A. Pre-admission Assessment

In 1995 the Legislature adopted a policy of universal pre-admission screening for long-term care services. As the “first stop” the assessment is intended to:

· Provide timely and objective functional eligibility decisions for nursing home and all state and Medicaid-funded home care programs

· Educate consumers and families about their choices, and

· Support fair allocation of resources based on need.

Maine is one of only three states to use both a uniform assessment form and a single, independent agency to conduct assessments. The pre-admission assessment is mandatory for all nursing home applicants, including those paying privately.

The Department contracts with Goold Data Management to operate the assessment program statewide. Because provider staff have a financial interest in the outcome of the assessment, the assessment program is set up to be independent. This assures that consumers receive an objective and accurate assessment of their needs. Assessment costs represent 1% of annual long-term care spending.

Of the 15,849 persons who received assessments last year, 11,969 were new to the long-term care system. In a recent survey, more than 90% of respondents reported satisfaction with the assessment process.

Nurses using a laptop application of the assessment form meet with the consumer, often with one or more family members present, conduct the assessment, establish medical eligibility on the spot, and authorize a service plan. Previously, this process took weeks. Department staff determine financial eligibility for Medicaid programs separately.

The Department uses the information collected through the assessments for reports, to identify the characteristics of persons using long-term care services, to analyze the fiscal impact of proposed program changes, to respond to Legislative inquiries, for research and to comply with the requirements of the Supreme Court’s decision in the Olmstead case. This decision found that inappropriate institutionalization is a form of discrimination under the Americans with Disabilities Act and requires states to offer individuals the opportunity to return to the community.

Chart - Home 51% Residential Care Facility 4% Nursing Facility 41% Hospital, other 4%

· Over half the people are living at home when they first receive a long-term care assessment.

· Many first time assessments occur during a Medicare covered skilled stay in a nursing facility.

B. Nursing Facility Care

Long-term care reform began at the same time Maine implemented “case mix” reimbursement for nursing homes. Under this system, payment is based on the needs of the residents. This caused the acuity level in nursing homes to increase because of incentives created by the payment system. Nursing homes were also mandated to increase their participation in Medicare by certifying more beds. As a result, Maine achieved a dramatic shift in the composition of the nursing home population.

· Medicaid census declined 18% from 1995 – 2002.

· Medicaid length of stay declined approximately 44% between 1994 and 2002.

· Medicare days doubled during this period, and now represent approximately 11.4% of all resident days in nursing facilities.

· Total days of care declined nearly 26%.

· The number of licensed beds decreased from 10,207 to 7,708 between 1994 and 2002. This was primarily the result of converting excess space in nursing homes to residential care, and by closing outdated, antiquated or unnecessary facilities.

· A DHS report in 1990 recommended replacement or renovation of 37 of Maine’s older facilities. Since that time, and particularly due to changes in the long-term care marketplace, at least seven (7) have been renovated/replaced or have plans to do so, ten (10) have converted in whole or in part to residential care, and eleven (11) closed permanently.

There were also changes in nursing facility reimbursement.

· Average Medicaid rates increased approximately 41% between 1994 and 2002. Today, the average Medicaid payment rate is $132.84.

· Nursing home rates were re-based in 1996 (base year 1993) and 2000 (base year 1998).

· The Legislature instituted higher minimum staffing ratios and appropriated additional funds to address staffing shortages.

· Money appropriated for increased rates was directed toward increasing the wages of direct care workers.

1. Certificate of Need. Certificate of Need, or CON, regulates the supply of nursing facilities/beds and capital investment over $500,000. CON laws were amended to provide tighter controls on capital expenditures and growth. Legislation prohibited approval of projects that would add costs to the Medicaid program, and eliminated unregulated “bed creep”. Other changes called for better standards to be applied in the review process, for more participation by the public at the local level [where projects are proposed], and to allow nursing facilities to “bank” beds. In total, 761 nursing facility beds were banked. Two CON applications were submitted and approved to bring 5 of those beds back into use. The remaining beds are still in the “bed bank”, unless the four-year term expired and was not extended by the facility.

2. Financial Viability. While many homes responded to changes in consumer preferences, others were slower to do so. Rising wage costs that outstripped reimbursement increases, increasing reliance on “per diem” staff, the effect of expensive lease agreements all contributed to financial crisis for many homes. Receivership, once used primarily to assume control of facilities with quality of care problems, has become an alternative for bankruptcy. The Department has petitioned the Court for receivership of several facilities to ensure the health and safety of residents by lending funds or providing a “stay” from creditors that has allowed facilities to keep operating while long-range plans are developed. Only one of the three nursing homes that have gone through this process has closed, one has transferred to a new operator, and the third is working through its financial problems one by one.

3. Consumer Satisfaction Survey.

Market Decisions, LLC, a Maine survey research firm, was selected to conduct a face-to-face survey of a sample of nursing facility residents to determine their satisfaction with their surroundings and the care they receive. The contract award followed the issuance of a Request for Proposals developed by the Department with providers, advocacy groups and elder individuals. The study report is due by late spring 2003.

4. Nursing Home Provider Tax. The 120^th Legislature enacted a 6% tax on net operating revenue. Assuming federal approval, the tax will take effect in February 2003. The Legislature appropriated a portion of the proceeds from the tax towards the budget deficit and the balance for Medicaid reimbursement rate increases for nursing facilities, residential care, and home care programs. The rate increases are intended to assist providers to recruit and retain staff.

C. Assisted Living and Residential Care Programs

1. Residential Care: Residential care programs, formerly known as “boarding homes” provide a more homelike setting where residents share bedrooms and common living space. Residential care had a period of unprecedented growth between 1994 and 2002. Funds to support this growth came from a 1996 legislative appropriation that funded approximately 300 new Medicaid placements. Additional growth resulted from conversion of nursing facility capacity to residential care. Demand for residential care services continues to exceed the available resources.

The Department implemented a new payment system in 2001. For the first time, Maine has gone from a cost-based payment system for facility services to one based on an acuity-adjusted price. This system fairly allocates Medicaid payments based on resident characteristics instead of facility historical costs and management practices. Changes in the Principles of Reimbursement also allowed the Department to obtain federal Medicaid matching funds for some facility overhead costs and other support costs that previously were paid for with General Fund dollars.

A new type of residential program, called adult family care homes, was established to meet the demand for small, home-like settings for elderly individuals at risk of placement in nursing facilities. Today, there are 24 adult family care homes, many located in rural Maine communities. Medicaid supported, these homes serve a number of individuals who would otherwise qualify for placement in a nursing home. Most families express a high level of satisfaction with the care provided in these settings.

2. Adult Day Services The number of Adult Day Services locations has increased steadily since 1995. There are now 54 programs statewide. Adult Day Services are used to support a home care plan; to provide respite to family caregivers; or to allow caregivers to work outside the home during the day.

3. Assisted Living Programs. Assisted Living programs are designed to offer the privacy of individual apartments, along with the types of supportive services normally offered in a residential care facility. Until recently, many of the 24 programs licensed in Maine served only private pay residents.

Using funds specifically appropriated for this purpose, the Department joint-ventured with the Maine State Housing Authority to build affordable senior housing that would offer the same array of supportive services to low income elders in individual apartments. The first program opened in Camden in 1998. There are now seven sites whose construction was financed with federal Low Income Housing Tax Credits. Individuals rent their own apartments and the Department contracts with a provider, using General Fund dollars, for 24-hour staffing and services, including meals. Consumers pay a co-payment for their services based on their income and assets. The U.S. Department of Housing and Urban Development has approved the conversion of three federally funded elderly housing projects to assisted living.

Maine is one of eight (8) states to receive a grant from the Robert Wood Johnson Foundation’s “Coming Home” Program. This grant is allowing the Department to study the feasibility of bringing affordable assisted living to smaller, rural markets in Maine. The grant is also helping to fund the necessary study for the development of a Medicaid-funded payment model that will allow the program to reduce its reliance on General Fund dollars.

4. Assisted Living Study Commission: The Legislature enacted “An Act to Implement the Recommendations of the Commission to Study Assisted Living.” The legislation included changes to the definition of “aging in place,” rules regarding transfer of assets, and requirements for licensing and fire safety inspection

D. Home Care Programs

1. Home Care Coordination

Home Care is the preferred choice of most people. And in many cases, services at home are less expensive than care in a nursing or residential care facility. The number of persons using home care grew from 7,700 in 1995 to 12,690 last year.

Individuals and families may qualify for home care through a variety of state and Medicaid funded home care programs. Program criteria and services vary based on the individual’s income and level of need. For example, the state funded Homemaker program serves people who only need assistance with household tasks such as grocery shopping, laundry and house cleaning, while the Medicaid Home Care Waiver programs serve individuals who otherwise would be admitted to a nursing facility.

State and Medicaid funded home care programs require a pre-admission assessment. The purpose of the assessment is to match the person with the program that best meets his/her needs, and to assure that services are authorized equitably statewide. If the consumer chooses a home care program, the statewide home care coordination agency is responsible for arranging and coordinating services. In 1996, the Department selected through competitive bidding a single agency to coordinate the major state and Medicaid home care programs. This has resulted in lower administrative costs, and a more consistent approach statewide to working with consumers, families and providers.

Elder Independence of Maine (EIM), a division of SeniorsPlus which is the area agency on aging for western Maine, is the statewide home care coordination agency. EIM receives a monthly, per person payment to:

· Arrange services

· Coordinate and monitor care

· Collect consumer co-payments

· Administer contracts with service providers

· Pay claims

· Audit provider agencies

· Participate in quality improvement activities.

Services are delivered through a network of more than 200 local home health agencies, adult day services, personal care agencies, and independent nurse contractors. Elder Independence of Maine also works with consumers, or their families, who choose to hire their own staff, rather than using an agency.

The Department contracts with two agencies, Home Resources of Maine and Aroostook Home Health Services to manage the Homemaker services program statewide.

Home care agencies, like facility-based service providers, are not able to recruit sufficient qualified staff to meet the demand. In certain areas of the state, individuals can wait weeks for home care services to begin because agencies do not have staff available.

2. Consumer Satisfaction

The Bureau sponsored a mail survey of all home care consumers in late spring 2002. The response rate was 49%, which is excellent for a survey of this type. Consumers were asked questions about their experience with home care. Eight in ten respondents believe their care coordinator does a good job in setting up services. Most consumers indicate a positive relationship with, and appreciate the help they receive from EIM. This is evidenced by the 86% who would recommend their care coordinator to a friend who needed the same kind of help and the many respondents who added a positive comment about how kind, caring, helpful their care coordinator was.

Consumers are very appreciative of the in-home help they receive. Nine out of ten respondents said their home care worker knows what to do and takes an interest in them as a person. Consumers are aware of lack of staffing. Some commented about not receiving the hours they were supposed to get and they express concern that they will lose the help they do have because of the staffing shortage. Responses indicate some dissatisfaction with workers not having enough time for the tasks that need to be done, not coming when they are supposed to, not enough choice among providers, and concern about some workers not doing what was required. This is consistent with the findings of earlier surveys, and probably to be expected given the extreme shortage of staff. Yet, 87% would recommend their worker to a friend who needed the same kind of help.

E. Special Populations

A significant number of persons who use long-term care services have dementia, brain injury, or a mental illness. Nursing facilities were designed to serve persons with primarily medical problems, but had become the placement of last resort for persons with diverse needs, because there were no alternatives. When nursing facility admission changed to focus on those with nursing care needs, demand for alternatives was particularly strong for persons with Alzheimer’s and other dementias.

· The Department targeted development to make specialized residential programs for people with Alzheimer’s and other dementias available regionally. The number of programs grew from one to 16. Other types of specialized residential care facilities were also needed. Members of the AMHI Consent Decree class, who also were wards of the Department, also had unmet housing needs. Several new group homes for persons with serious and prolonged mental illness (6) and traumatic brain injury (5) were developed.

· BEAS was awarded an Alzheimer’s Disease Demonstration grant that developed a model respite program for caregivers of persons with a dementia. It has become a statewide program administered through the five area agencies on aging called Partners in Caring and is funded at over $700,000. This program provides needed short-term relief through the provision of in-home respite, adult day services or overnight respite at a residential facility and served over 470 families last year.

In addition, the Department has supported efforts to bring the “Best Friendsä” Approach to Alzheimer’s Care training to over 90 facilities and community-based organizations throughout the state. One new initiative, funded with federal grant monies, funds Elder Independence of Maine to provide three Alzheimer’s Specialist positions to work directly with caregivers of persons with dementia receiving long term care services in six demonstration counties.

· The Joint Advisory Committee on Select Services for Older Persons continues to advise the Departments of Human Services and Behavioral and Developmental Services regarding the needs of older people with mental illness, mental retardation, and substance abuse problems. They have focused attention on the incidence of depression and the unrecognized problem of substance abuse among older people.

The Committee is monitoring a study being conducted to review inappropriate prescribing of psychotropic medications for older Medicaid recipients. The Committee also endorsed a pilot project to test a new, more comprehensive mental health assessment tool for older people. The Joint Advisory is assisting in determining a response to the relatively high suicide rate among Maine’s older adults and how to more effectively meet the needs of people with coexisting dementia and mental illness, especially those whose behavior is difficult to manage. Finally, the Joint Advisory continues to advocate that direct care staff in facilities and home care agencies, as well as long term care assessors and home care coordinators, receive the training they need to better understand the needs of consumers with mental heath problems.

F. Family Caregiver Services

The reauthorization of the Older Americans Act in November 2000 created the National Family Caregiver Support Program. Five categories of services were included in the program: information about available services; assistance in gaining access to those services; individual counseling, support groups and caregiver training; respite care; and other supplemental services. Services are available to adults who are informal providers of in-home and community care to an older individual. Services are also available to grandparents (age 60 or over) or older individuals who are relative caregivers of children not more than 18 years old. Services are delivered by the area agencies on aging

G. Meeting Workforce Challenges

Finding and keeping qualified people to provide “hands-on” care has never been easy. It becomes especially difficult during periods of low unemployment, such as Maine is experiencing now. Demanding working conditions, combined with low pay and in many cases, no benefits, make these jobs relatively unattractive in good economic times. In addition, the adoption of training requirements and criminal history standards, that are intended to protect consumers, may further diminish the potential pool of workers.

This is not an issue that will be solved by an economic downturn, as it has in the past, because demographics are working against Maine. The population of persons, of all ages, who need supports is growing. At the same time growth in available workers is not keeping pace. Fewer people are entering the labor force and the in-migration of working age individuals is low. Other states rely heavily on immigrants to perform these jobs, but this population also is relatively small in Maine.

Fortunately, this is an issue where providers, advocates, regulatory agencies, and educational institutions have been able to find common ground and are working together on solutions. Several active workgroups are looking at such areas as training, reimbursement, scope of practice, and work design. The State of Maine has received a grant from the federal Centers for Medicare and Medicaid Services that will include a project aimed at creating opportunities for workers to be more directly involved in these discussions. In addition, a coalition under the sponsorship of Coastal Enterprises, Inc. recently submitted a proposal to the Robert Wood Johnson Foundation to support additional initiatives aimed at improving recruitment and retention of direct care staff.

IV. Who Uses Long-term Care Services

The charts on this and the following pages describe the population in Maine that has received an assessment. Long-term care consumers are predominantly older, low-income women. Many live alone and rely on adult children for support, in addition to the paid services they receive. The charts were prepared by the Muskie School on the basis of MECARE data for fiscal year 2002.

15,849 persons received assessments during the period July 2001 to June 2002.

Chart - Age at first assessment

· The average age at first assessment is 77 years old.

Chart - Home 51% Residential Care Facility 4% Nursing Facility 41% Hospital/other 4%

· Over half the people are living at home when they first receive a long-term care assessment.

· Many who are at a nursing facility when first assessed were admitted under Medicare.

Chart - Income as % of poverty level 65 and older
What is the Income of Persons Receiving Assessments?

Chart - Income as % of poverty Under Age 65

· The Federal Poverty Level for an individual in 2002 was $739.00/month.

Usual Living Arrangement chart

· ‘No Help’ means no reported non-paid caregiver at time of assessment.

Chart - Who provides care for people living in community

Many individuals receive paid care in addition to care provided by family and friends.
NOTE: The combined total adds up to more than 100% because some persons receive care from more than oneperson.

Chart - No reduced social interaction 72% Reduced social interaction 28%

· 5,886 people in community report reduced social interaction. This may be due to illness, lack of transportation, depression, or individual choice.

Chart - Transportation need - Drove self 10% Needed Transportation 80% Needed escort 74% Did not use/need transportation 11%

Chart - Top 10 Reported Health Conditions

Chart - Percent with Mental Health or Dementia diagnosis

Chart - What kinds of Help do Individuals Need?
Chart: # meds taken

The amount of help required to do daily tasks is a key factor driving the need for long-term care services.
People who do not require assistance are represented by the white portion at the top of each column. For example, 13% of persons assessed are independent in dressing.
The dark sections of the bars indicate persons who are totally dependent on others in performing the activity. For example, 9% of those assessed are totally dependent on others for eating.

Chart: How people qualify for Nursing Facility Level of Care

· 61% of all persons assessed are found eligible for nursing facility level of care.

Chart: NF Level receive services: Home 17% Nursing Facility: 77% No choice 5%

Of the 9,692 persons found nursing facility eligible, 17 percent chose to receive care at home rather than in a nursing facility.

V. System Oversight

A. Appeals and Grievances

At the individual level, consumers, families and service providers who are dissatisfied with the long-term care assessment, or with their services, may file an appeal and request a review by an independent hearing officer. The Department’s designated long term care assessment and home care coordination agencies are required to inform the consumer about appeal rights. Other service providers must also have grievance and appeal policies. Consumers who wish to appeal receive assistance from the Long-term Care Ombudsman Program, Legal Services for the Elderly, and Pine Tree Legal. The Department’s Administrative Hearings Unit hears appeals. Each year, approximately 300 persons request hearings.

B. Quality Improvement

Federal rules govern quality assurance activities in nursing facilities and Medicare certified home health agencies. Maine adopts rules at the state level to license other home care programs, assisted living, residential care and adult day services.

Maine’s system also includes activities aimed at monitoring the quality of state and Medicaid funded home care services. This is accomplished through regional Quality Assurance Committees that meet quarterly to review cases and to discuss system issues. Additional quality assurance activities include consumer surveys, Department of Human Services record reviews, staff training requirements, licensing standards, provider audits, mandatory reporting of abuse, neglect or exploitation, appeals, financial audits, and data analysis.

The Legislature has established the following Committees to provide advice and oversight to the development and implementation of long-term care services in Maine:

Ø Long-term Care Steering Committee (1996)

Ø Long-term Care Implementation Committee (2000)

Ø Home Care Coordination Quality Review Committee (2001)

Ø Blue Ribbon Commission to Address Financing of Long-term Care (2002)

Maine's Long-term Care System
			Percent
Program	1995	2002	Change

Nursing Home
Medicaid Census	9,945	8,175	-18%
Beds	10,207	7,771	-24%

Residential Care/ Assisted Living
Census	2,174	4,976	129%
Number of Programs	380	793	102%
Alzheimer's Programs	1	16

Adult Day Services
Census	39	324	731%
Number of Sites	30	54	80%

Alzheimer's Caregiver Respite Program	None	472

Home Care	7,623	12,690	66%

Total Persons Served	19,742	25,650	30%
Total LTC Spending	$284,715,157	$333,133,826	17%

Long-term Care Status Report

Table of Contents

1. Residential Care

2. Adult Day Services

3. Assisted Living Programs

4. Assisted Living Study Commission

D. Home Care Programs

1. Home Care Coordination

2. Consumer Satisfaction

E. Special Populations

F. Family Caregiver Services

G. Meeting Workforce Challenges

IV. Who Uses Long-term Care Services

I. Some History

II. Benchmarks of Progress

Percent

Change

A. Pre-admission Assessment

B. Nursing Facility Care

G. Meeting Workforce Challenges

A. Appeals and Grievances

B. Quality Improvement