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Community Services

Senior & Long Term Care Division
Department of Public Health & Human Services

Olmstead Plan Update

July 2006

Introduction
The Senior and Long Term Care (SLTC) Division is responsible for long term care services to seniors and to individuals with physical disabilities and brain injuries. The availability and quality of community-based services largely determine whether individuals in need of long term care can live in the community instead of an institutional setting such as a nursing facility. In 2001 the SLTC Division established the Senior and Long Term Care Olmstead Advisory Council. The Council’s purpose was to develop, using the guidelines established by the federal Medicaid authority, Centers for Medicare/Medicaid (CMS), a comprehensive ADA/Olmstead plan containing recommendations to the SLTC Division for measures to provide services in the most integrative manner. All meetings were open to the public.

Progress on implementation of features of the plan follows:

Key Element Number One:
Ensure that appropriate stakeholders participate in the development of the plan and follow up.

The SLTC Division believes that individuals should themselves make decisions concerning their long term care services. The SLTC Division seeks to provide information on what service opportunities are available and to facilitate access to those services. In the same vein the SLTC Division believes that planning for service development should be consumer driven. The membership of the original Senior and Long-Term Care Olmstead Advisory Council included consumers and advocacy organizations. Representatives of providers and other key interests also participated.

The SLTC Division in the administration and development of services remains committed to seeking input from consumers and their advocacy organizations. For example, the SLTC Division is a Core Management Team member of the Montana Disability and Health Program with the University of Montana’s Rural Institute.  The SLTC Division also sponsors Legislative Issues forums to hear from consumers, providers, and other interested parties about possible new legislation, budget priorities, unmet service needs, and any other issues they believe need to be addressed related to senior and long term care services.  Additionally, the SLTC Division requires that each of its HCBS Waiver teams maintain a consumer advisory council.

Key Element Number Two:
Take Steps to prevent or correct current and future unjustified institutionalization of individuals with disabilities

The SLTC Division routinely identifies and assesses the needs of individuals in institutions and in the community regarding the range of available supports for persons in the community and develops new service options if warranted. 

  1. Over the past several years, the SLTC Division has implemented a series of “Money Follows the Person” initiatives through which many persons who were institutionalized but capable of receiving long term care services through community services have been placed into Medicaid funded home and community services.  “Money Follows the Person” means that the money necessary for community-based services “follows” an individual out of the nursing facility into the community.

    Since the initial development of Montana’s first program of Medicaid-funded home and community services in 1982, residents of Montana nursing facilities have routinely returned to their own homes, or moved into small residential settings such as licensed assisted living facilities, supported by Medicaid funded home and community services.  In addition to these ongoing placements, beginning in FY2000 the SLTC Division implemented, in cooperation with nursing facilities and the home and community case management teams, a more proactive strategy to identify nursing facility residents who might want to move into community services, and for whom appropriate, cost effective, community services could be developed.

    Beginning while the Olmstead plan was being developed, the first of four comprehensive efforts to assess, identify and develop appropriate in-home and community residential services for nursing facility residents who want, and are able, to live in more integrated community settings was initiated. In fiscal year (FY) 2001, the SLTC Division successfully transferred 30 individuals from nursing facilities into Medicaid funded home and community services at a projected cost of $500,000. In FY 2002, the SLTC Division repeated the process of assessing resident need and interest and developed plans for 27 individuals to be transferred to community service placements.  In FY 2004, a more comprehensive effort resulted in the transfer of 76 individuals to community service programs at a projected cost of $1.5 million dollars. Again, the dollars necessary to provide community services for these individuals was moved from the nursing facilities budget. The effort continued in FY 2006, in which 23 people were identified and are in the process of being moved from nursing facilities into community services, at an anticipated cost of $615,615.  While the cost of services varied according to the needs of each individual, the total cost of Medicaid funded home and community services did not exceed the cost of serving this group of people in Medicaid funded nursing facilities.

  2. The SLTC Division's Medicaid funded home and community services offer Medicaid recipients a number of choices. To be eligible for this program, an individual must be elderly or disabled, Medicaid eligible, and require nursing facility or hospital level of care. The majority of recipients served under this program require nursing facility level of care. A small percentage of individuals served at home are ventilator dependent. Without these services they would be in a hospital setting. In addition, the program serves a small number of individuals with a traumatic brain injury who would have been served in out-of-state rehab facilities, inpatient rehabilitation, or remain inappropriately placed in nursing homes, group homes, or other institutions were it not for the specialized services made available through this program.

    In FY 2001, when the Olmstead Plan was developed, the SLTC Division's Medicaid funded home and community services program served 1686 persons. That number has since grown to 1844 persons served in FY 2005. Much of that growth was due to the SLTC Division's initiatives to facilitate the transfer of nursing facility residents to Medicaid funded home and community services. The 2005 Legislature provided additional funding to provide these services to an additional 100 persons.

  3. In addition to the Medicaid funded home and community services program, Montana has provided the optional Medicaid service of personal assistance since the late 1970's. Montanans refer to this program as the "agency- based" program, as enrolled provider agencies manage the services on behalf of the consumer. As a state plan program, there are no restrictions based on age or disability, rather services are authorized based on functional limitations resulting from a discernable diagnosis. The goal of this program is to prevent or delay institutionalization by providing medically necessary maintenance or supportive care in the home. Personal care services are available to Medicaid eligible persons on an entitlement basis. The utilization of this service has grown over time with the increase demand for services due at least partly to the aging of Montana’s citizens.

    As a result of grass roots legislative efforts, Montana launched the self-directed personal assistance program in October 1995. The program is designed to allow consumers to hire, train, manage, schedule and discharge their attendants. Consumers must demonstrate personal capacity to manage their care or have a surrogate or personal representative manage their care. Those who do not are referred to the agency-based program. Consumers in the self-directed program can receive the same services outlined in the agency-based program with the addition of health maintenance activities. This is an exemption to Montana's Nurse Practice Act that allows the consumer to manage their bowel care, catheter care, and medication administration and wound care.

    Montana is the recipient of a three year, Independence Plus grant of $499,963, titled Big Sky Bonanza. The purpose of the grant is to foster the expansion of consumer-directed service delivery options, to increase consumer control, and to establish effective consumer protections through development of a cash and counseling option for the elderly and persons with disabilities. The option of paying spouses and parents as care givers under certain circumstances is also being explored.

  4. Overall, the SLTC Division's budget for community-based programs that provide services to people in their homes and communities rather than nursing facilities has grown from approximately $36.6 million in FY2000 to over $46.7 million in FY2005. This includes the combination of Medicaid funded home and community-based services waiver, personal assistance and home health services.

Key Element Number Three: 
Access to and Availability of Services

The essential factors in community placement are the availability of community services and easy access to those services.  In a frontier state such as Montana, access to services can be tremendously difficult.  Add to that the current lack of hands on caregivers, which is a factor in Montana’s urban and rural, as well as frontier communities, and the situation becomes even more problematic. Individuals cannot live in communities without proper supports, and deinstitutionalization becomes a moot point without service providers and caregivers.  Lack of information also limits access to services.  As long as individuals are unaware of available services, they are unable to access them. Cumbersome application processes may further curtail access to appropriate supports.

The SLTC Division applied for and was awarded two grants, which address this issue.

  1. One was the development of a “One Stop Shop” approach or system, which is being piloted in Billings, which allows people to seek information and apply for a variety of services at one location. Known as the Aging and Disability Resource Center Program, its goal is to empower individuals to make informed choices, to streamline access to long-term support and organize the long-term support system.

    The goal of this program is to have Resource Centers in every community serving as highly visible and trusted places where people can turn for information on the full range of long term support options and a single point of entry to public long term support programs and benefits.  The Centers will be a resource for both public and private-pay individuals. Resource Centers will gather and manage information from individuals in a way that ensures their confidentiality, but limits repeated collection of the same information throughout their long-term support careers.  The SLTC Division is currently working on incorporation of the Medicaid application process into the Resource Center.

    Resource Centers will move beyond information and assistance and will assume the role of primary entry point into the long-term support system.  Long term people who are eligible for Medicaid long-term support, including HCBS waiver services or Medicaid funded nursing home services, would be able to access those programs through the Resource Centers.  The SLTC Division is currently exploring ways to expand this project statewide.

  2. The Montana Choice grant was implemented in October 2001, and ended in September 2005.  It was responsible for improving upon the provision of direct care services through the following activities:

    • Develop a central training mechanism by which care attendants will be recruited, screened, and trained across the home care continuum.

    • Attract, train and place older workers as direct care workers.

    • Develop a public relations campaign to better educate the community to service needs and attendant abilities and challenges in providing this service.

    • Develop caregiver support groups.

  3. The SLTC Division also received funding during the 2005 legislative session to significantly increase the wages of direct care staff in the personal assistance and home and community services programs as well as the nursing facility program through I-149 tobacco tax revenues.  These wage increases have been implemented.

Key Element Number Four:
Informed Choice

Individuals cannot have real choice if they unaware of existing services and options.  Educational materials should be available in all formats, readily accessible and obtainable.

In response, the SLTC Division is currently reformatting its website to make it more user friendly for consumers and others who visit the website.  It has always attempted to provide materials in usable formats, most have been provided or linked on the SLTC Division's web site as well as.  A toll free number (1-800-551-3191) is available to Montana’s senior citizens to receive local information about services and supports available to them. 

One of the SLTC Division's Goal and Objectives for 2006/2007 is to increase the ability of Montanans to prepare to meet their own long term care needs, or the long term care needs of a relative or friend.  We will seek to achieve this by:

  1. Increasing the number of requests for information on the Aging Hotline/AAA toll free number each year;
  2. Continue to develop and provide long term care education materials, such as information included in the "Your Future is in Your Hands" packets through multiple sources such as, web site, Governors Conferences and paper media;
  3. Produce and air 50 Aging Horizons TV shows each year of the biennium;
  4. Maintain the number of State Health Insurance Program individuals served each year;
  5. Increase the number of Information and Assistance program contacts each year;
  6. Increase the number of participants at the Governors Conference on Aging each year;
  7. SLTC Division staff will conduct at least 100 public presentations each year of the biennium;
  8. Increase the number of visits to the SLTC Division WEBSITE each year of the biennium;
  9. Develop a coordinated continuing public education campaign to inform Montanans about long term care issues and options emphasizing the need for individual long term care planning and personal responsibility for individual health care needs; and
  10. Revise or update the “State of Aging in Montana” report each year of the biennium.

Key Element Number Five: 
Quality Assurance

Quality assurance guarantees the availability of quality services to the people who need them.  It also provides the SLTC Division with information on how providers can provide improved care. Long range planning is also essential as it points to the issues the state will have to face in the future. 
The Olmstead Council recommended that the SLTC Division seek ways to increase its adult protective services and ombudsman networks to ensure that individuals in communities are free from abuse, exploitation and neglect.

Since the Olmstead plan was developed, the SLTC Division, through the Aging Services Bureau, has added five regional ombudsmen, and has requested the addition of one state-level ombudsman through the upcoming legislative session. The ombudsman program advocates for residents of long-term care facilities, including nursing facilities, assisted living facilities and other adult care homes. It provides information and direct assistance to consumers concerning complaints about the health, safety, welfare and rights of residents.

The SLTC Division also added four adult protective services workers over the 2001 legislative session. There are currently 34.75 FTE social workers who help ensure the health, safety and welfare of vulnerable senior citizens and people with disabilities.

During the 2005 legislative session the SLTC Division requested that two pieces of legislation be passed to strengthen the statutes pertaining to abuse and neglect. House Bill 196 delineated the fiduciary responsibility of an agent to a principal in the Montana statutory power of attorney form. HB 197 amended the Montana elder and persons with developmental disabilities abuse prevention act, making it a felony to purposely or knowingly abuse, sexually abuse or neglect an older person or a person with a developmental disability, making it a misdemeanor for a first offense of negligently abusing or neglecting an older person or a person with a developmental disability.