Olmstead Now Campaign Primer
What is the Supreme Court Olmstead decision?
What is the Olmstead Now Campaign? 
What is the current state of Olmstead reform in California in regards to allowing low income seniors who require 24-hour custodial care the choice to reside in a RCFE or assisted living setting vs. a skilled nursing home?
What is the Assisted Living Waiver program? (ALW)?
What are the primary goals of the Olmstead Now Campaign? Take the pledge here.
What is Money Follows the Person (MFTP) or nursing home transition?
What is the percentage of patients in Skilled Nursing Facilities (SNFs) who may be eligible for nursing home transition?
What is the average daily medi-cal reimbursement rate for a SNF patient?
What is the average daily cost for medi-cal patients who receive care at home (for example, through the In Home Supportive Services program) at home?
What is the average daily medi-cal reimbursement rate for an ALW RCFE provider?
How does ALW demonstrate cost neutrality?
What are the barriers to increasing waiver slots for nursing home transition?
What are the primary goals of the Olmstead Now Campaign?
What is the Supreme Court Olmstead decision?
In Olmstead v. L.C., 527 U.S. 581 (1999) (the "Olmstead decision"), the Supreme Court construed Title II of the ADA to require States to place qualified individuals in community settings, rather than in institutions, whenever treatment professionals determine that such placement is appropriate, the affected persons do not oppose such placement, and the State can reasonably accommodate the placement, taking into account the resources available to the State and the needs of others with disabilities.
Many Olmstead measures are implemented by submitting waivers to the federal government that would allow medicaid dollars to be used to provide care services either at home or in community based care settings.
Total costs for individual patients covered by these waivers cannot cost more than what the state currently pays for that patient to be in a SNF.
What is the Olmstead Now Campaign?
An on-line petition used to form a coalition to coordinate legislative efforts to urge lawmakers to enact prudent, cost-efficient Olmstead measures that stop the forced institutionalization of the low income frail/disabled.
Our primary focus is improving nursing home transition for skilled nursing facility residents already on medi-cal who choose not to reside in these settings. Nursing home transition saves the state medi-cal dollars, monies that can be used to offset other Olmstead measures (such as preventing patients from being unnecessarily institutionalized) which involve new medi-cal expenditures.
What is the current state of Olmstead reform in California in regards to allowing low income seniors who require 24-hour care the choice to reside in a RCFE or assisted living setting vs. a skilled nursing home?
California has enacted the Assisted Living Waiver (ALW).
What is the California Assisted Living Waiver program (ALW)?
ALW currently allows approximately 1,400 qualified individuals in California in certain counties (Los Angeles, San Bernardino, Fresno, Sonoma, San Joaquin and Riverside) to use medi-cal funding to receive care in RCFEs, community based care homes, and publicly subsidized housing sites.
Eligible patients are anyone 21 years of age or older who is eligible for medi-cal without a share of cost and who has been determined to need a "skilled nursing" level of care. In some instances, ALW will remove barriers which currently prevent low-income patients with certain conditions (eg. patients who require insulin shots) from living in RCFE or public housing settings.
What is Money Follows the Person (MFP) or nursing home transition?
One component of ALW is Money Follows the Person (MFTP) or nursing home transition which allows eligible individuals to move with their medi-cal dollars from institutional settings to home or community based care settings. For some background information, see Nursing Home Transition under publications.
Nursing home transition does not involve new medi-cal dollars and holds the best promise for extending Olmstead relief to the most participants in California. If implemented properly it could save the state millions of medi-cal dollars a years (since care in an assisted living or RCFE setting is far more affordable than institutional care) and help fund portions of Olmstead that involve new medi-cal dollars: aging in place and transitioning from home to a RCFE. See: DHS California Community Transitions Project webpage.
What is the percentage of patients in Skilled Nursing Facilities who may be eligible for nursing home transition?
Medi-cal pays for about 2/3 of SNF patients (there are approximately 240,000 SNF beds in California). About 90% of these patients are elderly.
California does not currently assess how many SNF patients on medi-cal could be in lower level care settings. Although some SNF patients have g-tubes, iv's, tracheostomies, ventilators, open wounds, etc., and need nurse supervision, many have identical care needs as private paid RCFE residents with only custodial care needs (eg. help with dressing, bathing, help out of bed, incontinence, etc.).
The California Little Hoover Commission estimates at least 30% of the residents in SNFs have only custodial care needs. Many senior care professionals feel the true percentage is far higher.
What is the average daily medi-cal reimbursement rate for a patient in a SNF?
The average medi-cal reimbursement rate to a SNF is approximately $180/day.*
What is the average daily medi-cal reimbursement rate for an ALW RCFE provider?
The average patient daily reimbursement rate paid to a RCFE is about $75/day.*
What is the average daily medi-cal cost for patient who receives care at home (for example, through the In Home Supportive Services program)?
DHS estimates the medi-cal costs for a low income patient requiring care at home (many are on the IHSS program) is $35/day.*
What is the medi-cal cost savings to the state for a ALW participant on medi-cal who transfers from a nursing home into a RCFE setting?
The state saves approximately $100/day for each patient who transitions from a nursing home into a RCFE or community based housing setting.
How does ALW demonstrate cost neutrality?
ALW demonstrates cost neutrality when new medi-cal expenses for patients transferring from non-institutional settings (from home or from an exisiting RCFE) is offset by medi-cal cost savings generated by nursing home transition. To achieve cost neutrality ALW mandates one of every three ALW participants must transfer from a nursing home.
What are the barriers to rapid nursing home transition in California?
Limited waiver slots: Currently, California only allows 1,400 ALW participants. The largest number of waiver slots (about 300) are in Los Angeles.
Limited capacity: Most RCFEs choose not to participate with ALW. In Los Angeles, for example, out of approximately 1,400 RCFE providers only 45 are participating with ALW.
Reasons for a lack of RCFE participation include: lack of knowledge about the program, inadequate reimbursement rates, onerous medi-cal paperwork, and unfunded expenses related to hiring or contracting nurses for patients who, as they progress through the four tiered levels of care, may require nursing services (for example, an ALW provider (who generally is not a nurse) must pay for a nurse to administer insulin shots).
Of the few RCFEs that do participate with ALW most are larger (40-100 bed) settings which benefit from economy of scale and can more easily accommodate new standards, such as nurses, by accepting a large number (20-30) of ALW participants. Delays in medi-cal payment (due to budget crises, for example) also make small RCFE participation problematic.
Lack of outreach to current nursing home residents:
Some ALWPP care coordinators say it has been difficult to locate nursing home residents currently on medi-cal who would like to participate in ALW.
Possible solution: DHS or other relevant agencies send an annual letter to SNF medi-cal patients and/or their families informing them about nursing home transition.
Provider bottlenecks:
Increasing ALW RCFE participation is essential for advocacy efforts to increase ALW waiver slots and nursing home transition. Nursing home transition cannot be significantly scaled up if there is not sufficient capacity (ALW RCFE provider beds).
Possible solution: DHS or other relevant agencies send an annual letter to all RCFEs in ALW approved counties with information about the program.
Lack of coordination between the Department of Health and Community Care Licensing:
The Department of Health administers medi-cal and the ALW program. Community Care Licensing, a branch of the Department of Social Services, licenses and inspects RCFEs.
DHS will only consider approving RCFE ALW provider applicants if they have been visited by CCL within the past year even though CCL generally does not visit RCFEs in good standing (without compliance issues) more than once every five years.
DHS informs CCL as to the ALW provider applicants that have not been visited within the past year prompting a inspection by CCL but there is no specific time frame given by CCL as to when a visit will actually take place.
Possible solution: A state mandate requiring CCL visit within a timely fashion (e.g. within 1 month) RCFEs that apply for ALW that have not been inspected within the past year.
What are the primary goals of the Olmstead Now Campaign?
We support:
1. A robust nursing home transition program which will fund other parts of Olmstead that involve new medi-cal dollars (for example, aging in place).
2. A two-fold increase of ALW waiver slots (currently there are 300 waiver slots in Los Angeles) by promoting the cost savings associated with nursing home transition patients.
3. A two fold increase from the current number of ALW RCFE providers (as of June, 2011 there are currently 53) with special outreach to small 4-6 bed facilties that have high staff to resident ratios.
4. Increased outreach by care coordinators, Ombudsman, nursing home staff. etc. to medi-cal patients currently in nursing homes who may want to participate with nursing home transition.
5. An up to date state website specifically devoted to assisting RCFE become ALW providers with input from stakeholders, current ALW providers, etc. including pros and cons of waiver participation, best case practices, question and answer section and useful links, etc.
6. An analysis by state agencies as to the percentage of patients previously on IHSS entering a nursing home who could be eligible for ALW (to determine cost savings to the state by accelerating nursing home transition).
7. The encouragement of small RCFE ALW providers to target specialized populations (e.g. younger disabled people who would like to live in care settings with residents more or less their age).
8. An update to the ALW provider list including staff to resident ratios, bed capacity, and if the setting has a dementia unit and is licensed for wheelchairs.
*Sources: Bernie Finneran, Program Manager ALW at the Department of Health.