Info for Consumers

POINT OF ENTRY REQUEST FOR INFORMATION
SUMMARY OF RESPONSES

The New York State Office for the Aging (NYSOFA) and the New York Department of Health (DOH) released a request for information (RFI) to collect input on the design and implementation of a point of entry model for the long term care system in New York State. The point of entry concept (POE) was a major component contained in the interim report of the Governor's Health Care Reform Working Group. Responses to the RFI were received from 127 individuals and organizations, including state and local governmental agencies, provider groups and associations, and consumer advocacy groups. As New York State moves forward with advancing the implementation of the point of entry model, it is anticipated that there will be on-going consultation with stakeholders. The request for information was the first step in this process.

NYSOFA and DOH staff reviewed all responses to the RFI and catalogued the information received related to each of the sections and questions in the RFI. The following is a narrative summary of the RFI responses. The narrative follows the groupings of questions contained in the RFI document and includes information related to: the purpose of the point of entry; design, planning and implementation factors that need to be considered in advancing the point of entry model; perspectives on each of the point of entry functions, specifically which should be included and how they should be carried out; and, administrative roles and responsibilities related to a point of entry model.

Section A: Information, Assistance and Assessments

What kinds of tools are necessary to perform strength-based social and medical screenings, create service plans and/or referrals? Are they available? Will new tools need to be developed and if so, how?

Most respondents said that tools should be: unbiased; simple; address social, psychological, financial, supportive, housing and health needs; offer choices to consumers; focus on community settings; standardized; Health Insurance, Portability and Accountability Act of 1996 (HIPAA) compliant; a component of a comprehensive integrated data collection system designed to assess and evaluate from a strength-based perspective an individual's status and needs; comply with federal and State regulations; and, web-based and consumer friendly. While the screening tool should be simple and only capture limited critical information, persons who responded to the issue said assessments should be comprehensive and identify a broader range of care needs.

Regarding existing tools, respondents listed tools in use and indicated they need to be combined or modified. Existing tools should be modified and built upon rather than

create new ones. Existing tools such as COMPASS, PRI and DMS-1 were discussed with respondents noting the merits of each tool.

The State should have the lead role in designing the tools with input and involvement of all stakeholders. There are too many individual State agency requirements that must be resolved before designing the questions for the tools. The tools must not contain extraneous questions. There must be collaboration and consensus among State agencies.

What is the best way to organize NY ANSWERS staff?

Most respondents were in agreement that the POE must be administered locally. NYC should be devolved to the borough level with staff organized into multiple neighborhood access points. Co-location and cross training of staff are important considerations.

How can duplication with existing information, assistance and case management services be avoided?

Most respondents indicated that there should be a single POE in each county that provides "one stop shopping" for the consumer to avoid duplication. A standardized form completed once by the consumer and the family can be shared with stakeholders. Computerized forms, a centralized data base and electronic transmittal of information would facilitate options and communication. The system must avoid multiple agencies collecting the same information using separate and different forms. A statewide entity needs to be the data management entity, setting the parameters but letting the locals use what works best for their communities.

How should NY ANSWERS relate to existing services for infants and children?

Most respondents said NY ANSWERS should be available to anyone who needs LTC. This includes infants, children and their caregivers. Service provision to this group must take into account the special needs of children but must not replace the basic care responsibilities of parents. A few respondents stated that because of the special needs of children there should be a separate POE for this population. The State must include providers that now service children in the planning of the POE.

How can NY ANSWERS effectively integrate informal/family supports into consumers' care plans?

Regarding informal/family supports, twenty of the thirty-seven respondents to this question stressed the need to include the caregiver supports from the start of the initial assessment process and into care plans. The national Family Caregiver Support Program was acknowledged as an essential element to the Aging network's informal/family support to providing services.

Are there particular functions NY ANSWERS should not provide?

All stakeholders responding to this question were in general agreement that the POE should provide information and assistance. Implementation of a POE providing information and assistance would be a success for the State, consumers and their family members. Respondents recommended that the State should not wait to implement the POE until the much more complicated issues of LTC system reform are resolved. Respondents stated that the POE should not focus on more than it can accomplish. The focus should be on an information and assistance system.

The POE must be unbiased as to services and service provider. While pre-admission assessments for nursing home placement might benefit consumers who desire nursing home placement, some respondents who preferred community placement feared such assessments might be a detriment for seniors and individuals with disabilities who want to remain in the community. Some respondents expressed concern that there is the possibility this would create dangerous bottlenecks in the POE system and lead to long waits for services, inappropriate levels of care and increased emphasis on institutionalization.

Providing consumers with comprehensive information about care options, appropriate types of care and even identifying providers is an appropriate function of a POE; however, steering admissions through referrals is not. It was also noted that service providers, including managed care providers, should not administer the POE. Financial eligibility for Medicaid belongs to the local DSS and should not be assigned to the POE.

Are there additional functions NY ANSWERS should provide?

Responding to the question of what additional functions should NY ANSWERS provide, respondents indicated: education; evaluation; monitoring; tracking; counseling; adequate and timely information for consumers and caregivers; outreach and maintaining a current database on community services and providers.

Section B: Community, Capacity, Coordination and Communication

How can NY ANSWERS staff be made fully aware of the populations to be served and the community resources and programs to serve them?

With respect to how the POE would stay aware of the populations served and available community resources, respondents indicated the use of: advisory boards/coalitions of stakeholders (with consumers and providers recommending such boards at both the local and State levels); only experienced, cross trained, knowledgeable staff who would be active participants in the community; State agency and state association data and by developing a comprehensive electronic data system which was constantly updated either by the POE or by providers themselves.

How can NY ANSWERS work and collaborate with local stakeholders?

Suggestions to promote collaboration among stakeholders emphasized the importance of a local component that included formal boards and/or coalitions and mechanisms to promote exchanges of information. The majority of local government responses asserted that they currently had adequate collaboration mechanisms in place. Some consumer groups were in favor of a tiered system with a State agency convening public and private stakeholders into an advisory board with sub-networks of local POE advisory boards. Nearly all respondents urged better collaboration among State and local agencies directly or indirectly engaged in long term care programs and/or services.

How can NY ANSWERS monitor community service gaps and work with appropriate partners to address them?

There was no preponderant theme concerning how to monitor for service gaps locally and statewide. Some saw it as a local function exclusively, providers preferred tracking the data statewide but there was no clear preference by respondent category. Consumer groups were particularly concerned that service gaps are not just identified but that the barriers that create those service gaps should be recorded and analyzed. Local government responses reiterated the importance of a good shared electronic database to track gaps and unmet needs. Provider groups mentioned using statewide data and analysis.

How would NY ANSWERS coordinate with other parts of the system?

Achieving actual coordination between the POE and other parts of the LTC system was recognized by most as a key to success. If the POE is to truly function for all stakeholders, all government entities and service providers must be directed by the State to participate. Providers would be compelled to coordinate services with other parts of the system. NY ANSWERS would implement State standards and analysis and improvement of procedures for the local consortiums. Many respondents across categories noted that timely, appropriate and beneficial movement from one level of care to another depends on communication between system participants. It should be supported by State set performance standards. A web-based universal assessment tool and a universal database will assist in coordinating with other parts of the system. A few respondents suggested coordinating with the 211 phone system being developed.

How would NY ANSWERS obtain community feedback about its services?

All categories of respondents mentioned the importance of a broad, reliable, updated and shared data base both to gather information about clients and about the service system itself. Feedback to the POE to gauge its effectiveness in information gathering, consumer satisfaction and systems change was supported by all. The majority of respondents across categories recommended the use of surveys (of consumers, caregivers and providers) to obtain feedback on NY ANSWERS services. It was specifically noted that feedback should be obtained from consumers, caregivers, local government and providers through formal and informal responses.

Section C: System Performance, Evaluation, Data Collection and Management

What data should be collected about consumers and services to promote effective systems and how would data be shared for the purposes of evaluation and planning?

County government, providers, consumers and advocates agreed that demographic, clinical, financial, caregiver support and social needs information are essential data elements. Data should be stored electronically. The system should take full advantage of the Internet and information should be shared while maintaining privacy, confidentiality and be compliant with HIPAA. Respondents distinguished between data needed locally to administer the POE and data used statewide to observe demographic trends and utilization comparisons and patterns. Systems must support POE information including, billing and tracking. To the extent possible new systems must be integrated with current systems such as Welfare Management System (WMS) and Medicaid Management Information System (MMIS).

What skills and qualifications must staff have in order to carry-out POE functions?

Respondents commented that staffing qualifications and experience were dependent upon the functions of the POE. If the POE provides information and assistance (not assessments) staff must have good communication skills and knowledge of available services to meet the diverse needs of persons of all ages with disabilities in the community but may not require medical and/or licensed staff. However, if the POE provides assessments, licensed medical, social and mental health professionals may be required. A qualified, caring and reasonably compensated workforce is essential to provide appropriate services along a flexible continuum of care. Training and education for POE staff (as well as community/provider education) was deemed critical.

What support and technology would be required for information, billing, and tracking systems?

Most respondents said that POE systems should have the capacity to produce management reports (including costs, service and quality reports) and be connected to billing and tracking. They should enable the sharing of information between the POE and involved agencies (as long as patient privacy rights can be protected) and have the capacity to identify trends, consumer preferences and consumer demographics. The technology used should enable POE staff to utilize laptop computers so that they can use them in the field. Real-time updates must be possible so that case information can be shared or changed. They should support information systems and the use of 211 numbers. They should be web-based instead of server based. Additionally, a web client database would also serve seamless transfer of data between authorized agencies. They should allow for longitudinal tracking of consumer data so that the information can be analyzed and program improvements can be made based on data. They should also be designed as an integrated system that interfaces with all components of the LTC system.

Section D: Organization and Finance

What are the advantages/disadvantages of a single contract for NY ANSWERS with one statewide entity?

Advantages of a single statewide contract for the POE include: standardization; consistency; assuring uniform procedures; ease of technical assistance; potential for less bias; more cost effective and an easier way to build a statewide data base and analyze outcomes.

Disadvantages of a single statewide contract included: too distant to accommodate local variations; less able to incorporate information of interest to particular locality; potential for the system to fail statewide instead of at a single location; potential gaps in information and less responsive customer service.

What are the advantages/disadvantages of multiple contracts with several NY ANSWERS providers?

Advantages of contracting with multiple entities for the POE included: maximizing use of existing staff expertise; familiarity with local factors; competition and ease of keeping information up to date.

Disadvantages included: difficulty with oversight and coordination; lack of uniformity; fragmentation; difficulty tracking and evaluating; less cost effective and difficulty with data comparisons statewide.

Should NY ANSWERS services be organized around single counties, consortia of counties (regions), or both?

The majority of respondents were in favor of the POE being organized around a single county entity or, where it is more practical, a regional approach for specific POE functions such as information and assistance. Whatever the unit of organization, respondents suggested developing specific requirements for the POE agency, the State maintaining a lead role particularly in establishing and enforcing performance standards, beginning with information and assistance only and insuring that all databases link with others.

How would the number and location of NY ANSWERS sites be determined for each county/region?

Most respondents indicate the number and location of sites should be determined based on local needs assessments. This should include demographics, geography, travel patterns, population density, and knowledge of local needs and availability/lack of services. The number and location of sites should be organized to allow for convenient/easy access. The sites need to be on public transportation routes and in areas where populations usually congregate.

Opinions about where the POE should reside included: some local governments recommending that the POE reside within a new or existing local government agency; some consumer advocates stating their preference that the POE reside in a statewide or regional organization and some provider associations and providers recommending that the POE not reside in county government agencies.

Should a NY ANSWERS system be phased in by geography and/or function?

Responses were evenly divided about whether NY Answers should be phased in by geography and/or by function but a majority urged a phased in implementation.

How can statewide performance standards and the need for local flexibility/variation be accommodated/reconciled?

The majority of respondents felt a statewide oversight entity should be responsible for performance standards. All stakeholders should participate in the development of the standards through the formation of a statewide advisory committee with regional representation of all stakeholders. Regulations and standard assurances should be incorporated into operations and plans approved by NYS.

Should the NY ANSWERS entity be required to provide all required services itself or should it be able to subcontract?

Most respondents support a POE model that allows for subcontracts. They stated that subcontracting would build upon the inherent strengths of community based services and local expertise and provide for flexibility. Subcontracting would maximize community based resources, subcontracting is an essential component of an efficient local/regional model, and would provide for necessary local flexibility. Subcontracted services must be fully integrated and function as a single system, seamless to the consumer.

What should be the relationship of NY ANSWERS to Medicaid, Medicare and other health insurance programs?

Many respondents noted that absent regulatory reform, the POE may act as a link to, but has no control over public or private insurers such as Medicaid, Medicare or private managed care. Payers will need to see the POE as an advantage to them (rather than a duplication of services) and they will be concerned with cost. On the other hand, respondents were concerned that the POE not become primarily a vehicle for cost containment. A common theme, particularly for consumers and providers, was the importance of linking a POE system to a thorough revamping of the NYS long term care system and to regulatory reform.

What kinds of technology to support the POE functions are necessary, available and cost efficient?

Many respondents advocated the use of computer technology, either alone or in tandem with other devices such as cellular phones, palm-held devices with e-mail and scanning capability and laptop computers for field staff.

What reimbursement system for NY ANSWERS would best insure a comprehensive, quality, cost efficient, unbiased entity: grant or program dollars based on cost or cost plus incentives; fee for service; regional/local capitation; other? If incentives are part of the reimbursement to a NY ANSWERS entity, what are some examples of outcomes to be rewarded? Recognizing that there are many unknown factors, please give an estimate or range of the probable POE cost.

Cost and reimbursement are major issues. Responses can be summarized as emphasizing that the State must be willing to invest public resources to support the POE system with the goal of saving health care dollars. The cost of operating and maintaining the POE must not fall on counties. The service should be available to all NYS residents and should be reimbursed at full operational costs to the entity operating the system. Reimbursement should be based on results. Suggested results included: maintaining individuals in the community; shorter hospitalizations; reduced hospital re-admission and ER visits; customer satisfaction as indicated by improved health and sense of general well being; and, achievement of targeted systemic improvements.

Many respondents across all categories raised the question of costs. Responses were inconsistent whether POE should have individual capitation limits, service region capitation or some other capping mechanism.

How could the transition from the current system (with considerable local variations) to the NY ANSWERS system be accomplished?

Most respondents said that a participatory process is critical to the transition from the current system to NY ANSWERS. Respondents suggested there must be a phased transition that includes pilot programs and demonstrations.

How should NYS (the contractor) oversee and evaluate the service?

Oversight of the POE should be independent and neutral.

Additional Comments

Respondents offered a wide range of comments regarding funding, eligibility, different populations, multiple locations for the POE, access, continuing care, appropriate provider of care, education, marketing, and the necessity for a POE. Planning at the local level with State coordination and support was universally cited as essential for buy-in and success. Respondents overwhelmingly stated that the design and development of a POE is a huge challenge that will require careful analysis, input and consideration before implementation.

No one disagreed that little systems change can occur at the local level unless the many State and federal regulations which drive the way services are provided as well as funding constraints which limit amount and kind of services available are addressed. Most respondents observed that a POE could be the first step toward establishing the statewide standards necessary to improve the system overall.

Local government respondents were virtually unanimous in describing their particular county system as effective and in being strongly opposed to a POE being located anywhere outside county agencies. So long as the State requires a county share of the LTC costs as well as the provision of housing and residential placements, cash assistance, Food Stamps, medical and social transportation, non-Medicaid home care and case management services, home delivery and congregate meal programs and Protective Services for Adults, the counties will continue to have a key role to play.

Consumer groups expressed concern about creating meaningful choices for community- based services and avoiding nursing home placements. Some also said that they felt the POE was really about cost cutting and gate keeping. Consumer groups were more likely to prefer a statewide or region-wide entity for providing specific POE functions. They were emphatic that POE functions are confined to information and assistance and that all planning should include consumer groups, be public and transparent.

Providers put less emphasis on whether the POE should be statewide, regional or county based. Provider Associations appeared most concerned about re-designing the system including extensive revision of the regulatory system which they see as in conflict with many of the proposed assessment and access changes. Many observed that the POE appears to raise a serious risk of merely adding another layer of bureaucracy to the existing system.

A cross-section of stakeholders noted workforce issues cannot be ignored. There is a serious staff shortage in many parts of the state, particularly upstate. Approval for services that cannot be provided in a quality manner is an issue that must be addressed if there is to be meaningful consumer choice.

Supporting consumer choice requires respect for individual decisions even if they run counter to the expected preferences, especially when a person may be appropriately placed in more than one setting.

Another perspective offered is that payment for services must be calibrated to the level of disability and must be case mix sensitive to populations across a continuum of need.