HD86 - Blueprint for the Integration of Acute and Long-Term Care Services


Executive Summary:
Governor Timothy Kaine, with support from the 2006 General Assembly, set in motion a major reform of the Virginia Medicaid funded long-term care services program, which will focus on care coordination and integration of acute and long-term care services for our most vulnerable citizens—low-income seniors and individuals with disabilities. The legislation (Special Session I, 2006 Virginia Acts of Assembly, Chapter 3) directed the Department of Medical Assistance Services (DMAS), in consultation with the appropriate stakeholders, to develop a long range blueprint for the development and implementation of an integrated acute and long-term care system. In addition to this plan, the Department was directed to move forward with two different models for the integration of acute and long-term care services: a community model and a regional model, which are explained below and in the body of the report. Finally, the legislation provided $1.5 million in start-up funds for six potential PACE sites.

The degree of chronic illness and disability among seniors and individuals with disabilities is a key policy and budget issue for the Commonwealth. Seniors and individuals with disabilities make up 30 percent of the Medicaid population in the state, but 70 percent of the costs of a budget that now exceeds $5 billion annually. The challenge is how to curb Medicaid growth in the long run without compromising access to services for vulnerable populations. While Virginia has been successful in implementing managed care for low-income children and families, it has not applied the same successful principles to programs specifically designed for the long-term care populations. Currently in Virginia, most Medicaid seniors and individuals with disabilities receive acute and long-term care services through a patchwork of fragmented health and social programs that are not necessarily responsive to individual consumer needs. Acute care is provided in a fee-for-service environment with no chronic care management. Long-term care is provided in a nursing facility or by a variety of home and community-based care providers with no overall care coordination or case management. In addition, most Medicaid seniors and individuals with disabilities qualify for both Medicare and Medicaid, which further complicates the access, quality, and funding of an integrated system.

In response to the legislation, DMAS held three meetings during the Fall 2006 to involve the community and state level stakeholders in the development of the Blueprint. The meetings provided an overview of other states’ integration models and the opportunity for the public to comment and provide input into the design of the program. DMAS intends to involve the stakeholders throughout the design and implementation of the integrated acute and long-term care models to ensure that consumer protections, consumer choice, consumer direction, quality of care, and access to needed services are maintained. DMAS supports the vision of One Community, the Olmstead Initiative to allow individuals to live as independently as possible and in the most integrated setting.

This report provides the Blueprint for moving forward with the community and regional models for the integration of acute and long-term care services. The overall goal for this Blueprint is to offer some form of coordinated or managed care for the entire spectrum of seniors and individuals with disabilities (also known as Aged, Blind, and Disabled under federal terminology) from the well to the frail. The focus will be on providing the “right services at the right time” and eliminating healthcare delivery systems based solely on funding sources and the need for long-term care services.

Integration of Acute and Long-term Care Services for Seniors and Individuals with Disabilities: Community Model

The community model is the Program of All Inclusive Care for the Elderly (PACE). PACE serves persons 55 and older who meet nursing facility criteria. All health and long-term care services are provided in the community, centered around an adult day health care model, and with Medicaid and Medicare funding combined. This is a voluntary program and is one community alternative to nursing facility care. DMAS intends to move forward with this model in two phases.

The current system is one pre-PACE site that has been in existence more than ten years, serving Hampton Roads (Sentara Senior Community Center). Phase I is the implementation of seven full PACE sites across the Commonwealth. Phase II will be the implementation of additional PACE sites in underserved areas of the state.

Integration of Acute and Long-term Care Services for Seniors and Individuals with Disabilities: Regional Model

The regional model could range from a capitated payment system for Medicaid and/or Medicare for acute care costs only and care coordination services for the home and community-based services, to a fully capitated system for all acute and long-term care services. Unlike the PACE model, where all health care professionals and all services center around an Adult Day Health Care Center, a regional model utilizes a variety of community health care providers. By design, regional models will coordinate the care needs of both seniors and individuals with disabilities and are not limited to only those with long-term care needs. While DMAS fully supports integrated and coordinated care, it is likely that one model will not meet the needs for all seniors and individuals with disabilities. DMAS also intends to move forward with a regional model in two phases.

The current system provides managed care for primary and acute care needs for more than 49,000 seniors and individuals with disabilities who are not Medicare eligible and who do not have any long term care needs. However, once these clients need long-term care services and/or become both Medicaid and Medicare eligible (known as dual eligibles), they are moved out of a managed care environment into a fragmented fee-for-service environment with little or no coordination of their health care needs. Phase I is a preliminary step to expand managed care for seniors and individuals with disabilities for at least their primary and acute care needs. Instead of moving Medicaid only seniors and individuals with disabilities into fee-for-service when they need long-term care services, DMAS intends to keep them in the coordinated care system for at least their primary and acute care needs, while keeping their long-term care services fee-for-service. Phase II is the most dramatic phase of the integration because the true integration of services (primary, acute, and long-term care services) and funding (both Medicaid and Medicare) takes place. This model develops a seamless system of care that adjusts with clients as their care needs change over time. This model intends to include all long-term care services, except for certain home and community-based care waiver services.

The integration of acute and long- term care services should be successful in Virginia because:

1. The Governor and the General Assembly have provided a clear mandate that an integrated primary, acute, and long-term care service delivery system is what they envision for Virginia’s seniors and individuals with disabilities.

2. Virginia has successfully utilized Medicaid managed care principles for its children, families, seniors, and individuals with disabilities for many years.

3. The Department of Medical Assistance Services has a good track record for ensuring the smooth transition to new programs by involving the stakeholders throughout the development and implementation process.