Jan, 2005: DHS responds to Questions about the Assisted Living Waiver Pilot Program (ALWPP) From the American Parkinsons Disease Association From:
John Amber
West Coast Assistant Director
American Parkinson Disease Association, Inc
To:
Mark Mimnaugh, R.N., CCRN, M.P.A.
Nurse Consultant III, DHS Home and Community-Based Services Branch
Project Leader ALWPP
----Original Message-----
From: APDA West Coast Office [mailto:apdawc@earthlink.net]
Sent: Wednesday, December 15, 2004 4:17 PM
To: Connections; Mimnaugh, Mark (DHS)
Cc: Connections; Nate Solov - Staffer/ Assemblywoman Pavley; Pinzler,
Arlene; Acosta, Paula (DHS-EX-OOLTC); Joan B Lee - California Grey
Panthers; Jackie McGrath - California Council of Alzheimers
Associations; Allisan Ruff - Assembly Aging Committee; Sue Eisenberg
Subject: Re: A Few More Questions about ALWPP
Hi Mark,
Thank you for being so responsive to concerns expressed by senior advocacy groups, including my own, regarding ALWPP. There still persists confusion about ALWPP because only bare bones information about ALWPP has actually been published. For instance, what are the four levels of care, what is the level of nurse involvement for each level, etc.
The reason senior advocacy groups have expressed concern about ALWPP is that many of us believe that the pilot program is based on inconsistent statute that inadvertently restricts Olmstead to only a narrow band of eligible participants. The defininition AB 499 uses for eligible participants is outdated and does not reflect progressive Olmstead terminology used for other current waiver programs which accomodate patients at risk of pre-mature institutionalization or current low income SNF who may be nursing home transition eligible. I do not believe the point of AB 499 was to make mini-nursing homes out of community based care settings.
I know ALWPP is only a small pilot program and is not intended to be the end all of Olmstead reform in California, but you have made it repeatedly clear that it will only accomodate the small population of the disabled/frail patients who truly need care by licensed care professionals (i.e., patients with g-tubes, i.v.'s, tracheotomies). We may be able to debate what current SNF residents truly need care by nurses but the bottom line is this: if their care needs are identical to current RCFE residents these patients do not need care by a nurse. Unless the state plans to pay for nurses for patients who do not need nurses, ALWPP will exclude patients with only custodial care needs.
So be it: DHS has created a pilot program literally based on statute. Allowing patients with advanced nursing care needs to live in the community is a noble goal and I am sure at some point part of every Olmstead plan. Although you and I may disagree on a few significant components (cost savings for shared vs. private rooms) I am sure knowing your dedication to this topic you have helped develop a good pilot program. The vexing problem
is: even with the weight of Olmstead, DHS does not seem to be doing anything to allow aging in place or to accomodate MFTP patients who have identical care needs as current RCFE residents. What happens to these patients who deserve Olmstead but are excluded from ALWPP participation?
On behalf of the American Parkinsons Disease Association, I formally request that DHS publish specific information about the four tiers of care (including the level of nurse involvement for each level) and allow for stakeholder comment.
Also, so that I may have DHS responses for publication purposes, would you be kind enough to answer the following specific questions:
1. Will ALWPP allow current RCFE residents to age in place?
2. Will current SNF patients with Parkinsons who need help with dressing, bathing, and use awheelchair qualify for ALWPP eligibility?
3. Will RCFEs that meet ALWPP provider criteria now be allowed to accept high functioning Parkinsons patients with g-tubes?
4. Please provide some examples of patients who are considered at the NF LOC level of care. 5. What other waivers are you aware of that DHS is currently developing that fullfills the state's obligation to allow aging in place?
It is critical for the success of Olmstead that DHS clear up any confusion about ALWPP immediately: 1) to allow time for new medi-cal waiver legislation to be introduced next year and 2) since the pilot program for nursing home transition has already begun. Kind regards,
John Amber----------------------------------------------
John Amber
West Coast Assistant Director
The American Parkinson Disease Association, Inc.
10850 Wilshire Blvd., Suite 730
Los Angeles, CA 90024
Tel: 800-908-2732
Fax: 310-474-0292
Website: www.apdawest.org
___________________________________________________
Mark Minmnaugh (DHS) replies January 7, 2005:
Dear Mr. Amber:
Thank you for your e-mail of December 15, 2004, and for this opportunity to address your concerns regarding the Assisted Living Waiver Pilot Project (ALWPP).
The ALWPP was created by Assembly Bill (AB) 499 (Aroner, Statutes 2000, Chapter 557). This legislation requires the Department of Health Services (DHS) to pilot assisted living in two settings: 1.) Publicly funded senior and disabled housing projects; and 2.) Residential Care Facilities for the Elderly (RCFEs). In your email you expressed concern regarding eligibility criteria for the ALWPP. DHS must conform to the enabling legislation in developing this new waiver benefit. AB 499 specifically directs DHS to submit a federal waiver to secure funding for this project. The federal government specifies that Home and Community-Based Services (HCBS) waivers be offered to beneficiaries as an alternative to long-term placement in a facility.
The ALWPP represents an alternative for individuals who otherwise qualify for services at the Nursing Facility (NF) Level Of Care (LOC). The ALWPP will be operated under a federal Medicaid 1915(c) waiver. Federal regulations require that people entering these waivers be at the NF LOC. Per discussions with CMS, this is a mandated requirement of these waivers. It is the intent of the ALWPP to provide another option to Medi-Cal eligible individuals at the NF LOC to remain in a community setting. This is consistent with California's Olmstead Plan and is the directive of AB 499. Individuals with custodial care needs, but without skilled nursing needs, may not meet this LOC.1 In your e-mail you stated that you do not believe the point of AB 499 was to make mini-nursing homes out of community-based care settings. The intent of AB 499 and the ALWPP is to enable individuals to choose an assisted living setting as an alternative to a nursing home.
In your e-mail you also requested more information regarding the four tiers of care identified by the ALWPP. All four tiers are within the NF LOC. The distinction between them is the product of the assessment tool that was developed specifically for the ALWPP. DHS will discuss this tool publicly in greater detail after the waiver is submitted to the federal government. Individuals who do not meet the NF LOC, but have need for assistance with activities of daily living, may be served by the In-Home Supportive Services program.
Please allow me to answer the five questions posed in your e-mail:
1. Will the ALWPP allow current RCFE residents to age in place?
The ALWPP will provide an option for full-scope Medi-Cal eligible persons at the NF LOC to choose an assisted living setting as an alternative to placement in a nursing home. If the resident is residing in an RCFE that is an ALWPP provider, the resident could choose to receive services without relocating.
2. Will current SNF patients with Parkinson's who need help with dressing, bathing, and the use a wheelchair qualify for ALWPP eligibility?
It is not possible to determine eligibility for the NF LOC based on this description. ALWPP eligibility is determined by full-scope Medi-Cal eligibility and meeting the criteria of the NF LOC.
3. Will RCFEs that meet ALWPP provider criteria now be allowed to accept high functioning Parkinson's patients with g-tubes?
The ALWPP is not a disease-specific waiver. As mentioned above, ALWPP eligibility is based on full-scope Medi-Cal eligibility and meeting the criteria of the NF LOC. Current regulations do not permit RCFEs to admit and retain residents at the NF LOC.1 DHS and the Department of Social Services have identified specific conditions prohibited by these regulations that would be waived to accommodate ALWPP participants. Details regarding those prohibited health conditions will be made public after final agreement between the two departments.
4. Please provide some examples of patients who are considered at the NF LOC level of care.
The NF LOC is described in Title 22 of the California Code of Regulations (CCRs), sections 51124 and 51335. Please refer to the regulations for additional detail. The website for the CCRs is: www.calregs.com.
5. What other waivers are you aware of that DHS is currently developing that fulfills the state's obligation to allow aging in place?
DHS is always exploring new options to protect and improve the health of all Californians. Specific information regarding other projects is not available at this time.
Thank you for bringing your concerns to my attention. I would also refer you to the ALWPP website: www.californiaassistedliving.org for further information.
Sincerely,
Mark Mimnaugh, R.N., CCRN, M.P.A.
Nurse Consultant III
Home and Community-Based Services Branch
(916) 552-9379
1. Underline and bold type added for emphasis.