Wednesday, November 2, 2011

Assisted Living Facilities Regulatory Oversight and Reform

The Florida Legislature has been working hard on crafting proposals that would reform the health quality assurance system that provides regulatory oversight of quality and care that Floridians receive in state licensed assisted living facilities.

The current survey system now in use by the Agency for Health Care Administration has evolved over the last 30 yrs and was derived from the hospitals and nursing homes which are themselves medical models of care that require a citation driven deficiency model survey.

The major question for policy makers during the 2012 legislative session will be to answer one fundamental question; "If Florida were to purchase a new health quality assurance system today, would we buy the one we have today?"

It is my view that the current system is outdated and no longer serves the long term public policy interest of the state's need to have a cost effective system that provide regulatory oversight and contributes to the development of a robust system of ALF care that can meet the challenge of rising acuity.

Two major forces are underway that will create a need for substative change in how state's regulate assisted living facilities. As many states seek to manage their long term care costs many will seek to adopt policies that will place more people into managed care plans.

We know from Florida's experience with the nursing home diversion program that 50% of the placements in these long term care managed care plans are referred to assisted living facilities. It is a reality that the ALF can provide a comparable level of care due to a lower cost structure than the nursing home and managed care plans will increase their utilization of ALFs in Florida and should be expected to ask ALFs to do more and manage residents with higher levels of acuity.

The second major driving force that will affect assisted living facilities is the issue of rising acuity. It is expected that as the nation begins to age both the elderly and the adults with mental illnesses will begin to experience a rise in chronic medical conditions which impact on the rise in acuity that must be managed in the ALF.

The currentsystem now in use in Florida only focuses on the facility and not the system of care. The reality is the ALF only provides the residential function and some supportive services and DOES NOT provide medical care or clinical supervision. It is important how the clinical supervision is rendered and this is why any new system created should focus on the "system of care" that is in use as opposed to the narrow focus on the facility.

The basic elements that really matter most in my view to ALF residents and their families include the following;

1. Qualifications and involvement of the administrator.

2. The relationship between the frontline staff and the resident.

3. The presence of a well coordinated 'system of care" that promotes scheduled care over crisis care.

4. Collection of information on changes of condition and the speed with which information is linked to key decision makers in the system of care.

House Bill 397 by Representative Fresen is a real move towards a consultative model that includes a regulatory hammer for low performing facilities. It calls for higher standards for ALF administrators and creates a RFP for a statewide data collection system that can be useful in forecasting trends in resident care.

The need for real reform in how we consider or weigh the options for improvements to the oversight and regulatory system will play a critical role in how sucessful Florida will be in meeting the new challenges associated with an aging population and growing numbers of the mentally ill who need assistance in the next ten years.

Sunday, November 7, 2010

Medicaid Changes on the Horizon

The election of Rick Scott as the new Govorner for Florida will usher in a new era of changes for health care. It is expected when lawmakers return to Tallahassee on November 16th for the re-organization session that they will call a special session to override some vetos and among other things take up a memorial that will detail principles for Medicaid Reform.

The reform of Medicaid is needed, but the current reform plans have fallen short in deliverying on the promise of managing care. It is generally well known that the managed care plans focus most of their attention on managing inpatient care costs and the pharmacy costs, these are the two largest drivers behind costs so rightfully they garner the greatest attention.

Last year Sarah Hunter was found deceased in her HUD apartment in Fernandina Beach, she was deceased for almost ten days. The records show that over seven abuse reports were filed with the Department of Children and Families regarding self neglect and her failure to care for herself. Ms. Hunter had over 67 admissions to the hospital setting during the two years she lived in her apartment.

You see Sarah Hunter lived at our facility in Hilliard ( Dayspring Village) for two years prior to being relocated to her own apartment with her roommate. Sarah was stable and was sober when she left Dayspring Village. She no longer needed the hospital and was doing exceptional in all areas. Sarah Hunter had a disgnosis of bi-polar and a long history of substance abuse, she could be complex to manage and often would make poor decisions.

A review of the Medicaid costs for Sarah Hunter while she lived at Dayspring Village revealed that her costs were a fraction of what they became when she was relocated to her apartment in Fernandina Beach. What was amazing her Medicaid Reform plan completely missed the issues even though her hospital care was going through the roof while she had the apartment.

The need for changes to the Medicaid Reform plans is apparent and the Sarah Hunter cases surfaces real questions about how managed care plans deal with people who have serious mental illnesses and complex medical needs.

The new proposed plan that lawmakers are expected to take up will roll most of the institutional care into managed care plans. While on the surface the state policy makers hope this will create greater predictability and help manage costs, we need to be careful. You see what happens is the plans create what is called encounter data, this data reflects the service utiliuzation histort associated with the people they serve.

Just this month the Sunshine Health Plan which bought the Provider Service Network (PSN) in Nassau County called Access Solutions has decided to call it quits after less than a year. They plan to discontinue operations on December 31st. A new managed care company called First Coast Advantage is expected to be approved to enter Nassau and Baker Counties on January 1, 2011. First Coast Advantage is a PSN that is owned and operated by Shands Hospital. At the present time they can operate as a fee for service system of care but that will all end once the new legislation is adopted and PSNs and HMOs must all compete on a captiated basis.

It is likely that the PSN once they have picked up the 8000 Medicaid lives in Nassau and another 3000 in Baker will likely look for a takeover partner to take on the larger risk pool, just like Access Solutions did with Sunshine Health Plans.

With the added burden of caring for those in need of institutional care, the risk for many managed care companies will increase dramatically as they struggle with how to manage the costs of these deep end systems of care.

The potential innovvation associated with the shift to managed care is exciting as it offers a real chance for innovative providers to shop proposals to the managed care companies for downward substitution strategies that will help reduce costs associated with institutional care.

For many of the mentally ill, they already find themselves in the nursing homes, unlicensed ALFs,county jails and homeless centers because there is no incentives in how state funding works for licensed care facilities to accept those withy complex needs.

We will wait with great expectation for the changes we see on the horizon to open the doors to greater competition and choice.

Wednesday, March 3, 2010

Limited Mental Health ALFs - OPPAGA Study needed now!

The 2010 legislative session is now underway. This year I am working to ask lawmakers to authorize the Office of Program Policy and Governmental Accountability (OPPAGA) to conduct a review of Assisted Living Facilities that hold a limited mental health license.

The need for lawmakers to gather information about these facilities is critical to the sucess of state efforts to realize cost savings in their efforts to reduce the state budget for health care. It is commonly known that institutional utilization in Florida runs around 93% whereas states like Orgeon have a much lower utilization rate around 78%.

The reliance on institutional care has dominated our state budget process for many years, now with a $3 billion short fall it is no longer sustainable to continue funding policies that create a heavy reliance on institutional systems of care to meet the needs of the low income and vulnerable.

It is well known fact that over 50% of the diversions from nursing homes under the "nursing home diversion program" are placement in licensed ALFs. The need for good quality ALF care that can be offerred at effective prices is critical to state efforts to change policy to capture savings.

Unfortunately in Florida the ability of state funded ALFs to continue serving the low income and the vulnerable is fading away and is being replaced by increased reliance on jails, forensic mental health treatment facilities, nursing homes and hospitals.

The problems associated with the funding programs for state funded ALFs center on the funding programs for providing access to care ( Optional State Supplementation) and the Medicaid Assistive Care Services. There are serious changes needed in how these programs function not to mention the need to examine how residents are accessing services under the new managed care programs ( pre paid mental health and medicaid reform).

The current reimbursement system for care contemplates a rate of $9.28/day for a whole list of Medicaid ACS services. We need to re-examine how these services are funded and perhaps look at a creating a three tiered payment system so that the system will focus bed space at those with the greatest need.

According to DCF there has been a loss of 2400 state funded ALF beds in Florida since 2001. This loss in capacity means that people must go elsewhere for care. With a growing elder population and rising levels of need for the disable as they age the need for stable housing and stable service is more critical now than ever.

The last OPPAGA study was in Feb 1997, because there are so many factors affecting the viability of these important facilities the need for a closer look by OPPAGA is critical to help identify how lawmakers can make changes that result in a more effective system of care and also enable these facilities to play a role in helping the Florida create the savings that are needed in the budget.

I will keep you updated on this blog.

Douglas D. Adkins
Executive Director
Dayspring Village, Inc.
Hilliard, Florida

Tuesday, July 14, 2009

Assisted Living Facilities and Federal Health Reform

Today the much anticipated Federal Health Reform proposal HR 3200 was released in the US House of Representatives. This massive 1016 page legislative proposal is wide ranging and filled with many changes to Federal Law that are intended to help reduce costs and improve access to care.

Health Care is a complicated issue and has many varied dynamics all at work. The Federal Plan will impose many new requirements for the health care providers and consumers and just like most of these other changes to our health care system people will respond to these changes and come up with new approaches that will allow for the provision of care.

The reality is that to reduce the cost of health care we must find ways to reduce the need for institutional care. The demand and dependence on instuitional care is expensive and in many instances not necessary.

While community based care COULD play a role in reducing the need for institutional care the reality is that it does not play a key role in reducing institutional costs because there is no incentive for community based care to delay, divert or otherwise avoid the need for institutional care. In many instances community based care improves consumer satisfaction and improves access to care but as it relates to reducing the need for institutional care there is no incentive for these care systems to play a central role in that goal or task.

For many years it has been well understood that licensed Assisted Living Facilities are frequently used by the Nursing Home Diversion Managed Care Program as a way of reducing long term care costs. In fact approximately 50% of the diversions in this program go to ALF care because it is effective in reducing the need for institutional care. For one monthly fee the ALF accepts the risk associated with acuity and care and provides a predictable, capitated environment that promotes healthy living routines and improves access to preventative care.

ALF care is a life style choice and in many instances the improvement of these routines and systems that surround a person whether they ben social, environmental or medical and dietary have a profound influence on what happens several years down the road. These congregate living arrnagements are vibrant communities with their own unique social structure and culture.

Sadly access to ALF care for the low income and state funded individuals is on the decline and is fast disappearing from the shores of Florida. Last year the Florida legislator reduced the optional state supplementation program from $25 million to $15 million. The lawmakers also reduced the Medicaid assistive care services program which pays for services in these settings from $32 million to $25 million, no other social service program sufferred cuts in theior budgets similar to these twin pillars that provide access to care. So why the cuts? The answer is simple, many of the beds for care of the low income are fading away as the mounting prolems with the economy encompass many of the samll facilities.

The reality is that many of the ALFs that care for the state funded residents have closed and gone away quietly. The state has lost olver 2100 beds for low income ALF residents since 2001, in the last four years it has 980 beds for the low income adults with mental illness. The chronic substandard rate of reimbursement for care at $9.28/day coupled with the increasing costs associated with meeting the current regulatory standards has all but made the business model for continuation of this important housing link all but unsustainable.

The cost saving role of the ALF has been significant over the years in providing stable housing for persons with mental illness. On frequent instances the courts, homeless shelters, hospitals, crisis stabilization units and others will look for a good ALF to care for a complex person with mental illness, often with emerging medical needs and in many instances problems with substance abuse. The loss of these beds is now beginning to show up in the data, over the last few years in Florida the numbers of mentally ill headed to forensic mental health treatment facilities has shot up creating a crisis. In Florida that number has gone from 1200 to 1500 today and is costing taxpayers $140,000 per year for each bed.

In Florida we see that 125,000 citizens each year are arrested and charged with a crime who also have a mental illness. There are 17,000 residing in state prison beds, 14,000 in county detention facilities and another 40,000 under supervision of probation and parole. The Department of Corrections spends $68 million each year on the mental health needs of its inmates and this number continues to grow. The large percentage of crimes committed by these people were committed while the person was not taking their medications and is in part due to their mental illness.

The data shows that 12 months after discharge from a state mental health treatment facility of 1300 people discharged annually in Florida 782 end up on a correctional facility, hospital, nursing home, homeless shelter or unknown. These are not the desired outcomes that people would expect and this is the reality that feeds the revolving door because of the lack of stable housing and services.

When you look at how effective the limited mental health ALF setting is in reducing the need for forensic mental health treatment beds, the data in Florida shows that over the last four years only 26 mentally ill residents of the ALFs are sent for care in an forensic mental health institution. By contrast when you compare to the FACT team, the assertive community treatrment teams, over 200 on average are sent to a state mental health treatment facility. In many instances the provision of FACT services is not enough to avoid the need for instutional care, what is needed is a combination of stable housing and stable services.

So what can fgederal lawmakers do to help reverse the slide toward rising costs and greater use of jails to care for the mentally ill in Florida and nationally. The development of proper incentives to care for the most functionally impaired is of broad puyblic interest, people would like to ensure the mentally ill are cared for in an appropriate way at the lowest cost possible.

Clearly as the Nursing Home Diversion Program has learned the proper use of an ALF can help divert risk, reduce the need for expensive institutional care and improve customer satisfaction. The federal lawmkers would be well served to consider using the savings from the continuing disability review program that is funded through the social security administration to create a federal subsidy for those individuals with a serious and persistient mental illness who meet certain criteria relative to functional impairment to fund access to care in a state licensed limited mental health assisted living facility, personal care homes or other state regulated residential care facility. The federal subsidy would be expected to be from $150/month to $320/month and would be based upon the income of the resident.

The use of the savings from the SSA continuing disability review program would create an incentive for licensed residential facilities to offer care for the more functionally impaired and would help reduce the need for jails, prisons and ER visits that would otherwise arise when these individuals do not have access to stable housing and supervision. This approach would be based on the availability of funds and would be a federal subsidy that would be based on the allocation of slots for care and would include a process for recertification of eligibility and recoupment when funds are paid for persons determined to be ineligible.

The development of a federal plan to expand the access to state licensed limited mental health assisted living facilities would help reduce the cost of health care for the low income chronically mentally ill. The need for immediate attention in viortually every state is a growing crisis. The unintended consequences associated with decisions made on a federeal level too many times leaves the most functionally impaired left out and struggle to find a new way just to survive the change that imposes new burdens and new struggles. The plan for federal health reform should consider changes that would offer the right incentives and work to fully utilize the care settings that help control costs and reduce the need for institutions, these are the investments and changes in federal policy that should be pursued.

Todays decisions will impact on the results we see 30 years from now. How will the mentally ill be treated in our society in the future? The absence of changes that will offer adults with mental illness the stable housing and services they need will result in the further collapse of the limited resources now available and result in new costs for institutional care. Now is the time for change in how America provides for the chronic adults with mental illness and their need for stable housing. This one change will produce a significant change in the need for crisis care and will allow these important Americans to join the community in building a prosperous future for everyone.

Friday, May 1, 2009

cig taxes and schizophrenia a formula for new state budget woes

With any change in state policy there is always unintended consequences. Jacksonville is home to a large population of persons who have a serious and persistent mental illness. Some of these people with the greatest needs are persons with schizophrenia.

It is estimated by researchers that 44% of all cigarettes sold in the United States are sold to people with mental illness. Studies show that persons with mental illness spend 27% of their income seeking tobacco products. It is well known there is a strong connection between schizophrenia and how nicotine works in the brain. The nicotine provides brief alleviation of psychotic symptoms or voices and can help improve memory for persons with this disabling condition.

In Florida there are 5379 individuals with a mental illness who are reported to live in a state licensed limited mental health assisted living facility. Many of these residents have a primary diagnosis of schizophrenia and 90% are addicted to smoking or nicotine products.

For most of these people the terrible consequences of nicotine addiction include cardiac problems, COPD, bladder cancer and a host of other complications. It seems to make sense, just raise the price and they will quit. This is a case of easily said than done.

Even though residents will seek to quit smoking and we get them started on the nicotine patch, because of the diminished insight that accompanies schizophrenia many will keep on smoking cigarettes in addition to using the nicotine patch, a very dangerous combination. Often once the physician knows they are doing both they will discontinue the patch out of caution.

For many of the state funded residents who reside in Florida's licensed limited mental health assisted living facilities they received $9.28/day from Medicaid to help pay for their care and services they need and they received $54/month in a personal needs allowance that is to pay for dental care, vision, clothing, shoes and personal care products.

At our facility we have a tobacco resale license which allows us to purchase cigarettes from a wholesaler. We will purchase the cigarettes each month on behalf of the residents, for what we consider to be a month's supply would generally be $38/month at wholesale prices. This provides enough tobacco for 4 cigs per time four times per day.

The new federal cigarette tax will pay for children's health insurance will exact a significant toll on persons with mental illness. According to our sources the average cost of cigarettes will increase by $6/carton and so what use to cost $38/month will now be around $56/month just for cigarettes. The next proposed wave of taxes from the state will drive up costs another $10/carton for a total of $86/month.

Recent DCF data demonstrates clearly that stable housing and stable services are keys to keeping people with schizophrenia, for instances of 5329 mentally ill residents who were reported living in an ALF only 26 per year get charged with a crime and sent to an expensive ( $140,000/bed) forensic mental health treatment facility.

By contrast if you are enrolled in one of Florida Assertive Community Treatment Teams which serve 3200 adults you have 200 per year headed to forensic care costing taxpayers $28 million.

It is well established fact that when persons with schizophrenia re psychotic and aggressive having available a small supply of cigarettes can help everyone stay in control and avoid someone getting hurt. When you think about the problem this can create, Florida spends $250 million each year caring for the mentally ill who have committed a crime, 48% of the people charged in FS 916 are charged with battery on a law enforcement officer.

Absent doing nothing here is a description of the unintended consequences, as the price of cigarettes go up, residents will only be able to purchase a smaller quantity, residents who have higher demand for cigarettes will start to engaged in "panhandling" behaviors, they will commit petty crimes that include stealing cigarettes from local stores or friends. The utilization rates of hospital emergency rooms, already "psychosis" is the number three diagnosis seen in Florida's hospital emergency rooms.

You will likely have people decide they would prefer to get their nicotine needs met and will elect to live at a homeless shelter, take up housing in an unlicensed assisted living facility where there is no supervision or will seek housing in settings that could be best described as unstable. This all creates a tsunami for state budget planners and new dangers for patients and families.

Douglas D. AdkinsExecutive DirectorDayspring Village, Inc.PO Box 1080Hilliard, Florida 32046

Saturday, April 18, 2009

Optional State Supplementation - Florida Trends Down

Access to care for low income individuals with mental illness to stable housing and stable services is one step closer to a crisis. The Optional State Supplementation Program which helps fund access to state funded ALF care in Florida is collapsing. Recent numbers show that in 2001 there were 10,272 and in 2008 according to the Department of Children and Families which runs the OSS program there were only 7935 funded OSS slots.

The legislature over the last 10 years would hold funding for this program at $26 million. The last two years saw significant "raids" on the limited funds in this vulnerable program by lawmakers. The program was reduced in 2008 to $18 million and in 2009 it is projected to drop to $15 million.

The last time there was any increase in Florida was in response to the 1999 OSS workgroup that was authorized by the legislature. This workgroup recommended a $100 increase in OSS funding and what was funded in 2000 was an increase of $35/month for room and board and they moved the personal needs allowance from $43/month to $54/month.

The need for an increase in the rate for care for the state funded ALF residents has been a constant need for years. There have been numerous attempts to increase the OSS rate of funding only to be vetoed by then Gov Jeb Bush.

In Florida the OSS funding is used to as a state match to pull down medicaid resources under the state plan amendment called the medicaid assistive care services program. The rate of reimbursement for a low income individual is $9.28/day a rate that has not been adjusted since 2001.

The decreasing number of beds in Florida is a critical concern for persons with serious mental illness. We know that of the 7935 beds for OSS residents that 5379 are occuippied by persons with mental illness, the vast majority of these located in Miami Dade County. The major diagnosis associated with this population is schizophrenia.

Florida lawmakers should discontinue the practice of holding the rate of funding for care at the 2001 rate and "raiding" this fund for surplus funds to use in other programs. These funds should be utilized if surplus to increase the rate. The low rate of reimbursement has led to the closure of many facilities in Florida eliminating access to housing that offers some supervision and assistance with medications.

The decline of state funded ALF beds in Florida only spells that Florida taxpayers will pay an increased cost associated with greater demand and use of institutions; whether they are jails, nursing homes or state mental health treatment facilities.

The ALF model is a low cost and effective system of care for many people with chronic long term needs like those with schizophrenia. The absence of quality and available supply of beds will only lead to an expanding crisis that will drive up health care costs.

Even if lawmalkers started now to address the emerging policy and budget crisis facing state funded ALFs, there would be several years to correct the many issues that years of neglect have brought.

Saturday, January 24, 2009

Florida Care

Florida is a unique state and perhaps one of the most important elements of its health care delivery system is the housing and support provided by the 858 state licensed limited mental health assisted living facilities. These facilities care for around 10,000 adults with serious mental illness. According to state data approximately 90% of the residents who choose to live in these settings have a diagnosis of schizophrenia.

The challenges faced in Florida with the serious budget shortfalls creates a chance to examine the cost effectiveness of various programs and systems of care. What we know is people with schizophrenia need stable housing and stable service delivery system. The limited mental health ALF in Florida has some unique capabilities that have long gone under utilized in how state policy addresses the needs of this with the greatest level of functional impairment.

The average GAF score ( global assessment functioning) is around 45, whereas the average for those community mental health clients who reside in the community in Florida is about 55, a full ten point drop this is because people with schizophrenia who reside in the LMH-ALF setting have greater needs.

A review several years ago of these residents showed that they consumer services at 4 times the rate that those in the community do. Now some of this is because of the level of need and some is due to over utilization or billing practices associated with the mental health agencies that are responsible for supervising their clinical needs.

The current rate of reimbursement for care in these facilities has not changed since the lawmakers last increased the funding in 2001 when lawmakers authorized medicaid proceed with a plan to create a state plan amendment that would allow state policy planners to move some of the nearly $32 million in optional state supplementation ( general revenue) into the new medicaid assistive care services. There were only two other states that were doing this Vermont and North Carolina at the time. The medicaid rate was $9.28/day for assistive care services in 2001 and it has not changed since. What is interesting when you review the medicaid claims data it shows that the facilities actually only recover on average $5.28/day for each day a resident lives in their facility. This income erosion seriously compromises what a facility can provide and limits their ability to create the type of stable housing routines that all persons with schizophrenia to propsper.

When you think about it the residets spend 70% of their day where they live and 30% at the community based mental health center. When you look at how we fund access to care or allocate dollars we spend 80% of the funds where the residents spend 30% of their time, so when we ask what is wrong with the care of these individuals and why so many end up in the jails and prison systems we dicover we have inverted the funding for care at the expense of creating a balance between stable housing and stable services.

Lets face it one of the most critical elements that affect the sucess of care with this adversely selected subgroup is the development of stable routines. It is these predictable routines that have a stablizing influence on care over the course of time. These routines must be paired with appropriated array of targeted clinical mental health services that allow for ongoing assessment of medicaitions, individual and group therapy and of course an ability to respond to psychiatric emergencies. Too often the mental health system is AWOL when it comes to effective response to emergency psychiatric care and this where things deteriorate and law enforcement gets involved.