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New Transition Plan, New ADHC Options

There’s an interesting phrase in the state’s new transition plan for the adult day health care program: “ADHC-like services.”

It’s one of the care options listed in the state’s recently released transition plan, and it will be part of the discussion today in Sacramento, when the Department of Health Care Services holds an ADHC stakeholder meeting.

“Current ADHC [centers] could provide ADHC-like services under the waiver,” according to Toby Douglas, the director of DHCS. “There are ways we can do that as part of the transition plan.”

Douglas mentioned possible expansion of two federal waivers (the In Home Operations waiver, or IHO; and the Multipurpose Senior Service Program waiver, or MSSP). Most ADHC beneficiaries have not hit the legal limit for In-Home Supportive Services, so some of their needed care could be met in that way, as well, Douglas said.

ADHC advocates remain concerned that the state’s plan is unfocused and unrealistic, and will make their views heard today at the stakeholder meeting.

“It still seems very unclear to me who’s responsible for what,” Lydia Missaelides of the California Association of Adult Day Services said. “We still don’t know how the state’s going to allocate resources. We just don’t know ultimately who’s responsible for getting them services. They’ve never talked to us or to providers about any of that.”

The state will eliminate the Medi-Cal benefit for ADHC services on Dec. 1, and a judge will deliberate on the state’s transition plan in a court hearing Nov. 1. DHCS needs to come up with a plan to handle roughly 37,000 senior and disabled patients who use ADHC services during the day so that they can remain living at home. The program helps keep them out of nursing homes and emergency rooms.

Keeping those patients independent is precisely what DHCS has in mind, Douglas said.

“Our goal here is to get all beneficiaries in cost-effective services, and we’re building off our managed care plan to do that,” Douglas said. “Our goal is to enroll them in managed care, then assess their needs. They might need some or few or all of those services.”

Missaelides said she really hopes the state can do all of that, but that so far, at least, the plan doesn’t include actual services. For instance, IHSS is a service that has no medical component, and every patient in ADHC has medical issues, she said.

More than 28,000 ADHC patients need skilled nursing services, 18,000 receive restorative physical therapy, another 9,000 have dementia. Those are serious conditions that require specialized services, Missaelides said, that can’t just be covered by moving people to managed care plans.

“I do see the state wanting to shed risk and cost,” she said, “shifting them to local plans and to counties. This is one bite of that apple.”

Elimination of ADHC as a Medi-Cal benefit was originally scheduled for Sept. 1, but the state asked for a three-month delay to come up with a better transition plan.

“My concern is to do this transition right, and make sure these people can remain in the community,” Douglas said. “Everything here takes a huge amount of energy and commitment, it is all hard lifts. It’s a difficult change for everyone — patients, providers, all of the staff here. It’s very challenging.”

Douglas mentioned several other points pertinent to the ADHC transition:

  • Most services, he said, will be coordinated by managed care plans, once the beneficiaries enroll in one of them — either Medi-Cal managed care or other managed care options.
  • The designation of approximately 20% of the ADHC population (roughly 7,000 people) as being especially vulnerable — “frail and at-risk” is the DHCS term — is a rough estimate, Douglas said. It’s based on a review of records, where patients who receive four hours of care per day for at least four days a week were considered to be the highest-acuity patients. That estimate could change, either up or down, once all of the assessments are completed, Douglas said. That is expected to finish up sometime in October.
  • In-Home Supportive Services (IHSS) “is an essential component to this effort,” Douglas said. He added that only 300 ADHC patients were at the hourly limit for IHSS care, and most were at about 170 hours — with the limit set at 283 hours, he said. “We will be reassessing IHSS hours,” Douglas said, “and we expect the number of hours will likely increase.”
  • Expansion of PACE (Program of All-Inclusive Care for the Elderly) is also a possibility under the transition plan. “We’re always looking at expanding PACE sites,” he said.

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