Published in the National Association of Social Workers Newsletter - California newsletter (April 2019) 

Of Gears and Conveyor Belts: Is legislation the only way to keep the state from forcing seniors into nursing homes when they do not need to be there?

By Jason Bloome

When robots go haywire and cars with five wheels start rolling off the assembly lines we know we have a problem. Poor outcomes often result from failures in design. The California Coordinated Care Initiative (CCI) was supposed to save Medi-Cal dollars by shifting long-term care delivery from expensive institutions to more affordable community-based care; but a design flaw ensures the opposite outcome when seniors are denied the right to receive care in residential care facilities for the elderly (RCFEs), and CCI Managed Care Organizations (MCOs) are given fiscal incentives to keep seniors in instead of out of skilled nursing facilities (SNFs).

Fixing the CCI rate tables to reward rather than punish CCI MCOs that promote community-based vs. institutional care was the subject of a letter written to the Department of Health Care Services (DHCS) by the California Collaborative for Long Term Support and Services (CCLTSS), a coalition group of more than 34 disabled and senior right groups. Nothing was done about the issue.

I wondered if a legislative solution might have a better outcome. I drafted a bill proposal that would test the efficacy of CCI pilot programs that reimburse CCI MCOs for RCFE expenses by either adding a new RCFE rate category or incorporating RCFEs into the existing Home and Community-Based Services High (HCBS High) category which pays a capitated rate of approximately $1,800/month. The HCBS High payment plus the senior’s SSI contribution (approximately $1,100/month) would cover the cost of a shared room in many RCFEs. The bill’s intent was to develop a few small-scale (100 person) pilot programs for SNF diversion (e.g., for seniors who required too much care to remain at home who could safely reside in RCFEs) and SNF transition (e.g., seniors on LTSS in SNFs who choose to transfer to RCFEs).

Since requiring the state to spend new Medi-Cal dollars would torpedo the bill, the idea was to include only budget neutral components. SNF transition would produce cost savings (since RCFEs are more affordable than SNFs), and SNF diversion, for the sake of the pilot programs, would only include participants already in CCI at the HCBS High category of care.

I submitted the bill proposal to the office of Assemblywoman Blanca Rubio. I picked her office since she represents a district in Los Angeles, a county where CCI has the largest number of participants and because many of her constituents reflect the demographic group of many SNF residents: low-income minorities.

Although the Assemblywoman did not commit to “authoring the bill” (i.e., including it in her package of bills introduced this session), a kind staffer forwarded the bill proposal to legislative council which revised the language and crafted it into bill form. The legislative summary can be found at By the time the bill language was complete it was too late to find a bill author (the deadline for new bills for this session was February 22, 2019). The bill is currently “unbacked” but ready to move forward next year once I find an author willing to introduce the bill.

I’ve gathered some advice about the proposed bill from consumer and industry stakeholders. First, the muscle behind the bill pushing it past the various committees should come from the CCI MCOs since they would be the ones developing the pilot programs and not so much from consumer groups who have less pull in Sacramento. Second, using the legislative route to change the CCI rate tables wouldn’t be necessary if DHCS administratively made the changes on its own. Third, the timing might not be right for changing CCI when the program is already on critical life support and, since it does not show significant Medicare and Medi-Cal cost savings, is at risk of failing.

Without being able to develop SNF diversion/transition programs, CCI MCOs cannot provide Medi-Cal cost savings to the state by providing community-based vs. institutional care options.  California continues to waste millions of Medi-Cal dollars each year for tens of thousands of seniors in SNFs who do not need to be there. Since DHCS has expressed no interest in fixing the CCI rate tables, change will only come by the state being sued under the Americans with Disabilities Act (this is currently being done by Justice on Aging against the state of Florida) or via legislation. When bureaucratic inaction perpetuates the flow of seniors being forced unnecessarily into nursing homes, the state is asleep at the controls while faulty conveyor belts run in the wrong direction. Throwing a few wrenches into the gears is one way to stop a defective machine.


Jason Bloome is owner of Connections–Care Home Referrals, an information and referral agency for care homes for the elderly in Southern California. More information can be found at