Priority Components for Inclusion in a Integrated Managed Care System

The expansion of acute managed care into the area of long term services and supports is growing as states are looking for ways to control the growth of Medicaid funded acute and long term service and support health care expenditures for people with physical disabilities and older Americans. The growing integration of acute and long term services and supports present a growing challenge for advocates who are concerned about managed care growing in an era of scarce Medicaid funding. Advocates fear that rationing of services and support will be the way states balance their Medicaid budgets.

Some of our options are as follows:

1. Actively oppose the move towards integrated Medicaid managed care by organizing a state by state campaign against its implementation;
3. Actively design how long term services and supports should be integrated into a Medicaid managed care model, by developing the components that must be included in any contract the State signs for a integrated managed care program;
5. Ignore it and let the managed care locomotive run over us.

Below are a few suggestions on what components an integrated Medicaid managed care program should have IF it is implemented in your state:

Social model

• The philosophical and value base of the program should be based on the principles underlying the independent living movement of choice and control.
• The long term services and supports component of the program should not be directed by physicians or home health agencies. This would create a medical model. Long term services and supports must be delivered with assurances of a social/independent living model based on choice and control with person-centered planning. Consumer directed services must be offered as a first delivery option.
• Linkage/coordination to the acute services must be seamless. Access to long term services and supports must not be fragmented.
• Service coordination must be done by organizations/individuals understanding the principles of choice and control with experience working with people with disabilities and older individuals.
• Individual receiving services should partner with Service Coordinator to agree on Plan of Services (POS). All services must be signed off by the consumer.
• Health maintenance tasks should allowed to be delivered by an attendant through doctor/nurse delegation/assignment or by program designation.

Implementation logistics

• If implemented in multiple sites, the program should have a staggered rollout implementation schedule and be tested for effectiveness.
• The program should subcontract with community based organizations with expertise working with people with disabilities and older individuals for consumer education and outreach. This should begin three to six months prior to the implementation of integrated managed care rollout in each area proposed.
• Expansion statewide should not take place until thorough evaluations are conducted for program effectiveness.
• Managed care contracts should include monitoring community integration and independent living indicators. Reimbursement should be based on meeting community integration standards.

Service coordination

• Long term services and supports must have independent service coordination with service coordinators qualified by:
  • experience working with people with disabilities and older people;
  • knowledge of consumer control/self determination/independent living;
  • expertise and knowledge of community based service programs;
  • knowledge of person-centered planning.
  • Services coordinators must haves seamless access to home and community based services to assure ease of access to services for the individual.
• Access to specialists, for durable medical supplies, assistive technology as well as all acute services should be as seamless as possible.

Consumer directed services options

• Consumer directed service option must be first option offered for all long term services and supports.
• Service coordinator must offer and explain this type of delivery system without bias to all consumers.
• Integrated managed care program design should prioritize a consumer directed/self-determination approach by measuring how often this option is selected.
• All types of consumer directed service delivery options should be offered such as using a fiscal intermediary model or an agency with choice model.

Decision Making

• Medical/Rehabilitation decisions are made by medical/rehabilitation providers, selected by the consumer, who actually treats the person rather than reading a written record.
• Long term supports and services authorizations are made final by the consumer agreeing to the service plan.
• Both an informal independent and a formal external process must be available if the person and the managed care system disagree with a decision, with a timely process to accommodate emergencies.
• Parents of children with special health care needs and adults with disabilities may decide to use a specialist as a primary care provider.

Eligibility for home and community services

• The managed care program will develop and implement a plan to reduce any waiting list that exists for home and community services.
• Eligibility should be for SSI and the MAO population (300% of SSI).
• There should be no financial eligibility difference between the home and community service and the institutional programs.
• Medicaid buy-in recipients, if included, should be eligible for the same services.

Community Integration

• The program will facilitate diversion and relocation from institutions by partnering and subcontracting with community based organizations, such as CILs and/or AAAs, DD Centers, with expertise in relocation and diversion.
• Effectiveness of relocation and diversion will be measured in community integration outcome measures. This will be measured by how many people go into nursing homes and other institutions and how many people get out.
• Program should provide an adequate number of acute and community service providers in order to promote health, independence and consumer choices.
• Self-determination/Consumer directed services should be offered as a first delivery option along with the traditional agency delivery model.

Meaningful consumer input

• Program has a functioning mechanism of meaningful consumer input. At least 1/2 of any committee should be consumers. There should be a statewide advisory committee as well as local/regional advisory committees to assure local input.
• Develop, with consumer input, effective Long Term Services and Supports Community Integration Indicators that evaluate the program based on consumer satisfaction.
• Monitoring of integrated managed care program should be ongoing at the state and local levels.

Sustainability of community care workforce

• The program will develop and implement a plan to increase wages and benefits for community service attendants.
• Program should promote strategies that will increase the number of community attendants available for employment.
• Attendants should be part of any planning/evaluation process designed.

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