Wednesday, November 6, 2002 State Legislatures and Olmstead: What's New in 2002? Presenters: Jo Donlin and Barbara Coleman SHARON: Good afternoon every one and welcome to the Web cast teleconference, State Legislatures and Olmstead, What's New in 2002. I'm Sharon Finney with ILRU and I'll be your moderator today. Just a couple of technical things to go over with you before we get started. Our presenters will pause for questions during today's presentation, and for those of you who are on the telephone, the operator will give you instructions on how to direct a question. Please try to keep your questions relevant to the topic at hand. If you're going to ask a question, please take yourself off of the speaker phone and speak directly into a hand set or a headset. Also speak as loudly and clearly as possible for our captioner. For those of you listening on the Web today you can e-mail your questions directly by clicking on the link at the bottom of the real one player screen or by sending an e-mail to Web cast@ilru.org. I'll receive those questions and voice them to the presenter for you. If you should encounter any problems during the presentation today, you may call our technical support staff at (713)-520-0232. Today's presentation is sponsored by the Rehabilitation Services Administration as Part of the U.S. Department of Education. Now, I'd like to introduce Johanna Donlin. She Joined the National Conference of State Legislatures in 1996. Currently she serves as a Senior Policy Specialist in the health care program where she manages a special project to track state activities related to Olmstead vs. L.C. 1999, the Supreme Court decision. Prior to Joining NCSL, Jo worked for Wyoming U.S. Representative Craig Thomas and Wyoming State Senator Tom Stroock. She received her B.A. from the Colorado College and holds an MPA from the University of Colorado. She is a Wyoming native and lives in Denver, Colorado. Welcome, Jo. Jo: Thank you, Sharon and thank you so much for including us once again in your series of Web casts dealing with the Olmstead decision. Today we are going to talk about a report that we produced and published in July. In our earlier Web cast that we did in July for ILRU, we talked about a survey that we had done on Olmstead planning. And in fact we planned to do a large update of that at this Web cast, but in the survey results, there really weren't extensive changes than what we had found in July. I think the biggest change was probably that New York has a task force or working group in place now. But in looking at what we've done and what we're still working on regarding Olmstead and long-term care, we felt reviewing this report that is on the Web site and hopefully many of you have had a chance to take a look at it, will really give you a thumbnail sketch of the long-term care budgets, legislation and planning across the country. Certainly Olmstead was included in this study and we feel it's very pertinent to what's going on in all of your worlds as well as what we're trying to track. Today I'd like to introduce Barbara Coleman. Barbara was hired by NCSL as a consultant to serve as the lead on this report. Barbara worked for AARP for 14 years, the last eight years she was a policy research analyst for AARP's Public Policy Institute. She has extensive experience and expertise in long-term care systems and since leaving AARP in December of 2001, Ms. Coleman has been engaged in consultant work for NCSL, the National Conference of State Legislatures, as well as the National Association of State Units on Aging, and AARP. The report that she served as the main consultant on was titled "State Long-Term Care, Recent Developments and Policy Directions." She has done a fabulous job on this report and also working with Wendy Fox-Grage and Donna Folkemer of our staff. She holds a Masters degree from George Washington University and a B.A. from Barnard College. So I will turn it over to Barbara and following Barbara's presentation, I'm going to come back and talk a little bit about all the activity in state legislatures that happened yesterday on election day, and follow up with some budget information and state legislatures information. So Barbara, with that I think I will turn it over to you. Barbara: Thank you, Jo. I'm pleased to be with you today to talk about the report that Jo just described for you, State Long-Term Care: Recent Developments and Policy Directions. This was an interesting report. It's always interesting looking at 50 different state long-term care systems because, as you know, we have no national long-term care system in this country today. We have 50 different systems, characterized by diversity and fragmentation. The major source of public financing for these programs and services is Medicaid. And the only common theme there has been among state long-term care systems in recent years has been the predominance of funding -- Medicaid funding for institutional care compared to home and community-based care. In 1990, 90 percent of Medicaid long-term care dollars went to institutional care. Nursing homes and ICFMRs and 10 percent to home and community-based care services, including home health care, personal care, the Medicaid personal care program, the Medicaid home health program, and Medicaid home and community-based care waiver programs. But that picture has been changing gradually so that in 2001, the allocation of Medicaid long-term care dollars was 71 percent institutional, 29 percent home and community-based care. Still, a predominance of funding for institutional care, but much less than it had been a little more than ten years ago. But this trend may be slowed in coming years because of a fiscal crisis that's facing almost every state. I'm not going to spend a lot of time discussing the budget situation in the states because Jo will touch on that when she returns, but I did want to mention that it is a factor affecting the trend towards greater concentration of funds on public funding on home and community-based care. From fiscal 2000 to fiscal 2002, states realized about a 5 percent revenue growth, but over these same years, states have seen a 25 percent rate of growth in Medicaid expenditures. Even while these fiscal difficulties are causing some concern about the future expansion of home and community-based care alternatives, there have been developments at the same time that promised to spur the expansion of home and community-based care. One of these is the 1999 Supreme Court Olmstead decision. 40 states, as a result of that decision, set up, created task forces, commissions or state agency work groups in 2000 and 2001 to assess their current long-term care systems and to make recommendations for the future. Many of these reports, plans, were general in tone. Some states, however, like Iowa, Ohio and not Iowa, but Ohio and Texas developed detailed plans with specific strategies and goals, time lines and budgets. At the same time as the Olmstead planning was going on, some states had been developing plans regardless -- without relationship to Olmstead specifically. One of these was the Minnesota Long-Term Care Task force, which was created in 2000 and issued substantive recommendations in January 2001. I'm going to discuss Minnesota in a little greater detail in a minute; but I just want to say here that as a result of the recommendations of the long-term care task force in Minnesota, the legislature appropriated an additional 1.83 million dollars for fiscal year 2003 to carry out some of the task force recommendations. Key to these recommendations was reducing reliance on institutionalization and expanding home and community-based alternatives. Another example of a planning process during these recent years was the -- has been the Michigan long-term care work group. That group issued a series of recommendations in July 2000, which included proposals for testing four different models, capitated payment system models of long-term care in selected regions of the state. One of these was a long term care HMO model, another is a virtual organization, an electronic communication network, another one of the models is a care coordination model. And I mention these two states because -- and the task force reports under Olmstead because they suggest ways in which states have been looking at, considering, different ways to deliver long-term care services or different ways to reduce reliance, as I said before, on institutional care and expand home and community-based care. Another development that conceivably offers promise to spur the expansion of HCBS, the systems change grants awarded by the Centers for Medicare and Medicaid Services. Last year, CMS awarded grants totaling 70 million dollars to 37 states and Guam to encourage improvements in home and community-based long-term care services. In 2002, CMS awarded additional grants to the point where I think almost every state has received a systems change grant, except for I think South Dakota and perhaps one other. I can't remember right now. These grants total between 300,000 dollars and 3 million dollars. Many of the grants -- the grant proposals from the states were for moving people out of nursing homes who could live in the community, called nursing facility transition grants. The most prominent activity in other categories of the grants was for information, referral, assessment and outreach, followed by education and advocacy. While these are promising developments as I indicated earlier, tight budgets, state budgets are still a concern. The states are adopting a number of different initiatives to contain costs including containing -- in some places containing long-term care costs. The most prevalent practice, perhaps, is to target nursing home reimbursement rates by, say, freezing rates for a given year, for one year, at the previous years level. Other strategies include proposing tighter taxes, state recovery and asset transfer recoupment and capping enrollment in various state funded or Medicaid Waiver programs. While the states may be engaged in such practices at the same time as they are engaged in and test go out new practices with the systems change grants or following through on Olmstead reports, they are also engaged in other activities that influence the quality of care in nursing homes and home care, and one of those concerns about quality of care is the number and training of direct care workers. So states are looking at ways in which they can develop programs and practices that will recruit and retain many more direct care workers. Some states have, like Arkansas and Florida, have established minimum staffing ratios for nursing homes. Other states, Alabama, Arkansas, New Jersey, Texas, have promulgated new regulations for assisted living. The workforce strategies include wage pass through laws, career ladders, training and another development is encouraging consumer direction. I'm going to talk for a moment now, before turning over to Jo, about a couple of states. I want to make clear that I am not suggesting these particular states are by any means model states for long-term care systems or for expansion of home and community-based care. I think that they are doing some interesting activities. I think there are a variety of activities in these states, but even these states still -- are still allocating a considerable share of their Medicaid dollars, for instance, to institutional care. Minnesota, and it would be interesting first to mention that Minnesota in 1994 was devoting 82 percent of its Medicaid dollars to institutional care and 18 percent to home and community-based care. In 1999, that allocation was 65 percent institutional, 35 percent HCBS. The most recent figures I've seen for 2001, fiscal year 2001, are 58.4 percent institutional, 41.6 percent HCBS. That is -- that is a good record, frankly, even though I offered the caveat at the beginning that this was not necessarily a model state; but it is, to my mind, impressive to have gone from institutional, 82 percent, to institutional slightly over 58 percent for an allocation of funds. Minnesota's Long-Term Care Task Force was composed of state legislators and state agency commissioners, and as I mentioned before, they issued a report and recommendations in January 2001 called Reshaping Long-Term Care in Minnesota. The interesting thing about this report is its specificity. The report identified six policy directions and 48 strategies, and it prioritized the strategies so that 15 strategies were listed as priorities for action in the 2001 Legislative Session. These included reducing nursing home beds by 5,000, expanding consumer information and assistance, and ensuring adequate funding for waiver programs. The 2001 Legislature followed up on these recommendations by, as I said before, appropriating 183 million dollars in additional money for long-term care for fiscal 2002-2003. Push 108 million of the 183 went for cost-of-living increases for nursing homes and continuing care providers. 75 million was for expansion of elderly waiver and alternative care programs and funding of community service grants. The additional spending was to be offset by savings of 44 million that was expected by downsizing the nursing home industry. There were also measures to encourage recruitment and retention of workers, such as loan forgiveness and scholarship programs and internship programs. Now, I have a little bit of an update for you in terms of what's happened since the legislature appropriated that additional money. They realized a reduction of 1,000 beds, not -- they haven't reached 5,000, but 1,000 beds have already been taken out of the system. They've awarded 100 community service grants, ranging from 20,000 to 250,000, for such projects as caregiver respite, transportation initiatives and home modifications. They are developing a central information system to connect a 2-1-1 line with a senior link age line for elderly, and Minnesota centers for independent living to share databases. And they have set benchmarks at the county level to measure their progress towards meeting long-term care goals. They have what is called an Aging Initiative in the Department of Human Services, and that office is tracking these benchmarks. The five initial benchmarks include -- among the five initial benchmarks are two that I can mention today, long-term care spending for nursing homes, and the ratio of senior housing units to persons aged 65 plus. I'm just going to talk about one other state because I think I'm taking a fair amount of time already, but that will be Florida. And Florida had a number of different activities. First on the nursing home front because a number of lawsuits for the nursing home industry were causing the insurance companies in Florida to start talking about pulling out their business. The Florida nursing homes were too great a risk. That spurred action on -- to do something about -- to stabilize the long term risk for long-term care facilities which the 2001 legislature did. At the same time, the legislature also imposed higher nursing home staffing standards, set new training requirements for nursing assistants, and increased penalties for homes with deficiencies. The next year -- this year, the 2002 legislature, has created an office of long-term care policy in the department of elder affairs. Florida is like many states that -- in which aging programs, long-term care programs, are scattered within several -- among several different agencies. This new office of long-term care policy has been given responsibility for coordinating all state agency policies on long-term care. The programs are not going to be moved, but this office is to coordinate as I said and to recommend ways to increase availability and use of non-institutional settings. And it will have a 13 member advisory council. Another -- another development was through a piece of legislation that -- a kind of umbrella legislation that created this office of long-term care policy, also directed that consumer direction should be allowed -- a board of use of consumer direction in home and community-based care programs. Florida has a RWJ Cash and Counseling Demonstration Project underway in which a certain group of people, participants in the program, are called a control group who use the traditional agency methods of getting their services, while the other group of participants gets to hire and train and direct their own workers. So many people in the control group wanted to be able to direct their own care that the state has now expanded with federal permission -- has expanded the concept to everybody. Florida has also established a nursing home transition program to identify nursing home residents who could live in the community and move them out. It has also boosted the budget for the Medicaid, elderly and disabled waiver from 78 million in fiscal 2002 to 87 million in fiscal year 2003. Setting almost 1,000 more persons to the person. It has tripled funding for developmental disability services since 1998. The number of persons participating in the waiver program are people with developmental disabilities doubled from 12,000 to 24,000 from 1998 to 2001. I might also mention that Florida, compared to Minnesota, Florida's allocation of Medicaid dollars to institutional care is still very high. It was 81 percent in 1999. It was 75 percent in 2001. I'm now going to turn it over to Jo and I will be happy to answer any questions after her comments. Thanks. SHARON: Thank you. Jo: Thank you, Barbara very much. You've been a vital resource for the state legislatures and will continue -- I think that that gives the listeners a good sense of broad issues and some examples in innovations that are going on as well. I wanted to take this chance to update all of you on the election results. Much of the press obviously has dealt with the national picture and the U.S. Congress, et cetera, but I know that you all are on the door steps of your state legislatures, and it was a very interesting year for state legislatures around the country. I do have slides that were on the Web and if you don't have a chance to get those, I'm going to go through them. There is also a text version on there that you can follow up on as well. First of all, I would just like to start with my first slide that says election 2002, new faces everywhere you look, and that is really going to be the situation in many states that had very high turn over. Next slide, first of all, this was a big election year in the states. 85 percent of all legislative seats, 7400, were up. And the current party control as of yesterday, it was very, very close. 17 legislatures were controlled by the Republicans, 18 legislatures controlled by the Democrats, and 14 had split control. And of course Nebraska being a (inaudible) is the only nonpartisan legislature in the country. Many of the task forces for Olmstead, the planning, the assignment of planning came from the governor's offices, and this year, 36 governors were up for election. And 27 of those governors were Republican, 21 were Democrat, and two were independents in Maine and Minnesota. Next slide: what's important to remember and think about as I go through this is that as I had said, many of you have worked with your executive branch very closely. The policy people in the governor's office have really taken the lead in many cases. 20 of the governors were open seats. Because of term limits, 14 were termed out and six governors were not seeking reelection. Therefore, the Republicans were defending 23 seats, the Democrats defending 11. Next slide: undoubtedly, one of the biggest things affecting the huge turn over which we estimated three elections at 22 percent. I think we'll see that pretty close, was that term limits and redistricting collided. 17 states now have term limits, and 11 of those states are in effect for the 2002 elections. As a result, 330 legislators were termed out in 2002. As I've mentioned before, that means possibly your greatest obstacles were termed out, but it also means that possibly your greatest supporters of your efforts in Olmstead were also termed out. If you are in Michigan or Missouri, the effects were somewhat extreme. The Michigan senate, 27 out of 38 senators were termed out. So the freshman class will be very large. Missouri house, 75 of 163 were termed out. Most states are finished with their redistricting and that affected many states in changing districts and elections. So the big question, which is my next slide, the big question comes -- what happens? And on my slide I have a Web site that is www.NCSL.org/statevote2002 -- that is the main election page for NCSL, but I want to give you sort of some very brief but important summary information that you can look at on your own states and strategize and figure out how you want to approach these 2003 sessions. Very much like the national picture, Republicans did have a strong showing in the states yesterday. The Republicans took five new chambers: Texas House, Arizona Senate, Colorado Senate, the Missouri House, the Wisconsin Senate. And as a result of these changes, they gained control of four more legislatures, which brings the total of legislatures that are controlled by Republicans to 21. Although they had five new chambers, they lost the Illinois senate. So that's where that -- it didn't go up five, it only went four. The Democrats were controlling 18 states and now control 17. They gained Illinois, but Indiana and North Carolina are now tied and so they don't have predominant control for either party. One thing that I would encourage you to do is look at your governor's races -- 20 seats changed. As I said, a lot of the Olmstead planning has been in the executive branch with the support of the governors, and if you will have much education to do with governor's policy people or whatever the case may be, there are a lot of new faces. Also, I wanted to let you know that around a third of the top ranking leadership will change. That is significant because if the presiding officers change, committee chairs can change, and that can make a difference in the committee structures on topics that affect Olmstead, whether it be the health committee or the transportation committee, where very the jurisdictions lie. That could significantly change what's going on. Three states that were upset -- that were leadership upsets, the speakers in Georgia, Maine and Texas all lost their elections. So right there you know of three states where one chamber will have completely new leadership. One thing that I did want to bring up, and this is the next slide which deals with budget issues, and Barbara talked about this a little bit, but I wanted to talk a little bit more about it. From our surveys and what we have gained both in our survey and anecdotal conversations is that budget issues are still going to dominate 2003 and probably be an issue 2004 and 2005. The NCSL survey fiscal year 02, the states -- the aggregate state budget gap was 27 billion dollars. In fiscal year 03, the state budget gap is estimated to be as high as 49 billion dollars. And that includes the California budget gap which is, I believe, around 15 billion. I can check that if somebody needs it, but that is still a significant gap that states are dealing with. Obviously, as Barbara mentioned before, Medicaid is the main provider of long-term care, and we estimate that that will capture the largest amount of new spending. The expected growth in the Medicaid program -- these numbers have gone -- you can read different things in different estimates, but what wither erratic finding right now, with 48 states reporting is that it is expected to grow around 7.4 percent, and revenues are not going to grow that much. Which that budget will be at least twice the growth of k-12 education, higher education and corrections. And that gives you an idea of what is going on with Medicaid. Despite the fact that many states made efforts this year and went back into special sessions to clean up their shortfalls and balance them, many states are now anticipating a fiscal year 2003 shortfall. And this is despite those efforts to balance their programs. Income tax was much lower than anticipated -- 21 percent lower in fact for income tax, and the refunds were up. So state revenues are not coming in as anticipated. My next slide, having given you that dreary budget picture, I do want to let you know you play an important role and you can make a difference, and that you are a valuable resource for state legislatures. There are many, many new legislators who will need good information. So I urge you to be creative. I urge you to reach out to new members. It will be a challenge. There are many of them, but I would not encourage you to wait until session. The session is when everybody will be calling them, and it is the busiest time. If you can be creative and contact people before a session, it can be so valuable to the legislators. As I mentioned before, new leadership can mean new committee chairs and that's research that will have to be done about how that's all going to play out. But I want to encourage you to be accurate, reliable, honest, concise, and vigilant resources of information. Long-term care is a huge piece of the budget, certainly a huge piece of the Medicaid budget and legislators need to have reliable information on the issue as a whole and on the issue of Olmstead and what that might mean for your state. And offer to be a resource. They will need information. It will be a challenging year with so many new legislators, but I think that it can be an exciting time to move forward with initiatives and help legislators understand the issue of long-term care and the implications of Olmstead. As far as NCSL, we will continue to track Olmstead activities. On my next slide I have included our Web site, which is www.ncsl.org/programs/health /disabil2.htm. We continue to put together publications, meetings, technical assistance on issues revolving around Olmstead. I think that Olmstead implementation will have many faces, and I encourage you to keep in touch with me and my other colleagues if something goes on in your state, you may hear about it before other people. An example is the new waivers that have been approved by h. h. s. to implement cash and counseling. Arkansas and Texas -- these are important movements and I just want to encourage you, whether you view it as a success or failure, keep every one informed. And it's a challenging time and it's a challenging time because the legislation may be happening -- as Barbara said, long-term care is taking shape in many, many different ways and I hope you will keep in touch with us if you hear of things or if you want information. My final slide, once again I put up resources. Our Web site, the Web site for the Centers for Medicare and Medicaid Services, and also the contact for the national technical assistance exchange. Susan Reinhard at Rutgers University and Richard Petty at the Independent Living Research Utilization. They are working with states to provide technical assistance, and I urge you to use them and contact them if you need help or information about what is going on. And with that, Sharon, I think we can open it up for questions. Barbara, I don't know if you had any ending statements you wanted to make. Barbara: no, it would be fine to go to questions. Operator: at this time we'll open the floor for questions. If you would like to ask a question, please press the star key followed by the 1 key. Please limit your questions or comments to one at a time. Questions will be taken in the order in which they are received and if at any time would you like to remove yourself from the queue, press star followed by 2. SHARON: Thank you, Jeff. Thank you, Jo. Thank you, Barbara. I do have one e-mail question that Barbara may be able to address. The question is what are some other cost containment measures states are doing? Barbara: well, the ones that I mentioned were only long-term care ones. Actually the states are doing a number of things in other areas; one is -- has to do with the farm is I programs in some states. They may be choosing to limit the farm is I programs in some way because those have turned into big money users I guess you could say. They have become very expensive. Other things states are doing are freezing hiring and I've noticed recently in some -- looking at what's going on with some states, furloughs for employees, unpaid furloughs of a few days in the course of the year, and then there are other -- many, many, many other ways of cutting back, say a 5 percent reduction for all state agencies, across the board. But in long-term care, it is -- there have not been as many dramatic cut backs as you would probably expect to have happen. They have not really been hurt so far that I can see. I don't know what's going to happen in the next legislative session. Jo: If I could pipe in, Barbara. In our first Web cast in July, we did talk about sort of the difference in long-term care and Olmstead. In 2001 we did see expansion of waivers. We did see some things -- some wage pass-through that did have broader fiscal implications than what we saw this year. Much of the legislation this year revolvers around assessment, outreach, getting things -- information to the people who need it that weren't as big ticket items. So that may give you a gauge and you can refer some of that legislation on the archived Web cast, but those are just some other ideas. Barbara: Let me add that I should have said that what does affect long-term care is what doesn't happen. Some of the Olmstead recommendations, for instance, that were fairly ambitious may not be carried out in the near future. Other initiatives -- or family care in Wisconsin, the family care experimental program that is in five counties in Wisconsin, there was a plan to expand those to a couple of additional counties, and the governor vetoed that about six months maybe -- maybe it was a year ago. I'm not really sure, but at any rate that was put on hold. That kind of thing. Sharon: Jeff. Operator: Yes, Ma'am we do have a question from Kevin. Caller: I'd like to know more about the home service program. Sharon: Could you repeat that, please? Caller: The home service program. SHARON: The home service program -- Caller: Yes, with Human Services that came from Illinois, they didn't want people going to institutions. Jo: I'm sorry, I don't know of it. Caller: They have a home service program so you won't have -- you can get service in your home with human services -- the department of human service. We're in Memphis, Tennessee. She relocated to Memphis from Illinois. Is your question, carol, is I guess she's wanting to know what all Human Services will be doing in the future. Can you answer that? Barbara: No, I'm sorry, I can't. Caller: I know they've offered a lot of grants. Will they be offering any other system grants change in the future that you know of? Barbara: In Illinois? Caller: As far as nationwide, CMS has offered a lot of grants for System Change Programs. Do you know of anything else that might be coming up like that on the national level? Barbara: No. Sharon: Thank you. Jo: If I could say -- if you go to that CMS Web site, that would be the best way to track that. If something comes up for systems change grants or anything like that, that would be the place it would be notified SHARON: Thank you. Operator: Again, ladies and gentlemen, if you would like to ask a question, please press the star key followed by the one key on your touch tone phone. SHARON: Jo, I have another e-mail question. Has NCSL identified any states which have made significant shifts in funding from institutional to community services, if so, which states? Jo: I think as Barbara mentioned, we have not seen huge shifts since Olmstead, but I think if you look over time, and I can get this information for someone, that there are some states. Barbara talked a little bit about that in her presentation. Barbara, I think you talked about Minnesota going from 80 to 55? Barbara: 58. Jo: 58, and bash rashings I don't know if you know of other states that have over the years really made a big -- Barbara: Well, the two states that have always been in the forefront in this regard and continue to do so are Oregon and Washington. And they are almost at 50/50 between institutional and home and community based care. That's fairly remarkable compared to the rest of the country because, as I mentioned, nationally the average is 71 percent institutional, 29 percent HCBS. So 50/50 is about the best in the country at this point, and that's Oregon and Washington. Jo: And again, Barbara, correct me if I'm wrong, that was transition over many years and if the question is pertaining to just a large change since Olmstead or just in the last couple of years, I think these changes are coming slowly, but as Barbara highlighted, even since 1990, 90 percent used to be in institutional and now it's down to 71 percent. So I think these changes are gradual, but they are happening. Barbara: And what that doesn't take into account, unfortunately, it's difficult to figure this out, but some states have fairly good sized state funded programs. And what we're talking about when we talk about this allocation between -- of money between institutional and home and community-based care, we're talking about Medicaid dollars only which are the largest source of funds, but where there is state funding as well, that can make a big difference. Operator: We do have another question from Tina. You may go ahead. Caller: Can you hear me? I was curious -- talking about the models for different states. What is the virtual model? I've never heard of that one. Barbara: Well, it's a communication -- electronic communication model. What Michigan is doing, and if anybody is interested, they can e-mail me and I can probably find the Web page for the Michigan -- for the Michigan report; but at any rate, they have four models. One as I said is a virtual electronic -- it's a communication -- I'm looking at my notes here and looking at our report. The virtual organization initiative will use modern information technology and systems design to enable consumers to use telephone or Web technology to identify and arrange services, communicate needs and satisfaction with services, and use assistive technologies. So it seems to me, I guess, if I'm getting it right, it's away of using of the internet to communicate among people who need services and people who can provide services. Caller: Thank you. That's very interesting. Along the same lines, does that mean (inaudible). Barbara: In this virtual organization initiative, you mean? Caller: Yes, ma'am. Barbara: I suppose so. I suppose so, but as I said, I don't really have the details of how they plan to do this. They do have a systems change grant which they're going to use for developing this particular model. So it must be in pilot form in the state right now. And I suspect that the best way to find out more about it is to, as I said, to go to the state Web site, which I'll be happy to get for you or NCSL can get for you. The state Web site for the department -- I think it's the department of community health. Yeah, that administers that program. That would be the best way to find out what's happening and how exactly it operates. Operator: Thank you for your question. Our next question comes from Hillary. Caller: Yes, Hi. I want to know if there are any studies showing cost savings to Medicaid when states have changed to more home and community-based care as opposed to institutional care. Barbara: The difficulty always in proving that home and community-based care is more cost effective is that you have to assume a person getting those services would have gone into a nursing home if they had not been available. So it's proving a negative in effect, and that is -- although persons who receive home and community-based care waiver services are supposed to be people who would, without those services, be at risk of institutionalization. You can't assume exactly that they would have. I mean, you can't specifically that they would have gone into a nursing home. So some states attempt to point out the lower cost of serving a person at home or in the community compared to a day in a nursing home or a month in a nursing home, and assume that those dollars are saved dollars, but there are no real studies to prove this. Caller: And I agree with that. It's been an issue that anecdotally is talked about a lot; but I have yet to see the chart and if you look at things where some organization or private sector person puts a price on a day in a nursing home versus a price on, you know, a day at home, no two are ever alike, even when you're adjusting for different parts of the country. So I think that is a challenge. Anecdotally we hear about it a lot. I have not seen a report that clearly states that. Barbara: You know, another difficulty is that despite the fact that occupancy rates in nursing homes are continuing to go down, that is to say, I think the average occupancy rate across the country is about 82 percent now, and in some states, nursing homes have occupancy rates in the 70 percent range. However, costs keep going up. So it isn't a matter of simply taking people out because the nursing homes are there. And they are either serving the more severely disabled people over time or they have to cover the costs whether or not their beds are all filled. So states have trouble holding the line on nursing home spending. Operator: Thank you for your question. Our next question comes from Gordon. Caller: Hi, I'm wondering what we can do to get -- can you hear me? Barbara: Yes. Caller: I'm wondering what we can do to get legislators to force county social workers to implement elderly waivers to make people's homes more accessible to keep elderly in their homes before they're being forced into a nursing home when something happens or even in a timely fashion after something happens to them, to get them out of the nursing home before they are stripped of all their assets, dignity and die there? Barbara: Well, I know that some waiver programs cover home modifications as a service. Caller: Yeah, but nobody will tell anybody about it. It's like pulling teeth to get this to social workers. Barbara: Well, it may be. I don't necessarily want to go to their defense, but it may be that in the amount of money they can allocate to any one person for services, they may put a higher priority on the most immediate personal care kinds of activities like helping people to meet -- carry out activities of daily living and they may not have -- be able to come up with the additional funds for home modifications. Caller: That's 45.38 dollars a year in Minnesota, okay, and if they start working on this, chances are if somebody falls and breaks a hip or something like that, they'll be able to come back in their home rather than paying the 6,000 dollars a month that it takes too keep them in the nursing home because their home isn't accessible. Jo: Gordon, I just wanted to say that we talked a lot and you had mentioned earlier I think that people don't know what their options are, and many states have looked at the issues of outreach, information and education. So I don't know if that would play a role or not. I can't speak to the direct issue of how to get the Job done, but those are -- education and outreach issues are in many states. Caller: That's the field I'm? Is outreach and stuff and to get the social -- I'm wondering if this could come from a higher up authority and stuff so we could educate the social workers county wise. You know, on a national basis, just to try and implement this, I think it would make sense and dollars. Barbara: You know, maybe consumer direction is one of the ways to get at this. If you have a consumer directed program, the consumer can say -- the individual recipient can say I need my home modified. I don't want this service or that service. I want the dollars to go to building a ramp or to, you know, making my home fall proof or something like that. There is more -- taking the responsibility away from the case worker and giving it to the individual consumer may be one way of addressing that issue. Caller: Yeah, I've found that's about the only way the social workers will bring it up. Thank you. Sharon: Thank you, and we have a couple of e-mail questions I wanted to get to. First question, what in your opinion constitutes a good Olmstead plan? Which state plans are exemplary and why? Jo: I can take a stab at that, Barbara, based upon our report. Barbara: Yes. Jo: If you go to our Web site, we have a report called the state's response to the Olmstead decision, and it talks about the plan. It specifically -- and I'm trying to think right off the top of my head of the four -- Ohio, Mississippi, Texas, and there is a fourth that I'm for getting about, but we based our judgments on the criteria that by HHS and CMS in their letters to Medicaid directors about what would create an effectively working comprehensive plan. So you can take a look at some of those examples, but it includes things as Barbara mentioned -- they have budget lines. They have recommendations. They have outcome ideas, but it's very specific and we made those judgments based on the criteria set out by CMS. Do you have anything to add, Barbara? Barbara: Well, I think that that's why I singled out the Minnesota report as well, even though it's not an Olmstead report as such. It's because of the specificity and the attention to that detail. One of the problems for any plan today is -- is being realistic about the budget problems. So it makes sense to come up with a plan that has time lines out into the future so that if there isn't money available this year, there might be the following year, and you can realistically set goals over time. Sharon: Thank you, Jo. One more e-mail question. Since it is unlikely that states can continue to fund institutional care and community services simultaneously, has NCSL tracked how many institutional beds have been transferred to community services? Along with Minnesota, which other states are doing the best job at this? Jo: We don't track that kind of detail. Barbara, I don't know if you have thoughts on that. We're tracking more of the policy angles on this and not the specific beds. Barbara: I'm trying to remember, and unfortunately when you deal with 50 states, it's hard to remember which did what, but if the person who sent that e-mail wants to e-mail me to ask me it again, I'll try to look it up. The point is that I know that there is some material somewhere, and perhaps somewhere in this 50 state report we did, that mentions some states that are trying to convince nursing homes to convert some of their beds to assisted living, and that is one way of -- to either convert an entire nursing home or beds within a floor, for instance within a nursing home, to assisted living. Just taking beds out of circulation does not necessarily mean that that money for those beds goes to home and community-based care because unfortunately, as I mentioned before, costs in those nursing homes continue to rise any way. There is also an idea that was enacted in Texas. The Texas legislature directed that the money for a person who is leaving a nursing home -- the money that would have been spent on that person in the nursing home must follow the person into the community. So therefore the higher amount that is spent on a person in a nursing home, would be transferred to their home and community-based care. This is a new concept and I have yet to see how it's operating. Jo: I think they may have tried that in Missouri as Barbara mentioned. But that idea of the money following the person certainly is being tried, and I know that Allan Bergman did a Web cast about transfers in tough budget times and I don't know if this person was on that, but that might be another idea. He might have some ideas about other ways in budget crunches. Barbara: I also should mention that I think there are creative ways states have gotten money for home and community-based care that goes beyond Medicaid. Because of the restrictions on Medicaid and because the Medicaid dollars must go to nursing homes if there are individuals in nursing homes who need that money and are eligible, one way is tobacco money in some states has been used, and in other states it's lottery money. New Jersey uses lottery money, I believe, or is it ka seen oh revenues for some of their caregiver prams and lottery money is used in Pennsylvania. So there are other ways to raise money. And in Ohio, they have local levies in certain counties that goes to long-term care services. Sharon: Jeff, are there any callers? Operator: We do have one more question from Debra. Caller: Hi, ladies. First of all I want to thank you for acknowledging the difference that state general fund and county general fund expenditures make in long-term care because of course that was a huge issue in California where, no, a quarter of a million people getting home supportive services. I actually wanted to ask a question about how exactly the money following the person is working in Texas because it's something that we're interested in pursuing, but it's not at all clear to me, first of all, how it works mechanically, and then although it seems easy to say it that it is budget neutral, that doesn't seem to me that could be the case if the nursing home bed isn't being closed behind the person. It seems like in a lot of these situations what we need to be realistic about is that there are going to be parallel systems of care going on at least for a while, and so many of us think it behooves us to be honest about that and say that costs will go up, but specifically in Texas I don't really understand how it works. It's a transfer between departments, the money is attached to the individual somehow -- does anybody know how it's really working? Barbara: No, I'm sorry, I don't. I would think that what would happen is that an allocation is made within the community program that the person goes to, that the money is not really transferred from the nursing home. The nursing home fills that bed behind the person who leaves and therefore that new resident -- nursing home resident or bed, will still get the same amount of money for that bed and that person, but instead of -- let's say the community program generally allocates 2,000 a month at a maximum for an individual, if this person's cost in the nursing home was 4,000 a month, I would assume that what happens is the budget then in the community program goes up to 4,000 for that individual. Obviously that means the program -- the community program is going to cost more in the long run. There is no magical way to realize this money except to allocate it. I just think what that might mean in the community program is they could take in fewer people because they are now spending 4,000 on an individual instead of 2,000 they normally spend. So it might have negative consequences in terms of, you know, waiver programs have certain allocated number of slots and they just have -- they can't go above those number of lots until and unless some people drop out of the program for one reason or another. There are limits to what they can do, I think, and I'm not sure whether this is just a nice sounding kind of proposal and doesn't have too much meaning or maybe means a lot for the individual, but doesn't mean a lot for the program. I think Bob has said they have gotten hundreds of people out, but the scenario you described set up a disparity between people -- it's sort of an incentive to go to a nursing home and get out if you can get a higher level of services than the person who stayed in. I'm just really trying to figure out what -- Barbara: you might not need expensive services. I mean that's one of the things -- Caller: No, I understand that. Barbara: That if you are inappropriately put into a nursing home when you can live in the community, you might be able to function fairly well in the community without that level of expenses. The real problem, it seems to me, or one of the problems, in taking people out of nursing homes is the transition costs. That's why I think the CMS programs and other efforts like this are important because, you know, somebody has lost their home or their apartment, they don't have a place to go back to. So first you've got to find adequate housing for people, and then you've got to move them and provide them with enough -- just furniture and things they need to get going, and then monitor their care for a number of months to make sure it's going all right. I think it's very difficult. I don't think -- I think it's promising, but I don't think it's easy to do these nursing home transition programs. Jo: I think on our Web site we have an article on that how these transition grants are being used and that transition is taking place. That might be another resource for folks that are listening. Operator: there are no more questions at this time. SHARON: I have some e-mail questions that are rolling in. First question, in working with legislators, how can we brake the strangle hold the nursing home industry has on funding? Jo: I'm not in the business of how to tell you to lobby the legislature, but I think with so many new faces this year, I think that it will be a challenge, and regardless of what organization or what issue you're trying to deal with to understanding exactly who is involved in these issues, who is now on the committees, what changes have taken place in your political landscape could make a big difference, and I think staying informed about some of these issues, about what has happened in this election can be a successful way to work with legislators. I would not wait until session. As I said, many people feel that it's during session when they should be contacting their legislators, and legislators are legislators 365 days, 24 hours a day. I don't suggest you call anybody at 2 a.m., but I do suggest that you feel free to be creative and take legislators maybe on a field trip to see a successful placement or just to think creatively and try to get your resources together because I think for everybody with term limits out there and this big election, there are going to be so many new faces that we'll have to be diligent, regardless of the topic, regardless of anything like that. So maybe that will be helpful. SHARON: Great. Another question: recently CMS has shown television commercials which advertise a toll free number which viewers may call to find out about how to get into nursing homes. Do you know of any national to*el toll free number which people can call to get information about community services? Barbara: Well, a number of states have their own statewide systems. There is one in New Jersey which is called New Jersey Ease, Easy Access -- I always forget the rest of how that -- what that spells out. But at any rate the point is you can call one number and they will link you up with local -- a local county office. In New Jersey it's a county. In some states when they have this one number, the number will hook you up with the nearest area agency on aging near you. Now how to find out if there is a statewide number is probably to call the department of aging, whatever it's called in the state, and I know that's not the only -- you may want to know for persons with mental retardation or developmental disabilities, but at least one agency will know -- should know if there is a statewide number. Or call your legislator and ask about -- they can find out for you, even if they don't know themselves. There are a number of them around the country, and states are all trying to establish this kind of system, and then there is the elder care locate tore which is a national number. Unfortunately, I don't even know it offhand, but the elder care locate tore which is run by the administration on aging, the u.s. administration on aging, is supposed to transfer your call, link you up with your local area services. Jo: I think more and more of these telephone numbers where it's a single point of entry, I think that's the phrase that's been used a lot, in the states trying to make it easier to access resources and make it easier for the consumers. So I think even more of those are on the way. SHARON: this is in response to the question about Texas and money following the person. Texas has a new fiscal year 2002 provision that allows a person leaving a nursing home to have a money follows the person happen. That is, the Medicaid dollars are transferred to community-based line item. This essentially creates a new waiver program slot. Just over 1,000 people used this in 13 months. Any other states have a similar provision? Also another response from the same individual: Texas has a 75 percent occupancy, so there is usually not someone waiting for that bed. Most people are receiving community services at much lower costs than nursing homes and there is a real cost savings and more people are then being served. Barbara: The only other state that comes to mind, and I need to check this, was I thought that Missouri did a program that's similar to that, but I would have to check on that and get back to that person if I can do if you forward their name to me, Sharon. SHARON: Certainly. Barbara, I think this question is for you. It seems Florida may be a well weather state for community services because of the state's population. Do you agree? And if so, what about Florida's service system and services do we need to watch now for future trends elsewhere? >> Barbara: well, Florida is a mixed picture, really. The need is great in Florida so that's why even -- and Jeb Bush while he was campaigning was always boasting that he had done a great deal for the elderly population in Florida. In January 2001 he unveiled his elder friendly initiative which called for major increases in funding for nursing homes and nursing home quality of care reform. So that wasn't exactly expanding home and community-based care, although they have done some of that, but they also -- for instance, on the nursing home staffing standards issue, I talked to a Florida legislator not too long ago, a couple of months ago, about those staffing standards, and they were -- they had a plan for a three year gradual increases in the number of hours of staffing time. The minimum staffing standards were supposed to be 2.3 hours of direct care per resident per day beginning January 1st, 2002, and then it was to increase to 2.6 hours beginning January 1, 2003, and 2.9 hours beginning January 1, 2004. Well, this legislature mentioned that some nursing homes were having trouble meeting the 2.3 standard for this year, and there was probably going to be much more -- many more homes, nursing homes complaining about reaching 2.6 hours when they get to January of next year. So you can pass this legislation and then making it happen is another thing. I think that Florida is doing some interesting things, but I'm not convinced that that is, by any means, as much as they may need to do in that state. And I have seen other states -- Maine is a good example -- which has over the last few years been gradually moving its system -- it's long-term care services to the point where they are trying to expand home and community-based care considerably and I'm looking now to refresh my memory about Maine. And they started trying to change their system back in 1993 and 1994, and then they began to implement more stringent nursing home admission standards and by 1996, the governor had proposed a long term care initiative that called for expansion of the home and community-based care and by 1997 more people were receiving carat home than in nursing facilities. So it is not just -- I singled out Florida simply because some of the new initiatives were kind of interesting and different, having an office of long-term care policy, expanding consumer direction, that kind of thing, and a couple of other things that I didn't mention, a model integrated health and long-term care pilot program they're going to try in one area of the state. So they're doing some ipt interesting things but they have a long way to go, too. SHARON: Jeff, are there any callers? Operator: Yes, ma'am. Next question from Carol. Caller: Yes, I was wondering if you have any information on the state of Iowa as far as where they are with the -- trying to implement any of the Olmstead decision? Jo: On our Web site that we have -- that states response to the Olmstead decision, and this that document there is a small profile of the states, and also in the report that Barbara summarized there, are profiles of each state. Is that correct, Barbara? Barbara: Yeah. Jo: So both of those reports should be able to give you a pretty good thumbnail sketch of what's going on in Iowa. And if you have any trouble finding them, I can e-mail you or you can contact me. Operator: Thank you for your question, ma'am. There are no more questions at this time. Sharon: Thank you, Jeff. Another couple of e-mail questions: this is regarding the voice of the retarded has commissioned a peer-reviewed article, a finding of all things being equaled is that cost savings will not be realized so that people from institutional community-based care -- all things being recall relate to adjusting comparisons to account for case mix, level and cost shifting et cetera. Historically, most cost savings relating to the institutional isolation relates to the appropriate movement of people who are less disabled and whose care cost less than the setting from institutional setting to community setting and the reality that many community programs are under funded. A savings may have been realized but only due to the fact that some people were not getting what they need by way of services, and they are citing the study that's been peer-reviewed and published in spring 2003, executive summary from the VOR Web site. I'm assuming this is informational. Jo: Okay, Thank you for that information. Sharon: One more question. Recently we've seen some survey information which indicates members of state legislatures are heavily vested in nursing home ownership. Do you have figures on this? What's your knowledge of this issue? Barbara: I have not seen any numbers like that, and we do an occupational survey every several years, but I don't think it gets as specific as -- you know, specific to a private industry like that. I do know in some states that legislators are involved, but I think there also are legislators who have been very involved with people with disabilities and broader issues. So I don't know about the numbers that you're quoting or about that study. SHARON: Okay, thank you. Thank you, Jo and Barbara. We're just about out of time today. I wanted to thank every one for participating. Today's presentation will be archived on the ILRU Web site at www.ilru.org. As well as on that Web site you can check out our calendar of upcoming Olmstead Web casts for the next couple of months and into 2003. Also we'd like your feedback on today's presentation. So please fill out the evaluation form on the ILRU Web site. We do need to thank those who made this presentation possible, our Funder, the Rehabilitation Services Administration, part of the U.S. Department of Education, and this Web cast would not be possible without the efforts of our ILRU in-house staff, Marj Gordon, Dawn Heinsohn, Rachel Kosoy, Mark Richards, and the technical expertise of Rob Dickehuth and our Real time captioner, Marie Bryant. Welcome back. Again, Jo, Barbara, thank you so much for your presentation today, and good afternoon everyone.