing facility. At a low average per month cost of assistance in congregate facilities of
$675, the state will avoid the costs associated with providing the necessary care to these individuals in
skilled nursing facilities of nearly $6,000 per month. In addition, Governor Malloy is recommending
expanding the Private Pay Assisted Living Pilot. This program subsidizes the service costs for persons
age 65 and older who reside in participating private assisted living communities and who are eligible for
the Connecticut Home Care Program for Elders. Currently, the pilot can serve a total of 75 individuals,
who, after living in a private assisted living facility, have spent down their assets and now require help
with their living expenses. The Governor is proposing to increase this pilot from 75 to 125.
Hospital discharges are also important in keeping individuals out of nursing facilities in the first place. In
Connecticut, approximately half of the persons requiring long-term care after hospital admission are
currently discharged to nursing homes while the other half are discharged to the community. For
vulnerable populations, being discharged to a nursing home often leads to permanent
institutionalization and loss of community ties – only a third of Medicaid participants who are
discharged to a nursing home eventually return to the community. More discharges to the community
would occur if there was ready access to information on the availability of home and community-based
services. To address this need, Governor Malloy’s budget includes $250,000 to create a web-based
information system, which will facilitate the transition of care from the hospital to the community by
promoting individualized, person-centered planning. This system will work in conjunction with the prescreening initiative described above.
Finally, with the vast majority of people preferring to receive services in their homes and communities
rather than in institutions, the demand for home and community-based services is expected to grow
significantly over the next decade. Recognizing the shift away from institutional care, Governor Malloy’s
budget includes $10 million in bond funding and $3 million in general fund support to help nursing
facilities “right-size” by diversifying, downsizing and/or modernizing. The new funding will help nursing
facilities diversify their business model consistent with the state’s strategic right-sizing plan.
Consistent with his goal to provide diversification opportunities, the Governor’s budget includes $2.6
million in partial year funding to support the development of nursing home capacity for a new
population and to cover anticipated costs to the Medicaid program. The Departments of Mental Health
and Addiction Services and Correction, in collaboration with the Department of Social Services, is issuing
a request for proposals to identify nursing home level of care for clients under state care who are
difficult to place. These individuals may be transitioning from a correctional facility, have criminal
justice involvement and/or transitioning from a higher level of care provided by DMHAS. Proposals are
being sought from organizations who are presently providing skilled nursing care and are interested in
reorganizing their present business model to afford this population accessibility to long-term nursing
home care.