Long-Term Care - Illinois General Assembly

It’s a complex decision. When we look at what states are doing, they're typically making
reasonable modifications, and, over the long-term, looking at some fundamental alterations to
improve their system.
The elements of the Olmstead decision fit very nicely with the kinds of things that we often think
of when we talk about strategic planning, such as “community integration.” What does that
mean? What are the elements of this initiative? What kinds of supports and services are
needed in order to make it happen? What benchmarks are needed to measure progress?
What kinds of delivery models are out there? How do you measure individual outcomes? How
do you document progress?
The Olmstead case establishes guideposts for strategic planning, including:
• promoting consumer choice of providers, settings and services;
• seeking maximum service benefit for the dollar spent, which typically then means looking at
the sets of services that people want and need;
• reducing reliance on services that might be more restrictive than people want;
• promoting high quality and optimal outcomes; and
• making the system understandable, accountable and affordable in the future.
Consumer-directed care may involve individuals hiring their own workers. It may also involve a
less dramatic change than that, by simply giving consumers more choices of services.
Managed care, prospectively paid long-term, is another model. Twenty states have at least one
model that can be classified as managed long-term care, which is where financing and service
delivery are integrated, typically with a capitated payment.
The Lewin Group recently identified some best practices in home and community-based waivers
in three states: Colorado, Washington, and Wisconsin. Home and community-based waivers in
those states seemed to be responsive to what consumers want, and seemed to provide a set of
services that are consistent with what's needed in the state.
Lewin identified 4 common themes that enabled these states to reallocate Medicaid funds from
institutions to home and community-based services. The states that did well with waivers had
some kind of controls in place to manage home and community-based services' growth and its
impact on service provision. The states that did best have strong locally-based systems with a
single-point-of-entry, where issues around functional status and financial eligibility can be
determined, along with other services like information and referral. They have streamlined
provider enrollment activities, so that providers know where to go and where to sign up.
Colorado was one of the early states that had a single-entry-point. They have a system where
they issue an RFP in particular regions and then identify an entity to be the single-entry-point.
They have a variety of types of entities that are the single-entry-points. Some of them are
county human services agencies. Some are Area Agencies on Aging. Some are nonprofit
organizations. In rural areas, public health agencies serve that function. They have a fast-track
eligibility function for people in hospitals so they can move them more quickly into the waiver
situation, and so that they can get the community services more quickly. They have a per
capita monthly payment for case management activities provided by the single points of entry.
In the state of Washington, another state that's been around awhile with a single-point-of-entry,
they have state staff at local locations doing the level-of-care determinations and the financial
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