BILL ANALYSIS Ó AB 664 Page 1 Date of Hearing: April 21, 2015 ASSEMBLY COMMITTEE ON AGING AND LONG-TERM CARE Cheryl Brown, Chair AB 664 (Dodd) - As Introduced February 24, 2015 SUBJECT: Medi-Cal: universal assessment tool report. SUMMARY: Requires the California Department of Aging, The California Department of Social Services the California Department of Health Care Services and specified stakeholders to evaluate and report to the Legislature, outcomes and lessons learned from the universal assessment tool pilot project. Specifically, this bill: 1)No later than January 1, 2017, directs the Department of Health Care Services (DHCS), the Department of Social Services (DSS) and the California Department of Aging (CDA) to consult with a work group required to have been convened by those three department to develop a universal assessment process, including a universal assessment tool for In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS), and Multipurpose Senior Services Program (MSSP) services. 2)Evaluate and report to the Legislature on the outcomes and lessons learned from the universal assessment tool pilot authorized by SB 1036 (Chapter 45, Statues of 2012) a trailer bill of the Budget Act of 2012, related to Human Services. AB 664 Page 2 3)Specifies that the evaluation include findings from interviews with consumers who chose to be assessed using the universal assessment. The evaluation shall include: a. The level of satisfaction consumers experienced compared to previous assessments. b. The level of satisfaction that the consumer experienced from the assessor. c. The ability of consumers to understand and respond to the assessor administering the universal assessment tool for the duration of the assessment. d. Findings from consumers choosing to be evaluated using previous assessment tools, including reasons why the consumer chose the previous assessment process, and concerns that the consumer had with the universal assessment tool. e. Data on the amount and type of services identified by the previous assessment tools as compared to the amount and type of services determined through the universal assessment process to identify and understand discrepancies, if any. f. Data on home-and community-based services utilization and costs of those services before and after the use of the universal assessment tool in order to understand how and if the universal assessment tool impacts the Home and Community Based Services (HCBS) system. AB 664 Page 3 g. Data on the rate of hospitalizations and skilled nursing care utilization in order to understand how the universal assessment tool may impact acute hospital care utilization. EXISTING LAW: 1)Establishes the Medi-Cal program, a free or low-cost health care service for families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults with incomes below 138 percent of the federal poverty level (FPL). Benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, and long term services and supports. Medi-Cal is administered through federal-state-county partnerships with the federal Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), and county welfare departments in each of the 58 counties. 2)Establishes the Coordinated Care Initiative in Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara counties which begins the process of integrating the delivery of medical, behavioral, and long-term services and supports while attempting to integrate Medicare and Medi-Cal for people in both programs, known as "dual eligible" beneficiaries. Consumers at the local delivery points know the program as "Cal MediConnect," while policy makers in Sacramento know the program best as "Coordinated Care Initiative." AB 664 Page 4 3)Requires DHCS, the Department of Social Services, and California Department of Aging (CDA), in consultation with a stakeholder work group comprised of IHSS and other home and community-based service consumers (or their representatives), managed care plans, counties, IHSS, MSSP, and CBAS providers, area agencies on aging, independent living centers, legislative staff and unspecified others, to develop a universal assessment process drawing upon the IHSS uniform assessment process and hourly task guidelines, the MSSP assessment process, and other appropriate Home and Community Based Services (HCBS) assessment tools, to develop individual plans of care, and to consider how the assessment tool may be used to assess the need for nursing home care, and to divert individuals from nursing facility level of care and to HCBS. 4)Authorizes the testing of the Universal Assessment Tool (UAT) in no fewer than two, but no more than four counties. Requires DHCS, DSS, and CDA, to report to the Legislature on the counties and beneficiary categories for which the universal assessment tool may be implemented. 5)Requires DHCS, DSS, and CDA to, no later than nine months following the implementation of the universal assessment process, report to the Legislature on the results of the initial use of the process, and authorizes the departments to propose additional beneficiary categories or counties for expanded use of the process. 6)Repeals these provisions by January 1, 2017. AB 664 Page 5 FISCAL EFFECT: Unknown. COMMENTS: Author's Statement: "California provides Home and Community Based Services (HCBS) to low-income seniors and persons with disabilities to help them remain in their own homes and communities. Each of the three main HCBS programs rely on workers to determine eligibility and conduct an assessment for the type of services that are needed. Currently, those who receive services for more than one program undergo multiple assessments that, in some cases, collect duplicative information. In 2012, the Legislature recognized that competing eligibility determination and assessment processes create several forms of inefficiency in the administration of these programs. The Universal Assessment Tool (UAT) was identified as an alternative to the current assessment system. A UAT is a single application and data system that would streamline eligibility determinations and assessments. It would shift the existing HCBS framework from a "program-based" approach to a "person-centered" approach. The goal of this new framework is to facilitate better care coordination, enhance consumer choices, reduce administrative inefficiencies, improve data analysis capabilities, and potentially create long-term fiscal savings. Without fully AB 664 Page 6 understanding the outcomes of the Universal Assessment Tool, it will be difficult for the legislature to determine if this is worth implementing state-wide." A Shattered System: According to "A Shattered System: Reforming Long-Term Care in California," a thorough assessment of the state's deficiencies in program and service design and delivery to meet the growing needs of an aging population published recently by the Senate Select Committee on Aging and Long Term Care, the most critical issue facing California's Long Term Care (LTC) system is the fragmentation of programs at the state, regional, and local levels. This fragmentation reflects decades of bureaucratic convenience, though it creates barriers to citizens accessing appropriate services, and drives, supports and promotes a lack of usable data to inform policy-makers struggling with critical decisions about scarce resources. California lacks a strategic plan on long-term services and supports that would set priorities for services for the future to maximize the use of finite resources. Despite the lack of a strategic plan, the state should take specific steps to position itself in a more favorable position to absorb the impact of a rapidly expanding population of individuals in need of long-term services and supports. California has an array of programs and services for individuals with disabilities. The programs are located in multiple agencies, use different delivery systems and challenge consumers, family members, seeking to access services. Law makers, agency staff, and providers are routinely confounded by AB 664 Page 7 the results of a poor long-term care strategy. Multiple reports have concluded that California's long-term care services delivery system operates in different 'silos' causing so-called 'fragmentation,' and a barrier to service between each fragment, or silo. As a consumer ages, and develops greater dependence on services, they are challenged by an assessment process that invades their privacy, seeking detailed information about their health, personal, and familial lives. The repetitive exposure of personal information serves to deter people from accessing services as the discomfort of disclosing deeply personal details about themselves to yet another stranger can aggravate and demoralize the client. Universal assessment offers a single uniform process to connect services and corresponding data elements about service needs and preferences, while evaluating an individual consumer's needs in a consistent manner. According to one of the five principle recommendations within the Senate Select Committee on Aging's report, the state should commit to universal assessment as a statewide initiative that can transform the existing system; it can be utilized not only for more accurate and efficient service delivery purposes, but also to support outcome analysis by gathering information that can be used as quality measures. At the state level, universal assessment data can help law makers and program planners simultaneously understand the needs of individual consumers, and consumers as a whole, support more strategic allocation of resources, and evaluate quality. A universal assessment tool will also assist the state to develop a data infrastructure with the capacity to collect and report integrated data from across programs to reduce redundancies and duplication while driving high quality program, fiscal and policy decisions. AB 664 Page 8 Arguments in Support: The American Federation of State, County and Municipal Employees (AFSCME) cites AB 664 as a measure that will help the state shift the existing framework of the HCBS system to one that is more "person centered," and though it was piloted, no formal investigation of its outcomes were authorized. LeadingAge, a not-for-profit organization representing over 400 providers of HCBS and institutional services for about 100,000 Californians cites improved efficiencies in the existing service delivery system for low income older Californians that foreshadows improved choices for consumers, reduced administrative inefficiencies, better data, and potentially long-term savings. Arguments in opposition: None. Dual Referral: AB 664 was previously heard by the Assembly Health Committee on April 7, 2015 and passed 17-0. Related Legislation: AB 664 Page 9 SB 21 (Liu) 2011: Require DHCS to work with stakeholders to develop or identify a long-term care assessment tool by July 1, 2013, that would identify eligible individuals' long-term care needs; died in Senate Appropriations Committee. SB 998 (Liu) 2009: Required DHCS to work with stakeholders to develop or identify a long-term care assessment tool that would identify an individual's long-term care needs; died in Senate Appropriations Committee. AB 3019 (Daucher) 2005: Required the Health and Human Services Agency to develop and test the Community Options and Assessment Protocol to minimize duplication and redundancy of multiple assessments for home- and community-based services, and to connect consumers with the appropriate program services; held in Senate Appropriations Committee. AB 786 (Daucher), Chapter 436, Statutes of 2003: Created a pilot project which required the county of San Mateo to seek funding for an evaluation of the use of an assessment instrument by an independent research organization, and would require the results of the evaluation to be reported to the Legislature and to the Long-Term Care Council in the California Health and Human Services Agency on or before May 31, 2009. The bill provided that state funds shall not be appropriated for its purposes, and required the county to implement the bill only to the extent that the county received federal or private funds for that AB 664 Page 10 purpose. AB 664 Page 11 REGISTERED SUPPORT / OPPOSITION: Support American Association of Retired Persons (AARP) American Federation of State, County and Municipal Employees (AFSCME), AFL-CIO California Association of Area Agencies on Aging (C4A) California Commission on Aging California Senior Legislature LeadingAge California United Domestic Workers of America-UDW/AFSCME Local 3930 Opposition None on file. AB 664 Page 12 Analysis Prepared by:Robert MacLaughlin / AGING & L.T.C. / (916) 319-3990