Home and community based services for elderly and physically disabled : measurable goals, better reporting, and program integration would benefit system

Performance Audit 11-32

June 2012

Georgia Department of Audits and Accounts
Performance Audit Division
Russell Hinton, State Auditor Leslie McGuire, Director

Why we did this review
The State of Georgia paid more than $1.4 billion for long term care services for the elderly and physically disabled in fiscal year 2011. These expenditures paid for nursing home care and home and community based services (HCBS).
While nursing homes are necessary for some, other individuals can remain in their home or in another community living arrangement with significantly less assistance. HCBS programs can provide services, such as assistance with eating or bathing, homedelivered meals, and others, at a significantly lower cost than that of a 24-hour skilled nursing facility. In addition to being less expensive, HCBS are often preferred by the public.
Who we are
The Performance Audit Division was established in 1971 to conduct indepth reviews of state programs. The purpose of our reviews is to determine if programs are meeting their goals and objectives; provide measurements of program results and effectiveness; identify other means of meeting goals; evaluate the efficiency of resource allocation; assess compliance with laws and regulations; and provide credible management information to decision-makers.
Website: www.audits.ga.gov Phone: 404-657-5220 Fax: 404-656-7535

Home and Community Based Services for Elderly and Physically Disabled
Measurable goals, better reporting, and program integration would benefit system
What we found While the state has spent an increasing portion of long term care funds for the elderly and disabled on home and community based services, it could improve decision-makers' ability to evaluate the state's success in rebalancing services for these populations by adopting improved measurable goals and reporting. Dashboard measures would include HCBS and nursing home spending for the elderly and disabled, as well as number of individuals served (or days of service) by HCBS and nursing homes.
Between 2008 and 2011, Georgia's nursing home spending grew 1% (to $1.03 billion) while spending on the Elderly and Disabled Medicaid Waiver and the Non-Medicaid HCBS programs increased 21% (to $386.9 million). Despite the HCBS increases, HCBS demand exceeds capacity and new limits on waiver enrollment could increase the deficit. These challenges make it vital that those state leaders who recommend and appropriate funds to HCBS programs and nursing homes have access to useful performance information about rebalancing efforts.
We found that numerous sources of information about Georgia's long term care system exist, but the information is generally isolated by department, program, or initiative. None of the documents provide the context needed to assess the degree that the HCBS programs, as a group, impact long term care spending and utilization for the elderly and disabled populations. This is partly due to no single agency being responsible for these populations. The Department of Human Services' Division of Aging Services (DAS), which is required to produce planning and annual report documents, operates waiver and non-waiver programs but does not have information on all HCBS programs or nursing homes. The Department of Community Health (DCH) operates the larger waiver program but does not have purview over non-waiver programs.

We also found that the current operation of separate programs under the Elderly and Disabled Medicaid Waiver impedes the state's ability to direct services to those most in need. DAS operates the Community Care Services Program (CCSP), while DCH operates Service Options Using Resources in Community Environments (SOURCE). Both programs require that clients qualify for a nursing home level of care, but clients applying for CCSP have generally been placed on a waiting list while those applying for SOURCE have had access to services.1 The two paths to E&D waiver services allow a SOURCE client to access services before a CCSP client, even if the CCSP client has a higher risk of nursing home placement. And while SOURCE instituted a waiting list in January 2012, the programs' waiting lists will be managed separately, permitting lower risk clients in one program to receive services before a higher risk client in the other program. In addition to unequal access to typical services, the current structure does not effectively allocate enhanced case management services to those who may derive the most benefit. Enhanced case management, which involves a medical director and primary care physician in the development of the patient's care plan, is provided to all SOURCE clients but is unavailable to CCSP clients.
As a long term care option, Georgia's HCBS programs have two disadvantages compared to nursing homes: awareness and availability. The general public and healthcare professionals are more familiar with nursing homes as an option for those requiring assistance with daily needs. Although Georgia's 12 Aging and Disability Resource Connections (ADRCs) provide information on HCBS and other services, Medicaideligible individuals are not required to contact them before seeking admission to a nursing home. Upon admission, a nursing home is required to provide information on HCBS and is later required to provide its residents with the opportunity to receive options counseling from the ADRC. In July 2011, nursing homes become responsible for referring certain residents to ADRCs for options counseling, but as of January 2012, 27% of nursing homes had not referred a resident.
Even when individuals are aware of HCBS programs, the programs are frequently not as accessible as a nursing home. CCSP had more than 1,000 individuals on its waiting list in April 2012, and SOURCE instituted a waiting list for the first time in January 2012. Clients who began receiving CCSP services in 2011 had spent an average of eight months on the waiting list. Even if a client is not placed on a waiting list, the processes to determine eligibility, assess needs, develop a case plan, and identify a service provider typically take several weeks. When an individual or family has an urgent need for services, nursing homes are often able to meet the need more quickly than CCSP or SOURCE. We found that other states have developed programs that can deliver services in a matter of days, through ensuring capacity is reserved for urgent cases and presumptive eligibility based on the initial screening.
We also noted that Georgia's client cost sharing requirements are less generous than those in many other states but we could not determine if the current policy led to individuals refusing CCSP services and requiring earlier admission to nursing homes. Raising the current threshold to protect all income under the federal poverty level would cost approximately $5.8 million annually, which equates to the cost of serving 580 clients.
Finally, we found that Georgia provides similar services in the community as other states, when looking at all programs. However, we could draw no conclusions about the adequacy or depth of the services within a particular category. In interviews with HCBS staff in the AAAs, home modifications and better transportation options were frequently cited as needed improvements to Georgia's HCBS system.
In its response, DHS stated that its staff is in agreement with the "content, findings, and recommendations" in the draft. DCH noted that many of the findings are being addressed through a combination of a waiver renewal, the state's Balancing Incentive Program Application, and its review of HCBS in conjunction with the Medicaid Redesign.
1 Program qualifications primarily differ in relation to income, not need for services. SOURCE is restricted to Medicaid recipients who also receive Supplemental Security Income (SSI). A Medicaid recipient on SSI may participate in SOURCE or CCSP.

HCBS for the Elderly and Physically Disabled

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Table of Contents

Audit Purpose

1

Background

Home and Community Based Services for the Elderly and Disabled

1

Georgia's Elderly and Disabled Medicaid Waiver

1

Other HCBS Programs that Impact the E&D Populations

3

Points of Entry to Long Term Care System

4

Financial Information

4

Activity and Performance Data

6

Future Changes for HCBS System

7

Findings and Recommendations

Spending on home and community based services (HCBS) for elderly and disabled populations has expanded in recent years. However, current capacity does not meet demand for these services, and the state lacks the measurable goals required to assess the effectiveness of current strategies. 9

Limited awareness and availability of Georgia's HCBS options results in

greater use of nursing homes for long term care.

12

The current practice of operating two programs within Georgia's Elderly and

Disabled Medicaid waiver impedes the state's ability to direct the

appropriate services to those most in need and introduces operational and

management inefficiencies.

16

While Georgia's cost sharing requirements impact lower income clients

more than those of most other states, the cost effectiveness of the policy

cannot be evaluated with current data. Modifying the policy to shield all

income below the federal poverty level will raise Medicaid costs by

approximately $5.8 million or reduce the number of clients served.

19

Georgia provides a typical menu of services within the Elderly and Disabled

Waiver programs. However, the need for home modifications and improved

transportation services were identified as deficiencies in the state's HCBS

system.

23

Appendices

Appendix A: Objectives, Scope, and Methodology

26

Appendix B: Map of Area Agencies on Aging (AAAs)

28

Appendix C: SOURCE Providers by County

29

Appendix D: Services Offered Under the E&D Medicaid Waiver

33

HCBS for the Elderly and Physically Disabled

ii

HCBS for Elderly and Physically Disabled

1

Audit Purpose
The purpose of this audit was to review the state's primary home and communitybased service programs for elderly who meet a nursing home level of care. The primary focus was whether the state could make greater use of the two programs that are part of the state's Elderly and Disabled Medicaid Waiver: Community Care Services Program (CCSP) and Service Options Using Resources in a Community Environment (SOURCE) program. These programs serve the elderly and the physically disabled who qualify for nursing home care; therefore, our findings would impact both groups. We did not conduct a complete operational review of the two programs, but instead identified barriers to more efficient and effective use of the waiver. Details regarding the objectives, scope and methodology are located in Appendix A.
A draft of the report was forwarded to appropriate personnel with the Departments of Community Health and Human Services. Pertinent responses from the two agencies have been included in the report as appropriate.

Background

Home and Community Based Services for the Elderly and Disabled
Home and community based services (HCBS) are an alternative to caring for individuals within an institutional setting, such as a nursing home. The services and supports provided by HCBS programs appeal to elderly and disabled (E&D) clients, who frequently prefer to remain in their homes or in an alternate community living arrangement, such as a personal care home.
State and federal governments also prefer community care. In 1982, the Georgia General Assembly stated its intent that "a continuum of care be established so that functionally impaired elderly persons age 60 and older may be assured the least restrictive environment suitable to their needs." And the federal government enforces the Supreme Court's Olmstead decision that requires states to provide "services in the most integrated setting appropriate to the needs of qualified individuals with disabilities." Governments often find HCBS programs desirable because they have a lower cost per client than services provided in an institutional setting.

Georgia's Elderly and Disabled Medicaid Waiver
Medicaid waivers allow states to deliver healthcare in ways that are not included in the state's traditional Medicaid plan and are an option available to states for the delivery of HCBS. Georgia's 1915(c) Elderly and Disabled Medicaid Waiver allows the state to provide care in a home or community setting for individuals who qualify for nursing home care. As part of the waiver, Georgia operates two programs: Community Care Services Program (CCSP) and Service Options Using Resources in Community Environments (SOURCE). As shown in Exhibit 1, the programs have different management agencies and service delivery methods. While they both serve the E&D populations, specific requirements vary between the programs.

HCBS for Elderly and Physically Disabled

2

Exhibit 1 Overview of E&D Waiver Programs

CCSP

Financial

Medicaid

Client Age Requirement

65+ (or totally disabled or blind)

Client's Functional Needs

Meet Intermediate Nursing Home Placement Level of Care requirements

State Administrator

DCH Medicaid Division/ DHS Division of Aging Services

SOURCE
SSI Medicaid 65+
(or disabled) Meet Intermediate Nursing Home
Placement Level of Care requirements
DCH Medicaid Division

Intake 12 Area Agencies on Aging (AAAs)

12 SOURCE providers

Case Management

Case management providers

SOURCE providers

Service Provision

Case management provider brokers services with Medicaid
providers

Source: Program regulations; interviews with program officials

SOURCE providers contract services with selected Medicaid
providers

CCSP CCSP is a program available to individuals who: 1) have income below Medicaid limits, 2) are either 65+ or physically disabled, and 3) are in need of a level of care traditionally found in a nursing home. If an individual meets these requirements, they are placed on a waiting list ranked by need and then provided services when funding is available. Depending on the individual's income level, they may be required to contribute to the cost of their services.
The Department of Human Services contracts with the state's 12 Area Agencies on Aging (AAAs) for the regional management of the CCSP program (see Appendix B for a map of AAA regions). AAA staff conducts the screening of individuals, but the AAA contracts with other organizations that provide client case management, including a more detailed assessment of needs and creation of a case plan. Clients then receive HCBS services from licensed Medicaid providers, who bill Medicaid directly. Services are a combination of medical and non-medical services. Examples of services include assistance with activities such as bathing or eating, delivery of meals, assisted living care, and various types of health services (see Appendix D for a complete list of HCBS services).
CCSP has been in operation as part of Georgia's 1915(c) Elderly and Disabled Waiver since 1982. As a Medicaid program, it is funded with federal and state funds. While DCH is the state's Medicaid agency and is ultimately responsible for the program, the day-to-day operations of CCSP are contracted to the DHS's Division of Aging Services (DAS).

HCBS for Elderly and Physically Disabled

3

SOURCE SOURCE is a Medicaid program that links primary medical care to an individual's HCBS needs. It is available to individuals who: 1) receive Medicaid because they qualify for Supplemental Security Income (SSI) due to age (65 or older) or disability coupled with low income/resources, and 2) are in need of a level of care traditionally delivered in a nursing home. SOURCE instituted a waiting list in January 2012; however, as of April, individuals could still receive services upon application approval. All SOURCE clients' income is below the cost share threshold used by the CCSP program; therefore, SOURCE clients do not contribute to the cost of services.

The Department of Community Health (DCH) contracts with 12 SOURCE case management providers to provide enhanced case management to waiver clients. They conduct intake and assessment of clients for program eligibility. The SOURCE providers employ case managers and a medical director who manage the client's care in consultation with a primary care physician. The physician is part of a network developed by the SOURCE case management provider. Based on the care plan developed by the SOURCE provider, clients receive HCBS services from licensed Medicaid providers that bill Medicaid directly. Other than enhanced case management, the services available to SOURCE clients are the same as those available to CCSP clients (see Appendix D).

SOURCE case management providers include both for-profit and non-profit entities, some of which are affiliated with hospitals, nursing home companies or other medical providers (see Appendix C). The providers serve overlapping geographic
Other HCBS Programs that Impact the E&D Populations
While the primary focus of this report is on the programs offered as part of the Elderly and Disabled Medicaid Waiver, which are the largest HCBS programs for the E&D populations, they may receive HCBS through other programs as well. Many elderly individuals are served by the Non-Medicaid HCBS Program, while the Money Follows the Person federal grant targets the elderly, disabled, and other populations that are currently receiving institutional care.
Non-Medicaid Home and Community Based Services (NMHCBS) NMHCBS is available to individuals who are 60 or older or who have Alzheimer's disease or a related disorder. Individuals with Medicaid coverage may receive services through NMHCBS, and the program may be used by those on the waiting list for CCSP services. Depending on income level, an individual may be responsible for contributing to the cost of services.
DHS's Division of Aging Services manages NMHCBS and contracts with the state's 12 AAAs. Each AAA determines what services will be offered in its region, and service menus may include items unavailable through the E&D waiver. Once a person requests services, the AAA determines a client's needs and places the client on separate waiting lists for each service. As a slot becomes available, the client will receive the service from a provider under contract with the AAA. As of April 2012, there were approximately 23,000 individuals receiving services and over 11,000 individuals waiting for NMHCBS services statewide.
NMHCBS is funded by a combination of federal, state, local, and other funds. In fiscal year 2011, NMHCBS spending totaled $54.6 million. The average cost per client for a full year of services was $4,200.
Money Follows the Person (MFP) Since 2008 Georgia has participated in the Money Follows the Person Demonstration Grant that helps transition individuals on Medicaid from long term care institutions into the community. MFP is available to elderly, physically disabled, and developmentally disabled individuals who have been in a nursing facility for at least 90 days. The program provides the state with enhanced federal matching rates for HCBS spending on program participants.
Nursing homes identify potential participants through a series of questions required by the federal government. Once identified, the nursing home must provide the resident's contact information to the nearest ADRC. An options counselor then provides face-to-face assistance to the resident to determine available resources and services necessary for a transition to their home or community. Once MFP participants leave an institution, they are enrolled in CCSP or SOURCE for most HCBS services, but they receive enhanced transition services through MFP. For example, MFP support can include assistance with deposits and rental agreements, purchase of household items and furniture, and contracting for home modifications. As of December 2011, 744 individuals had transitioned from long term care institutions; approximately 47% of those were elderly or physically disabled.

HCBS for Elderly and Physically Disabled

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areas approved by DCH; some serve a single county while two are permitted to offer services in most or all 159 counties. With a single exception, each county is served by at least two SOURCE providers.

DCH initiated SOURCE in 1997 as a demonstration project in Savannah. The program's coverage increased over time, and by 2008, it was added to Georgia's existing Elderly and Disability waiver and expanded statewide. As a Medicaid program, it is funded with federal and state funds. DCH manages and operates the program.

Points of Entry to Long Term Care System
Individuals typically access Georgia's community-based long term care system through an Area Agency on Aging or a SOURCE provider.

Area Agencies on Aging (AAAs)/Aging and Disability Resource Connections (ADRCs) AAAs were created in the 1970s to provide programs and services to senior citizens. Since 2010, Aging and Disability Resource Connections have been present in all 12 of Georgia's AAAs. The ADRCs, which were created after federal funding became available, serve as a single point of entry for all individuals elderly and disabled that may be in need of services. The state's ADRCs have a single toll-free phone number that allows those in need or their family members to obtain information and assistance regarding long term care needs. The ADRC may refer individuals to an HCBS program available through the AAA (e.g., CCSP) or to the SOURCE program. The ADRC may also provide information related to nursing home care, social programs, long term care planning, or other relevant services.

SOURCE Providers Georgia's 12 SOURCE case management providers reach out to potentially eligible clients, or can be contacted directly by individuals in need of services. These SOURCE providers2 are not expected to provide the same type of education and information services as an ADRC; therefore, if an individual is not eligible for SOURCE, the individual may be referred to an ADRC. SOURCE providers, however, are under no obligation to make a referral.
Individuals contact these organizations as a result of the organizations' marketing or outreach efforts or as a result of a referral by a physician, insurer, hospital, social services agency (e.g., DFCS), or a Medicaid provider serving a family member or neighbor. However, ADRCs and SOURCE providers are only gateways to community-based services; individuals may present themselves to a nursing home without being aware of community-based options.

Financial Information
As shown in Exhibit 2, both CCSP and SOURCE derive a majority of their funding from the federal government. In fiscal year 2011, approximately $377 million was spent on the two E&D waiver programs.

2 Two AAAs also serve as SOURCE providers.

HCBS for Elderly and Physically Disabled

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Exhibit 2 HCBS Expenditures by Fund Source Fiscal Years 2010 and 2011

Expenditures Direct Services to Clients Contracts - Intake/Care Coordination State Administration(1) Total
Fund Sources(2) State Federal Total
Expenditures Direct Services to Clients Contracts - Intake/Care Coordination State Administration(3) Total

FY10
$109,157,037 24,657,653 957,353
$134,772,043
$41,157,638 93,614,405
$134,772,043
FY10
$179,131,927 34,795,104 N/A
$213,927,031

CCSP

%

FY11

%

81% 18%
1% 100%

$111,994,526 24,151,409 1,116,376
$137,262,312

82% 18%
1% 100%

31% $ 42,596,753 31%

69%

94,665,557 69%

31% $137,262,310 31%

SOURCE

%

FY11

%

84% $203,131,087 85%

16% 37,041,823 15%

0%

N/A

0%

100% $240,172,910 12%

Fund Sources State Federal Total

$53,797,243 160,129,788 $213,927,031

25% 75% 100%

$64,441,363 175,731,548 $240,172,911

27% 73% 100%

Source: PeopleSoft records
(1) DHS is responsible for enrolling and training all CCSP and SOURCE providers; therefore, some portion of CCSP's state administration costs is associated with SOURCE.
(2) CCSP fund source amounts are estimates based on federal FMAP percentages for direct services and administrative costs.
(3) DCH does not track administrative costs for SOURCE. In addition to those costs borne by CCSP noted in footnote 1, during FY10 and FY11, SOURCE was supported by approximately four individuals in the DCH state office.

As shown in Exhibit 3, the annual cost of providing HCBS services are significantly lower than the annual cost of nursing home care. While the state's cost was approximately $52,250 for 365 days of nursing home services in fiscal year 2011, an individual could receive a full year of waiver services for approximately $14,000. In fiscal years 2009 through 2011, SOURCE program costs ranged from approximately $12,000 to $13,600. The vast majority of costs were for the HCBS services delivered directly to clients; intake and case management fees accounted for approximately 15% of the annual cost. Annual costs for a CCSP client were similar to SOURCE for the three-year period, ranging between $15,600 and $16,300. Again, HCBS services constituted the vast majority of costs, with intake and care coordination representing 18%. It should be noted that while clients served by waiver programs qualify for a nursing home level of care, the services delivered to them are not the same as those delivered in a nursing home. Nursing homes provide 24-hour skilled nursing care to their clients, something that is not available in an HCBS program.

HCBS for Elderly and Physically Disabled

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Exhibit 3 Annual Cost per Slot/Bed Fiscal Years 2009-2011

$60,000

Intake/Care Coordination and Direct Services Contract - Intake/Care Coordination

Direct Services to Clients State Administration

$50,000

$40,000

$30,000

$20,000

$10,000

$0 FY09

FY10

FY11

SOURCE

FY09

FY10 CCSP

FY11

FY09

FY10

FY11

Nursing Homes*

Sources: SOURCE expenditure data; DAS CCSP Client Data; DCH nursing home data * The Nursing Home amounts reflect the Medicaid cost of services for 365 days. Most reported average annual costs (approximately $27,500 per year) do not reflect the amount of time a client received nursing home care; those calculations

Activity and Performance Data
Program Capacity Funding levels determine the waiver programs' capacity, though the method of receiving appropriations varies between the two programs. CCSP is given an annual state allocation that determines the number of clients that can be served in the year. State appropriations for SOURCE are part of the larger Aged, Blind, and Disabled (ABD) program budget, allowing DCH flexibility in allocating resources within the ABD program.
As shown in Exhibit 4 on the following page, waiver enrollment has increased from approximately 30,000 in federal fiscal year 2008 to about 33,500 in federal fiscal year 2011. All of the growth has occurred within the SOURCE program. The program had 17,600 clients in 2008 but grew to more than 22,800 by 2011. CCSP enrollment has declined slightly since federal fiscal year 2008, dropping from just over 12,000 in 2008 to approximately 10,600 in 2011.

HCBS for Elderly and Physically Disabled

Exhibit 4 Unduplicated Count of Waiver Clients Federal Fiscal Years 2008-2011

40000 35000 30000 25000 20000 15000 10000
5000 0 FFY08
Source: CMS 372 Reports

SOURCE FFY09

CCSP

Total

FFY10

7
FFY11

Length of Time in Program DAS calculates the length of stay in CCSP to measure the "nursing home delay" resulting from the program. However, the measure is an approximation of delay since it is unknown at what point, if ever, individuals would decide to enter a nursing facility. DAS data shows that clients who left CCSP in state fiscal year 2011 had been in the program an average of 45 months. There is currently no length of stay data available for the SOURCE program.
Reasons for Program Exits DAS and DCH track the reasons for leaving the waiver programs. According to CCSP's Fiscal Year 2011 Annual Report, the two most frequently cited reasons were death (40%) and entrance into a nursing home (28%). For SOURCE, calendar year 2011 data shows the three most frequently cited reasons were no longer meeting the nursing home level of care at the time of reassessment (21%), entrance into to a nursing home (16%), and death (15%).
Future Changes for HCBS System
Medicaid Redesign DCH is currently conducting an assessment and redesign of Georgia's Medicaid and Children's Health Insurance programs, and recommendations in this report will have to be addressed within the context of any adopted changes. Preliminary recommendations from Navigant, the firm hired to perform the assessment, include an expansion of managed care services to those currently served by home and community based waivers. As quoted in the Navigant report, a U.S. Health and Human Services publication noted that managed long-term care increases access to HCBS waiver and other community services. People enrolled in managed LTC programs are generally not subject to caps on the number of slots available for HCBS waiver services. Plans have the flexibility to provide LTC services to members who need them when they need them, and have incentives to do so when community services can prevent or reduce institutional use.

HCBS for Elderly and Physically Disabled

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State Balancing Incentives Payment Program (SBIPP) SBIPP is intended to reduce institutionalization and improve access to community based care. States that make structural changes favoring community based services under SBIPP receive an increased federal funding match. Georgia is eligible for a 2% increase in the federal medical assistance percentage. SBIPP requires states to create or make improvements to the single entry point for community based services, ensure conflict-free case management (i.e., case management provider should not also be service providers), and adopt a core standardized assessment.

DCH submitted a proposal for participation in March 2012. Proposed initiatives include the expansion of the number of slots in the Medicaid waiver programs, adoption of Georgia's 12 ADRCS as the primary point of entry for HCBS, and provision of web-based training on community-based long term care services available to targeted referral sources. If approved, these initiatives will be phased in over the next few years.

HCBS for Elderly and Physically Disabled

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Findings and Recommendations
Spending on home and community based services (HCBS) for elderly and disabled populations has expanded in recent years. However, current capacity does not meet demand for these services, and the state lacks the measurable goals required to assess the effectiveness of current strategies.
Georgia has increased HCBS spending and served more elderly and disabled clients in recent years, but the state still spends a much greater amount on nursing home services for these groups. For the state to improve upon current efforts to rebalance long term care spending for these populations, decision-makers need transparent information about HCBS and nursing home spending and utilization.

HCBS has constituted an increasing proportion of Georgia's long term care spending and utilization for the E&D populations in recent years. As shown in Exhibit 5, the percentage of spending and days of service increased for HCBS programs during the 2008 to 2011 time period. HCBS spending grew 21%, led by a 25% increase in E&D waiver spending to approximately $337 million. NMHCBS spending was largely unchanged at approximately $50 million annually. During the same period, nursing home spending grew just 1%, although it is more than $1 billion annually. Utilization was largely consistent with spending patterns. Combined waiver and NMHCBS usage increased over the period, while the number of nursing home days decreased slightly. While not shown, nursing home admissions increased, consistent with a national trend of shorter stays.

Exhibit 5 HCBS and Nursing Home Spending/Utilization for the Elderly and Disabled Fiscal Years 2008-2011

Spending

Days of Service

Millions Millions

Non-Medicaid HCBS E&D Waiver Nursing Home

$1,600

$1,400

$1,200

$1,000

$800

$600

$400

$200

$0 2008

2009

2010

2011

Non-Medicaid HCBS 30

E&D Waiver

Nursing Home

25

20

15

10

5

0 2008

2009

2010

2011

HCBS
Nursing Homes

24.0% 76.0%

25.9% 74.1%

27.0% 73.0%

27.4% 72.6%

66.3% 33.7%

67.3% 32.6%

68.4% 31.6%

69.0% 31.0%

Source: CMS 372 Reports, HFR data, DAS financial information Note: E&D Waiver data is federal fiscal year and does not include administrative expenditures; NMHCBS and nursing home data is state fiscal year

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Rebalancing Efforts in Other States

Several other states have had success in rebalancing their long-term care systems in favor of HCBS and away from institutional care. Minnesota and Washington both spend a larger percentage of long term care funds on HCBS than institutional care as a result of rebalancing efforts. According to studies commissioned by CMS, each state has taken part in the following rebalancing efforts.
Minnesota Minnesota has taken several steps to encourage greater use of HCBS. The state created financial incentives for nursing homes to close or downsize their facilities, such as paying a higher rate for facilities that volunteered to close beds. State law requires client screenings before any individual enters a Medicaid nursing facility. By 2004, the number of nursing home beds in Minnesota had decreased 25% from 48,000 in 1987 to 34,000. Minnesota also has a Long Term Care Consultation program that assists clients in choosing long term care options and emphasizes the wide availability of community-based services. And in 2004, Minnesota added the Elderly Waiver population to its existing mandatory Medicaid managed care system, consolidating program management in the process. These efforts have resulted in a higher proportion of spending and enrollment going toward HCBS. In 2005, Minnesota spent 56% of long term care funding on HCBS, and by 2009 the percentage increased to 60%. In addition, between 2000 and 2004, enrollment for nursing facilities decreased by approximately 15% and the Elderly Waiver enrollment increased by approximately 65%.
Washington Most of Washington's rebalancing efforts began in the late 1990s. By 2000, the HCBS programs were already serving approximately 30% more than the nursing homes. The state created a consolidated management structure, essentially combining policy, implementation and budget control, into one agency. Due to this structural change, the ADSA has full control over long term care spending. Funds can be taken directly from nursing home spending and redirected to HCBS programs. Washington has also taken steps to facilitate rapid access to HCBS programs. The implementation of the Comprehensive Assessment Reporting Evaluation (CARE), a paperless assessment system, is credited with improving the delivery and management of long term care services statewide. In addition, care managers may "presume" a client's Medicaid eligibility and provide a 90 day service plan while Medicaid eligibility is being determined. Applications for HCBS programs may be taken over the phone from clients in the community or in hospitals. The eligibility process has decreased from an average of 37 days to 17 days. The HCBS waiver program does not have a waiting list; therefore, clients can receive services as soon as they are presumed eligible. In 1995, Washington assigned case managers to nursing homes in order to identify residents that could receive care in home and community settings. Case managers contact all nursing home residents who have been admitted from a hospital within seven days of their admission. As a result of all efforts in the previous decade, the Medicaid nursing home caseload decreased through 2004, and the HCBS enrollment slightly increased.
Despite the increase in waiver spending, demand for HCBS is not being met and a new limit on waiver enrollment will likely further impact service availability. The growth in waiver expenditures was driven by a rapid increase in SOURCE clients since 2007; however, in 2012, DCH implemented an enrollment cap for SOURCE, creating a mechanism for the program's first waiting list.3 CCSP already had a waiting list of more than 1,000 in April 2012. While enrollment is limited, demand for HCBS is expected to grow.4 In 2005, Georgia had the eighth highest aging population growth rate in the country, result of an aging baby boomer population and the "in-migration" of elderly people to Georgia. In 2009, 10% of Georgia's population was 65 and older; the percentage is projected to increase to 16% by 2030.

To address the projected growth in the elderly population and associated long term care costs to the state, Georgia should have clearly outlined measures and goals that allow for a comprehensive assessment of current programs and strategies, regardless of the entity administering them. However, our review of several documents found the each lacked information necessary for an accurate assessment. Each document contained important information on particular programs or plans, but no document provided the necessary context to assess the degree that the state's programs, as a whole, were impacting long term care spending for the elderly and disabled.

3 As of April, no individuals were on the SOURCE waiting list. However, SOURCE providers were informed that the program would only admit the number of clients that leave the program in a month, which has apparently led providers to self-regulate the submission of applications.
4 Unlike HCBS, demand for long term nursing home beds is not growing. From 2001 to 2010, available nursing home beds increased less than 5% and occupancy rates dropped 4%. Also, DCH's Healthcare Facility Regulation Division has predicted a net surplus of more than 1,300 beds in 2014.

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State Plan on Aging DAS publishes a four-year plan that is required by the federal Older Americans Act of 1965. As stated in the plan, it "provides leadership and guidance in rebalancing the long-term care system and development of a comprehensive and coordinated infrastructure for home and community based services." The plan details goals and objectives related to numerous programs and initiatives; however, it is limited to those activities under DAS's purview. It does not include information on SOURCE, which serves two-thirds of all waiver participants, nor does it include information on nursing home utilization and spending.

CCSP Annual Report DAS is required by O.C.G.A. 49-6-62(g) to publish an annual report on the activities of CCSP. Because O.C.G.A. 49-6-60 et seq. was passed in 1982 as the General Assembly's authorization for communitybased services for the elderly, the annual report was expected to cover all services for the population. However, since most waiver participants are now SOURCE clients, this annual report includes the activities for a minority of waiver clients. Additionally, the report does not provide details on nursing home utilization. (It should be noted that the law authorizing CCSP includes only the elderly; the program also serves the physically disabled.)

Olmstead Plan Georgia's Olmstead Plan includes many actions intended to provide disabled populations and the elderly with the option to receive care in the community instead of an institution. However, the Plan covers numerous populations, most notably those with mental health issues and developmental disabilities, and its goals do not specifically track the success of rebalancing spending to the community for elderly and/or physically disabled populations covered by CCSP and SOURCE.

The fact that no single source of information about the effectiveness of state efforts is readily available is partly a result of no agency having the clear responsibility for the populations. O.C.G.A. 49-6-62 made DAS responsible for creating a community system for elderly care and annually reporting progress to the General Assembly. However, DCH's SOURCE program provides services to most waiver clients, and DCH possesses the information on nursing home utilization that would assist in determining the effectiveness of community programs.

Without a clear measure of where the state is and where it desires to be, decisionmakers are less able to determine whether programs and initiatives are successful in allowing the E&D population to remain in the community. In addition, a recently adopted limit to waiver enrollment makes measurable goals more essential to ensure that the state's progress in redirecting E&D individuals and funding to HCBS is not reversed.

RECOMMENDATIONS 1. DCH and DAS should work together to determine measures and goals for the
E&D population. Specifically, the measures should include total spending on HCBS and nursing homes, annual spending per HCBS client and nursing home bed, and total clients served by HCBS programs and by nursing homes.

2. The General Assembly should consider revising O.C.G.A. 49-6-60 et seq. to recognize the inclusion of the physically disabled in CCSP. It should also require

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that that the annual report include performance information on the entire waiver (CCSP and SOURCE) and comparable information for nursing homes.

DHS Response: DHS stated that it is in agreement with the report's content, findings, and recommendations.

DCH Response: DCH noted that it has "sought technical assistance in redefining the performance measures required for waiver approval and is currently in the process of weekly technical assistance with CMS to more clearly define quality measures. These performance measurements will help provide more clearly defined outcomes for participants in the program. Also, as you note in the audit, the Money Follows the Person Program tracks annual progress toward the rebalancing initiatives which serves as a tangible measure of the success of the programs."

Limited awareness and availability of Georgia's HCBS options results in greater use of nursing homes for long term care.
Nursing homes are currently the most recognized and accessible form of long term care. The elderly and disabled populations, as well as their healthcare providers, are less familiar with HCBS options, and those options are often not readily accessible when a need arises. With limited awareness and availability of HCBS, individuals are less likely to remain in their homes as long as possible, resulting in earlier than necessary nursing home admissions and an inefficient use of long term care funds.

With long HCBS waiting lists and reliance on nursing homes to conduct Medicaid preadmission screening of people already in their facilities, it is a struggle for consumers to find alternatives.
- AARP Case Study of Georgia's LTSS

Awareness Awareness of community based options is vital to diverting individuals from unnecessary nursing home admissions; however, there is some evidence to indicate that neither citizens nor healthcare providers are fully informed of these alternatives to institutional care.
Nursing homes have existed as an integral part of the healthcare continuum for many years and are undoubtedly a recognized long term care solution for individuals and the healthcare providers who make recommendations to individuals in need and their families. By contrast, HCBS are a much newer option, may be harder to understand due to their delivery through a myriad of programs, and are generally less available. These factors can lead to individuals to be either less aware of the existence of HCBS or less aware of how HCBS can serve their needs.
While recent studies of individuals' awareness have not been conducted, a number of other factors point to lower awareness of HCBS. In a 2007 report, the Georgia Health Policy Center noted that just 12% of Georgia citizens were aware of the services offered by the statewide aging network. Additionally, a recent AARP analysis of Georgia's long term care system noted that two-thirds of new Medicaid recipients of LTC services first receive those services in institutions rather than in the community. Finally, recognizing a deficiency in the nation's long term care system, awareness and visibility of all long term options was one of three core functions of the ADRC program when it was created in 2003.

Knowledge of HCBS options on the part of healthcare workers also impacts utilization. Because a majority of nursing home admissions come from hospitals, it is important to ensure that hospital discharge staff is well-informed about HCBS

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options. During our site visits, AAA staff expressed frustration with previous efforts to engage and inform hospital staff and noted that there was a need for better relationships with area hospitals.

Increasing HCBS awareness is the goal of several current efforts of DAS, DCH, and those entities under contract. The creation of ADRCs, the development of public service announcements in conjunction with Georgia Public Broadcasting, a statewide toll-free phone number for ADRCs, and plans for a web-based resource are all intended to improve individuals' education of long term care options. Locally, AAAs and/or SOURCE providers participate in health fairs and visits to senior centers, churches, and civic events, and some have formal marketing plans and dedicated marketing staff. Regarding hospitals, several AAAs noted that penalties tied to high readmission rates required by the Affordable Care Act have encouraged hospitals to work with community care providers to ensure successful transitions from hospitals. Finally, with the implementation of Section Q of the federally required Minimum Data Set questionnaire, all nursing home residents are now asked at regular intervals if they would like to speak with someone about the possibility of returning to the community. If a transition is desired, an assessment of its feasibility is conducted and the resident is provided with options counseling by personnel with the nearest ADRC. This requirement was implemented in October 2010.5

While all of these actions improve the awareness of HCBS options, we noted several opportunities for improvement.

AAAs indicated varying levels of contact with healthcare providers in their region, and we found no evidence that either DAS or DCH has established relationships with professional healthcare associations, such as the Georgia Hospital Association, for the purpose of promoting HCBS.

Data suggests that nursing homes may not yet be fully compliant with the MDS-Q questionnaire requirement. Between July 2011 and January 2012, 112 of 360 Medicaid licensed nursing homes made no referrals; 163 made five or fewer. It is possible that no residents of these nursing homes have expressed an interest in returning to the community or that a return is not feasible for any interested clients. Nursing home personnel decide if the transition is feasible.

Georgia does not have an effective method of ensuring individuals are aware of community options before nursing home admission. While state regulations require nursing homes to provide clients with information about HCBS waiver programs upon admission, the timing may not be optimal because 1) the client or family has generally made the admission decision by that point, and 2) the document is one of many that is received and acknowledged upon admission.
A recent review by AARP noted that Georgia misses an opportunity to discuss community care options because preadmission nursing home eligibility screenings are conducted by nursing home personnel. While nursing homes have a primary responsibility of providing healthcare, ADRCs were specifically created to provide information and referral services to the

5 Implementation requirements have been refined periodically since that date.

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elderly and disabled. In states that require ADRCs to conduct nursing home admission screenings, the ADRC staff can ensure that individuals are aware of HCBS options. Without this opportunity, it makes other forms of outreach to individuals and healthcare providers even more vital.

Availability and Timeliness Improved awareness will only increase HCBS utilization for the elderly and disabled if the state has the capacity to serve those in need of community-based services and can provide the services in a timely manner when needs are urgent. However, current demand for waiver services exceeds availability and the assessment and admission process for CCSP and SOURCE is lengthy. By comparison, nursing homes often have the capacity and the ability to address needs immediately.

Although not every nursing home has available beds, there are available nursing home beds in every region of the state, and nursing homes can generally handle admissions quickly when a sudden need arises. As of September 2011, Georgia nursing homes had an average occupancy rate of 79% across the state, indicating that 21% of beds were available. Regional variations exist, with occupancy rates generally lower in the eastern central part of the state and highest in the northeast. According to DCH and DAS personnel, nursing homes with an available bed can frequently accept an individual for admission within a day of first contact.

HCBS are less available. After several years of growth, waiver capacity has been limited to current levels. In January 2012, approximately 1,300 individuals deemed eligible for a nursing home level of care were on a waiting list for CCSP services. In the same month, DCH instituted a cap on net admissions to maintain SOURCE capacity at current levels. Clients, who are prioritized for services based on their need, spent an average of eight months on the CCSP waiting list. Since the admission cap was instituted, SOURCE is using the same need determination tool to rank the severity of client needs.

Even if an individual is not placed on a waiting list, it may take several weeks before services can begin, which can be a problem if there has been a sudden change in the potential client's needs or a caregiver's availability. In urgent situations, the assessment process for the waiver programs can limit their usefulness to those in need. Determining client eligibility, evaluating a client's needs, developing a personalized care plan, and brokering services with providers require staff with clinical expertise and can take a month to six weeks. As a result, the programs cannot adequately address urgent needs of new clients6.

While these assessments ensure that all waiver participants meet a nursing home level of care, other states have found methods to quickly deliver HCBS and ensure clients are eligible for approved services. Pennsylvania has a program in several counties designed to deliver services in as few as three days, while an Oregon aging official said that services can be provided within a day. In addition to having the capacity for clients, these programs admit clients more rapidly by presuming a client's eligibility based on the limited information obtained during the screening process or by facilitating "fast track" eligibility processing. Research conducted in those states has found the risk of error during this process to be low. We found that

6 Once a client is in service with CCSP or SOURCE, timely adjustments can be made as client needs change.

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in 2011, of more than 3,500 individuals on Georgia's CCSP waiting list that were referred for full assessment, fewer than 35 were found to be ineligible.7

In order for the elderly and disabled to remain in the community for as long as possible, it is necessary for them and their caregivers to be aware of the communitybased options as early as possible and for those options to be available in a timely manner when needed. When factors other than health needs result in nursing home admissions for the elderly and disabled, long term care funding has not been used in the most efficient or effective manner.

RECOMMENDATIONS 1. DAS should continue current and planned outreach efforts to individuals and
direct additional efforts to healthcare providers, possibly through professional organizations.

2. DAS should encourage AAAs to share with each other their successful outreach efforts to individuals and healthcare providers.

3. DAS and DCH should continue to analyze the MDS-Q referrals and identify any nursing homes whose number of referrals appears to be unexpectedly low. The agencies should determine what corrective actions are necessary if a nursing home has not complied with reporting and referral requirements.

4. DCH and DAS should determine whether an option to provide services more quickly would be cost effective. It would be necessary to determine how frequently nursing home admissions could be avoided because the admission is due to a situation (e.g., loss of a caregiver) that requires quick service delivery. The agencies would also need to determine if the policy would require reserving waiver slots.

5. DCH should consider requiring options counseling earlier in a nursing home stay. It should also consider the costs and benefits of shifting preadmission screening to ADRC or waiver staff to ensure unbiased assessment.

DHS Response: DHS stated that it is in agreement with the report's content, findings, and recommendations.

DCH Response: DCH stated that the Balancing Incentive Project, which is scheduled to begin on July 1, 2012, "charts a course for Georgia to reach the attainable goal that HCBS comprise 50% of the long term care expenditures by 2015 and requires mechanisms for outreach and enhancing accessibility to services. Within the first year of the project, BIP will develop a no wrong door approach to entry into HCBS services with information sharing across agencies."

DCH also noted that, "Medicaid Redesign analysis has resulted in the consideration of all options in effort to provide incentives for timely admission to HCBS programs in an effort to avert nursing home placement."

7 Approximately 1,200 individuals were removed from the CCSP waiting list for non-eligibility reasons. These included the agency being unable to contact the individual, the individual being deceased, the individual receiving services through SOURCE or in a nursing home, and other reasons.

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The current practice of operating two programs within Georgia's Elderly and Disabled Medicaid waiver impedes the state's ability to direct the appropriate services to those most in need and introduces operational and management inefficiencies.
Even though waiver spending has grown 25% over the past four years, the growth has not been managed to ensure that services are directed to those most in need or most at risk for nursing home placement. The current structure of two separate programs, managed by different state agencies, does not allow services to be prioritized for the entire population in need of services nor does it promote the state's ability to manage limited resources.

CCSP and SOURCE are E&D waiver programs with several key similarities and one fundamental difference. The two programs serve E&D individuals who qualify for a nursing home level of care but prefer to stay at home. The two programs provide the same menu of services, such as personal support and home delivered meals. And the two programs use the same Medicaid providers of community services, though SOURCE uses a subset of providers. The primary difference between the programs is SOURCE's enhanced case management, in which a network primary care physician and a SOURCE medical director are involved in the coordination of the client's care.

The duplication in program characteristics results from SOURCE's origin as a demonstration project intended to address problems some practitioners observed in CCSP. SOURCE added the enhanced case management component to the community based services already offered through the waiver. Georgia added enhanced case management to the list of waiver services in 2007. Since that time, SOURCE has continued to operate as a program separate from CCSP.

While the type of case management is the only difference in the services provided to clients, the two programs have differences in their organization and operation that impact the effectiveness of the waiver. The two programs are operated by different state agencies DHS and DCH. DHS's Division of Aging uses the AAA infrastructure to contract with a care coordinator in each region, while DCH has approved 12 case management providers for SOURCE across the state.8 And the programs' points of entry have different responsibilities when screening applicants for services. As discussed below, these differences in program operations limit the options available to individual waiver participants and impede the state's ability to ensure the best use of limited resources.

Services not prioritized over entire waiver population With limited resources for waiver services, the state must ensure that home and community based services go to those most in need and most at risk for nursing home placement. However, CCSP has maintained a waiting list for years, while SOURCE has provided services to all of its clients. The different treatment of the two programs' clients is not due to SOURCE clients' greater need of services or risks of nursing home placement. Since the two programs have the same functional requirement of a nursing home level of care, the existence of the CCSP waiting list means that CCSP applicants have not received the same access to services, even if they have greater need or risk of placement.

8 There are three entities that provide both CCSP care coordination and SOURCE case management.

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In January 2012, DCH began requiring case management entities to rank applicants by need in order to facilitate a SOURCE waiting list if required. However, placement decisions will be made separately for the two programs, meaning that clients with fewer needs in one program could receive services before higher need clients in the other program. On April 2, 2012, the average needs score9 of potential clients on the waitlist to services for CCSP was 36, while anyone with a score of 15 or greater was offered SOURCE services immediately. There were more than 1,000 individuals on the CCSP waitlist with scores over 15.

Enhanced case management not provided to clients based on need Enhanced case management comprises 10% of total waiver costs, but there is no assurance that this service is always necessary or goes to those most in need. Those knowledgeable of both programs reported that the service provides the most benefit to a particular type of client, such as those with poor compliance with physician recommendations or those with inadequate family support. Instead of basing the provision of service on a client's identified needs, enhanced case management is currently provided automatically to all SOURCE participants and is not available to any CCSP participants.

Program options limited by point of entry Individuals are less likely to be informed of all available program options if they are contacted by or call a SOURCE case management provider for long term care information. ADRCs are designed to be the primary point of entry for E&D individuals needing information on various services. By design, ADRCs screen callers to assess their needs and resources and then inform them of all services for which they are eligible. The ADRCs provide information on services offered through all providers, including the AAA and SOURCE providers, if applicable. By contrast, SOURCE providers are not information and referral agencies. Individuals whose initial contact is with a SOURCE case management provider directly are screened for that company's services only10. According to DCH staff, if the client is ineligible or uninterested in the program, SOURCE case management is under no obligation to share information about alternative programs.

Inefficiencies exist in managing two programs By operating separate programs, the state is creating a dual infrastructure that does not take advantage of management systems already in place. DCH has begun changing SOURCE policies to address issues such as determination of need scoring and waiting list management, requiring the development of policies, training, and information systems that already exist for the CCSP program. However, two programs result in two sets of program policies and forms, two program integrity auditors, and two program directors.

9 Using client answers to a standardized set of questions, screeners assign clients a score. The score indicates a client's level of risk for entering a nursing home by evaluating their ability to meet their daily needs (dressing, feeding, bathing, etc.). The minimum score for admission to CCSP or SOURCE is 15.
10 Three of 12 SOURCE providers are also care coordination providers for the CCSP program, and therefore, would be more knowledgeable of an alternative program.

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The existence of two programs segregates useful systems and management information. Available to ADRC, AAA, and CCSP care coordination staff, DAS's AIMS system allows information about a client's contact with the ADRC, referrals, and services to be recorded in a single system. Regional and state staff can generate reports containing aggregate information about service costs, performance, and utilization, as well as reports on individual clients. On the other hand, the SOURCE program has no state-level office with a shared database to manage service provider performance. Each of the 12 SOURCE entities tracks clients differently, and the information is not available to the state. Instead, the state receives a report from the Georgia Health Care Association11 that contains only the number and type of admissions and discharges for each provider.

Finally, the existence of separate programs impacts providers that serve both SOURCE and CCSP clients. Despite similarities in programs, enough differences exist in the program management that those entities that provide both SOURCE case management and CCSP care coordination operate with separate staff and systems.

Limited ability to evaluate performance of waivered services State officials cannot measure utilization, costs, or client outcomes across the waiver population. Because there is no shared database, client-level management data is not available for the two-thirds of waiver participants served by the SOURCE program. In contrast, state and local users of the DAS AIMS program have access to dozens of management reports for CCSP and non-Medicaid HCBS. For example, users can generate reports to monitor compliance with promptness standards such as timeliness of assessments; obtain lists of clients due for rescreening; look at outcomes of screening and numbers on waitlists; get a snapshot of clients being served by age, gender and other demographics; review spending statewide or by service type, region or county; obtain lists of clients with costs over any spending threshold; or review deaths and incident reports.

Access to Medicaid data is problematic for both programs, and the state's Medicaid management information system (MMIS) has not been optimized for use with this population. DAS has limited access to data from the MMIS. Further, limitations in the provider data tracked by MMIS means that DCH cannot compare utilization patterns among different offices of the same SOURCE case management provider, or between CCSP and SOURCE providers in a particular region.

Finally, although CCSP and SOURCE are operated as separate waiver programs, this structure is not apparent in the E&D waiver, which is the state's contract with CMS about how Medicaid funds will be spent on HCBS. The waiver describes enhanced case management as part of the continuum of services offered under the waiver, which would be a more appropriate use of this resource. The waiver is up for renewal in October 2012 and representatives from both CCSP and SOURCE are working on revisions for the renewal application.

11 GHCA is under contract with the SOURCE providers for this and other services.

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RECOMMENDATIONS 1. DCH and DAS should consider combining SOURCE and CCSP into a single
program with a single agency responsible for day-to-day management. Currently, O.C.G.A. 49-6-62 recognizes DAS as the entity responsible for community services for the elderly, and the waiver states that DAS is responsible for day-today management of the waiver.

2. DCH and DAS should design the program to include enhanced case management for those who exhibit a need for the service.

3. DCH and DAS should develop a common intake and assessment process so that needs of all waiver participants are prioritized.

4. DCH and DAS should ensure that information systems allow management to assess the performance of the sites responsible for managing care.

DHS Response: DHS stated that it is in agreement with the report's content, findings, and recommendations.

DCH Response: DCH stated that it "sees opportunities in the recommendations related to administrative streamlining in order to avoid a duplication of activities...The waiver renewal work group meetings have brought the stakeholders from the two programs together to analyze best practices across each program and begin to incorporate those practices across programs. As the audit points out, efforts are underway to combine processes in all possible tasks in order to create greater efficiency."

DCH also added that it agrees "that varying levels of case management are not utilized as effectively as they should be for all waiver participants. Through the upcoming waiver renewal, that will be addressed through offering enhanced primary care case management to both program populations and efforts are underway now to define eligibility for enhanced case management versus traditional case management based on participant need versus program type."

While Georgia's cost sharing requirements impact lower income clients more than those of most other states, the cost effectiveness of the policy cannot be evaluated with current data. Modifying the policy to shield all income below the federal poverty level will raise Medicaid costs by approximately $5.8 million or reduce the number of clients served.
Georgia has cost sharing requirements that are less generous to clients than those in many other states, and officials are considering raising the threshold at which cost sharing is required. Due to inadequate data, we were unable to determine if the current policy is leading potential clients to refuse services and ultimately require earlier nursing home admission. We did determine that raising the cost share threshold to the federal poverty level in fiscal year 2011 would have cost approximately $5.8 million.
Many Medicaid waiver programs include a cost sharing requirement for higherincome clients. For the E&D Waiver, DFCS determines the cost share amount based on the client's income and marital status. The waiver requires that clients contribute

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any income over the SSI12 level to the cost of services. The client pays the service provider and the designated cost share is deducted from the Medicaid payment to the provider. Since waiver eligibility is limited to a monthly income of less than three times SSI, cost share applies to clients who receive between $675 and $2,021 per month. While 65% of CCSP clients are in this category, the state's Community Spouse Maintenance Allowance policy, which allows clients with a spouse not receiving waiver services to protect a portion of family income, reduces the number of clients subject to cost sharing. In March 2011, 12% of waiver clients were required to contribute to the cost of their services. This represented 38% of CCSP clients.13

As shown in Exhibit 6, a majority of CCSP clients who paid cost share had an income between SSI and the federal poverty level (FPL). An individual with income at FPL would be responsible for paying the first $234 of HCBS. The average contribution is $103. More than one-third of those subject to cost share are in the next category ($909-$1,348).

Exhibit 6 Income of CCSP Clients Subject to Cost Sharing March 2011

Monthly Income Amounts $675 $908 (SSI to FPL)

Range of Monthly Client Contributions
$1 $234

Average Monthly Client Contribution
$103

$909 $1,348 (FPL to 2x SSI)
$1,349 $1,816 (2x SSI to 2x FPL)

$235 $674 $675 $1,142

$343 $668

$1,817 $2,022 (2x FPL to 3x SSI)

$1,143 $1,348

$808

Number of Clients
2,029
1,209
225
25

Totals

$228

3,488

SSI = Supplementary Security Income FPL = Federal Poverty Level Source: DAS AIMS report, March 2011; we determined that CCSP spending does not vary significantly from month to month.

Comparison to Other States Georgia's cost share threshold for E&D clients is lower than most other states. According to a 2010 report by the AARP, Georgia was one of 13 states that required cost sharing by individuals at or below the federal poverty level. Georgia was one of five of those states that had set the cost share threshold at the SSI level or lower.

While Georgia subjects clients under FPL to cost sharing, Georgia has policies that protect a higher level of spousal income than many other states. In 2010, Georgia and 35 states allowed the spouse of an HCBS client a monthly income of $2,739. No states permitted a higher spousal income and the income limit matches that applied to spouses of nursing home clients.

12 Supplementary Security Income (SSI) may be paid to disabled adults and those over 65 with limited income. In 2011, the SSI monthly payment was $674.
13 All SOURCE clients are SSI recipients with income levels that do not exceed the cost share threshold.

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Impact of Current Policy DCH, DAS, and AAA officials indicated that the current cost share policy has become an increasing burden for existing and potential CCSP clients in recent years. They stated that potential clients with incomes below the federal poverty level often do not have the flexibility in their budget to assume such a new expenditure. In addition, they stated that the cost share burden has increased due to inflation and the higher unemployment rates affecting the ability of a client's family members to provide financial assistance.

CCSP data indicates a significant number of individuals refusing services due to cost share. The refusal can occur at several points in the process; from initial screening for waiver services to after services have been received. Of 7,206 individuals screened for CCSP in fiscal year 2011, 370 refused CCSP services due to the cost share requirement. Another 58 refused due to cost share when they were referred for a full assessment, 65 refused after the assessment was completed, and 45 already receiving services left the program due to cost share. The number refusing due to cost share may be even higher. At screening and just before the full assessment, more than 660 individuals withdrew applications without providing a specific reason.

While the cost share policy does offset HCBS costs to the Medicaid program, the policy could be counterproductive if, as a result, a significant number of individuals who refuse to participate ultimately require earlier Medicaid nursing home admissions. We were unable to confirm this possibility due to the quality of information on those who refused CCSP services, limiting the ability to match these individuals with Medicaid nursing home admissions. Those who refuse CCSP services would not have Medicaid IDs and may not even qualify for Medicaid, in which case they would not be present in Medicaid nursing home admission data.

It should be noted that the existence of the CCSP waiting list lessens any negative financial impact of refusers on the Medicaid program. When an individual refuses to participate in CCSP, another individual, who also meets a nursing home level of care, is able to participate. The state is still serving the maximum number of individuals in CCSP.

Impact of Policy Change DAS is considering the elimination of the cost sharing requirement for anyone with an income below the federal poverty level (pending approval by DCH and CMS). The federal poverty level (FPL), which is set annually by the US Department of Health and Human Services, is used as an eligibility measure for several federal benefits including the Supplemental Nutrition Assistance Program. DAS officials did not have a cost estimate for the policy change. Below we have included our analysis of the financial impact of raising the cost share threshold.

Raise income limit to FPL ($908/month) As shown in Exhibit 7, CCSP clients had a cost share of approximately $794,000 in March 2011. If income below FPL was no longer subject to cost share, clients' contributions would drop to approximately $308,000. This change would eliminate the entire cost share for clients below the federal poverty level and reduce the maximum client contribution for all others by $234 per month. The state/Medicaid contribution would increase by $486,000 for one month, or $5.8 million annually. If CCSP funding remained the same, the program would be able to serve 580 fewer people a year.

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Exhibit 7 CCSP Client Cost Share by Income Category March 2011

Current Cost Share Paid

Proposed Cost Share Paid

$900,000

$800,000

$700,000

$600,000

$500,000

$400,000

$300,000 $200,000

$208,288

$100,000 $0

$0 $0
SSI 3,199 Clients

$0
SSI - FPL 2,029 Clients

SSI = Supplementary Security Income FPL = Federal Poverty Level

Source: Analysis of AIMS data

$793,733

$414,902

$308,100

$175,783

$150,336 $113,637

$20,207 $18,680

FPL - 2x SSI 1,209 Clients

2x SSI - 2x FPL 2x FPL - 3x SSI

225 Clients

25 Clients

Total 6,687 Clients

Eliminate cost share If the cost share requirement was changed to match other Medicaid waivers (3x SSI), cost share would essentially be eliminated because Medicaid recipients generally must have income below this amount. Completely eliminating the cost share for all clients would increase the state's/Medicaid's costs by nearly $800,000 per month and $9.6 million annually. The program would be able to serve an estimated 950 fewer people without additional revenue.

RECOMMENDATIONS 1. DAS and DCH should consider the impact of raising the cost share threshold on
the waiting list. If the agencies are willing to pursue additional funding to offset the policy change, they should first consider whether the same level of funds would be better used to expand access to currently limited or unavailable services (e.g., additional CCSP slots, home modifications).

2. DAS should emphasize to ADRCs the importance of capturing the reason that individuals refuse CCSP services to address the significant number of potential clients broadly categorized as "chose to withdraw application."

DHS Response: DHS stated that it is in agreement with the report's content, findings, and recommendations.

DCH Response: DCH stated that "CCSP cost share as an impediment to program admission" is a "known issue to DCH." The agency also noted that there are fiscal concerns with the recommendation though DCH is supportive of a change and will continue to analyze the issue.

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DOAA Response: Our recommendation takes no position on changing the current cost share policy. As noted in the finding, with the waiting list currently in place, the impact of the policy on the state is unclear. However, we do recommend that DAS and DCH consider the implications of a policy change.

Georgia provides a typical menu of services within the Elderly and Disabled Waiver programs. However, the need for home modifications and improved transportation services were identified as deficiencies in the state's HCBS system.
The services covered by Medicaid waivers may vary depending on what is offered in each state's basic Medicaid program and what may be funded via other sources. When considering all funding streams for HCBS, Georgia provides similar types of services available in other states, though we could draw no conclusions about the adequacy or depth of services within a particular category. However, local HCBS representatives and/or surveys identified home modifications and more reliable transportation as services needed to improve or ensure access to HCBS.
Comparing services provided across states presents several difficulties. States have a variety of funding streams available to provide HCBS to the elderly and physically disabled. In addition to Medicaid waivers, states may provide services through the State Medicaid Plan, CMS grant-funded programs, Older Americans Act-funded programs, and state-funded programs. Therefore, comparing only waiver services could misrepresent the availability of services within a state. Furthermore, states may provide the same general type of service but the actual service delivered could vary significantly. For example, two states could provide very different levels of assistance with household chores or provide case management in very different ways. In Georgia, even CCSP and SOURCE, which operate under the same waiver, provide different types of case management.
While precise comparisons are difficult, a 2010 report by National Academy on an Aging Society showed that Georgia provided some level of service in each of the categories used by researchers. Within the E&D Waiver, Georgia provided the services most common in other states, such as case management, respite care, assistance with homemaking/chores, and home health services.
Although waivered services are not required to be offered statewide, DCH and DAS make an effort to ensure the same services are available in every service region. However, we mapped the distribution of services across the state and found that areas outside of metro Atlanta have fewer provider choices for most services. This pattern is also demonstrated with NMHCBS, where waiting lists can be extensive for certain services and provider availability is limited.
There are additional critical services outside of traditional, ongoing HCBS that can influence a person's ability to remain at home. HCBS staff in six of the nine AAAs contacted identified home modification services as a critical need for HCBS clients, while five of six AAAs we visited identified transportation services as critical to an individual's success in HCBS. Surveys of Georgia residents planning for retirement also identify transportation as a primary anticipated concern.

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Home modifications Home modifications are changes made to a home that allow a resident to continue to live independently. Modifications can be relatively simple and inexpensive, such as changing a door knob to a lever or adding supporting railing in a bathroom, or they may more expensive or complex, such as installing a wheelchair ramp or widening doorways. Unlike most HCBS, a home modification is a one-time expenditure instead of an ongoing service cost.

Studies have shown that home modifications are effective at allowing people to remain in their homes by improving home safety, facilitating caregiving, and reducing the amount of care assistance required. Home modifications also result in a long-term reduction in costs because a client can defer nursing home admission and perform more tasks independently or with less assistance. For example, a client may be able to bathe himself or need less assistance after a bathtub modification.

HCBS staff in six of the nine AAAs contacted identified home modification services as a critical need for clients. Additionally, we found that three of the four "best-practices" states we interviewed offer home modifications under their Medicaid waivers. An official in another state described these services as vital to a client's ability to receive care in the home.

Although the state does not provide home modifications as a waiver service, some AAAs use a limited amount of non-Medicaid HCBS funds for the service and MFP pays for home modifications for those transitioning from institutional care. The six AAAs that identified home modifications as a critical need reported spending $151,000 on 151 clients (average of $1,000) in fiscal year 2011. However, three reported a waiting list for home modifications and three stated that due to limited funds, the service was not provided on a regular basis. The home modification need was also identified by SOURCE providers. One statewide provider reported using fund-raising efforts among employees to fund home modifications for SOURCE clients. It should be noted that, in some locations, home modifications may be available from non-profit organizations unaffiliated with the AAAs. Through the ADRC service database, AAAs can refer clients in need of home modifications to non-profits.

Transportation Services In both the previous and current state plans on aging,14 when Georgians 50 and over were asked what services they will need to stay in the home, transportation was listed more frequently than any other need, including those offered by HCBS programs (e.g., caregiver respite and home delivered meals). Results for the most recent survey are shown in Exhibit 8. The Georgia Council on Aging also identified transportation as a legislative priority for the 2012 legislative session because it was "one of the most frequently requested and most necessary services for older adults."

14 The Division of Aging Services creates a 4-year plan for the federal Administration on Aging. The most recent plan was recently released and covers federal fiscal years 2012-2015.

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Exhibit 8 Services Georgians Expect to Need to Remain at Home as They Age

Service Transportation Caregiver/ Respite Meal Delivery/ Food Assistance with ADL

Percentage 47% 27% 27% 25%

Financial Assistance

23%

Homemaker Services Health Care Prescription Drug Assistance Nutrition/Exercise Assistance

22% 21% 15% 13%

Source: Georgia State Plan on Aging, FFY2012-15

Individuals remaining in their homes or in community placements need access to transportation services for doctor visits and other errands in order to be able to stay at home. DCH contracts non-emergency transportation services for Medicaid recipients in Georgia; this transportation is meant to address the needs of all Medicaid clients, but may not be appropriate for the E&D populations. A number of local representatives we talked with expressed dissatisfaction with the services provided to the E&D populations. For example, local staff reported clients being picked up several hours before or after an appointment, having to remain on a bus for several hours and not being provided opportunities to eat, take medicines or use a restroom. DHS provides transportation for nonMedicaid clients as well. However, there still seems to be a gap in options for clients, especially those in rural areas of the state. Evaluating the effectiveness of transportation programs was not within the scope of this audit.

RECOMMENDATIONS 1. DAS and DCH should centralize and standardize data collection processes
regarding the need for home modification so demand can be quantified. The agencies should also identify best practices within AAA regions and SOURCE providers to determine how these needs are currently met.
2. DAS and DCH should consider the costs and benefits of adding home modifications to the waiver. If implemented, modifications could be limited to those below a certain cost and could require the use of transferable/reusable items, such as ramps, when possible.
3. DCH and DHS should seek to determine and address the causes of client and caregiver dissatisfaction with current transportation services.

DHS Response: DHS stated that it is in agreement with the report's content, findings, and recommendations.

DCH Response: DCH stated that the recommendation for additional services such as home modifications is a "known issue to DCH." The agency also noted that there are fiscal concerns with the recommendation though DCH is supportive of a change and will continue to analyze the issue.

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Appendix A
Objectives, Scope, and Methodology

Objectives This performance audit of the state's use of HCBS for the elderly and disabled within the Georgia Departments of Community Health (DCH) and Human Services (DHS) was selected based on an internal risk assessment, which determined that the state's provision of services in the least restrictive environment is a timely and relevant audit topic. The primary objectives of this audit were to:
1) identify the benefits of home and community based services for this population;
2) determine whether the state has maximized use of HCBS; 3) identify barriers to greater use; and 4) determine if current HCBS structure ensures efficient delivery of services.
Scope The performance audit of HCBS primarily focused on the Elderly and Disabled Waiver programs (CCSP and SOURCE). Our work covered fiscal years 2010 through 2012 with consideration of earlier periods when relevant. Our review did not include comprehensive operational reviews of each program, but operations were evaluated as relevant to audit objectives. Home and community based services for other populations, such as the developmentally disabled, were outside the scope of this audit.
Information used in this report was obtained by reviewing relevant laws, rules, and regulations; interviewing officials from DCH, DHS, Area Agencies on Aging, CCSP Case Coordination organizations, SOURCE providers, state and local long term care ombudsmen, and other states' Medicaid or Aging agencies; reviewing documents such as the State Plan on Aging, the CCSP Annual Report, the state Olmstead Plan, the state's Elderly and Disabled Waiver, accounting records, and various CCSP and SOURCE programmatic reports; and reviewing studies of Georgia's and other states' HCBS programs conducted by various groups, such as the Kaiser Family Foundation, the Benjamin Rose Institute, and the AARP.
Government auditing standards require that we also report the scope of our work on internal control that is significant within the context of the audit objectives. The scope of our review of internal controls was limited. As part of objectives 2 and 3, we reviewed reports used by agency management or other state leaders when assessing the performance of the programs or program providers.
Methodology To identify the benefits of home and community based services for the elderly and physically disabled populations, we reviewed industry documents and research on the effectiveness of HCBS and reviewed available evidence about public opinion on the subject. We compared Georgia's spending for to that of other states and reviewed performance measures tracked by DCH and DHS, as well as national organizations.
To determine whether the state has maximized use of HCBS, we obtained and compared spending for each program from 2008-2011 and compared to Medicaid expenditures for nursing home stays within the same periods. We compared

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spending patterns and utilization data with that of other states and investigated other state's efforts to encourage use of HCBS. We reviewed activity data and waitlist statistics and interviewed local program staff and LTC advocates.

To identify barriers to greater use, we reviewed current literature and best practices, reviewed previous audits of Georgia's programs and those of other states, and reviewed current program and nursing home policies and procedures. We interviewed staff within DCH and DHS, and visited employees of six AAAs, their CCSP Care Coordination entities, and a sample of SOURCE case management providers. During these site visits we also talked with local Long Term Care Ombudsmen. We interviewed budget staff within DCH and DAS, spoke with analysts within the Senate and House budget offices, and reviewed multiple years of budget documents. We compared Georgia's menu of services with those from other states, and reviewed multi-state comparisons of HCBS performance.

To determine if current HCBS structure ensures efficient delivery of services, we reviewed waiver requirements and compared with policies and practices of the CCSP and SOURCE programs. We interviewed program and audit staff within DCH and DHS, and visited employees of six AAAs, their CCSP Care Coordination entities, and a sample of SOURCE case management providers.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objective.

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Appendix B
Map of Area Agencies on Aging (AAAs)

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Appendix C
SOURCE Providers by County

SOURCE Providers

Albany ARC Columbus Regional Healthcare System Corners of Care SOURCE Crisp Care Management Crossroads Community SOURCE Diversified Resources, Inc. Faith Health Services Legacy Link Inc. Source Care Management LLC SOURCE Partners Atlanta - VNHS St. Joseph's/Candler Health System UniHealth Solutions SOURCE Grand Total

County (Organized by AAA) Atlanta AAA Cherokee Clayton Cobb DeKalb Douglas Fayette Fulton Gwinnett Henry Rockdale Central Savannah River AAA Burke Columbia Glascock Hancock Jefferson Jenkins Lincoln McDuffie Richmond Screven Taliaferro Warren Washington Wilkes Coastal Georgia AAA Bryan Bulloch Camden Chatham Effingham Glynn Liberty Long McIntosh































4 4 4 4 2 2 4
5
3 4



2



2



2



3



2



2



2



2





3



2



2



2



2



2



3



3





3



3



3





3



3



3



3

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Albany ARC Columbus Regional Healthcare System Corners of Care SOURCE Crisp Care Management Crossroads Community SOURCE Diversified Resources, Inc. Faith Health Services Legacy Link Inc. Source Care Management LLC SOURCE Partners Atlanta - VNHS St. Joseph's/Candler Health System UniHealth Solutions SOURCE Grand Total

County (Organized by AAA) Georgia Mountains AAA Banks Dawson Forsyth Franklin Habersham Hall Hart Lumpkin Rabun Stephens Towns Union White Heart of Georgia AAA Appling Bleckley Candler Dodge Emanuel Evans Jeff Davis Johnson Laurens Montgomery Tattnall Telfair Toombs Treutlen Wayne Wheeler Wilcox Middle Georgia AAA Baldwin Bibb Crawford Houston Jones Monroe Peach Pulaski Putnam Twiggs Wilkinson





































































3 3 4 3 3 2 3 3 3 3 3
2
3
3 2
3 2 2
3 3
2 2 3 3 2 3 2 3 2 4
2 2 2 3 2 2 2 3 2 2 2

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Albany ARC Columbus Regional Healthcare System Corners of Care SOURCE Crisp Care Management Crossroads Community SOURCE Diversified Resources, Inc. Faith Health Services Legacy Link Inc. Source Care Management LLC SOURCE Partners Atlanta - VNHS St. Joseph's/Candler Health System UniHealth Solutions SOURCE Grand Total

County (Organized by AAA)

Northeast Georgia AAA

Barrow

Clarke

Elbert

Greene

Jackson

Jasper

Madison

Morgan

Newton

Oconee

Oglethorpe

Walton

Northwest Georgia AAA

Bartow

Catoosa

Chattooga

Dade

Fannin

Floyd

Gilmer

Gordon

Haralson

Murray

Paulding

Pickens

Polk

Walker

Whitfield

River Valley AAA Chattahoochee Clay Crisp Dooly Harris Macon Marion Muscogee




Quitman

Randolph

Schley

Stewart Sumter Talbot



Taylor

Webster








3 2 2 2 3 3 3
1
2 2 2 2
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 2 2 2 2 3 3 2

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Albany ARC Columbus Regional Healthcare System Corners of Care SOURCE Crisp Care Management Crossroads Community SOURCE Diversified Resources, Inc. Faith Health Services Legacy Link Inc. Source Care Management LLC SOURCE Partners Atlanta - VNHS St. Joseph's/Candler Health System UniHealth Solutions SOURCE Grand Total

County (Organized by AAA) Southern Georgia AAA Atkinson Bacon Ben Hill Berrien Brantley Brooks Charlton Clinch Coffee Cook Echols Irwin Lanier Lowndes Pierce Tift Turner Ware
Southwest Georgia AAA Baker Calhoun Colquitt Decatur Dougherty Early Grady Lee Miller Mitchell Seminole Terrell Thomas Worth
Three Rivers AAA Butts Carroll Coweta Heard Lamar Meriwether Pike Spalding Troup Upson
Totals





2



3





3





3





3





3





3





3





3





3





3





3





3





3





3





3





3





3





2





2





3





2





3





2





2





3





2





2





2





2





3





3



2



2



2



2



2



2



3



2



2



2

15 5 1 6 1 20 7 20 159 8 16 148 407

Source: DCH SOURCE Program provider listing

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Appendix D
Services Offered Under the Elderly & Disabled Medicaid Waiver

Service
Adult Day Health
Out-of-Home Respite Care Personal Support Services
Personal Support Services Extended

Description
Social, health and rehabilitative daytime services in a community-based, medically supervised, protective, congregate setting. Includes nursing and medical social services, skilled therapies, assistance with the activities of daily living, therapeutic activities, food services, transportation, education of caregivers, emergency care and preventive and rehabilitative services.
Provides temporary relief to the caregiver responsible for performing or managing the care of a client who is functionally impaired and cannot be safely left alone in the home.
Personal assistance, standby assistance, supervision or cues to functionally impaired persons. Tasks include: meal preparation, hygiene, bathing, feeding, light housekeeping, shopping and other support services.
Provision of personal support services over an extended period of time in a home setting which may include relief of the caregiver who normally provides care and oversight of the functionally impaired individual who is at risk for institutionalization. In addition to PSS tasks, in-home respite care is provided by a personal support aide.

Alternative Living Services

Twenty-four hour supervision, medically-oriented personal care residence, regularly scheduled nursing supervision, and health related support services in a state licensed personal care home. Group Model is licensed for 7-24 residents and Family Model is licensed for 2-6 residents.

Emergency Response Services/Systems

Provision of a constant in-home electronic support system which provides two-way communication between isolated persons and a response center. Installation of the ERS is also a provided service.

Enhanced Care Management

For SOURCE clients, a service that coordinates the delivery of waiver services with primary medical care, and other community services. Case Managers assist waiver participants in gaining access to needed waiver and other state plan services, as well as medical, social, educational and other services.

Financial Management Services
Home Delivered Meals
Home Delivered Services/Extended Home Health

Consumers who choose Consumer Directed Personal Support Services (CD-PSS) are required to enroll with an approved DCH Financial Management Services provider to support their role as the employer of CD-PSS. Services include the provision of basic budget support, consultation services and consumer orientation to common law employer functions.
Provision of nutritious meals or special diets, nutrition education, nutrition screening and nutrition counseling to maintain or improve nutrition and enhance consumer health and well-being.
A licensed home health agency may provide HDS to members in their home. Includes skilled nursing, occupation, physical, and speech therapies, home health aides, and medical social work.

Skilled Nursing Services

Provision of time limited skilled nursing services to individuals by a private home care provider licensed to provide skilled nursing services when ordered by a physician in a plan of care.

Source: DAS Taxonomy of Services, 1915(c) Elderly and Disabled Waiver

For additional information or for copies of this report call 404-657-5220 or see our website: http://www.audits.ga.gov/rsaAudits