What’s the Status of
Long-Term Care
Rebalancing?
March 9, 2006
videoconference
History of Long-Term Care Reform
Project 2030
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Two-year project (1997-1998) housed within
DHS and in partnership with MBA.
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Engaged public and private groups to answer
two questions:
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What does the aging of the state’s population
mean for Minnesotans?
What do we need to do now and in the future to
prepare – individually and collectively?
History of Long-Term Care Reform
Long-Term Care Task Force
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Composed of State Legislators and
Commissioners of Health, Housing Finance
and Human Services Departments.
Met during 2000 to develop
recommendations for reform.
Key recommendations were implemented in
the following legislative session.
History of Long-Term Care Reform
Long-Term Care Financing Study
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The 2003 MN Legislature called for a study of
long-term care financing options.
Looking for a new mix of public and private
approaches to financing long-term care.
Recommendations focused on private
financing options available to individuals as
well as system-wide efforts to meet future
challenges in the financing of long-term care.
Current Effort
Transform 2010
“Hurricane” Alert!
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We know the Age Wave is coming.
We know our communities are not prepared.
Hurricane Strength Predictions:
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Category 3: predicted to hit our state in 5 years
Category 4: predicted to hit our state within 15 years
Category 5: disaster strikes within 25 years without preparation
State of emergency has been declared.
No emergency communications plan.
No alternative plans until disaster is here.
Transform 2010
Intensify the state’s efforts to prepare for the
coming age wave in Minnesota.
 Special partnership with MDH and MBA
 Working with 10 other state agencies too
 Identifying key strategies for action at the
state, community and individual levels

Current Effort
Transform 2010
Examples of the Age Wave in Minnesota Counties
 Anoka County
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Relatively young - 7.1% is age 65+
In 2030, that percent will increase to 17.1%
Caregiver ratio is 5.8 now, will be 14.6 in 2030
Traverse County
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Smallest county in state by population (4,134)
Already experiencing the Age Wave
(26.2% of population is 65+)
In 2030, that percent will increase to 31.6%
Caregiver ratio is 49.1 now, will be 52.2 in 2030
Current Effort
Transform 2010
Some preparation for the hurricane has occurred.
Over the past five
years, we have
taken steps to
control utilization
and costs of public
programs.
However,
we must
pick up the pace
and
broaden our efforts
to be prepared
for the full impact
of the hurricane.
Current Effort
Transform 2010
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Regional Meetings in January 2006.
More than 1,000 people attended and
provided their input regarding strategies to
prepare for the aging population.
Notes for each meeting are available on the
DHS Transformation website:
www.dhs.state.mn.us/2010
Then click on “2010 meetings”
Transform 2010
Next Steps

Focus groups with tribal organizations and
ethnic and immigrant communities
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Citizen Workgroups
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Meetings with state legislators
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City-level Transform 2010 meetings
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Regional and county data profiles
Transform 2010
Demographic Data
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Older Adult Population Projections
Older Adult Population Estimates by Race
and Ethnicity
Elderly Dependency Ratio
Percent of Older Adult Population Living
Alone
Family Caregiver Ratio
Percentage of 85+ by County 2000
Percentage of 85+ by County 2030
Elderly Dependency Ratio by County 2000
Elderly Dependency Ratio is the ratio of 65+ population to the 1564 population
Elderly Dependency Ratio by County 2030
Elderly Dependency Ratio is the ratio of 65+ Population to the
15-64 Population
Percent 65+ Living Alone by County 2000
Percent 65+ Living Alone by County 2030
Transform 2010
Benchmarks
Total Public Long-Term Care Expenditures on Institutional vs.
Home/Community-Based Services for the 65+ Population
in Minnesota
Fiscal Year
Percent Nursing Home/
Percent HCBS
2000
88 / 12
2001
86 / 14
2002
84 / 16
2003
80 / 20
2004
79 / 21
Transform 2010
Benchmarks
Percent of Older Adults Served in Elderly Waiver and
Alternative Care Programs with Higher Care Needs
Fiscal Year
Total AC/EW
Clients
Total NonCase Mix A
Percent NonCase Mix A
2000
22,392
7,985
35.7%
2001
22,991
8,125
35.3%
2002
24,350
9,049
37.2%
2003
25,435
10,099
39.7%
2004
25,566
10,820
42.3%
Transform 2010
Benchmarks
Nursing Home Beds per 1,000 Older Adults
Calendar Year
State Beds Per
1,000 65+
State Beds Per
1,000 85+
2001
69.69
483.8
2003
65.7
431.4
2005
60.4
378.6
Consumer Focus

Increased effort to get input from consumers
on what they want for their long-term care
needs
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Consumer Experience Survey of recipients of EW
services as part of our overall quality effort
Survey of sample of residents in all nursing
facilities in the state – on quality of life and
satisfaction
Consumer Focus
Consumer Experience Survey
 363 Elderly Waiver consumers interviewed by DHS
staff and ombudsman volunteers in the summer of
2005
 Interviews conducted in consumers’ homes
 Provided direct consumer feedback on what types of
services they use, who gives them the most help,
and if they are satisfied with how things are going in
their lives
Consumer Experience Survey
Results
General Results
 Seniors living in the community on EW
generally are happy with where they live and
feel safe in their homes
 1 in 5 consumers cannot get to the places
they need to or want to go
 3 in 10 consumers are not as socially active
as they want to be
Consumer Experience Survey
Results
Daily Living
 Consumers get the most help with laundry and
grocery shopping, which seems predictable for
people with mobility and transportation challenges
 Over half of interviewees have someone set up their
pills and medications for them
 Over half of consumers get help with taking a bath
or shower

Consumers also indicate that they have the most trouble
getting a bath or shower when they want to
Consumer Experience Survey
Results
Caregivers
 Informal caregivers
(family and friends)
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More consumers get help
from their daughters than
anyone else at 27%
Informal caregivers give
the most help with
transportation and
getting groceries or other
shopping done
Quality of Care from Informal Caregivers
(n=194)
Good, 44,
23%
Fair, 3, 2%
Excellent,
147, 75%
Consumer Experience Survey
Results
Caregivers
 Paid staff: Consumers in general are pleased with
the service they receive from paid staff
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There is room for improvement in terms of scheduling –
coming when they are supposed to and spending enough
time with the consumer
1 in 10 consumers report that changes in staff have been a
problem for them
Three-quarters of respondents report that they did not help
to choose the people who are paid to help them
The most common person to call when an EW consumer
wants to change or complain about their services is their
county case manager, at over 40%.
Consumer Experience Survey
Results
• 57% of consumers say
that their life is better
because of the help they
receive. An additional
39% say that their life is
about the same as it
would be without the help
they receive
Overall quality of paid help, n=310
Good
36%
Fair
3%
Excellent
61%
Consumer Experience
Survey Results
Case Management
In the last year, how often has a case manager
contacted you?
More than
once a month,
31
Every few
months, 147
About once a
year, 66
About once a
month, 44
Don't Know,
39
0
50
100
Number of respondents
150
200
Consumer Experience Survey
Results
Case Management
 92% of interviewees either said that their case
manager had solved a problem that they told them
about, or would help them if they reported a problem
 About 50% have not talked with a case manager
about special equipment that could make their life
easier
 60% have not experienced a change in case
managers. 23% have experienced a change, but it
was not a problem for them
Consumer Experience Survey
Final thoughts
 85% of consumers say that their life is better
because of the help they get
 About 10% of interviewees said they needed
more help or services than they are currently
getting
Consumer Experience Survey
Future plans
 DHS plans to do the Consumer Experience
Survey every other year as part of an overall
quality improvement plan
 DHS will work with counties, tribes, and
health plans to develop consumer surveys
that they can use on their own as well
Survey of Nursing Home Residents
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First ever survey of NH residents on quality of life
and consumer satisfaction in Minnesota
First done in spring and summer of 2005
All nursing homes in the MA program – 400
Sample of 13,000 people
Face-to-face interviews – all ages
Excluded only most severely cognitively impaired
residents
55 questions focusing on satisfaction
Domains Included in NH Survey
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Autonomy
Comfort
Satisfaction
Dignity
Environmental
adaptation
Food enjoyment
Individuality
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Meaningful activity
Mood
Privacy
Relationships
Security
Spiritual well-being
Survey of Nursing Home Residents
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Used in nursing home report card
www.health.state.mn.us/nhreportcard
Went live on January 20, 2006
Got 75,000 hits the first day
Gaps Analysis
Home and Community-Based Services
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Follow-up survey to 2001 and 2003 gaps
analyses by counties
76 counties responded between August and
October 2005
Information will be used to help AAAs, DHS,
and counties to develop long-term strategies
for planning and development around longterm care services
Gaps Analysis
Home and Community-Based Services
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Home and Community-Based Services
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Generally adequate around the state
Counties expressed concern about the migration
and integration of HCBS into managed care
17 counties reported services in surplus, including
in-home respite services, Assisted Living, Adult
Day services, Grocery Shopping, and Adult Foster
Care
Some communities expressed the need for these
services in their communities. This underscores
the point that all service development is local, and
that the needs of individual communities are
different.
Gaps Analysis
Home and Community-Based Services
Inadequate or Unavailable HCBS
Homemaking
10
11
11
11
11
12
Service
Home Mods
Home Delivered Meals
Guardianship
14
19
Companion
25
27
Chore
30
32
Transporation
35
0
5
10
15
20
25
Num ber of Counties
30
35
40
Gaps Analysis
Home and Community-Based Services
Sufficient service/program flexibility to meet changing consumer expectations for more choice and
personal direction
Adequate
Inadequate
Unavailable
61
18
1
76%
23%
1%
56
15
9
70%
19%
11%
52
25
3
65%
31%
4%
68
12
-
85%
15%
-
64
16
-
80%
20%
-
25
55
-
31%
69%
-
Capacity for quality assurance and consumer protection in private homes and apartments
Cultural competence in health and support service systems to adequately meet needs of minority
elderly and disabled
Access to information and assistance for all persons (regardless of income) to make informed
choices about long-term care
Communication patterns and referral protocols between health care and long-term care providers to
maximize care coordination
Workforce necessary to meet local health/LTC industry and market needs
Gaps Analysis
Home and Community-Based Services
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The biggest concern amongst counties is
having the necessary workforce to meet longterm care needs. This concern is consistent
and clear, and spans both facility-based and
home-based care.
Counties also expressed concern about their
changing roles in regard to managed care
and waiver services.
Gaps Analysis
Housing Options

82% of counties responded that there has
been new development of senior housing or
housing with service arrangements in the last
2 years.
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211 buildings with about 5,100 new units across
the state.
CS/SD or other state grants helped in this
development.
Gaps Analysis
Housing Options
Overall Housing Supply
Surplus/underutilized
10.0%
Adequate
57.5%
Inadequate
32.5%
Gaps Analysis
Housing Options
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Over half of counties think that their overall housing
supply is adequate
Two-thirds of counties reported that there are
housing options in short supply
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Subsidized rental apartments with services and Adult
Foster Care in greatest need
Other housing concerns
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Lack of sufficient affordable housing
Converting existing homes and buildings into accessible
living situations
Changes to Alternative Care funding for assisted living.
Need for providers to house and serve persons with high
and complex needs
Gaps Analysis
Nursing Homes
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Three-quarters of counties rate their overall
supply of LTC nursing home beds as
adequate.
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Still a significant need to develop certain types of
beds, including dementia care and heavy
care/complex medical management.
The major issue in Nursing Homes in the
concern over adequate workforce to meet the
needs of the population.
Consumer Directed Community
Supports (CDCS)
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Helps older adults needing assistance
live independently at home.
Allows the consumer to be in charge
of services that help them live at
home.
Wraps services around the person
instead of fitting the person into the
services.
Changing Focus
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From being system-focused (current
paradigm)
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Rules prevail
Experts “know best”
Consumer lacks direct control over needed
supports
To person-centered (CDCS)
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Consumer along with family and friends are
“experts”
Consumer gains control over resources
Plan based on personal preferences and priorities
CDCS
appeals
to
those
who:
Want more control over support and services
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Are willing to accept the responsibility for planning and
directing their support and services
Want more flexibility
Want consistent, reliable and typically relationship-based help
Want to hire a spouse, parent of a minor, family member,
friends, neighbors
Want to use a therapy that is an alternative to those available
through Medical Assistance
Have special dietary needs
Need equipment and supplies directly related to their
disability/health and safety that are not fundable through any
other waiver service or straight Medical Assistance
Research Findings on
Consumer Direction
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Consumer direction increases satisfaction
More people receive paid care – overcome
worker shortages
Fewer total hours of care provided
Works for older adults as well as disabled
No adverse health outcomes
Programs need to help consumers with steps
necessary to receive allowance
Transform 2010
Examples of Suggestions for Action
Preparing for Retirement and Old Age
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Make saving easier by requiring automatic (not voluntary)
“opt-in” to retirement plans at work
Provide tax incentives to employers that offer retirement
planning services
Redesign retirement, employment and health benefit
policies to align better with dramatic changes underway in
retirement patterns, pensions and health care benefits
Transform 2010
Examples of Suggestions for Action
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Preparing for Retirement and Old Age
Governor should send a letter to Minnesota households
with persons ages 40-70 urging them to start planning for
retirement and long-term care
Develop state-sponsored long-term care insurance-like
program that includes a large risk pool and provides basic
LTC coverage for all participants
Rethink current design of health insurance in order to
address needs of those unable to get affordable coverage
through traditional sources, e.g., early retirees, those in
career change, volunteers, employees of small businesses
and nonprofits
Transform 2010
Examples of Suggestions for Action
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Leading Healthy Lives
Provide information and education on benefits of
healthy living to all age groups. Model after nosmoking campaign.
Increase financial incentives for healthy living, e.g.,
reduced health premiums, individual health
assessments, use of community centers, schools
malls for exercise and education.
Transform 2010
Examples of Suggestions for Action
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Supporting Family Caregivers
Provide information in a variety of ways, including
establishing local caregiver resource centers in
every community
Provide financial incentives to family caregivers
Increase number of elderly-friendly employers
Increase use of technology by family caregivers
Beef up state’s adult protection system at all levels
Transform 2010
Examples of Suggestions for Action
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Supporting LTC Workforce
Recruit older workers retiring from career jobs into health
and long-term care positions
Increase use of technology to change nature of work
Create more opportunities for contact between young and
old
Make LTC jobs a more viable career choice
Transform 2010
Examples of Suggestions for Action
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Creating Healthy and Livable Communities
Set goal that by 2015, 50% of all Minnesota
communities will include essential components of a
livable community
Create state imitative focused on providing
incentives to communities to become livable
Re-establish MN Board of Innovation and
Cooperation to provide grants or cut red tape on
projects that build livable communities
Transform 2010
Examples of Suggestions for Action
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Improving and Integrating Health and LTC
Maximize use of technology to improve continuity of
care, e.g., electronic health records
Change reimbursement to support integration of
health and LTC in both Medicare and Medicaid
Allow longer appointments for physicians caring for
elderly with multiple conditions
Integrate geriatric training into the training
curriculum of all health professionals
Discussion of State and Local
Strategies
Pick a theme and discuss barriers to action
on this theme in your community and identify
most creative solutions to address them
(state and local)
OR
 Within a theme, what needs to happen at the
local level to successfully implement the
strategies?
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Resources for Systems Change
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CMS Promising Practices
www.cms.hhs.gov/PromisingPractices
Administration on Aging
www.aoa.gov
Visiting Nurse Service of New York
Center for Homecare Policy & Research
www.vnsny.org/research
Community Partnerships for Older Adults (RWJF)
www.partnershipsforolderadults.org