Community Care Services Program: annual report, state fiscal year 2004

COMMUNITY CARE SERVICES PROGRAM
Annual Report State Fiscal Year 2004
"A partner in the Aging Network"
Division of Aging Services Georgia Department of Human Resources

Issued December 2004

PROVISIONS OF COMMUNITY CARE SERVICES ACT
This Annual Report reflects State Fiscal Year 2004 activities completed by the Georgia Department of Human Resources Division of Aging Services and other agencies. It is prepared in accordance with provisions set by the Community Care and Services for the Elderly Act for the following legislators and officers:
SPEAKER OF THE HOUSE OF REPRESENTATIVES PRESIDENT OF THE SENATE CHAIRMAN OF THE HOUSE HEALTH AND ECOLOGY COMMITTEE CHAIRMAN OF THE HOUSE HUMAN RELATIONS AND AGING COMMITTEE CHAIRMAN OF THE SENATE HEALTH AND HUMAN SERVICES
COMMITTEE
The General Assembly, in enacting the Community Care and Services for the Elderly Act, indicated its intent (O.C.G.A. 49-6-60 [et seq. 49-6-64]) as follows: To assist functionally impaired elderly persons in living dignified and
reasonably independent lives in their homes or with their families or caregivers through the development, expansion and coordination of various community-based services; To establish a continuum of care for such elderly persons age 60 and older in the least restrictive environment suitable to their needs; To maximize use of existing community social and health services to prevent unnecessary placement of individuals in long-term care facilities; and, To develop innovative approaches to program management, staff training, and service delivery that result in cost avoidance, cost effectiveness and program efficiency.
i

COMMUNITY CARE SERVICES PROGRAM
In National Association for Area Agencies on Aging remarks, Josephina Carbonell, Assistant Secretary for Aging, Administration on Aging, referenced the Georgia CCSP Annual Report data on program cost effectiveness and community based service delivery as a way for the entire aging network to be thinking.
The CCSP continues to be the least costly of all the other long term care programs in Georgia.
SUCCESS STORIES: THE CCSP MAKES A DIFFERENCE
"Community Care services mean a lot to me and my family. The services have helped me tremendously. I don't know what I would do if not for the 5 hours that I get twice a week, because that time away from my mother gives me a little quality time for myself that I really need. I hope and pray that the CCSP can continue on. Again, I will say thank God for the CCSP."
Caregiver, Female consumer, age 91 Lumber City (Heart of GA / Altamaha Area Agency on Aging)
"My grandmother is 86 and I am 18 years old. She raised me from a baby but now I am her only caregiver here in Macon. Community Care has helped us a great deal. If it wasn't for the CCSP I would not have been able to go to school and focus correctly without knowing that my grandmother was being cared for. I thank the CCSP for their help. It is supportive to know there is a program out there to help make things better for the elderly."
Granddaughter caregiver, female consumer, age 86 Macon (Middle Georgia Area Agency on Aging)
1 Comparative Assessment of Cost and Care Outcomes Among Georgia's Community-Based and Facility-Based Long-Term Care Programs, Final Report, June 22, 2004.
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"With the services the CCSP provides my mother is at home in her own environment and has excellent professional care almost daily with all the things she cannot do. She has a better quality of life than she would have in a nursing facility, and I am able to continue working. My husband has a terminal illness and without my job we would not be able to afford the medical insurance that we need for him. Mother has been in and out of hospitals and was in a nursing home for physical therapy after a series of strokes left her partially paralyzed. She was miserable, homesick and terribly depressed. When she was able to come home she improved mentally and physically each day. She has everything to look forward to like being with her little pet dog, watching her flowers grow and being surrounded by all the little personal things that are so dear to her which she would not have in a nursing home and this is encouragement for her to try and get well."
Caregiver daughter, Female consumer, age 79 Lumber City (Heart of Georgia / Altamaha Area Agency on Aging)

"I was injured in 1999 in an automobile accident and was paralyzed. I went into a deep depression. I basically just gave up. I was letting everyone do everything for me. Community Care was sending someone out for 5 hours a day. Eventually I decided it was time for some changes and to try to become more independent. I started to feel like a whole new person. My mother has been able to work again. Community Care only has to send someone 2 hours a day to help with my shower. I decided to pursue my education and received my GED. Next I plan to pursue some college courses. I feel as if my life is on track now. This is the happiest I have been. Don't take life for granted, take time to enjoy the little things in life, even if it is just wiggling your toes. You never know when it can be taken away."
Female consumer, age 23 Tallapoosa (Northwest Georgia Area Agency on Aging)

"If I did not have Community Care I would have to go into a nursing home. I

want to remain in my home for as long as possible. Since my health is failing,

Community Care allows me to keep my independence and dignity. I thank God

for it every day."

Male consumer, age 50

Columbus (Lower Chattahoochee Area Agency on Aging)

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"My wife and I were both in the Nursing Home at the same time. I have Parkinson Disease and can hardly do anything much for myself. My wife has many health problems also. She had a stroke and a heart attack. There was no one to care for us so we went to the Nursing Home. We learned about the services of CCSP. I was in the Nursing Home for one year. Now we live in a nice Personal Care Home where all of our needs are taken care of by the people who work here. If I had a choice I would have been in CCSP and living at the Personal Care Home a long time ago. This is the next best thing to being at home."
Husband and wife consumers, ages 62 and 65 Perry (Middle Georgia Area Agency on Aging)
"The CCSP has been good to me! The CCSP has allowed me to stay in my home, where I am able to still be the king of my castle. I am able to enjoy my grandkids, my wife and my family. With CCSP it has helped my family take care of me without getting burned out. CCSP has helped me as well as others to stay a part of our family. I do not want to go to a nursing home and no one else does."
Male consumer, age 61 Hawkinsville (Middle Georgia Area Agency on Aging)
"My mother is 96 years old. She is very alert with a good mind but she has some physical limitations. She is able to walk slowly with the use of a walker, but she is unable to care for her home and other necessities. I am not in a position to give her the help that she needs. Having an aide to come in daily to help her has enabled her to continue to live alone and independently. This makes her happy and contributes to her mental and emotional health. It would be a sad thing as well as an injustice to put someone in her present condition in a Nursing Home. Without this program of homecare, many families will have no other choice. I do hope that you will continue this provision for people like my mother who with a little help can live in their homes instead of a Nursing Home."
Caregiver daughter, Female consumer, age 96 Jones County (Middle Georgia Area Agency on Aging)
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TABLE OF CONTENTS
PROVISIONS OF THE COMMUNITY CARE SERVICE ACT................ i COMMUNITY CARE SERVICES PROGRAM QUOTES & SUCCESS STORIES ..........................................................................ii-iv TABLE OF CONTENTS..................................................................1 INTRODUCTION..........................................................................2 STATISTICAL DATA.....................................................................3 PROGRAM STRUCTURE AND ADMINISTRATION...........................4 PROGRAM SAVINGS & COSTS...................................................5-6 CONSUMER ASSESSMENTS AND WAITING LIST..........................7-9 CONSUMER DEMOGRAPHICS.................................................10-11 CCSP SERVICES.....................................................................12-13 PROVIDERS OF SERVICE............................................................14 CCSP ACCOMPLISHMENTS.....................................................15-16 SERVICE DEFINITIONS AND CONSUMER / CAREGIVER QUOTES................................................................................17-23
1

INTRODUCTION
VISION The Division of Aging Services (DAS), its 12 Area Agencies on Aging (AAAs), and our service providers comprise Georgia's Aging Network. We assist older consumers, their families and caregivers to achieve safe, healthy, independent and self-reliant lives. Georgia's Community Care Services Program (CCSP) is the leader in community-based care options, providing support and direction to the Aging Network to ensure that Georgians eligible for nursing facility placement have the option of remaining in their homes or communities.
SERVICES The CCSP has successfully completed its 22nd year of operation. The program provides a range of community-based services designed to delay or prevent more costly nursing facility placement. These services include telephone screening, face-to-face consumer assessment, care coordination, Adult Day Health, Alternative Living Services, Emergency Response Services, Home Delivered Meals, Home Delivered Services (Home Health), Out-of-Home Respite Care, and Personal Support Services.*
ELIGIBILITY CCSP is the cost-effective alternative to institutional placement. The CCSP provides Medicaid eligible consumers with community based services that support the consumer's choice to remain at home or in the community. Consumers must meet the same medical, functional, and financial criteria as for placement in a nursing facility. A physician certifies that the needs of the consumer may be met by the CCSP and available community resources.
FUNDING Under Title XIX of the Social Security Act, the Georgia Medicaid Program, funded with federal and state dollars, reimburses provider agencies for services through a federal Medicaid 1915(c) waiver for Home and Community-Based Services. Provider agencies render services in the consumers' homes, licensed personal care homes, or adult day health facilities. The Department of Human Resources (DHR), Division of Aging Services (DAS) administers and manages the CCSP through an inter-agency agreement with the Georgia Department of Community Health (DCH), Division of Medical Assistance (DMA).
* Refer to page 17 for CCSP SERVICE DEFINITIONS
2

STATISTICAL DATA SFY 2004
The CCSP served 14,099 consumers; Georgia taxpayers saved $17,616 for each consumer served by the CCSP
instead of a nursing facility - a statewide savings of over $248 million; The cost to taxpayers to support a consumer in the CCSP was only 26% of the
Medicaid cost to maintain a person in a nursing facility; One hundred-eighty consumers served were 100 years of age or older; 15%
were 90 or older; 29% were 85 or older; 57% were 75 or older; 82% of CCSP consumers were 60 or older; and, 18% of consumers were under age 60; Personal Support Services was utilized by 78% of consumers. It was the most frequently used CCSP service; The average length of stay for CCSP consumers was 48 months, an average increase of 8 months over the previous year.
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PROGRAM STRUCTURE AND ADMINISTRATION
Consumers receive CCSP services through the cooperation and partnership of the following state and local agencies and private businesses:
The Division of Aging Services of the Department of Human Resources has the primary responsibility for development and administration of the CCSP. Coordination of the various entities working together to deliver quality consumerfocused and cost effective services to consumers is the priority of the CCSP.
The Division of Medical Assistance of the Department of Community Health reimburses service providers and monitors services for quality and appropriateness.
The Division of Family and Children Services of the Department of Human Resources determines consumer Medicaid eligibility and cost share for services.
The Division of Mental Health, Developmental Disabilities and Addictive Diseases of the Department of Human Resources provides consumer psychological and psychiatric evaluations and therapeutic services.
Area Agencies on Aging (AAAs) contract with the Department of Human Resource's Division of Aging Services to serve as Lead Agencies or regional managers of the CCSP. The twelve AAAs serve as the local "Gateway to Community Resources" for consumers and their families, service providers, and potential service providers. The AAAs manage service benefit allocations, assuring the CCSP does not exceed budget limitations.
Care coordinators assess consumers for CCSP eligibility, link consumers to service providers and other community based support services, and monitor consumer care. Care coordinators assure reliable, cost effective, consumerfocused service delivery, avoiding duplication and over-utilization of services.
Providers enrolled in the CCSP deliver services ordered by the consumer's care coordinator and physician. The Division of Aging Services recommends service provider applicants for enrollment in the CCSP.
4

PROGRAM SAVINGS AND COSTS
EXPENDITURES

CCSP PROGRAM EXPENDITURES SFY 2001 - SFY 2004

CATEGORY
Consumer Service Benefits
Care Coordination
State Administration

SFY 2001 $78,200,923 $16,471,682 $1,242,719

SFY 2002 $84,738,390 $17,806,115 $1,403,005

SFY 2003 $85,717,353 $17,806,114 $1,035,747

SFY 2004 $88,866,386 $18,174,150 $1,336,010

TOTAL

$95,915,324 $103,947,510 $104,559,214 $108,376,546

Figure 1 In SFY 2004 the CCSP reimbursed provider agencies over $88 million for consumer services provided, yet state administrative cost was only 1% of total expenditure for the CCSP.

OTHER SERVICES

CARE COORDINATION COST - SFY 2004

DOLLARS EXPENDED

CONSUMERS SERVED

AVG. COST PER CONSUMER

$18,174,150

14,099

$1,289

Figure 2 Care coordination is key in providing consumer-focused care to CCSP consumers. Care coordination assures that consumers admitted to the program receive cost-effective, appropriate, and coordinated services.
5

MEDICAID SAVINGS

ANNUAL SAVINGS PER CONSUMER SERVED IN CCSP INSTEAD OF IN A NURSING FACILITY

SFY 2001

SFY 2002

SFY 2003

SFY 2004

AVG. SAVINGS SFY 2001 - 2004

$13,090

$14,247

$16,315

$17,616

$15,317

Figure 3 The above chart illustrates the cost effectiveness of CCSP.
COM PARISON: M EDICAID DOLLARS EXPENDED IN NURSING FACILITIES VS. THE CCSP

$25,000 $20,000 $15,000 $10,000
$5,000 $0

$17,725

$19,335

$22,151

$23,919

$4,635 SFY 2001

$5,088

$5,836

$6,303

SFY 2002

SFY 2003

SFY 2004

CCSP

NURSING FACILITY

Figure 4 Since SFY 2001, CCSP Medicaid per-consumer expenditure has averaged 26% of nursing facility Medicaid expenditure.

SUMMARY
The CCSP saved the State and Federal governments over $248 million for SFY 2004, $17,616 per consumer. In SFY 2004, the average annual benefits cost to the CCSP for a consumer's services was $6,303. If the consumer had received Medicaid reimbursed care in a nursing facility, the average annual cost to taxpayers would have been $23,919 instead of $6,303 per consumer.
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CONSUMER ASSESSMENTS AND WAITING LIST
ASSESSMENTS
Community Care Services Program (CCSP) consumers must meet the same medical, functional, and financial criteria as consumers receiving nursing home care under Medicaid.
Area Agencies on Aging staff conduct telephone interviews to screen consumers for potential service eligibility.
Consumers are prioritized for assessment based on the results of the telephone screening. Consumers with high impairment levels and unmet need are the first to enter services.
A face-to-face assessment determines the consumer's need for services. Care coordinators determine consumer medical and functional
eligibility. Eligibility staff at the Division of Family and Children Services
determine consumer financial eligibility for Medicaid.
The CCSP care coordinators visit consumers at least every four months or more frequently as needed to assure they remain eligible for services and services are addressing the consumer's needs.

ASSESSMENTS COMPLETED - SFY 2004 Initial telephone assessments Average number on monthly waiting list Initial face-to-face assessments completed

10,442 5,018 3,316

Figure 5 Demand for the CCSP exceeds available funding: 10,442 telephone screenings were conducted, and only 3,316 face-to-face initial assessments were conducted with consumers. Of consumers assessed, the CCSP is the undisputed choice over institutional placement for 94% of consumers.

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GEORGIA'S CCSP WAITING LIST

By 2030, there will be over 71 million older persons in the United States, more
than twice their number in 2000. People 65 and older represented 12.4% of the population in the year 2000, and will represent 20.7% by the year 20501.

Georgia had the tenth fastest growing elderly population (ages 60+) in the United States during 1990-2000. Over the 20th century (1900-1999), the number of
Georgians ages 60 and above increased ten-fold, compared to a four-fold growth
in the population overall.

PERCENT INCREASE IN POPULATION AGES 65+

20.0%

12.6%

20.0%

13.5% 16.0%

10.0%

0.0%

1990-2000 Actual

2000-2010 Projected

United States Georgia

Figure 6 shows the projected increase in Georgia's elderly population from 1990 20102.

Georgia and United States, 1990 - 2010 % Increase in Population, by Age Group

300.0% 250.0%

264.9%

200.0% 150 .0% 100 .0% 50.0%
0.0%

81.6 % 33.7%

120 .4% 41.3 %

87.9%

60+

75+

Unite d S ta te s

85+ G e o rg ia

Figure 7 shows the projected increase, by age group, in Georgia's elderly population. This is significantly greater than the anticipated U.S. increase.

1 U.S. Bureau of the Census, "US Interim Projections by Age, Sex, Race and Hispanic Origin"

<http://www.census.gov/ipc/www/usinterimproj/> 2 US Bureau of the Census, Summary File 1, 1990 and 2000; Governor's Office of Planning and Budget

Projections 2010.

8

CCSP WAITING LISTS SFY 2001 - SFY 2004

SFY

AVG. COUNT OF CONSUMER WAIT LISTS

2001

3,198

2002

4,115

2003

5,560

2004

5,018

Figure 8

The above demonstrates the correlation of the number of

consumers on the CCSP Waiting List and the increased growth of Georgia's

senior population.

PROJECTION OF POTENTIAL CCSP CONSUMERS

Years
Estimated Number of Potential CCSP Consumers

2015 54,007

2020 65,337

2025 80,003

Figure 9

The above projections calculate the number of consumers who

may need CCSP services over the next 21 years. Projections are based on U.S.

2000 Bureau of the Census population statistics: older Georgians served by

Medicaid who have chronic conditions, no spouse, and who are not in nursing

facilities or candidates for services provided by the Division of Mental Health,

Developmental Disabilities and Addictive Diseases.

SUMMARY
Growth projections for Georgia seniors with chronic conditions clearly demonstrate the growing demand for home and community-based services.

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CONSUMER DEMOGRAPHICS CONSUMERS SERVED BY CCSP

18,000 16,000 14,000 12,000 10,000
8,000 6,000 4,000 2,000
0

13,224 13,193

14,185 14,194 12,681

1994 1995 1996 1997 1998

16,873 16,653

15,228 14,848

14,687 14,099

1999 2000 2001 2002 2003 2004

Figure 10 The above illustrates a 7% increase in the number of consumers served over the last decade.

PROFILE OF CCSP CONSUMERS - SFY 2004

Unduplicated consumer count Consumers 100 years of age or older Consumers 90 years of age or older Consumers 85 years of age or older Consumers 75 years of age or older Consumers 60 years of age or older Consumers under 60 years of age Percentage of consumers who are female Percentage of consumers who are minorities (non-white)

14,099 1% 15% 29% 57% 82% 18% 75% 43%

Figure 11 In SFY 2004, the CCSP served 14,099 consumers. Seventyfive percent were female. Fifty-seven percent were over the age of 75, and 29% of consumers were 85 or older. Eighteen percent of consumers served were younger than age 60. Consumers 100 years of age or older numbered 180.

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AVERAGE LENGTH OF STAY & DISPOSITION OF CONSUMER DISCHARGES
SFY 2004

Average Consumer Length of Stay

48 months

Disposition of Discharged Consumers:

- Death

50%

- Nursing facility placement - Refused Service/ Hospice/ Other Waiver

35%

Programs/ Ineligible/ Moved From Service

Area

15%

Figure 12 The above chart shows the average time a person remains in the CCSP. Thirty-five percent of those discharged from the CCSP enter a nursing facility because of their need for continuous higher level of skilled care services. Since SFY 1994 the average length of stay in the CCSP has increased from 26 months to 48 months, an 85% increase in time consumers lived in the community.

CONSUMERS BY PAYMENT SOURCE - SFY 2004

Consumers receiving SSI Medicaid

42%

Consumers receiving Medical Assistance Only

55%

(MAO)

Consumers whose Cost Share covered service costs

3%

Figure 13 Because consumer incomes are less than the federal Supplemental Security Income (SSI) level, 42% of CCSP consumer care is paid by Medicaid. Fifty-five percent of the consumers receive partial Medicaid payment for their services. According to their income levels Medical Assistance Only (MAO) consumers pay a portion of the cost of services known as Cost Share. Services for the remaining 3% are at no cost to the Medicaid Program because the consumer Cost Share pays the entire cost of the CCSP services received.
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CCSP SERVICES
UTILIZATION AND EXPENDITURES

CONSUMERS SERVED AND CCSP MEDICAID FUNDS EXPENDED BY SERVICE TYPE - SFY 2004

CCSP SERVICE
Adult Day Health (ADH)
Alternative Living Services (ALS) - Group Model - Family Model
Emergency Response Services (ERS)
Home Delivered Meals (HDM)

CONSUMERS % TOTAL

FUNDS

% TOTAL

SERVED* CONSUMERS* EXPENDED FUNDS**

596

4% $3,341,376

4%

1,831 672
6,287
2,835

13% $9,642,003

11%

5% $3,759,048

4%

45% $1,492,955

2%

20% $3,670,182

4%

Home Delivered Services (HDS)
Home Health Services Medicaid Home Health (HHS)
Out-of-Home Respite Care (OHRC)
Personal Support Services (PSS, PSSX)

75 2,362

1% $124,413 Less than 1%

17%

0***

0%

24 Less than 1%

$44,433 Less than 1%

11,024

78% $66,747,543

75%

* Duplicated consumer count. Consumers may receive more than one service.

** Percentages are rounded.

*** Covered under state Medicaid plan.

Figure 14 The above shows the CCSP service types by number of consumers and expenditure of CCSP Medicaid dollars provided and expenditures for each service.

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CONSUMERS SERVED BY SERVICE TYPE SFY 2004

2,835 2,437

2,503

596

6,287

11,048

PSS

ERS

HDS

HDM

ALS

ADH

Figure 15 This graph displays by service type the number of CCSP consumers who receive each service. Consumers may receive more than one service.
*NOTE: Personal Support Services consumer count includes Out-of-Home Respite Care consumers.

SUMMARY
Seventy-eight percent of CCSP consumers use Personal Support Services (PSS), the provision of personal assistance, stand-by assistance or supervision of consumers with inability to perform activities such as feeding, dressing, bathing, toileting, transferring or walking, or light housekeeping. It may also provide respite care to the caregiver. This service accounts for 75% of total CCSP expenditures. Alternative Living Services (ALS) ranks second in expenditures (15%).
Accounting for only 2% of CCSP Medicaid expenditures, 45% of CCSP consumers use the cost-effective Emergency Response Services (ERS).

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PROVIDERS OF SERVICE

PROVIDERS BY SERVICE TYPE* - SFY 2004

Adult Day Health

36

Alternative Living Services - Family Model

22

Alternative Living Services - Group Model

164

Emergency Response Services

11

Home Delivered Meals

30

Home Delivered Services

33

Personal Support Services

141

Out-of-Home Respite Care Services

6

* Some providers provide more than one service.

Figure 16 This chart indicates the number of providers enrolled in each CCSP Medicaid service.

The Community Care Services Program manages, coordinates, and provides services to consumers by partnering with 423 public and private licensed, CCSP enrolled businesses and agencies. The CCSP supports and grows small local businesses.

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CCSP ACCOMPLISHMENTS IN SFY 2004
QUALITY INITIATIVES
Partnerships
Specialist Providers In Teams for Dementia Care (SPRINT-D) The CCSP partnered in this community-based prevention research grant project with the Rollins School of Public Health, Emory University to establish a culturally appropriate, skills based training program to equip caregivers, aides, social workers and families with evidence-based strategies to deal with dementia related problem behaviors. Statewide project expansion is underway.
Decreasing Depression in Community Elders The CCSP partnered with the Fuqua Research Center at Wesley Woods, Emory University to prevent depression and suicide among Georgia's elderly population by training caregivers and other service providers on recognizing symptoms of depression and in referral and intervention strategies. Statewide rollout of this initiative has begun.
Aging and Disability Resource Center A three year Administration on Aging / Centers for Medicare and Medicaid Services grant awarded to GA will provide consumers across population, programs and needs with enhanced "one-stop-shop" referral to resources and service options.
Consumer Self-Direction The CCSP partnered with the Department of Human Resources Division of Mental Health, Developmental Disabilities and Addictive Diseases and the Department of Community Health to implement the option of consumer self-direction.
Nursing Facility to Community Transition The CCSP admitted 81 consumers from nursing facilities and transitioned them into the community.
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CONTINUOUS QUALITY PROGRAM AND SERVICE IMPROVEMENT
Activities
CCSP Consumer Satisfaction Survey The CCSP set a consumer satisfaction benchmark for consumers receiving Personal Support Services and Alternative Living Services. Results of the survey indicated satisfaction with services and affirmed the effectiveness of care coordination working with the service provider and consumer to provide quality care.
Comprehensive Care Coordination Emphasis was placed on continuous quality improvement in areas including disease management, community resources and monitoring of costs. An increased focus on disease management was emphasized in the following areas: Chronic Obstructive Pulmonary Disease; pneumonia; heart failure; hypertension; diabetes; and, stroke. CCSP care coordinators and providers participated in the statewide training sessions and workshops on foot care. These training sessions and workshops promoted awareness and identification of interventions to address common foot problems that occur in older adults.
Medicaid Demonstration Project The CCSP has partnered with the Department of Community Health and the Division of Family and Children Services to develop procedures that create a more timely approval of Medicaid applications for CCSP clients. This process allows prompt payment of the CCSP consumers' medical expenses. Statewide expansion is underway.
Service providers respond to consumer needs In order to allow caregivers in rural and/or underserved areas a respite from 24-hour a day caregiving responsibilities, Adult Day Health (ADH) services will also be offered as Adult Day Health- Mobile (ADH-M) in these areas. From the primary location of the CCSP ADH facility, staff will travel with supplies and materials needed for the day's activities to the rural or underserved area to provide this service.
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SERVICE DEFINITIONS
Care Coordination
The care coordinator screens and assesses the consumer's medical, functional and social problems/needs to determine the appropriateness for Community Care and, with input from the client and caregiver, develops a specific plan of care for each consumer admitted to the CCSP.
The care coordinator brokers/monitors provider services for consumers by planning, arranging, coordinating, and evaluating the service delivery to assure that appropriate, quality services are provided in a timely and cost effective manner and assures that consumer costs are contained.
`The CCSP care coordinator worked with community service providers to find resources needed by the client. Injured in an accident, he was 54 and bed bound, incontinent, had a feeding tube. His wife divorced him, took the children and he went to live with his 81-year old caregiver mother. The CCSP care coordinator found a tube feeding formula that Medicaid would reimburse, located several companies to provide client's equipment and supply needs, accessed an agency to provide him physical therapy, and the CCSP aide came to get the client dressed and ready for transport to it. Emergency Response Services were also approved. Today the client is no longer bed ridden; he can feed himself. He is now mobile, increasingly independent with the help of special equipment, and the care coordinator is seeking community resources to help the client speak again. The transformation in the client's condition and existence is truly a remarkable coordination of efforts.'
Male consumer, age 54 Rome (Northwest Georgia Area Agency on Aging)
"I was having a problem and the care coordinator took care of it right away. She is very efficient and always on top of things."
Male consumer, age 63 Fayetteville (Atlanta Regional Commission Area Agency on Aging)
"My mom was happy until the end and your caring concern was the biggest part of it."
Caregiver daughter, Female consumer, age 93 LaGrange (Southern Crescent Area Agency on Aging)
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"Thank you so much for all the help you have given us. The aides are kind, patient, understanding, and very professional. They make things so much easier for me and for my family. Please know how much we appreciate it."
Male consumer, age 77 Hiawassee (Georgia Mountains Area Agency on Aging)
Adult Day Health (ADH)
Provides care in a community-based day program for consumers who are functionally impaired. ADH provides a variety of health, therapeutic and social service activities in a group setting. Services include nursing care, special therapeutic services, personal care services, planned therapeutic activities, dietary services, transportation, and social work services.
"It is a great help for me and my wife for me to be able to come to the center. It gives her time for herself and time to keep appointments. I love it here."
Male consumer, age 78 Gainesville (Georgia Mountains Area Agency on Aging)
Every minute, every day and night the 67 year old caregiver daughter-in-law provided care to the client. For one and a half years she made no complaint, but the caregiver's feelings of increasing stress, of being overwhelmed and exhausted were slowly building up. Three hours a week respite was not enough time for her to relax or do something for herself. The CCSP care coordinator explained other services to the caregiver that might benefit both her and the client. The caregiver reported she was about to crack. Care coordination recommended the additional CCSP service to relieve caregiver burden. Now the client attends Adult Day Health two times a week; she likes socializing, and getting out. She is more active, and does more for herself. The caregiver is more relaxed and can enjoy her family. She writes the following about care coordination: "Thank you so much for everything. You listened when I felt I had no one to talk to, you gave me options and if it weren't for Personal Support and especially Adult Day Health Services I was going to leave my husband."
Daughter-in-law caregiver, Female consumer, age 89 Augusta (Central Savannah River Area Agency on Aging)
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Alternative Living Services (ALS)
Provides twenty-four hour supervision, medically-oriented personal care, periodic nursing supervision, and health-related support services in a residential setting other than the consumer's home. This service is provided in state licensed personal care homes.
"Community Care has been a great asset in my mother's care. When we have a problem, all we need to do is contact the administrator or care coordinator and they immediately address our problem. It is a good feeling to know there are people out there who really show they're interested in the client's care and are always willing to lend a helping hand."
Caregiver daughter, Female consumer, age 70 Unadilla (Lower Chattahoochee Area Agency on Aging)
"I am 80 years old and live in a personal care home. I cannot stay by myself and my family could not be there to care for me all the time. I need the help at the personal care home."
Female consumer, age 80 Warner Robbins (Middle Georgia Area Agency on Aging)
Emergency Response System (ERS)
Provides an in-home electronic support system for two-way communication between isolated consumers and a communication control center twenty-four hours a day, seven days a week.
"I fell this morning and I just couldn't get myself up. I pressed my button and my daughter got there before the ambulance did (she lives two houses down). The EMTs got here pretty quick and took me to the hospital. I'm just glad I have this button or I probably would of laid on the floor for a long time."
Female consumer, age 90 Gainesville (Georgia Mountains Area Agency on Aging)
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"The emergency response system has been great! I used it to get to the hospital last time."
Female consumer, age 89 Canton (Atlanta Regional Commission Area Agency on Aging)
"At first I didn't like wearing it, but one night I fell and it saved my life. It's nice to know help is just a touch of a button away."
Male consumer, age 69 Carrollton (Southern Crescent Area Agency on Aging)
"I am so appreciative for Community Care, without CCSP my grandmother would have been in a nursing home 3 years ago. As the owner of a full scale child day care facility I was worried that I could not care for my grandmother properly and continue with my business. The CCSP has made this possible."
Caregiver granddaughter, Female consumer, age 72 Savannah (Coastal Georgia Area Agency on Aging)
"This button is my company when my children are working. They do everything else for me, but they worry about me when I'm by myself. I'm thankful for it."
Male consumer, age 68 Sylvania (Central Savannah River Area Agency on Aging)
Home Delivered Services (HDS)
Medicaid Home Health Services (HHS) provides traditional home health on an intermittent basis to consumers in their homes. Services include skilled nursing; physical, speech and occupational therapy; home health aide and medical social services. The State Medicaid Plan pays for the first 50 home health visits, and the CCSP pays for needed visits in excess of 50.
"If it hadn't been for these CCSP services, I don't know what we would have done. I know that we wouldn't still be able to be at home. It has been wonderful."
Husband and wife consumers, ages 87 and 85 Tifton (Southeast Georgia Area Agency on Aging)
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Home Delivered Meals (HDM)
Ensures improved nutrition to enhance consumer health and well-being. Consumers may receive home delivered meals only in conjunction with another CCSP service.
"My daughter works and has four children. I like to live with them and CCSP helps me to have a meal when she is gone."
Female consumer, age 76 Warner Robins (Middle Georgia Area Agency on Aging)
"This program means everything to me. I don't have to be hungry when I come in from dialysis. I know I will have a hot meal when I am so weak. I know my clothes will be clean and my home clean, my bed, my floors, all the things I can't do and don't have anyone to do for me."
Female consumer, age 54 Warner Robins (Middle Georgia Area Agency on Aging)
Personal Support Services (PSS)
Provides a range of support services for CCSP consumers. Services include assistance with activities such as light housekeeping, running essential errands, and basic personal care needs including feeding, dressing, bathing, toileting, and transferring.
"I can't do much for myself and I live alone. It gives me something to look forward to by the aides and nurses coming to check on me 5 times a week. It means so much that I get up earlier and know that I will get someone to help me get my bath, help me with everything. The program is just a godsend for me. I've needed it for a long time."
Female consumer, age 60 Helena (Heart of GA / Altamaha Area Agency on Aging)
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"Community Care is a great program! They do whatever they can do to help me. Before I started receiving assistance I could only take a bath 1 time per week. Now the aides come 3 days per week and I can get a bath all 3 days."
Female consumer, age 65 Woodbine (Coastal Georgia Area Agency on Aging)
"Without your help, my mother would have to leave her home and go to a nursing home. Thank you for all of your help and understanding with my mother."
Female consumer, age 85 White Plains (Northeast Georgia Area Agency on Aging)
"CCSP helps me keep my own place and keeps me independent. I have a nice nurse and a nice aide who help me a lot."
Female consumer, age 57 Union Point (Northeast Georgia Area Agency on Aging)
"The services I receive from the young lady that comes from CCSP allow me to live a somewhat normal life again. I didn't like feeling as if I was totally dependent on the kindness of family and friends for every need."
Female consumer, age 69 Cedartown (Northwest Georgia Area Agency on Aging)
"I have suffered multiple strokes and live alone. I have support from my granddaughter, who works full-time and has small children, and a neighbor and family friend who does shopping, assists with bill paying and visits or calls daily. I could not remain in my home without the help the CCSP sends 5 days per week. I have been in the nursing home for rehabilitation and hope I never have to be there long term. The CCSP is a great and wonderful blessing to me."
Female consumer, age 88 Bremen (Northwest Georgia Area Agency on Aging)
"I am 94 and my husband is 96, he can't help me with my bath or do too much of the cleaning around the house. My aide does the things we can't do. She runs errands because I don't get out of the house to do those things anymore. The program has allowed me to stay at home with my husband because I have more problems than him."
Female consumer, age 94 Eatonton (Middle Georgia Area Agency on Aging)
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"We need the help. My wife and I are both in our 90's and have been married for seventy years. We have been in our home for thirty years. Without the CCSP we could not stay in our own home. Please do not take this service away."
Male consumer, age 90 Roberta (Middle Georgia Area Agency on Aging)
"I don't know what I would do without the CCSP. My husband requires help around the clock. He is confined to his bed all day but when his aide comes to visit, she gives him a good bath and helps him get up into a chair. It makes him so happy just to be able to get out of bed. I try to do as much as I can for him but am elderly myself with painful arthritis in my arms and legs and I can't get him up anymore by myself. I'm afraid without your services he would have already been admitted to a nursing home. I'll never be able to thank you enough for helping me keep him at home."
Caregiver spouse, Male consumer, age 82 Coweta (Southern Crescent Area Agency on Aging)
Extended Personal Support Services (PSSX)
Provides personal support services in a home setting that includes respite care for the full time caregiver over an extended period of time.
"I am so thankful for the services. I was becoming overwhelmed trying to handle both of them and now I have help."
Caregiver, Sister female consumers, ages 79 and 83 Dawson (Southwest Georgia Area Agency on Aging)
"The CCSP keeps me living in my own home and independent as much as possible. I am paralyzed. I need the aide to come in and get me out bed, do my bowel program, range of motion exercise, cook, clean and run errands. I don't know what I would do without the help I get."
Male consumer, age 44 Eatonton (Middle Georgia Area Agency on Aging)
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Community Care Services Program
Division of Aging Services Department of Human Resources
(404) 657 5307 (404) 657 5251 FAX Two Peachtree St., NW
Suite 9.398 Atlanta, GA 30303 3142
http://www2.state.ga.us/Departments/DHR/aging.html