Maine’s Home and Community-Based Care System

 

 

In 1993 Maine adopted a policy to reduce reliance on institutional long-term care and to offer more safe, affordable choices for consumers and families. Putting the policy into practice meant new kinds of home and community-based services, changes in how state and Medicaid-funded long-term care programs are administered, major changes to program policies, and “growing” the system to serve more people.

 

Reliance on nursing home care has declined dramatically and home care has grown.  At the same time, Maine reduced administrative costs and per person expenditures.  Because home care and assisted living generally cost less than institutional care, Maine has been able to serve more people with only modest increases in total spending.  The number of people using long-term care services has increased by 30% since 1995, while total spending has increased only 17%.

 

 

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/ Medicaid-funded home care programs

·        Educate consumers and families, about their choices: and

·        Support fair allocation of resources based on need.

The pre-admission assessment is mandatory for all nursing home applicants, including those paying privately.

 

The Department contracts with one agency, Goold Data Management, to operate the assessment program statewide. In order to avoid conflict of interest, the assessing agency may not be a provider of LTC services.

 

Nurses got to the persons home, conduct the assessment, establish medical eligibility, and authorize a service plan.  The Bureau has developed an automated system (MECARE) to collect and track assessment information.  Maine is only of only three states that uses a uniform assessment form and an independent agency to do assessments. Department of Human Services staff determine financial eligibility for Medicaid programs.

The Department uses assessment information to identify the characteristics of persons using LTC services, the types and costs of those services and to analyze the impact of proposed program changes.

 

 

 

 

 

 

Home Care Coordination

 

At the end of the assessment, the nurse tells the person which programs they may qualify for. If the consumer chooses a home care program, the statewide home care coordination agency begins the process of arranging and coordinating services.

 

In 1996, the Department selected a single area agency on aging to coordinate services statewide.  This resulted in lower administrative costs, and a more consistent approach to working with consumers and families.

 

The Home Care Coordination Agency, Elder Independence of Maine (EIM), receives a monthly, per person payment to:

• Arrange services
• Coordinate and monitor care;
• Calculate consumer co-payments
• Contract with service providers
• Pay claims;
• Audit providers;
• Participate in quality improvement activities.
  
  

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

 

 

 

 

Alpha One, the State’s Center for Independent Living, coordinates home care programs for adults who are able to direct their own care. Effective July 2002, oversight of these programs transferred from the Department of Human Services to the Bureau of Rehabilitation Services in the Department of Labor.

 

 

Appeals and Grievances

 

Consumers, families and service providers who are dissatisfied with the assessment, or with their services, may appeal. Goold or Elder Independence of Maine informs the consumer about appeal rights. Other service providers also must inform consumers of appeal rights. 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. Last year, 292 persons requested hearings.

 

Quality Improvement

 

The system also includes activities aimed at measuring the quality of services. This is accomplished through the Quality Review Committee that advises Elder Independence of Maine and regional Quality Assurance Committees that meet quarterly to review cases and to discuss system issues. Additional quality assurance activities include consumer surveys, DHS record reviews, staff training requirements, licensing standards, provider audits, mandatory reporting of abuse, neglect or exploitation, appeals, financial audits, and data analysis.

 

The Legislature’s Long-term Care Implementation Committee, established in 2000, also advises on the development and delivery of programs and services.