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Nursing Home Diversion


What is the Florida Nursing Home Diversion Program and what is the purpose of Medicaid Long-Term Care Waiver programs?

The purpose of Medicaid Long-Term Care Waiver programs is to avoid or delay unnecessary and costly nursing home placement and enhance quality of life by providing alternative, less restrictive long-term care options for seniors who qualify for Medicaid skilled nursing home care.  These options include care in the home, or in a community setting such as an assisted living facility or adult day care center.

What Medicaid Long-Term Care Waiver programs are available to seniors?

The Department of Elder Affairs (DOEA) administers three primary Medicaid Long-Term Care waiver programs for seniors:

the Medicaid Aged and Disabled Adult (ADA) waiver,
the Medicaid Assisted Living for the Frail Elderly (ALE) waiver, and
the Long-Term Care Community Diversion Pilot Project, more commonly known as the Nursing Home Diversion (NHD) waiver.

The department also administers the Consumer Directed Care Plus (CDC+) waiver, which  provides some seniors in the ADA waiver program greater control over choice and delivery of services.  For more information on these waivers, please see the Summary of Programs and Services on the department’s website.

In addition, the Agency for Health Care Administration (AHCA) administers the Alzheimer’s Disease Medicaid Waiver, Channeling Waiver, and Medicaid Adult Day Health Care Waiver for seniors in a few specific counties.  The Alzheimer’s Disease Medicaid Waiver provides services such as case management, adult day health care, respite care, behavioral assessment and intervention, and personal care to individuals with Alzheimer’s Disease in Broward, Miami-Dade, Palm Beach and Pinellas counties.  The Channeling Waiver provides services such as adult day health care, respite care, therapies, skilled nursing, and personal care in Broward and Miami-Dade counties.  The Medicaid Adult Day Health Care Waiver provides services such as case management, therapies, counseling, meals, and personal care assistance to impaired seniors at adult day health centers in Lee and Palm Beach counties.  For more information, see the Medicaid Summary of Services on the Agency for Health Care Administration’s website.

Department of Elder Affairs Nursing Home Pre-Admission Screening (CARES)

What is the purpose of the CARES program?

The CARES Program (Comprehensive Assessment and Review for Long-Term Care Services) is Florida’s federally mandated pre-admission screening program for Medicaid nursing home applicants.  The program’s purposes are to identify an individual’s need for long-term care, establish an individual’s medical eligibility to receive Medicaid funding for long-term care, and recommend the least restrictive and most appropriate placement.  The program emphasizes allowing people to remain in their communities by providing services at home or in alternative community setting, such as assisted living facilities.  For more information, visit the CARES website.

Who is served by the program?


The CARES Program makes medical eligibility determinations on all individuals seeking Medicaid coverage for nursing home care.  Because these individuals must meet both medical and financial eligibility criteria, CARES staff must work closely with the Department of Children and Families’ Economic Self-Sufficiency Program, which conducts the financial eligibility determinations in a separate process.  The CARES Program also certifies medical eligibility for potential clients in certain Medicaid waivers that provide community services and conducts reviews of nursing home residents to ensure that they continue to meet the level of care criteria.  The program also conducts level of care assessments for private pay individuals upon request.

How does the program make a medical eligibility determination?

To make a medical eligibility determination, a CARES assessor or a registered nurse assesses an applicant’s physical and mental capabilities and limitations, health care needs, and social support systems.  A consulting physician then reviews the assessment with CARES staff and makes the final decision (called a "level of care determination") about the applicant’s medical eligibility for Medicaid.  During this consultation, the team also makes a recommendation for the least restrictive placement that will meet the applicant’s service needs.  The recommendation may be to place the client in a nursing home; an assisted living facility; an adult family care home; or to provide needed services in the client’s own home or the home of a caregiver.

How many clients are assessed by CARES and how many were not placed in nursing home within 30 days of the CARES assessment?

During Fiscal Year 2005-06, the CARES Program staff and local agencies conducted a total of 87,218 assessments.  CARES staff conducted full assessments, level-of-care determinations and placement recommendations for 49,007 clients seeking long-term care services.  Of the 49,007 clients assessed, 15,037 (30.7%) remained in the community within 30 days of their assessment (this may include some clients who did not receive needed care).  

Local agencies conducted full assessments for 21,585 potential clients seeking long-term care services for other Medicaid home and community-based service waiver programs such as: Project AIDS Care, Assisted Living for the Frail Elderly, Aged and Disabled Adult, Cystic Fibrosis, or Traumatic Brain and Spinal Cord Injury.  Of these 21,585 assessments, 27.2% (5,868) remained in the community within 30 days of their assessment, which may include some clients who did not receive needed care. 

In addition, CARES conducted 10,829 reviews of nursing home residents to ensure that they continue to meet level of care criteria.

Other performance measures and standards for the department may be found in its Long Range Program Plan on its website.

How is the program funded?

The Legislature appropriated $16.3 million and 255 full-time and 62 OPS positions to the CARES Program for Fiscal Year 2007-08.  State general revenue accounts for 25.8% of this total, and the remaining 74.2% is derived from federal Medicaid funds.

Current issues

According to a February 2007 OPPAGA report (Report No. 07-12), delays in receiving physician forms, regional workload issues, and client unavailability can lengthen the time it takes the CARES Program to determine medical eligibility for long-term care services.  To a large extent these factors remain outside the program’s control. Delays in receiving physician forms, the financial eligibility determination process, and the Medicaid managed care payment system contribute most to the time that elapses before an individual can be enrolled in the Nursing Home Diversion Program.

Current state initiatives may help address these delays.  The Legislature and agencies could consider other options, such as improving inter-agency electronic communication or reducing the CARES Program’s workload, but each of these options has potential barriers to implementation.

Where can I get more information?

OPPAGA Reports

Aging Resource Center Initiative Is Substantially Complete, Report No. 08-14, March 2008.

An Aggressive Schedule Set to Complete Implementation of Aging Resource Centers, Report No. 07-38, September 2007.

Department of Elder Affairs Resumes Transition Activities for Aging Resource Center Initiative, Report No. 07-20, March 2007.

Several Factors Can Delay Eligibility Determination for Medicaid Long-Term Care, Report No. 07-12, February 2007.

Comprehensive Assessment and Review for Long-Term Care Services (CARES) FY 2005-2006, Agency for Health Care Administration, January 2007.

Proposals to Reduce Medicaid-Funded Nursing Home Bed Days in Florida, Agency for Health Care Administration, December 2002.

For reports issued by the Agency for Health Care Administration, call (888) 419-3456 or visit www.fdhc.state.fl.us/

Websites of Interest

Centers for Medicare and Medicaid Services
www.cms.hhs.gov/


Florida Agency for Health Care Administration
www.fdhc.state.fl.us/


Long-Term Care Link
www.longtermcarelink.net/ 

Agency for Health Care Administration’s Assisted Living Unit
www.fdhc.state.fl.us/MCHQ/Long_Term_Care/Assisted_living/

American Association of Homes and Services for the Aging
www.aahsa.org/


American Seniors Housing Association
www.seniorshousing.org/


Assisted Living Federation of America
www.alfa.org/i4a/pages/index.cfm?pageid=3278

Centers for Medicare and Medicaid Services
www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/

Consumer Consortium on Assisted Living
www.ccal.org/


Family Caregiver Alliance
www.caregiver.org/caregiver/jsp/home.jsp


Florida Affordable Assisted Living
www.floridaaffordableassistedliving.org/

Florida Assisted Living Affiliation
www.falausa.com/


Florida Association of Aging Services Providers
www.fasp.net/

Florida Association of Area Agencies on Aging
www.f4a.org/


Florida Association of Homes for the Aging
www.faha.org/


Florida Council on Aging
www.fcoa.org/

Florida Elder Services Directory
www.floridaelderresource.com/


Florida Policy Exchange Center on Aging
www.fpeca.cas.usf.edu/


National Center for Assisted Living
www.ncal.org/


National Family Caregivers Association
www.nfcacares.org/

What are the applicable statutes?

Section 409.912(15), Florida Statutes

Whom do I contact for help?

Sam Fante, CARES Administrator, (850) 414-2164/SunCom 994-2164, fantes@elderaffairs.org

Web Address:  elderaffairs.state.fl.us/ 

To access a local Elder Helpline, call 1-800-963-5337 or 711 (for persons with speech or hearing impairments). 

Who is eligible for Medicaid Long-Term Care Waiver services?

To be eligible for home and community-based long-term care services through a Medicaid waiver, individuals must meet the medical and financial criteria to qualify for Medicaid nursing home care.  The department’s Comprehensive Assessment and Review for Long-Term Care Services (CARES) Program determines medical eligibility and the Department of Children and Families Economic Self-Sufficiency Program determines financial eligibility.  For additional information about how this process works, see OPPAGA Report No. 07-12, February 2007.

Each waiver has additional eligibility criteria.  For example, clients in the ALE and NHD programs must meet at least one of several impairment criteria, such as requiring some or total help with a specified number of daily tasks essential for independent living (such as eating, dressing, bathing), having a diagnosis of Alzheimer’s disease or other dementia, or having a degenerative or chronic medical condition that requires nursing services.  The NHD waiver has the strictest eligibility criteria.

For more information about the eligibility criteria for the various waivers, please see the Summary of Programs and Services on the department’s website.

What services are provided through the waivers?

While each of the Medicaid Long-Term Care Waivers provides a different set of services, they all provide long-term care services intended to delay or prevent nursing home placement, including case management, chore services, companion services, personal care, nursing and physical therapy.

The ADA waiver provides services on a fee-for-service basis (i.e., the program pays providers a fee for each service received by recipients).  In addition to the services listed above, the waiver provides adult day health care, attendant care, case aide, consumable medical supplies, counseling, emergency alert response, environmental modifications, escort, family training and support, home-delivered meals, homemaker, pest control, respite, risk reduction, specialized medical equipment and supplies.

The ALE waiver supplements services available in assisted living facilities for residents with heavy care needs that exceed the cost of standard services provided by the facility.  In addition to the services listed above, the waiver provides attendant call system, attendant care, behavior management, homemaker, incontinence supplies, medication management, occupational therapy, specialized medical equipment and supplies, respiratory therapy, speech therapy and therapeutic social and recreational services.

The NHD waiver provides the most comprehensive set of waiver services through managed care organizations including adult day health care and assisted living services.  Unlike the ADA and ALE waivers, the NHD waiver also provides Medicaid-covered medical care, such as physician services and prescribed drugs.  NHD providers also are required to provide nursing home care and are paid a capitated monthly rate for the clients they serve.  Since it is far more costly to pay for nursing home care than to pay for services needed to keep participants in the community, diversion providers have an incentive to ensure that participants receive the services they need to avoid nursing home placement for as long as possible.

What is the role of the department and Area Agencies on Aging, in administering waiver services?

The department allocates waiver spending authority for the ADA and ALE waivers to each of Florida’s 11 Area Agencies on Aging, which enter into contracts with service providers to deliver services.  Area Agencies on Aging operate as public or non-profit organizations.  The agencies plan, fund, coordinate, and monitor programs and services for individuals in their planning and service areas.  Area agencies designate and contract with lead agencies in each county to provide case management, which includes collecting medical information to assess applicants’ needs for services.  In some cases, lead agencies serve multiple counties.  The ADA and ALE waivers operate state-wide.

The department directly contracts with Nursing Home Diversion managed care organizations to provide services around the state.  As of August 2007, NHD providers served clients in 28 counties.  The state has federal approval to provide NHD services in 49 counties.

How many clients do the waivers serve?

During Fiscal Year 2006-07 the ADA Waiver served 13,377 seniors, the ALE Waiver served 4,613 seniors, and the NHD Waiver served 13,757. 

As of August 1, 2007 the department was serving the following numbers of seniors:

10,494 on the ADA waiver,
3,273 on the ALE waiver, and
11,014 on the NHD waiver.

What potential nursing home costs might have been avoided by serving clients on the waivers?

The Department of Elder Affairs (DOEA) estimates that the state saved $2.14 of nursing home care for every dollar spent on ADA Waiver services, $2.74 for every dollar spent on ALE waiver services, and $1.45 for every dollar spent on NHD services during Fiscal Year 2006-07.  However, these estimates do not reflect all Medicaid costs for the state, such as hospital costs or prescription drug costs for persons served by the ADA and ALE waivers.  It also does not consider nursing home costs for people who leave the waivers to enter a nursing home. 

According to a May 2006 OPPAGA report, it has been more costly to serve frail elders in the NHD program than to serve similar frail elders in the other DOEA Medicaid waivers.  The total Medicaid costs for people served in the NHD program exceeded those of frail elders in the ADA and ALE programs and of frail elders who were not enrolled in any Medicaid community-based waiver.  However, this cost difference has narrowed and may no longer exist due to recent rate reductions.

The NHD program has successfully delayed participants' entry into nursing homes.  While all three waivers delayed nursing home placements, the NHD program was more successful than the ADA and ALE programs in delaying nursing home placement.  For additional details, please see OPPAGA Report No. 06-45.

Other performance measures and standards for department home and community-based long term care services may be found in its Long Range Program Plan on its website.

How are the waivers funded?

The Medicaid waivers are funded through a combination of federal Medicaid dollars, state general revenue, and the Tobacco Settlement Trust Fund.  For Fiscal Year 2007-08, the Legislature appropriated the amounts shown below.


Waiver
Total
General Revenue
Medicaid Funds
Tobacco STF
ADA
$85,485,333
$29,573,330
$47,912,003
$8,000,000
ALE
$33,186,632
$10,128,406
$18,058,226
$5,000,000
NHD*
$217,550,045
$93,874,034
$123,665,984
$0
* The total for NHD includes $10,027 from the Grants and Donations Trust Fund.

The Legislature does not appropriate FTEs for the ADA and ALE waivers.  Waiver services to elders are provided by outsourced providers.  Most ADA and ALE administrative duties are performed at the local level by Area Agencies on Aging.  The Legislature appropriated $0.9 million for 10 full-time and 3 OPS positions to administer the NHD waiver.  State general revenue accounts for 50% of the funding, and the remaining 50% is derived from federal Medicaid funds.

Current issues

The 2005 Legislature (Ch. 2005-133, Florida Statutes) directed the Agency for Health Care Administration, in partnership with DOEA, to develop a comprehensive, integrated, fixed-payment health and long-term care Medicaid waiver program providing all Medicaid services to seniors age 60 and older through managed care providers.

The 2007 Legislature passed legislation (Ch. 2007-82, Florida Statutes) that significantly altered the design of the integrated, fixed payment program, which is now called Managed Integrated Care.  The 2007 legislation added individuals under the age of 60 who are recipients of both Medicare and Medicaid to the population eligible to enroll in the program, made the Miami-Dade and Central Florida areas the program pilot sites, made enrollment in the program voluntary in both pilot sites, and eliminated certain requirements for competitive procurement.

The Agency for Health Care Administration and Department of Elder Affairs are working on implementation plans for the new program.