ALTSA Strategic Objective 1.1

AGING AND LONG-TERM SUPPORT ADMINISTRATION HIGHLIGHT STRATEGIC OBJECTIVE 1.1:

Serve individuals in their homes or in communitybased settings of their choice.

Aging and Long-Term Support Administration Mission

TABLE OF CONTENTS 2

Message from Leadership

3

Measure Overview

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Measure Data

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Importance

9

Program Innovations

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Action Plans with Stories

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Area Agencies on Aging

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Who Plays a Role

To transform lives by promoting choice, independence and safety through innovative services.

Vision Seniors and people with disabilities living with good health, independence, dignity and control over the decisions that affect their lives.

Values • • • • • • • •

Collaboration Respect Accountability Compassion Honesty and Integrity Pursuit of Excellence Open Communication Diversity and Inclusion

MESSAGE FROM LEADERSHIP The Aging and Long-Term Support Administration’s (ALTSA) mission is to transform lives by promoting choice independence and safety through innovative services.

We have a vision that seniors and people with disabilities living with good health, freedom, dignity, and control over decisions that affect their lives.

BILL MOSS

We believe that every Washingtonian deserves the right to make choices in how they live their lives and how and where they receive care. We serve about 74,000 individuals in Washington state that need long-term care services. Most of these individuals prefer to stay in their own homes or community residential settings to remain involved with their families and friends and connect to their local communities to maintain the most significant level of independence and selfdetermination.

Assistant Secretary Aging and Long-Term Support Administration

Every two years, AARP issues a national scorecard ranking states long-term services and supports system across several indicators, including Affordability and Access, Choice of Setting and Provider, Quality of Life and Quality of Care, Support for Family Caregivers and Effective Transitions. Washington overall ranking is #2.

This ranking is more than just a numerical value. It’s reflective of Washington’s bold and revolutionary efforts to support those who need long-term care. It means a robust and client first delivery system that values independence, choice and accessibility.

Moving forward we will continue to challenge ourselves, evaluate practices and adjust tactics in order to provide the highest quality care to seniors and people with disabilities. The success measure outlined in this resource is just one of many that we have taken on in our effort to reach our mission of transforming lives by promoting choice, independence and safety through innovative services.

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STRATEGIC OBJECTIVE 1.1 ALTSA developed Strategic Objective 1.1 to show how we prepare for Aging Washingtonians one of the Department of Social and Health Services six priorities.

The hallmark of Washington’s long-term services and supports (LTSS) system is that, whenever possible, individuals are given the opportunity to live and receive services in their own home or in a community setting.

Developing home and community-based services and ensuring individuals have timely access has meant Washingtonians have a choice regarding where they receive care. This has produced a more cost-effective method of delivering services and resulted in a better quality of life for clients, with control over the choices they exercise in their daily lives.

CONTINUED IMPORTANCE Washington’s population, like that of the nation, is aging rapidly.

This chart shows the growth of individuals ages 65 and older in 10 year increments. The blue line is the fastest growing population representing individuals ages 85 and older. We know from national statistics that 70% of us who are lucky enough to reach age 65 will need some form of long-term services and supports during our life-time.

In Washington we have managed the fiscal impact of the aging population through rebalancing the Medicaid system from nursing home reliance to home and community-based care. We are thinking about the changes we need to make to our service delivery systems and policy to avoid negative consequences in the future.

% Change in Population Relative to 2016

350%

300%

250%

85+ years

75 to 84 years

65 to 74 years

50 to 64 years

200%

150%

100%

50%

0%

2016

2020

2025

2030

2035

2040

2045

2050

-50%

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WHERE ARE WE TODAY? Within Strategic Objective 1.1, ALTSA created Success Measure 1.1.1:

Maintain the percentage of LTSS clients served in home and communitybased settings at or above 88% by June 2023.

Washington made a deliberate policy choice in the early 1990s to build a community-based system of care so that individuals would have the ability and would be supported in their choice to live in their own homes. For Washingtonians, this makes sense because regardless of disability type, the overwhelming preference of individuals who are aging or who have functional disabilities is to remain where they have ties to their community, their family, their neighbors, and their friends.

Prepare for Aging Washingtonians Percent of long-term services and support clients served in home and community-based settings.

GOAL: Maintain the percentage of LTSS clients served in home and community-based settings at or above 88% by June 2023.

WHAT DOES THIS LOOK LIKE? This chart shows the state’s progress in shifting spending and service delivery from a reliance on nursing homes to now a strong reliance on home and community settings. Nationally refer to as “Rebalancing of long-term services and supports systems”.

The blue on this graph shows the growth in the number of individuals served in home and community-based settings from 1993 when 53% of individuals were served in their own homes or licensed residential settings to today when we are serving nearly 90% of the population in the community.

The green shows the decrease over the same time period in the number of individuals served in nursing homes from 1993 when almost half of individuals needing Medicaid funded long-term services and supports were served in nursing homes and today 10% are.

Prepare for Aging Washingtonians Percent of long-term services and support clients served in home and community-based settings

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WHY THIS IS IMPORTANT • Cumulative estimated savings for SFYs 2000-2020 = $4.9 billion • Projected savings for SFYs 2021-2023 = $ 2.3 billion • Rebalancing has resulted in a significant reduction in Nursing Home (NH) utilization: • 8,558 actual nursing home clients in June 2020 versus a projection of 22,345 clients under SFY 1999 caseload distribution • Estimated 1.62 million fewer NH client months over SFYs 2000-2020 • Projected 0.54 million fewer NH client months over SFYs 2021-2023

LTSS PROGRAM INNOVATIONS The “Rebalancing of long-term services and supports systems” has been achieved incrementally over the past 30 years.

This chart shows some significant milestones in the state that have contributed to the success of our Long-Term Services and Supports system.

States must start from where they’re at in the process and understand the needs of clients who want to be served in community settings and the gaps in meeting those needs.

1981

1989

1999

 State-funded in-home program allows self-directed option

 State Plan personal care for individuals with physical disabilities

 First nurse delegation law and law allowing family members to be paid when providing skilled tasks

1983  1915(c) waiver approved

 Statewide respite program implemented

1984  First steps to control nursing home growth

2008  MFP (RCL) implemented in Washington

2009

1993

2000

 Mandates for Nursing Home reductions— state staff dedicated to nursing home and hospital transitions

 State Family Caregivers Program

 Statewide implementation of Standardized Caregiver Assessment Tool

2012  Long-Term Care Worker Training and Certification requirements

2001  Self-directed care providers vote to unionize

1985  Adult Protective Services statute

1995

2003

 State plan eligibility expanded to those with functional disabilities

 Standardized electronic assessment with acuity-based payment methodology used across all HCBS populations (aging, physical, developmental disabilities)

 Required training for all in-home personal care assistance

2012  State Plan Community First Choice Program

2017  1115 Waiver creates new options and eligibility for Long-Term Support Services

 Abuse registry

1980

1985

1990

1995

2000

2005

2010

2015

2020

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ACTION PLANS WHAT DO WE DO TO INCREASE THE PERCENT? We have developed three Action Plans with the assistance of staff engagement and feedback:

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2

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ALTSA will engage with clients and their families to help set up planning options that will assist individuals moving into a setting of their choice with the services and supports that fit their unique needs.

ALTSA will continue to inform community providers and create new services for specialized populations and individuals with multiple needs.

ALTSA will work with tribal governments and regional Area Agency on Aging (AAA) leadership teams to plan and simplify processes, review access to services and help staff support the changing needs of clients.

ACTION PLAN #1 ALTSA will engage with clients and their families to help set up planning options that will assist individuals moving into a setting of their choice with the services and supports that fit their unique needs.

According to the CDC, falls among adults aged 65 and older are common, costly, and preventable. Falls are the leading cause of fatal and non-fatal injuries among older adults.

Falls among adults age 65 and older are very expensive. Each year about $50 billion is spent on medical costs related to non-fatal fall injuries and $754 million on fatal falls.

Franklin is an example of one of our clients who had a fall that changed his life. The unfortunate reality is that a fracture in an older adult can cost that person and their family a great deal. Many people within our communities do not receive daily check-ins and do not have a personal emergency responses system.

As a result, they may be lying on the floor for hours or even days before getting help. Their injuries become much more life-altering the longer they go without help. Additionally, recovery can be long and very expensive. Because of the costsharing required for an extended nursing facility stay, many people find themselves unable to afford the nursing home and their apartment and end up stuck in the nursing home.

Our services helped Franklin get back into the community.

He chose an assisted living community and enjoys frequent activities and community connections.

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FAMILY CAREGIVER SUPPORT PROGRAM BETSY’S STORY Betsy cared for her husband Bill in their home, which happens to be a converted garage on their daughter Sandy’s property in a rural setting. Eventually, Bill began to exhibit symptoms of dementia and required increasing amounts of supervision and care. Through a Family Caregiver Support Program (FCSP) referral from Bill and Betsy’s physician’s office, they were able to have personalized in-home consultation with an occupational therapist (OT) for home safety evaluation and the provision of meaningful activities for Bill. A consultation with a physical therapist (PT) brought about training for Betsy and Sandy for how best to encourage Bill to get up, around, dressed, and showered without confusing or upsetting Bill by providing too many directions and without getting hurt themselves.

In addition to OT and PT, Bill and Betsy could access 22 hours a month of respite care from a local in-home care agency. Every week, a caregiver would stay with Bill so that Betsy could drive into town to attend to her health concerns and to do some shopping. While Betsy was out, Bill and the caregiver would take walks through the garden and down the road a bit for exercise and socialization. They would return home and watch sports on TV and eat a bit of junk food.

Eventually, Bill required placement and passed away. The family was grateful for all the help provided by FCSP and the caregiver.

Two years later, Sandy called FCSP to ask if they could bring in some supports to assist her in caring for her mother, who was beginning to need some help showering. Neither of them was incredibly comfortable with Sandy doing this.

Sandy was now the designated caregiver, and the same agency found a respite worker. They started weekly visits to provide a socializing walk in the garden, a shower, and some TV time with Betsy. Betsy’s memory was fine, but she had some frailties. Good friendships were formed with the caregiver by both Betsy and Sandy, and the visits became very meaningful to all of them.

The few services provided through FCSP have allowed Betsy to be in the home she shared with Bill many years ago. Betsy and her daughter can still live near one another but not under the same roof. It was essential to both as they like their independence and the respect it brings them for themselves.

ACTION PLAN #1. #2 ALTSA will continue to inform community providers and create new services for specialized populations and individuals with multiple needs.

Discharging from a state hospital has many different complexities. One of the biggest obstacles to overcome is a client’s willingness and desire to be successful in the community and take the proper steps needed to get there. Here is a journey of a 41-year-old gentleman who worked tremendously hard with his treatment team, family, Home and Community Service (HCS) case manager, and community providers.

This client has been institutionalized three times at a State Hospital dating back to 2001. The client’s path toward discharging into a stable community placement began after his second discharge from the hospital. The client was admitted to a clean and sober house with a voluntary readmission protocol approved by the hospital with his conditional release. After admission to the clean and sober house, the client noticed that he was not doing well in the community. He had the insight to understand that he needed additional treatment to become more stable.

The client returned to the State Hospital where he remained for two years. During those years, he worked hard with the ward administrator and social worker. He had very challenging behaviors, including assaultive and aggression, delusions, and hallucinations. He also had a history of substance abuse and an extensive criminal history. The client’s HCS case manager worked extensively to build a solid rapport with the client to finally feel comfortable exploring settings in the community.

The process was slow due to the need for a well-thought-out and carefully crafted discharge plan. The case manager and client were able to find a location for the client, but there were no openings initially. The client only wanted to go to this location and waited for several months to finally have space available. The day the facility accepted the client, he was delighted. The client went through a courtordered process and transitioned into the community to be closer to his family and live in a structured setting. He had access to services at the facility and in the community to meet his complex behavioral needs.

The client has demonstrated success in the community after being a year out of an institutionalized setting. He is a true example of overcoming barriers and collaborative efforts to transform lives.

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ACTION PLAN #1. #3 ALTSA will work with tribal governments and regional Area Agency on Aging (AAA) leadership teams to plan and simplify processes, review access to services and help staff support the changing needs of clients.

In partnership with Area Agencies on Aging, Home Care Agencies, and Supported Housing Providers, regional leadership developed the Coordinated Personal Care, a flexible Personal Care delivery system based on geographical efficiencies.

In the traditional home care model, the client’s needs are met via a set schedule based on caregiver availability. Clients must be available during those hours. Caregivers with multiple clients may have to travel to many different locations. If a client does not show, there is little flexibility to adapt and quickly serve another client. Caregiver agencies typically require a minimum of two hours per visit.

With Coordinated Personal Care, clients receive their total hours while meeting the client’s schedules with flexibility. Clients and caregivers benefit from the ability to have multiple shorts shifts if necessary, with different clients all at one location. Clients already on services and new clients have the option of participating in Coordinated Personal Care or the traditional in-home personal care model.

Geographic areas are identified, and the caregiver’s area is assigned to a building where they can review all client care plans with housing providers. This new service has proved to be very effective and will roll out to other counties through the following year.

AREA AGENCIES ON AGING PARTNERSHIP Area Agencies on Aging (AAAs) play a significant and important role in our planning and service delivery systems.

They are local government organizations responsible for planning, advocacy, and service delivery for older adults. There are 13 in Washington and two are within Tribal governance.

They provide Medicaid case management for inhome clients and oversee the network of providers for Washington in-home services.

They also provide services like Information & Assistance, Family Caregiver Support, and other programs under the Older American’s Act

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WHO PLAYS A ROLE Everyone within Aging and Long-Term Support Administration supports Strategic Objective 1.1. Increasing the percentage of in home and community settings is both a specific objective and a broad goal supported by many others.

Budget, Finance and Forecasting

Informaton Technology and Data Analysis

Training and Program Development

Assessments & Person Centered Care Planning

What it Takes to be Successful

Investigation reports of abuse & neglect

Quality Assurance

Contracts

Licensing & oversight of residential facilities