BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 547
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|AUTHOR: |Liu |
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|VERSION: |February 26, 2015 |
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|HEARING DATE: |April 29, 2015 | | |
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|CONSULTANT: |Shannon Muir |
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SUBJECT : Long-term care: Assistant Secretary of Aging and
Long-term Care: Department of Community Living
SUMMARY : Establishes the Department of Community Living within
the Health and Human Services Agency (CHHS) to serve as the
single state-level contact on issues of aging and long-term
care. Creates the position of Assistant Secretary of Aging and
Long-Term Care Coordination within CHHS, and tasks the position
with specified duties and responsibilities.
Existing law:
1.Establishes CHHS, an umbrella agency over the departments of
Aging, Child Support Services, Community Services and
Development, Developmental Services, Health Care Services,
Managed Health Care, Public Health, Rehabilitation, Social
Services, and State Hospitals.
2.Establishes the Coordinate Care Initiative which: mandates
that most Medi-Cal beneficiaries over age 21 enroll in a
Medi-Cal managed care health plan in order to receive Medi-Cal
benefits, including long-term supports and services; creates a
demonstration program for Medicare and Medi-Cal dual eligible
beneficiaries to coordinate medical, behavioral health,
long-term institutional, and home- and community-based
services through a single health plan; and, provides state
authority for Cal MediConnect.
3.Requires the Department of Public Health (DPH) to license and
certify long-term care facilities; to administer the
Alzheimer's Disease Program, California Arthritis Partnership
Program, Preventive Health Care for Adults, Well-Integrated
Screening and Evaluation for Women Across the Nation,
California Colon Cancer Control Program, Acquired Immune
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Deficiency Syndrome Waiver, Home Health Aide Certification,
Nursing Home Licensing & Certification, and Community-Based
Adult Services Facility Licensing & Certification.
4.Requires the Department of Health Care Services (DHCS) to
administer Medi-Cal, through which the following programs
operate: Community-Based Adult Services, Caregiver Resource
Centers, Acquired Immune Deficiency Syndrome waiver, Home and
Community-Based Services for the Developmentally Disabled,
Assisted Living Waiver, California Community Transitions
Project, California Partnership for Long-Term Care, Community
Living Support Benefit waiver, Proving Access, Counseling &
Treatment for Californians with Prostate Cancer, In-Home
Operations waiver, Developmentally-Disabled/Continuous Nursing
Care Program, Nursing Home/Acute Hospital waive, Home
Supportive Services Plus State Plan Option Program, Program of
All-Inclusive Care for the Elderly, Senior Care Action Network
Health Plan, State Plan Services, Medi-Cal Managed Care,
Prescription Drug Discount Program for Medicare Recipients,
and Genetically Handicapped Persons Program.
5.Requires the Department of Developmental Service to administer
Home and Community-Based Services for the Developmentally
Disabled, Developmental Centers, Office of Protective
Services, Foster Grandparent and Senior Companion Programs
6.Establishes the Department of Aging to administer programs
that serve older adults, adults with disabilities, family
caregivers, and residents in long-term care facilities
throughout the State.
7.Sets forth legislative findings and declarations regarding
long-term care services, including that consumers of those
services experience great differences in service levels,
eligibility criteria, and service availability that often
result in inappropriate and expensive care that is not
responsive to individual needs.
8.Sets forth legislative findings and declarations stating that
the laws governing long-term care facilities have established
an uncoordinated array of long-term care services that are
funded and administered by a state structure that lacks
necessary integration and focus.
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9.Under federal law, establishes the U.S. Administration for
Community Living (ACL), bringing together the Administration
on Aging, the Office on Disability and the Administration on
Developmental Disabilities to: reduce fragmentation in Federal
programs that address the community living service and support
needs of aging and disabled populations; enhance access to
quality health care and long-term services and supports for
all individuals; and, promote consistency in community living
policy across other areas of the federal government.
This bill:
1.Establishes the Department of Community Living (Department)
within CHHS, and requires the it to:
a. Align, to the extent possible, with the
federal Administration for Community Living;
b. Serve as the single state-level contact on the
issues of aging and long-term care;
c. Oversee statewide long-term care service
delivery;
d. Promote coordinated long-term care service
delivery and access to home and community-based
services at the local and regional level;
e. Provide leadership and information to local
agencies on best practices; and,
f. Serve as the organizational unit designated to
oversee all the long-term care programs in the state
and to consolidate all long-term care programs
administered throughout all departments of CHHS,
including programs serving older adults and those
serving person with disabilities.
2.Permits the Department to develop statewide standards for the
delivery of long-term care services to ensure consistent
access to those services throughout the state.
3.Requires the Department to provide sufficient flexibility to
local agencies to meet the specific needs of the local
population.
4.Establishes the position of Assistant Secretary of Aging and
Long-Term Care Coordination (Assistant Secretary) within CHHS,
be appointed by the Governor and confirmed by the Senate.
5.Requires the Assistant Secretary to:
a. Have an appropriate background in the
knowledge of long-term care;
b. Serve as a liaison to the federal
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Administration for Community Living;
c. Maximize federal funding opportunities;
d. Consolidate data and programs regarding
long-term care from all departments and programs
within CHHS;
e. Coordinate and direct establishment of the
Department;
f. Lead the development and implementation of a
statewide long-term care strategic plan;
g. Oversee and coordinate the integration of
health care and long-term care services;
h. Work with rural and urban communities to
identify infrastructure capacity issues and lead in
the development of access standards for home and
community-based services;
i. Facilitate the coordination of long-term care
services at the local level; and,
j. Report on an annual basis to legislative and
fiscal policy committees regarding the current status
of long-term care in the state, the level of state
spending on long-term care programs, federal funding
received, progress in improving the continuum of
services, and policy recommendations to enhance the
coordination and delivery of long-term care services.
6.Requires the Assistant Secretary develop a system-wide
long-term care plan that will:
a. Establish the priorities of the state;
b. Maximize the use of limited resources;
c. Engage a range of stakeholders representing
the population of aging and disabled persons who need
long-term care services;
d. Incorporate clear benchmarks and timelines for
achieving the goals set forth in the plan;
e. Address the expansion of managed care in the
Coordinated Care Initiatives counties, as defined;
f. Address the changes to, and differences in,
access to health care for older and disabled adults in
counties throughout the state;
g. Include a strategy for integrating the health
care system statewide, including recommended budgeting
practices and incentives to make home and
community-based services more accessible regardless of
where persons in need of long-term care reside;
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h. Propose a support network for unpaid family
caregivers in the state;
i. Review and analyze existing programs,
services, and deficiencies;
j. Consider employment-related policies and offer
to improve the support network, such as increasing the
length of protected leave;
aa. Develop principles and standards for
person-centering planning in an integrated system of
care to ensure that individuals and families have the
opportunity to engage in service planning across the
health and long-term care continuum in a manner that
reflects their needs, desires, and preferences;
bb. Include an analysis of workforce needs,
including the training and education requirements of a
long-term care workforce, and a strategy for aligning
the available resources to meet those needs;
cc. Include directives for ensuring that the
integrated long-term care system screens individuals
prior to placement in a "nursing home" or similar
long-term care facility, to avoid unnecessary
admissions to those facilities;
dd. Examine how a preadmission screening program
may be integrated into a managed care system and
include discussion of best practices in other states,
such as Oregon, that are used to determine whether an
individual is appropriate for community-based care as
opposed to institutional placement;
ee. Specify the minimum levels of functional
limitations that an individual must have in order for
a facility to receive Medi-Cal reimbursement;
ff. Include a strategy for developing a
public/private partnership to raise Californians'
awareness of, and engagement in, long-term care
planning;
gg. Consult advocates, private foundations, and
other stakeholders in developing a strategy to engage
the general population on long-term care issues;
hh. Include guidance on enhancing decision-making
capacity for impaired individuals, as well as options
for supported and surrogate decision-making that are
appropriate for various levels of impairment and risk;
ii. Specify measures to evaluate a consumer's
capacity to provide or oversee self-care and consent
to, or, refuse services;
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jj. Address how to educate long-term care
consumers and providers, the legal system, and the
public about "safe" advance directives, limited
conservatorships, and affordable access to
conservators;
aaa. Address end-of-life planning issues
emphasizing a consumer's rights to make decisions
about options to die with dignity;
bbb. Address improvements to end-of-life care while
promoting access to quality health and long-term care
services, including palliative care, for consumers and
their families;
ccc. Consider how to expand local and state-level
innovations designed to address the challenges related
to long-term care services delivery; and,
ddd. Examine model programs in various cities and
counties.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, California's
population of residents 65 years old and older will grow from
about 13 percent of the population to almost 20 percent of the
population by 2030. The state is not prepared for this
"silver tsunami." The overwhelming conclusion the Senate
Select Committee on Aging and Long Term Care drew from its
research and public hearings in 2014 is that California's
aging and long term care "system" of services and supports is
fragmented to the point of being almost impossible for
consumers, caregivers, and providers to navigate. We have 112
aging and long term care programs spread over 20 state
agencies and departments and very little coordination among
them. Change cannot happen overnight. We must begin now to
organize our services and supports delivery system and plan
our investments in long term care to maximize return in the
form of improved quality of life and cost savings to consumers
and taxpayers. It is time for California to commit to creating
a rational system of supports and services that will meet the
needs of aging and disabled adults. The costs of failure to
the state and to society are too great for us not to act.
2.California's aging population. According to the 2011 study "A
Long-Term Strategy for Long-Term Care" by the Little Hoover
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Commission, the number of Californians over age 65 is
projected to double by 2030 to 8.84 million people, or 18
percent of California's population. Working age adults with
disabilities likely will increase in number to more than half
a million by 2030, exerting additional pressure on
California's long-term care system. The aging population also
is living longer, many with physical or cognitive disabilities
or chronic illnesses such as Alzheimer's disease, high blood
pressure, diabetes and obesity, or with a history of heart
attack or stroke. According to a series of articles in the
Sacramento Bee from 2010 and 2011, California's growing
population will place unprecedented level of demand on the
state's health care resources.
3.Select Committee on Aging and Long Term Care Report.
According to the author, this bill is intended to implement
one of the recommendations of the Select Committee on Aging
and Long Term Care's 2014 report, "A Shattered System:
Reforming Long Term Care in California" (report). According to
the Select Committee on Aging and Long Term Care, this report
was the result of a comprehensive effort in 2014 to identify
the structural, policy, and administrative changes necessary
to realize an ideal long-term care delivery system and develop
recommendations and a strategy to achieve that vision. One of
the critical policy areas identified by the report was the
fragmented long-term care system, with the report stating that
California's fragmented structure complicates comprehensive
long-term care reform, and that in lieu of a cohesive
strategic plan, California has instead adopted a piecemeal and
reactive approach to change. To address this issue, the report
recommended creating the Department of Community Living within
CHHS, appointing an individual to lead the Department, and
developing and implement a long-term care strategic plan. The
Little Hoover Commission Report from 2011 recommends that the
Governor and Legislature should consolidate all long-term care
programs and funding into a single long-term care entity
within the CHHS.
4.Double referral. This bill was heard in the Senate
Governmental Organization Committee on April 14, 2015, and
passed by an 8-3 vote.
5.Related legislation. SB 571 (Liu), would require CHHS to
update the standards for CalCareNet and create an Internet Web
site that provides information to consumers, caregivers, and
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health and social service providers on how to effectively
navigate long-term care services and that assists consumers,
caregivers, and health and social service providers in making
informed decisions relating to long-term care services. SB 571
is set for hearing on April 28, 2015 in the Senate Committee
on Human Services.
AB 310 (Mathis), would require the Insurance Commissioner to
commission an annual study comparing the statutory
requirements for long-term care products in this state with
the statutory requirements governing long-term care products
as defined. AB 310 also requires the commissioner to provide
an annual report to the Legislature comparing the
marketability and affordability of long-term care insurance
products in this state with similar products in other states.
AB 310 is currently pending hearing in the Assembly Committee
on Insurance.
AB 332 (Calderon), would require the Insurance Commissioner to
convene a task force to examine the components necessary to
design a statewide long-term care insurance program, as
specified. AB 322 also requires the task force to recommend
options for establishing this program and to comment on their
respective degrees of feasibility in a report submitted to the
commissioner, the Governor, and the Legislature. AB 332 is
currently pending hearing in the Assembly Committee on
Appropriations.
AB 1235 (Gipson), declares the intent of the Legislature to
enact legislation to prohibit the use of in-kind value of
housing as a basis for calculating the home upkeep allowance
for a patient in long-term care. AB 1235 is currently pending
hearing in the Assembly Committee on Health.
6.Prior legislation. AB 2014 (Berg), of 2006, would have
establishes the California Department of Adult and Aging
Services for the purpose of coordinating and promoting those
programs that support adults who are aging or disabled so that
they may remain in their homes and communities as long as
practically possible. AB 2014 was referred to the Senate
Committee on Human Services but was never heard.
7.Support. Writing in support of this bill, the California
Retired Teachers Association states that "fractured oversight
and the complexity of the administrative 'spider web' have
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been ongoing issues of discussion in recent years, especially
with heightened interest in improving the system of long-term
care. For example, nursing homes are overseen by the
Department of Public Health, while residential care facilities
for the elderly are under the jurisdiction of the Department
of Social Services. As our population ages and requires more
nuanced and specialized care, the artificial bifurcation of
programs within the administration is illogical and burdensome
to navigate for seniors, their families, and caregivers.
Additionally, lack of coordination between state departments
has created a system with compromised transparency and
accountability, meaning that bad actors regulated by one
department may subsequently be licensed to run programs under
the banner of a second department."
The California Retired Teachers Association believes that this
bill will improve the likelihood that community-based services
will meet the needs of seniors, reducing hospitalizations and
institutional placements and ultimately improving their health
and well-being.
The National Association of Social Workers states that silos
and fragmentation have long been a problem in the delivery of
services to the state's most frail and vulnerable adults, and
that this bill with enhance coordination and provide consumers
with the services they need.
The California Association of Area Agencies on Aging states
that uncoordinated services for older adults and adults with
disabilities have created barriers in services, and that
services need to be individualized to empower older adults to
live independently in the community.
8.Opposition. The California Association of Public Authorities
(CAPA) has expressed concern about the bill's potential impact
on the In-Home Support Services (IHSS) program. CAPA points
out that the IHSS program provides personal care and domestic
services to aged, blind or disabled individuals in their own
homes. The purpose of the program is to allow these
individuals to live safely at home rather than in costly and
less desirable out-of-home placement facilities. The
California Department of Social Services (CDSS) has lead
responsibility for the administration of the IHSS program.
CAPA notes that the IHSS program has undergone extensive
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changes in the past few years and that one of the most
significant undertakings has been implementation of the
Coordinated Care Initiative (CCI) which was created to improve
care for California seniors and persons with disabilities who
are dually eligible for both Medi-Cal and Medicare. CAPA
states that even though this is a difficult population to
serve its members have had a great deal of "customer"
satisfaction with CDSS. CAPA emphasizes that CDSS has
displayed a cooperative and thorough manner of providing
assistance. CAPA believes that in light of the fact that CDSS
has several other major projects underway that impact Public
Authorities, the state-level reorganization of CHHS called for
in SB 547 is not well timed for IHSS consumers or providers.
9.Policy Comment. Historically, large-scale reorganization of
California state agencies and departments has been done either
through a Governor's Reorganization Plan, such as the plan
executed by Governor Brown in 2012, or through the Legislature
in the form of a bill, as with the reorganization of the
Department of Health Services (DHS) in 2006. In both examples,
the processes required extensive planning and review prior to
introduction of the legislation. In the reorganization of DHS,
in which it was split into DHCS and DPH, the resulting bill
(SB 126, Ortiz, Chapter 241, Statutes of 2006) included
structure and details regarding the authority of the new heads
of the departments, and which department would manage which
programs. Likewise, the Governor's Reorganization Plan No. 2
of 2012, which streamlined agencies and moved several
programs, was approved by the Legislature in the form of a 369
page bill, and the review of the plan by the Legislative
Analyst Office still found the plan to be lacking detail.
In this bill, there are several policy points that have yet to
be addressed. It is unclear if or when in the reorganization
process the Legislature will have the chance to review and
authorize the reorganization plan, or if the newly appointed
Assistant Secretary will have unilateral authority to
reorganize CHHS, perhaps at odds with the other directors in
the Agency. It is also unclear if the intent of the bill is
to disband the Department of Aging, or absorb the entire
department into the new Department of Community Living.
Additionally, the author cites 112 programs pertaining to
long-term care spread across agencies and departments, yet the
bill only calls for consolidation of programs and departments
within CHHS, which accounts for only 82 of the programs.
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Consolidation of programs will necessitate large changes in
personnel, and any plan will have to comply with statutes and
codes pertaining to hiring and firing state employees.
The Committee may wish to suggest the author and stakeholders
work through many of the details of this proposal before this
bill advances.
SUPPORT AND OPPOSITION :
Support: California Alzheimer's Association
California Association of Area Agencies on Aging
California Chapter of the National Association of
Social Workers
California Collaborative for Long Term Services and
Supports
California Commission on Aging
California Foundation for Independent Living Centers
California Retired Teachers Association
Congress of California Seniors
Justice in Aging
LeadingAge California
National Association of Social Workers
Service Employees International Union (SEIU) United
Long Term Care Workers
State Independent Living Council
Oppose: California Association of Public Authorities for IHSS
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