Home and community based services for the elderly and disabled

Follow-Up Review Report No. 14-28

May 2015

Georgia Department of Audits and Accounts
Performance Audit Division
Greg S. Griffin, State Auditor Leslie McGuire, Director

Why we did this review
This follow-up review was conducted to determine the extent to which recommendations in our June 2012 performance audit (11-32) have been addressed.
The purpose of the original audit was to review long-term care services for the elderly and physically disabled provided through the 1915(c) Medicaid Waiver for the Elderly & Disabled. These services allow individuals to receive services in their home or the community instead of being admitted to a nursing home. Receiving HCBS is often preferred by individuals and services are less expensive than nursing home care.
About the Elderly &
Disabled Waiver Programs
Georgia's 1915(c) Medicaid Waiver includes two programs Community Care Services Program (CCSP) and Service Options Using Resources in Community Environments (SOURCE). CCSP is managed by the Department of Human Services' Division of Aging and SOURCE is managed by the Department of Community Health. Each provides an array of services to elderly and disabled participants.
In fiscal year 2014, CCSP cost $160.9 million and SOURCE $266.3 million. The federal government paid approximately 65% of waiver costs, with the state funding totaling $148.6 million. Together, the programs served approximately 30,000 individuals.

Follow-Up Review
Home and Community Based
Services for the Elderly and Disabled
Action still needed to improve efficiency
of waiver programs
What we found While some issues identified during the original audit have been addressed, we found that it remains easier to obtain a nursing home bed than home and community based services (HCBS), that services are still not targeted to those most in need, and that performance measures have not been created to allow decisionmakers to assess the effectiveness of two waiver programs SOURCE and CCSP operated under the state's Elderly and Disabled (E&D) Medicaid waiver.
As shown in Exhibit 1 on the following page, Elderly and Disabled (E&D) Medicaid waiver spending increased between federal fiscal years 2011 and 2013, while the number of clients and waiver days decreased. The decreased utilization occurred within SOURCE.
The Department of Community Health (DCH) and the Department of Human Services' Division of Aging (DAS) have taken steps to address the awareness and accessibility of HCBS, but nursing homes often remain a more accessible option. According to agency officials, DAS has increased statewide marketing of HCBS programs and seven Area Agencies on Aging now conduct care transition planning for some patients in at least one hospital. However, it is unclear if those admitted to nursing homes are aware of potential HCBS options. Nursing home personnel, who have little incentive to discuss HCBS options, conduct pre-admission screenings of potential clients, and nearly one-third of nursing homes made no referrals for HCBS options counseling during a six-month period in 2014. Regarding accessibility, 100 slots were added to CCSP since the original audit

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Home and Community Based Services for the Elderly & Disabled

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but the program has a waiting list that averages approximately 1,500. Those in need of immediate longterm support services can generally receive them more quickly from a nursing home.

Exhibit 1 Additional Spending, Less Utilization for E&D Waiver, Federal Fiscal Years 2011 and 2013

Expenditures E&D Waiver (CCSP & SOURCE)

FFY 2011 $336,947,156

FFY 20131

Increase/(Decrease)

$400,659,199

$63,712,043

Utilization Number of Clients CCSP SOURCE Total E&D Waiver Clients

10,660 (32%) 22,882 (68%) 33,542 (100%)

11,637 (38%) 19,310 (62%) 30,947 (100%)

977 (3,572) (2,595)

Days of Services E&D Waiver

9,810,312

9,452,152

(358,160)

Annual Cost per Slot or Bed3

E&D Waiver

$12,536

$15,472

$2,936

Nursing Homes2

$52,242

$58,669

$6,427

1 Waiver information is obtained from a federal report unavailable until approximately 18 months after a federal fiscal year ends. 2 Nursing home data is for the state fiscal years 2011 and 2013 3 Calculated by multiplying the average cost per day of services by 365
Source: CMS 372 Reports, DCH nursing home data

SOURCE and CCSP continue to operate as separate programs, despite no clear benefit to clients and additional administrative costs to the state. According to DCH officials, since the original audit the agency has established common assessment and level of care criteria for the two programs and changed other SOURCE practices, such as eliminating preferred provider networks, to align the two programs' operations. However, instead of operating two identical programs, a more efficient solution would be consolidating the programs into one. A single program could also address service delivery issues, such as individuals being placed on a CCSP waiting list while individuals meeting the minimum requirements receive services through SOURCE. In addition, enhanced case management (the only service difference in the programs) has been provided to SOURCE participants while those in CCSP, who may have a greater need for those services, have been unable to receive them. DCH officials did state that enhanced case management will be available to CCSP clients in late 2015.

The operation of separate programs also makes it more difficult to assess the state's success at rebalancing spending between nursing homes and HCBS programs. The state does not have basic performance information that compares E&D waiver to nursing home spending, clients, or days of service. Tracking this information appeared to be the intent of state law adopted in the early 1980s, before the creation of SOURCE. The statutorily required CCSP annual report now provides only a portion of the information needed by decision-makers. The services and costs of a majority of HCBS clients are not included.

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Georgia's Rebalancing Efforts for Long-Term Services & Supports
Georgia is attempting to rebalance spending and utilization of long-term services and supports (LTSS) from institutional settings to community settings for numerous populations. The state provides LTSS for individuals with developmental disabilities, mental health disabilities, physical disabilities, and the elderly. Directing spending and utilization to HCBS occurs through various waiver programs and is supplemented by two significant programs: Money Follows the Person (MFP) and Balancing Incentive Program (BIP).
MFP The program helps fund the transition of individuals from long-term care institutions to a community setting. It provides an enhanced federal Medicaid match on program participants, with funds used for services not otherwise funded by Medicaid (e.g., rental deposits, home modifications, household items). The program is available to the elderly, physically disabled, developmentally disabled, or youth with mental health disabilities who have been in a long-term care facility for at least 90 days. Georgia began MFP participation in 2008.
BIP The program is intended to increase the HCBS portion of LTSS spending to 50%. It provides Georgia with a 2% enhanced federal Medicaid match for certain services, with additional funds financing initiatives to increase or improve HCBS for all or some populations. Examples of BIP initiatives include: creating an Integrated Eligibility System to replace Georgia's current eligibility data system, adding slots to several Medicaid waivers, and funding the Aging and Disability Resource Connection to perform certain tasks. BIP initiatives impact several populations using long-term services and supports, but a majority of BIP spending is targeted to expanding the waiver populations served by the Department of Behavioral Health and Developmental Disabilities.
According to 2014 BIP reports, nearly 50% of LTSS spending is for HCBS rather than institutional services. The state was approved to participate in BIP beginning October 1, 2012.

Department of Human Services Response: "The Department of Human Services continued to agree with the original findings, and concurs with the current status of those findings as presented in the draft report." DHS added that it will "continue to use the metrics, findings and recommendations as we work to more effectively serve Georgia's Aging and Disabled population."
Department of Community Health's Response: DCH stated that it concurred with much of the review elements, but it noted that its Medicaid rebalancing entails multiple populations and waivers not included in the follow-up review. DCH stated that under the Balancing Incentive Program, the rebalancing rate (or total investment in institutional versus HCBS) "has shifted from 47% in HCBS expenditures in 2012 to over 49% in 2014. While that increase is gradual, we shared in our interview that our challenge is that rate increases to nursing facilities results in a change to the denominator of the equation rather than a decrease in the waivers services provided or an increase in the nursing home enrollments."
DCH also noted that BIP is funding "infrastructure improvements such as the No Wrong Door/single point of entry initiative, Options Counseling, and funding for hundreds of direct slots in [CCSP]. All of these BIP efforts have had major and significant impact in serving individuals who are elderly or disabled across all waiver programs."

The following table summarizes the findings and recommendations in our 2012 report and actions taken to address them. A copy of the 2012 performance audit report 11-32 may be accessed at http://www.audits.ga.gov/rsaAudits/download/14876.

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Home and Community Based Services for the Elderly and Disabled Follow-Up Review, May 2015

Original Findings/Recommendations
Spending on home and community based services 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.
We recommended that DCH and DAS create and publish measures of the state's effort in rebalancing spending and utilization for the elderly and disabled population. We also recommended that the General Assembly revise state law related to the CCSP annual report.

Current Status
Not Addressed Improved measurable goals for rebalancing services and spending for the elderly and disabled population have not been created and published.
DCH and DAS have not developed useful performance information that allows the state's decision-makers to assess whether the elderly and disabled are increasingly using HCBS instead of nursing homes. As required by the Balancing Incentive Program (BIP) grant, DCH tracks rebalancing efforts for Medicaid. However, DCH measures success for the entire population that may be served in an institutional setting, including the elderly, mentally ill, developmentally disabled, and others; it does not report information for each population separately. Aggregate information does not inform those funding HCBS programs if the efforts targeting the elderly and disabled are successful.
The CCSP report, which is required by state law, continues to be of limited value. It once included the state's primary program for the elderly and disabled population, but the creation and expansion of the SOURCE program results in a report that does not convey a complete picture. The General Assembly has not revised the state law to require the inclusion of SOURCE data.

Limited awareness and availability of Georgia's HCBS options results in greater use of nursing homes for long-term care.
To address awareness, we recommended that DAS and DCH increase outreach efforts to individuals and healthcare providers and ensure nursing homes are properly referring individuals for potential community placements. To address availability, we recommended that the agencies consider mechanisms for providing services more quickly.

Partially Addressed DAS and DCH have taken steps to increase the public's awareness of HCBS services, though availability of CCSP services remains limited.
Regarding awareness, Aging and Disability Resource Connections (ADRCs) are now the primary single point of entry for long-term supports and services for all groups, including the elderly and disabled. According to agency officials, DAS has also increased statewide marketing of HCBS and ADRCs by utilizing radio, television and billboard advertisements. The Area Agencies on Aging (AAAs) have also established better relationships with hospitals, whose discharge planners can help inform patients of HCBS services. DAS officials stated that care transition staff in seven AAAs provide care transition services for certain patients discharged from at least one hospital in their region.
Despite improvements, we also noted practices that may limit awareness of HCBS options. Nursing home pre-admission screenings are still conducted by nursing home personnel, who have less incentive than ADRC staff to make individuals aware of HCBS options. Nursing homes also may not be asking residents if they would like HCBS options counseling from the AAA, as required by Medicaid. DAS data shows that approximately one-third of nursing homes with Medicaid patients made no referrals between July and December 2014. This is a similar portion found in the original audit.
Few steps have been taken to increase availability. While 100 slots were added to CCSP, the program maintains a waiting list of approximately 1,500. Individuals in need of services can be served by nursing homes almost immediately.

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Home and Community Based Services for the Elderly and Disabled Follow-Up Review, May 2015

Original Findings/Recommendations
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.
We recommended that DCH and DAS combine CCSP and SOURCE under one agency to ensure that individuals most in need are the first to receive services and that enhanced case management services are provided to the most appropriate clients.

Current Status
Partially Addressed Adequate measures have not yet been taken to increase the efficiency of the waiver programs and ensure that the individuals most in need are receiving appropriate services.
SOURCE and CCSP continue to operate separately, but DCH has taken steps to make them more similar. According to agency officials, the programs use a common assessment for new clients, and SOURCE clients are no longer restricted to their case managers' preferred network when selecting a service provider.
However, because CCSP and SOURCE are operated separately, the state cannot ensure that services are provided to those most in need. All clients must meet the same nursing home level of care, but the programs have different financial eligibility requirements. SOURCE clients receive Supplemental Security Income (SSI) while CCSP clients do not. Therefore, financial criteria, instead of functional need, determines the availability and type of services. For example, individuals with SSI can receive services before non-SSI clients because only CCSP has a waiting list. Also, SOURCE clients receive enhanced case management services that have been coordinated with a physician, while CCSP clients do not. DCH officials stated that this service will be available to CCSP clients beginning October 2015.
During the original audit, we also noted that DAS had an information system that allowed it to track CCSP clients and the performance of its case management providers, while no similar system existed for the SOURCE population. DAS has begun implementation of a new system to track its clients, providers, and services, including CCSP. DCH has no comparable system.

While Georgia's cost sharing requirements impact lower income clients more than policies in 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.
We recommended that DCH and DAS consider changing the cost share policy to impact fewer people seeking waiver services. We also recommended that ADRC staff better capture the reason for waiver service refusals, which may include the cost share requirement.

Partially Addressed DCH and DAS have not taken steps to change the cost share policy, but both agencies did consider the implications.
DCH and DAS officials stated that while they considered this policy change, they agreed that this was not the best use of existing funds. The agencies also have not requested funding to change the policy, determining that funding would be better spent on other priorities, such as maximizing the number of waiver slots.
DAS officials stated that ADRC staff receive regular training on how to capture applicant data, including reasons for refusal of referrals for services. No specific guidance or actions were taken to improve the quality of the information collected when someone refuses CCSP services.

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Home and Community Based Services for the Elderly and Disabled Follow-Up Review, May 2015

Original Findings/Recommendations
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.
We recommended that DCH and DAS determine the demand and cost-effectiveness of adding home modifications as a waiverapproved service and that they address client dissatisfaction with transportation.

Current Status
Partially Addressed DCH and DAS have taken some steps to address issues with transportation but have not moved toward adding home modifications to the waiver.
DCH has worked with transportation providers to improve transportation services for Adult Day Health clients. DCH officials stated that they have received fewer complaints regarding transportation services from Adult Day Health clients as a result.
The demand and effectiveness of adding home modifications to the waiver has not been fully evaluated. DAS officials believe that providing certain home modifications would be appropriate, while DCH officials stated that more information is necessary to determine if clients' need for home modifications necessitates adding it to the waiver. DCH also noted that the current budget does not permit additional service offerings.

5 Findings

0 Fully Addressed 4 Partially Addressed 1 Not Addressed

The Performance Audit Division was established in 1971 to conduct in-depth reviews of state-funded programs. Our reviews determine if programs are meeting goals and objectives; measure program results and effectiveness; identify alternate methods to meet goals; evaluate efficiency of resource allocation; assess compliance with laws and regulations; and provide credible management information to decision-makers. For more information, contact
us at (404)656-2180 or visit our website at www.audits.ga.gov.