Existing dollars could be used more effectively by allowing consumers to direct their abilities to purchase the services that they want and need.
(J.C.)
Ohio Access envisions a fundamental alteration in Ohio's approach to long-term services and supports, focused first on providing meaningful choices for people with disabilities, but also ensuring that taxpayers get the best possible value for their investment. Fortunately, greater consumer choice often leads to improved outcomes and greater cost-effectiveness, which is critically important given constraints on public budgets. The level of reform that is necessary to realign long-term services and supports toward consumer choice and public value can only be accomplished through comprehensive planning, including a participatory stakeholder process and integration with Ohio's legislative process. In this spirit, the Ohio Access cabinet will:
- Articulate clear principles for system design;
- Involve consumers in planning and program design;
- Coordinate across agencies;
- Convene an Ohio Access housing task force;
- Implement enhanced care management; and
- Stimulate demand for long-term care insurance.
D.1 Articulate Clear Principles for System Design
Comprehensive reform takes time and focus to accomplish. People are waiting for services now, so there is no time to waste on false promises that are abandoned later. It is important to set clear expectations from the outset of reform, and to articulate clear principles for system design that guide decision-making along the path toward complete reform.
Ohio Access always starts with a vision for Ohio in which seniors and people with disabilities live with dignity in settings they prefer; they are able to maximize their employment, self-care, interpersonal relationships, and community participation; and government programs honor and support the role of families and friends who provide care. These ideas take on very practical meaning when they are applied to the actual functioning of long-term services and supports. For example, they anticipate a system in which:
- Money follows people across all long-term care settings and services.
- People with disabilities control the resources they use to access services and supports.
- Public funds are allocated based on an individual's need and personal resources, and the availability of public resources.
- All Ohioans anticipate that they may some day need long-term services and supports and responsibly plan for that possibility.
Ohio has made progress toward achieving these principles for system design, particularly in behavioral healthcare (which is almost entirely community based) and MR/DD (which underwent a fundamental redesign during SFY 2002-2003). This entire report is devoted to making still more progress. Appendix A, in particular, outlines strategies to financially support consumer choice, provide information consumers need, expand home and community based Medicaid waiver services, and support informal caregivers.
Modernize and Simplify the Nursing Facility Reimbursement Formula
Ohio deviates from the system design principles listed above (and lags behind most other states) in its capacity to provide home and community based alternatives to nursing facilities. The nursing facility reimbursement formula is fixed in statute and, as a result, does not allow state policy to adapt to changes in consumer demand for long-term services and supports. As a first step, the nursing facility reimbursement formula needs to be modernized to:
- Simplify the reimbursement system;
- Reward providers of high quality long-term services and supports;
- Establish price competition to create efficient providers;
- Pursue regulatory reform;
- Maximize the reliability of the Medicaid funding base; and
- Control per member per month cost growth.
| D.1.1 | ODJFS, ODA and ODH will work with the Ohio General Assembly to recommend proposals for the SFY 2006-2007 budget (or before) to incorporate the outcomes listed above into the nursing facility reimbursement system. |
The same principles for modernizing and simplifying the nursing facility reimbursement formula already are being implemented in other publicly funded long-term service and support systems.
| D.1.2 | ODJFS and ODMR/DD will implement a new reimbursement system for all ODMR/DD-administered waivers in SFY 2004. |
| D.1.3 | ODJFS, ODMH and ODADAS will convert behavioral health care reimbursement systems during SFY 2006-2007. |
D.2 Involve Consumers in Planning and Program Design
Ohio Access places a high priority on consumer participation in the process of planning and program design. The original Ohio Access report — and particularly its vision — emerged primarily from consumer voices. [1] The Ohio Access departments again sought consumer input in the development of this report, and particularly relied on the leadership of the Ohio Olmstead Task Force. The Ohio Olmstead Task Force includes consumers of long-term services and supports and advocates for frail elders and Ohioans with disabilities. The Task Force is consumer-led and consumer-focused. It is the one forum where advocates for Ohio's elders, advocates for those with disabilities, and consumers of services come together to promote common objectives. The Ohio Access agencies support the Olmstead Task Force with information, participation in Task Force meetings when requested, and grant funds provide travel expenses and meeting accommodations to task force members.
| D.2.1 | ODA will ensure that federal grants related to Ohio Access are coordinated to provide ongoing financial support to the Ohio Olmstead Task Force. |
| D.2.2 | Each Ohio Access agency will broadly disseminate information about Ohio Access activities—and particularly this report—through existing advocacy networks. |
| D.2.3 | ODA will coordinate Ohio Access departments to provide consumer and advocate training about how to conduct effective legislative visits during SFYs 2004-2005. |
| D.2.4 | ODMR/DD will continue its self-determination initiative with a focus in 2004 of training individuals with MR/DD in self-advocacy. |
D.3 Coordinate Across Agencies
Ohio Access is a blueprint for coordinating similar activities across multiple state departments. It sets a clear vision for the future and identifies specific strategies for change. Ohio Access is a dynamic process, not a static report, and requires continued focus in order to achieve the best value for Ohio's taxpayers. In this regard, the Ohio Access cabinet will:
- Plan for the future;
- Improve data collection;
- Maximize federal grant opportunities; and
- Involve more state agencies.
Plan for the Future
The facts described in this 2004 Ohio Access report will soon be outdated, but the spirit of the report will not. It is grounded in values of opportunity, participation, independence, financial security, choice and consumer direction that will endure even as particular circumstances change. Ohio's departments need to update their activities as well, always be clear about the priorities that unite our effort to improve services and supports for people with disabilities, and enlist the support of others to achieve these objectives.
| D.3.1 | The Ohio Access cabinet will update the Ohio Access report every even-numbered year. |
| D.3.2 | The Governor's office will coordinate the Ohio Access cabinet to visit every state legislator during SFY 2004 to discuss Ohio Access principles and enlist support for its recommendations in the SFY 2006-2007 budget. |
| D.3.3 | The Governor's office will coordinate the Ohio Access cabinet to provide leadership and testimony in SFY 2004 to all legislative committees with responsibility for services and supports for people with disabilities. |
Improve Data Collection
Data-informed analysis is critical to the development and modification of Ohio Access long-term services and supports delivery systems. Typically, each agency captures and uses its own data, but a new strategy recently undertaken by the Ohio Access agencies will capture the Medicaid covered utilization of a consumer across systems for a more accurate picture of the services and supports that people with disabilities rely on. Better data collection will permit planning for the full range of services and supports necessary to accomplish Ohio Access goals.
| D.3.4 | ODJFS will immediately organize existing data to create a more complete picture of Ohio's long-term services and supports and work with Ohio Access agencies to refine data collection to be more useful in the development of the SFY 2006-2007 budget. |
| D.3.5 | Ohio Access departments will make recommendations in the SFY 2006-2007 budget for systems changes that are necessary to improve data collection. |
Maximize Federal Grant Opportunities
President Bush's New Freedom Initiative has created new grant opportunities for states that want to expand home and community based services for people with disabilities. Ohio is well prepared to compete for these grants and already has received seven grants worth $3.5 million to support Ohio Access. Ohio will continue to actively pursue federal grants—but it is important to be clear that the priority is to support Ohio Access, not to apply for every possible grant.
| D.3.6 | The Ohio Access cabinet will coordinate decisions about federal grants that involve more than one state agency to implement, and identify a department leader for each grant. |
| D.3.7 | The Ohio Access departments will rely on input from the Ohio Olmstead Task Force to make decisions about which federal grants to pursue. |
Involve More State Agencies
The original Ohio Access report focused primarily on medical treatment services. This report broadens that view to include other types of services and supports that are required for people to live in home and community settings. This is consistent with Olmstead planning guidance from CMS, which encourages states to include housing, transportation, employment, and education in state Olmstead plans. Access to affordable housing is particularly critical for people with disabilities to participate in community life, but housing services are scattered across multiple federal and state entities. An important first step toward addressing these issues is to involve more state departments in the Ohio Access planning effort.
| D.3.8 | The Governor's Office will identify and involve other departments in Ohio Access planning, including Development, Education, Insurance, Minority Health Commission, Natural Resources, Rehabilitation and Corrections, Rehabilitation Services Commission, Taxation, Transportation, Worker's Compensation, and Youth Services (SFY 2004). |
| D.3.9 | The Ohio Access cabinet agencies and the Ohio Department of Transportation will renew focus on the Statewide Transportation Coordination Task Force in SFY 2004. |
D.4 Convene an Ohio Access Housing Task Force
Affordable housing is essential for people with disabilities who want to receive long-term services and supports at home. However, despite its importance, housing is among the most difficult of services to coordinate. There are multiple federal, state and local jurisdictions that are responsible for housing policy, and no single strategy for making affordable housing more accessible for people with disabilities. In addition, more than other services, the availability of affordable housing depends on private market forces and decisions made by private developers. Any coordinated strategy requires the alignment of government and private interests. Finally, because there has not been a coordinated affordable housing strategy to date, it is not clear what priorities need to be pursued first—is it additional housing? or is it supportive services in existing housing? and do the answers to these questions vary by population group?
The action steps below are intended to improve interagency coordination and identify future priorities for improving access to affordable housing for people with disabilities. There are many issues that Ohioans face in regard to affordable housing (homelessness, for example), but the emphasis here is narrow—developing "housing with supports" that enables Ohioans with disabilities to exercise true choice in long-term services and supports.
| D.4.1 | The Governor's Office will convene an interagency task force in SFY 2004 to survey the state's current efforts to provide affordable housing for people with disabilities, receive input from consumers and advocacy organizations about expanding access to affordable housing, and develop recommendations for consideration in the SFY 2006-2007 budget. |
| D.4.2 | ODA and ODMH will jointly develop a coherent strategy for the Residential State Supplement program (RSS), which is currently closed to new participants and develop recommendations to the Ohio Access Housing Task Force for consideration in the SFY 2006-2007 budget. |
| D.4.3 | ODJFS will immediately hire a housing coordinator using resources from an existing federal grant to support the Ohio Access to Affordable Housing Task Force. |
| D.4.4 | ODMH will create a Mental Health Housing Leadership Institute in SFY 2005. |
| D.4.5 | OBM will evaluate Ohio's capital investments in long-term care, and report recommendations to the Ohio Access Housing Task Force in SFY 2004. |
D.5 Implement Enhanced Care Management
ODJFS has developed an enhanced care management (ECM) strategy to bring the benefits of enhanced care coordination, improved access to primary and preventive care, and expanded member services to additional Medicaid consumers who have chronic conditions. This strategy will prioritize individuals on Medicaid with chronic or critical health care conditions (the highest-cost users of Medicaid services) to improve cost predictability and administrative simplicity, assure the appropriate use of services and minimize preventable or unnecessary use of emergency care and inpatient services, and establish accountability for both access to care and quality of care.
ODJFS will competitively select service providers to provide enhanced care management. Applicants will have experience in providing a comprehensive care management program, including: care coordination and case management; a nurse/health advice line; provider relations, education, and support; consumer information, education, and support; and accountability for access to and quality of care, as well as quantifiable return on investment. Selected applicants will be expected to promote the appropriate use of cost-effective medical care, pursue rapid quality improvement, and minimize preventable or unnecessary use of emergency care and inpatient services.
Other components of enhanced care management include the continuation and expansion of the risk-based managed care program for children and families covered by Medicaid; the ongoing use of pharmacy management, including cost sharing, for "fee-for-service" consumers; and activities to educate consumers regarding the use of their Medicaid benefits.
| D.5.1 | ODFJS will competitively select qualified service providers and work to begin implementing the program in early SFY 2005. |
| D.5.2 | In SFY 2005 ODJFS will explore the feasibility of expanding ECM to Ohioans who are dually eligible for Medicare and Medicaid. |
| D.5.3 | ODJFS will report the extent to which ECM programs achieve the desired result of reducing per member rate of growth in cost of care for Ohio's Medicaid fee-for-service aged, blind or disabled population (beginning in SFY 2006). |
D.6 Stimulate Demand for Long-Term Care Insurance
Disability can enter our life at any point — through accident, illness and age. It is important that every Ohioan understand that he or she may some day need long-term services and supports, and responsibly plan for that possibility. According to the Center for Home Care Policy and Research, people who purchase long-term care insurance are much more likely to remain in community settings than those who have not purchased long-term care coverage, and less likely to require assistance from publicly-funded programs.
Unfortunately, the long-term care insurance market has been slow to develop, and many consumers are (with justification) skeptical about its value. However, as private insurers begin to cover alternatives to institutional care (as opposed to paying for care in an institution), the demand for these products is beginning to grow. If the state can further stimulate the demand for long-term care insurance, then it also might relieve pressure on publicly funded programs.
Ohio enacted a "long-term care partnership program" in 1993. Ohio's program is the same as model programs in four other states that let participants shelter assets that would otherwise count toward establishing Medicaid eligibility in exchange for purchasing an approved long-term care insurance policy. However, before Ohio was able to implement its program, Congress blocked all but the original four states from implementing partnership programs. Recently, Congress reopened the debate about allowing additional partnership arrangements.
| D.6.1 | ODA will immediately communicate Ohio's support for repealing the federal prohibition on long-term care insurance partnerships to the state's Congressional delegation. |
| D.6.2 | The Governor's office will convene an interagency task force to provide technical assistance related to other options to stimulate demand for long-term care insurance that are under consideration by the Nursing Facility Reimbursement Study Council. |
[1]Ohio Access principles were derived from consumer input received during the development of the ODMR/DD Vision Paper (1997-1999), the Ohio Commission on Mental Health report (1999), and regional Ohio Access public forums hosted by ODA and ODJFS (2000).