99015

Prepared by the North Dakota Legislative Council staff for the Budget Committee on Long-Term Care June 1997

STUDY OF EXPANDING HOME AND COMMUNITY-BASED SERVICE AVAILABILITY

House Concurrent Resolution No. 3004 (1997) provides for a Legislative Council study of the means of expanding home and community-based service availability, options for training additional qualified service providers, the adequacy of geropsychiatric services, and the feasibility of combining service reimbursement payment sources to allow payments to flow to a broadened array of elderly and disabled service options. The resolution cites as reasons for the study:

1. The availability of qualified service providers in rural areas may be limited and potential providers may lack the skills necessary to meet required competency standards.
2. The training opportunities are limited, which may require the rural elderly and disabled to choose between relocating to access services or going without necessary services.
3. Expanded training of qualified service providers could enhance the availability and improve the quality of home and community-based services.
4. The combining of service reimbursement payment sources may provide increased flexibility or portability of service payments to allow payments to flow to a broadened array of service options for the elderly and disabled.

Attached as an appendix is a copy of House Concurrent Resolution No. 3004.

PRIOR STUDIES

1995-96 Interim Budget Committee on Home and Community Care

Section 1 of 1995 Senate Bill No. 2460 directed a study of the use of the state's resources and services in addressing the needs of the elderly residents. The committee received the report of the Task Force on Long-Term Care Planning. Based on this report and the committee's study, it recommended House Concurrent Resolution No. 3004 and House Bill No. 1039 relating to the expansion of home and community-based service availability. House Bill No. 1039 allows the Department of Human Services to waive the imputed minimum occupancy level requirement for a nursing home that the department determines to be providing significant home and community-based services in coordination with home and community-based service providers to avoid duplicating existing services.

The committee also studied the licensing of home health care providers, including the determination of the appropriate agency to be responsible for the licensing of home health care providers. The committee recommended Senate Bill No. 2027, which failed to pass, which would have established a registry system of home health care providers to be administered by the Department of Human Services.

1985-86 Interim Budget Committee on Human Services

House Concurrent Resolution No. 3062 (1985) directed a study of the need for comprehensive in-home and community support services to maintain, enhance, or prolong the independence and self-support of the partially dependent and elderly population. The committee recommended a bill requiring mandatory preadmission screening of each person prior to admission to a skilled nursing, intermediate care, or hospital swing bed facility and required the facility to inform individuals of available in-home and community-based services and of the individual's opportunity to choose, in consultation with an attending physician or family member, among the appropriate alternatives. The bill was passed by the 1987 Legislative Assembly. House Bill No. 1277 (1991) repealed the sections relating to the preadmission assessment of persons and a facility's duties of preadmission assessment and alternative care. In addition, 1991 House Bill No. 1277 contained a section of legislative intent stating that the Department of Human Services, through senior agencies and senior centers, is to provide information to the elderly on available in-home and community-based services.

The 1985-86 Budget Committee on Human Services also recommended a bill which provided for a continuum of community-based services adequate to appropriately sustain individuals in their homes and communities and to delay or prevent institutional care. The bill passed the 1987 Legislative Assembly.

TASK FORCE ON LONG-TERM CARE PLANNING

The committee received the report of the Task Force on Long-Term Care Planning which stated that a home and community-based services system can be highly effective when a qualified service provider can be located in close proximity to a client. The report also stated that due to distances between qualified service providers and clients, in most cases, service delivery in the very rural areas tends to be more expensive. The Task Force on Long-Term Care Planning recommended the continued study of the means of expanding service availability, including options for training additional qualified service providers.

In regard to geropsychiatric service adequacy, the Task Force on Long-Term Care Planning indicated that the State Hospital is engaged in studying the issue of geropsychiatric care. The preliminary conclusions include that geropsychiatric care should be provided by the private sector as close to the patient's community as possible. The report indicated that the medical director of the State Hospital is developing a plan to provide outreach support for nursing homes in need of intervention services for this special population. The report also stated that if the private sector does not provide the service, the State Hospital is prepared to fill a gap in community services by providing geropsychiatric care in an inpatient unit. This would be contingent on the facility's ability to obtain a long-term care license and to operate the program at a cost lower than its inpatient hospital costs. The Task Force on Long-Term Care Planning recommended the continued monitoring of the issue, with no further action recommended until the completion of the studies by the State Hospital.

The task force also recommended the pooling of service reimbursement payment sources, the object being increased flexibility or portability of service payments in order to allow for a broadened array of housing options.

HOME AND COMMUNITY-BASED SERVICES

Medicaid Waiver

Medicaid waiver services are provided in lieu of nursing home placement under a waiver received from the federal government for eligible elderly and disabled. Recipients must be Medicaid-eligible and in need of the level of care provided in a nursing home.

Service Payments for Elderly and Disabled (SPED) Program

Service payments for elderly and disabled services are provided in home and community-based settings to functionally impaired elderly and physically disabled persons to allow persons to avoid institutionalization. Services provided include family home care, homemaker service, home health aid, respite care, case management, nonmedical transportation, chore service, adult foster care, adult day care, and personal care. The state pays 95 percent of the cost of the SPED program and counties pay five percent.

Expanded SPED Program

The expanded SPED program provides basically the same services as the SPED program with different program and financial eligibility criteria. The state pays the entire cost of this program.

Traumatically Brain-Injured (TBI) Waiver

Services are provided in lieu of nursing home placement under a waiver received from the federal government for eligible recipients. Recipients must be Medicaid-eligible and in need of the level of care provided in a nursing home and meet the following criteria:

• Have a diagnosis of traumatic brain injury or acquired brain injury;
• Have a neuropsychological evaluation;
• Be between the ages of 18 and 64;
• Disabled based on Social Security disability criteria; and
• Capable of directing own care as determined by interdisciplinary team.

HOME AND COMMUNITY-BASED SERVICES FUNDING AND RECIPIENT NUMBERS

The following table shows the funding for the various home and community-based services for the 1995-97 and 1997-99 bienniums:

1995-97 Biennium
Service	General Fund	Other Funds	Total
Medicaid waiver	$1,318,818	$2,924,922	$4,243,740
SPED program	$7,131,840	$375,360	$7,507,200
Expanded SPED	$1,423,266		$1,423,266
TBI waiver	$542,828	$1,202,998	$1,745,826
1997-99 Biennium
Medicaid waiver	$1,375,652	$3,213,880	$4,589,532
SPED program	$8,442,577	$444,346	$8,886,923
Expanded SPED	$1,522,417		$1,522,417
TBI waiver	$456,004	$1,322,352	$1,778,356

The following table shows the number of unduplicated recipients for each of the various home and community-based services for fiscal years 1993 through 1996:

	1993	1994	1995	1996
Medicaid waiver	429	366	313	298
SPED program	1,691	1,758	1,482	1,449
Expanded SPED program*			269	396
TBI waiver			9	11
*Expanded SPED payments began in November 1994.

HOME AND COMMUNITY-BASED SERVICE AVAILABILITY STUDY PLAN

The following is a study plan the committee may want to consider in its study of expanding home and community-based service availability:

1. Receive testimony from representatives of the Task Force on Long-Term Care Planning regarding the task force's recommendations, implementation status of its recommendations, and plans for any continued study of the needs of the elderly.
2. Receive testimony regarding the long-term care needs of the elderly, information on historic and projected costs and utilization of programs for the elderly, recommendations for improvements to the service options for the elderly, recommendations on how to expand service availability, training additional qualified providers, geropsychiatric service adequacy, and recommendations on the feasibility of combining service reimbursement payment sources from the following:
   • Department of Human Services.
   • Department of Health.
   • Home and community-based service providers.
   • Long Term Care Association.
   • Other interested parties.
3. Provide recommendations to the Legislative Council and the 1999 Legislative Assembly regarding expanding home and community-based service availability, options for training additional qualified service providers, the adequacy of geropsychiatric services, and the feasibility of combining service reimbursement payment sources and consider any legislation necessary to implement a proposed recommendation.

ATTACH:1

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