Home Services Program Annual Report 2010

Program Overview & Background

The Home Services Program (HSP) was established in December, 1979, to prevent the premature or unnecessary institutionalization of individuals with disabilities by providing care in the home as long as it did not exceed the cost of care in a nursing facility. HSP is dedicated to promoting independence, consumer control, and choice. Its goals are to support the desires and abilities of individuals with disabilities: to remain at home rather than in a nursing facility by having real choices and options for quality care; to retain control over the services they receive; and to live self-directed lives, being able to actively participate at home and in the community.

To achieve these goals, HSP continues to serve eligible people with disabilities on an individualized basis in their homes. Individuals participate in developing their own plan of care which helps to ensure that services address their needs and preferences and allows them to live as independently as possible in the home and community of their choosing. Individuals may live alone or with family or friends in any kind of private residence.

Although the guiding philosophies have remained unchanged, HSP has grown much since its origins 30 years ago when, in its very first year, then Department of Rehabilitation Services (DRS) provided personal assistant, homemaker and home health services to 1,256 individuals with disabilities with a total budget of $3 million. This "revolutionary" approach to long term care for adults had begun in California just three years prior, with then Illinois Department of Public Aid (DPA) replicating it the very next year as only the second state in the nation to do so. By FY80, the DPA home care program was transferred to the Department on Aging for individuals over age 60 and to DRS for individuals with disabilities under age 60 as the more appropriate implementing agencies.

From its beginnings, HSP quickly went from being a state initiative to become one of the first Medicaid Waiver programs in the country, serving both adults and children with all types of disabilities. Over the years, as the unmet needs of customers became more apparent, and after careful consideration of potential costs and benefits, HSP gradually added new services which have proven to be a tremendous value in both human and financial terms. These include emergency home response, adult day care, home delivered meals, assistive equipment, home modifications and respite. HSP has also been able to respond to other emerging disability issues with the addition of Medicaid waivers for HIV/AIDS (October, 1990) and Brain Injury (July, 1999). These waivers utilize community-based case management services which specialize in these disabilities and are able to link customers to other services tailored to meet their unique needs.

HSP continues to be a cost effective alternative to nursing facility care because its wide range of services enable it to serve the vast majority of persons needing a nursing facility level of care. HSP's personal assistant services, in particular, provide the flexibility and control which often make the difference as to whether a customer's needs may be met cost effectively or not. Unique among all the services, personal assistants are utilized by more than 80% of all HSP customers because this service allows customers to select, hire, train, supervise and terminate their workers and to set the hours of work. These workers can also perform a wide variety of tasks and can be trained to provide care in a way best suited to meet the customer's needs and preferences. In FY 2010, 33,976 individuals with disabilities were able to receive services through one of HSP's three Medicaid waivers as an alternative to nursing facility care.

Program Eligibility Determination and Service Planning

Prospective customers or those representing them may contact any one of 44 offices around the state to request assessment for HSP or may submit a request via the web-based referral for services which is on the DHS website at https://www.dhs.state.il.us. A case management staff member then goes to the home of the customer and administers the Determination of Need (DON) scoring tool which is used to determine program eligibility, to evaluate an individual's care needs and to identify available resources for meeting those needs. Based on the results of the DON, a service plan is jointly developed with the customer to address his or her unmet needs and to assist the customer and his or her family in coordinating safe, high quality, consumer-directed (when possible) services on the most cost-effective basis possible.

In order to be eligible to receive HSP services in FY10 and FY11, an individual must:

Be under age 60 at time of application unless applying for the HIV/AIDS or Brain Injury Waiver Programs.
Have a severe disability lasting at least 12 months or the duration of life.
Be at imminent risk of nursing facility placement as measured by receiving a minimum of 29 points on the Determination of Need (DON) eligibility determination tool, with at least 15 points in the "Need for Care" category.
Require services whose cost will not exceed that of nursing or other health care facility services.
For customers age 18 or older, have less than $17,500 in non-exempt personal assets; for customers under age 18, have less than $35,000 in family assets.
Apply for Medicaid and cooperate with the Department of Healthcare and Family Services (HFS) in the application process.
Be a resident of Illinois and a U.S. Citizen or legal resident.
Have a physician's approval of the plan of care.

As an additional consideration, since there are multiple Medicaid Waiver programs in Illinois including those through the DHS Division of Developmental Disabilities, individuals who are eligible for more than one waiver are evaluated and assisted in making an informed choice as to which waiver most appropriately meets their needs.

Program Services

HSP services are designed to preserve the dignity of individuals and their families, as well as to provide options that reflect their personal needs and preferences. Personal Assistant, Homemaker and Home Health are considered the "major services" in that they are used by more than 95% of all customers. Other services are used either alone or as a supplement to major services to address customers' unique needs. Brief descriptions of all available services follow:

Personal Assistant (PA) Services:

Services provided by individuals who are selected, employed, trained and supervised by the customer. These individuals may assist with household tasks, personal care and, with the permission of a physician, perform certain health care procedures. In order to use PA services, the customer or representative must be able to supervise PA's appropriately. This service has a uniform reimbursement rate statewide per a labor agreement with Service Employees International Union (SEIU).

Homemaker Services:

Personal care and household tasks provided by trained and professionally supervised staff employed by homemaker agencies. Instruction and assistance in household management and self-care are also available. This service has a uniform reimbursement rate statewide and is provided under a rate agreement with HSP. It is used by customers who are unable to direct the services of a PA or who have not yet found a PA.

Home Health Services:

Services provided by a registered or licensed practical nurse, home health aide or certified nurse assistant, or physical, occupational or speech therapist. These services are those which are beyond the scope of services covered under the Medicaid State Plan or private health insurance. These services must be provided in the customer's home and may be provided through an agency or by private individuals who are appropriately credentialed.

Emergency Home Response:

A rented signaling device which meets specified criteria to provide 24-hour emergency alerting coverage for medical, fire or other emergencies. The device may be worn in a variety of ways and have a variety of mechanisms to signal an emergency need. This service has uniform rates statewide and is provided under a rate agreement with HSP.

Adult Day Care:

The direct care and supervision of customers provided in a location outside the home by a community-based organization to provide personal attention and to promote social, physical and emotional well-being. This service has a uniform reimbursement rate statewide and is provided under a rate agreement with HSP. Transportation to adult day care may also be provided, if needed.

Home-Delivered Meals:

One or more ready-to-eat hot meals per day which are delivered to the home. This service is provided to individuals who can feed themselves but are unable to prepare a meal and is only provided when other services are not more cost effective.

Diagnostic Services:

Medical and functional evaluation services which are used to help determine program eligibility and to develop a service plan. This service is provided only when it is not available under the State Medicaid Plan or other funding source.

Assistive Equipment and Home Modifications:

Devices, equipment and/or home modifications that increase an individual's independence and capability to perform household or personal care tasks safely in the home. Must be able to reduce the need for another service or address a health or safety need.

Respite Services:

Intermittent care for adults and children with disabilities designed to relieve caregiver stress. Respite may be provided for vacations, rest, errands, a family crisis or other emergency. Respite services available are personal assistant, homemaker, home health, and adult day care. Respite is a stand-alone service and may not be received in conjunction with other ongoing services.

Background Check:

Background checks provided, upon customer request, for current or prospective PA's and other individual providers to enable customers to make an informed choice regarding the suitability of the potential employee.

Prescreening:

Prescreening of individuals conducted prior to nursing facility admission to ensure they receive the same minimum DON score required for eligibility for the HSP or the Department on Aging Community Care Program (DoA CCP), and to ensure they are offered the option of receiving home care. The screening of individuals coming from

hospitals to nursing facilities is performed for both programs by community-based Case Coordination Units. Prescreening for individuals under age 60 who are going from home to nursing facility may be conducted by either CCU or HSP staff.

For Brain Injury Waiver customers only

Day Habilitation:

Services provided to persons with brain injuries to assist with the acquisition, retention, or improvement of self-help, socialization and adaptive skills. These services are provided in a setting separate from the customer's residence.

Pre-Vocational Services:

Services provided to a person with a brain injury that prepare the individual for paid or unpaid employment by teaching concepts such as compliance, attendance, task completion, problem solving and safety.

Supported Employment Services:

Services provided to a person with a brain injury for whom competitive employment is unlikely. These services include intensive ongoing support to enable the person to perform in a paid employment work setting.

Behavioral Services:

Remedial therapy services provided to persons with a brain injury to decrease severe maladaptive behaviors. These services are intended to enable the customer to better manage his or her behavior and therefore be more capable of living independently.

Special Programs

Within HSP, there are two other program initiatives which are interrelated with each other but which are distinct in themselves:

Community Reintegration Program

Illinois' innovative Community Reintegration Program (CRP) was created as a natural adjunct to the Home Services Program to assist interested individuals with disabilities between the ages of 18-59 who were already in nursing facilities to transition back to the community. Since the inception of CRP as a small pilot in FY98, the program has grown to offer services statewide, and through FY10 has assisted more than1800 individuals in moving back to the community from nursing facilities. Staff of Centers for Independent Living (CILs) throughout the state provide the intensive case management services that customers need during the transition process from nursing facility to home as partners with HSP staff and provide a wide range of one-time services. This includes everything from assistance in finding housing, arrangement of home modifications for accessibility purposes, or funding for such items as housing deposits or furniture. Individuals very often are unable to leave nursing facilities because they no longer have homes to which to return, all of their income goes toward their care in the nursing facility, and/or it can be difficult to handle necessary logistics for transitioning from the nursing facility. Upon return to the community, CILs follow up and provide assistance with many other issues such as using public transportation to get to desired destinations, transferring prescriptions to local pharmacies, or linking with community programs. For customers eligible to receive HSP services once they are fully settled in the community, their case is transferred to the local HSP office.

CRP, together with HSP as a whole, is one of the centerpieces of the Olmstead plan in Illinois, dramatically increasing the quality of life for those served and embodying core independent living values, such as choice, independence, and community integration. In addition, this program has resulted in significant long-term care savings for the State. Each person returned to the community in the early years of the program saved as much as $10,000 per year in total costs to the State, but the margin of savings has narrowed considerably in recent years as home care provider costs have risen. Nonetheless, over time, CRP alone has saved the State tens of millions of dollars, making it a program offering both important societal and public funding benefits.

Money Follows the Person (MFP)

In FY07, the federal Medicaid agency offered all states the opportunity to participate in their Money Follows the Person initiative. At the federal level, this program was developed in response to independent living advocates nationwide who believed that, as in the Olmstead decision, if funding could be provided to maintain an individual in a nursing facility or other institution that those same funds could instead be used to allow the person to live in the community. Since the Medicaid program is a shared state and federal expense, and is accompanied by complicated sets of state and federal regulations and laws, Money Follows the Person was initiated as a five year pilot.

The Illinois Department of Healthcare and Family Services (HFS), as the State Medicaid agency, took the lead in coordinating Illinois' application process with the Department on Aging, the Department of Human Services, and the Illinois Housing Development Authority. These agencies, as representatives of Medicaid waiver programs, Medicaid-funded institutional programs, and/or housing, were required partners for the effort. The initial application was accepted and HFS then took the lead in coordinating the even more involved formal application process which was completed near the end of FY08. Approval of the formal application was received in FY09. The state is very pleased to be able to participate in this partnership as it is a key component of the state's commitment to community living.

The requirements of Money Follows the Person have been complex and have changed since initial application approval. While this program essentially accomplishes the same thing as the Community Reintegration Program, CRP has been able to address a broader population. In FY11, there are plans to limit CRP to being a Medicaid only program so most but not all recipients will meet the requirements of both programs.

Program Accomplishments in FY 2010

Money Follows the Person (MFP) began its fourth as the first full year of implementation of this program. The process ultimately required by CMS is very complex and extensive, with very detailed documentation requirements and many more forms than are required for the existing waiver and reintegration programs. However, the University of Illinois provided many very beneficial services: development of the program's IT system which allows mobile entry of required data by case managers on laptop computers; provision of and assistance with medical information and utilization data from HFS Medicaid records; and general technical assistance and training regarding specific cases as well as the program in general. Additional "bugs" remained to be worked out, but for the most part, the program ran much more smoothly in FY10, largely thanks to assistance from the University of Illinois.
A program utilizing spouses as paid caregivers of HSP customers was developed as a pilot for a limited number of individuals living in counties selected to provide a good cross-section of the HSP population. Spouses have been able to provide only "exceptional care," which is care required because of the disability and which a spouse would not ordinarily provide such as bathing and dressing. The program has been limited to customers with the most severe disabilities. Other criteria were also be required such as the customer's ability to direct the care, a limit on the number of hours per week which a spouse can provide so as to prevent caregiver burnout, and the ability of the spouse to provide the needed care. Background checks have also been required to ensure that there has been no history of domestic violence, abuse, neglect, or fraud by the spouse as it relates to or affects the services provided by DHS or HFS. In spite of hundreds of letters sent to potentially eligible current customers and outreach through CILs, doctors' offices and other medical providers, only 13 customers took advantage of this program. While the program is appreciated by those using it, very few customers and their spouses were either interested in the program or found that it could be a useful approach to service.
Processing personal assistant (PA) timesheets is one of the largest and most labor intensive activities in HSP. In an effort to provide greater accountability by providing more accurate timekeeping information, HSP pursued the development of an automated timekeeping system. One of the most promising models in the country has PA's call in start and end times for each work shift from the customer's home or personal telephone. The customer telephone is registered in the system so this system confirms that the PA is at the job site and the actual hours of work. HSP pursued the possibility of a "fit" for this service with an existing vendor providing similar services for state staff in other agencies. Effort on this continued through much of FY11 at which time it was concluded that there was no adaptation which would allow the existing vendor's service to meet the demands of the PA timekeeping system.
Because HSP, the Division of Developmental Disabilities, and the Department on Aging have waivers with potentially overlapping populations, efforts were renewed to conduct regular interagency meetings between HSP and these agencies to discuss these issues. Topics discussed included ways to maximize Medicaid claims, streamline intersecting policies and procedures, and pursue solutions which may have potential benefit to more than one of these interagency partners. As a result of these beginning meetings, some overlap of services was remedied and it was learned that many of the overlaps were in information technology systems (IT) rather than in program issues. As a result, IT staff from all three agencies began working to address the genesis of these issues and the needed solutions.
HSP has continued pursuing solutions to the issue of children transitioning from the MFTD waiver to HSP.

Program Plans for FY 2011

HSP will continue efforts to address barriers to improved outcomes in the Money Follows the Person Program (MFP). One of these efforts will be to require all persons eligible to be served in MFP to be served in the MFP program. Other individuals not eligible for MFP will continue to be served in the Community Integration Program (CRP) if they are eligible for CRP services.
HSP's Spousal Caregiver Pilot will be concluded and a final report is to be sent to the General Assembly in March with HSP recommendations regarding its potential continuance.
HSP will continue to pursue automation of its personal assistant payroll function. The ultimate goal is to have a telephonic system, but the Program is prepared to pursue interim solutions such as scanning technology for this staff intensive task.
Maximization of Federal Financial Participation in all areas of HSP will be a primary goal in FY11 with particular attention being planned for waiver duplicate cases with DD and Aging. For individuals actually receiving services from two agencies, transitioning them to services from one agency is very time intensive. However, where there is an IT problem at the heart of a duplicate issue, solutions are becoming closer as HFS and DHS IT staff work together to systematically resolve the problems, given the very complicated interagency systems which process and edit Medicaid claim.
HSP will be continuing in its interagency efforts to address the issues of the MF/TD waiver children transitioning to HSP. This will include the development of an interagency mechanism to review transition plans and proposed HSP service plans to ensure that medical considerations have been adequately taken into account.
HSP is pursuing program changes which will make services more equitable across the state and conserve financial resources at the same time. HSP will also be investigating ways it can address the tight fiscal times facing Illinois while ensuring that the state's most vulnerable citizens served by HSP can continue to be prevented from having to go to nursing facilities.
HSP will be among the agencies working with HFS to implement a managed care program beginning on July 1, 2011, for select northern counties to pilot an "integrated care" model which provides a medical "home" for all Medicaid customers as well as after hours care at the physicians office in an attempt to improve medical outcomes and reduce unnecessary trips to emergency rooms and hospitals. The program will also prioritize customer medical risks to provide increasing levels of case management as needed to ensure that all medical providers for each customer communicate with one another again in an effort to improve care, improve customer compliance with medical instructions, and to reduce unnecessary more intensive medical care.

As always, HSP will continue to review and update its rules and procedures and continue its training and other efforts to ensure that they reflect the historic mission, purpose and design of the program and that they maintain program integrity. HSP will also continue to strive to support any efforts which allow or improve customers' maximum choice, dignity and independence in long term care.

Historical Program Overview
FY 2004 through FY 2010

Category	FY 2004	FY 2005	FY 2006	FY 2007	FY 2008	FY 2009	FY 2010
Program Administration	$15,038,807	$16,425,127	$16,638,547	$20,536,461	$20,277,902	$23,494,016	$21,870,994
Other Provider Costs & Benefits	-	-	-	$1,320,420	-	$4,800,000	$8,000,000
Customer Services	$300,655,201	$343,171,116	$351,955,381	$381,018,497	$433,285,736	$476,528,337	$508,967,089
Total Spending	$315,694,008	$359,596,243	$368,593,928	$402,875,378	$453,563,638	$504,822,353	$538,838,083
% Admin to Total Spending	4.76%	4.57%	4.51%	5.43%	4.47%	5.60%	5.54%
Average All Service Cost Per Customer	$986	$1,073	$1,112	$1,176	$1,296	$1,386	$1,457
% Increase of Average Cost from Prior Year	3.97%	8.83%	3.67%	5.79%	10.17%	6.95%	5.12%
% Annual Rate Increases	3.22%	3.41%	3.75%	5.89%	11.08%	5.05%	5.70%
Customers Receiving Paid Services	31,071	32,549	32,704	32,944	33,662	34,309	33,976
Total New Customer Service Plans	5,554	6,021	4,858	5,144	5,061	6,135	5,225
Total Customer Applications	8,511	8,274	7,596	8,339	8,564	8,902	7,757

Historical Summary of Medicaid Claim & Reimbursement
FY 2004 through FY 2010

	FY 2004	FY 2005	FY 2006	FY 2007	FY 2008	FY 2009	FY 2010
Total Program Spending	$315,694,008	$359,596,243	$368,593,928	$402,875,378	$453,563,638	$504,822,353	$538,838,083
Administrative Medicaid Claim	$24,796,989	$26,469,839	$24,768,082	$30,642,078	$30,885,910	$35,971,261	$34,355,662
Customer Service Medicaid Claims	$212,348,800	$239,797,400	$244,134,288	$259,607,641	$280,466,047	$341,219,694	$365,004,971
Total Medicaid Claim	$237,145,789	$266,267,239	$268,902,370	$290,249,719	$311,351,956	$377,190,956	$399,360,633
Total Medicaid Reimbursement	$118,572,895	$133,133,619	$134,451,185	$145,124,860	$155,675,978	$188,595,478	$199,680,317
% Medicaid Claim to Total Spending	75.12%	74.05%	72.95%	72.04%	68.65%	74.72%	78.46%
Category	31,071	32,549	32,704	32,944	33,662	34,309	33,976
Customers with Medicaid Claim	24,538	25,072	24,616	25,554	26,495	27,116	26,320
% Customers with Medicaid Claim	78.97%	77.03%	75.27%	77.57%	78.71%	79.03%	77.47%

Waiver Summary by Year
FY 2007 through FY 2010

	FY2007			FY2008			FY2009			FY2010
Waiver	# Served	Avg. Cost Per Mo.	Total Spending	# Served	Avg. Cost Per Mo.	Total Spending	# Served	Avg. Cost Per Mo.	Total Spending	# Served	Avg. Cost Per Mo.	Total Spending
Persons with Disabilities	24,570	$1,097	$270,605,521	24,629	$1,087	$290,788,840	25,588	$1,374	$333,597,131	25,655	$1,371	$362,369,768.00
Persons with Brain Injury	6,599	$1,505	$88,174,546	7,287	$1,608	$118,780,830	7,005	$1,745	$118,647,549	6,636	$1,810	$123,094,050.00
Persons with HIV/AIDS	1,775	$1,242	$21,315,086	1,746	$1,325	$22,750,417	1,716	$1,292	$23,225,767	1,685	$1,374	$22,496,562.00
TOTAL	32,944	$1,176	$380,095,153	33,662	$1,296	$432,320,087	34,309	$1,386	$475,470,447	33,976	$1,457	$507,960,379.00

Note: Customer services only, excluding prescreening.

Summary of Spending by Waiver & Type of Service
FY 2010

	TOTAL		Brain Injury Waiver		HIV/AIDS Waiver		General Waiver
Type of Service	Customers Served	Total Expenditures	Customers Served	Total Expenditures	Customers Served	Total Expenditures	Customers Served	Total Expenditures
Personal Assistant	28,144	$411,316,293	5,524	$94,774,458	1,522	$18,469,063	21,098	$298,072,772
Homemaker	5,079	$56,658,042	835	$11,532,182	163	$1,506,374	4,081	$43,619,486
Maintenance Home Health	1,353	$15,086,930	276	$3,086,125	28	$219,544	1,049	$11,781,261
Home-Delivered Meals	2,837	$5,853,810	1,113	$2,809,832	33	$36,620	1,691	$3,007,358
Home Remodeling	187	$869,308	48	$281,435	2	$3,332	137	$1,338,130
Adult Day Care	263	$2,370,105	69	$547,633	-	$0	194	$1,822,473
Assistive Equipment	492	$544,259	53	$44,396	25	$13,428	414	$11,626
Electronic Home Response	6,395	$1,757,238	1507	$381,423	139	$37,684	4,749	$1,343,699
Brain Injury Services (duplicated)	581	$1,193,007	577	$1,181,381	-	$0	4	$11,626
Respite	652	$1,376,249	23	$32,550	-	$0	629	$486,434
Diagnostic Services	1,676	$50,589	219	$11,981	-	$0	1,519	$62,731
PA Background Check/Other	1,738	$76,794	343	$13,599	6	$464	1327	$38,607
Case Management Services	8,439	$10,807,757	6,283	$8,397,055	1640	$2,210,052	516	$200,650
Prescreening	10,933	$1,006,710	255	$26,143	60	$6,203	10,618	$974,364
Total (excl. Prescreening)	33,976	$507,960,379	6,636	$123,094,050	1,685	$22,496,562	25,655	$362,369,768
Total (with Prescreening)	44,909	$508,967,089	6,891	$123,120,193	1,745	$22,502,765	36,273	$363,344,131

Note: Total numbers are unduplicated; customers may receive multiple services.

Summary of Spending by Type of Service
FY 2004 through FY 2010

	FY2007		FY2008		FY2009		FY2010
Type of Service	Customers Served	Total Expenditures	Customers Served	Total Expenditures	Customers Served	Total Expenditures	Customers Served	Total Expenditures
Personal Assistant	27,043	$298,964,556	27,689	$346,642,122	28,014	$381,064,442	24,478	$411,316,293
Homemaker	5,026	$42,066,892	5,123	$43,783,449	5,144	$51,651,426	5,079	$56,658,042
Maintenance Home Health	1,691	$16,731,619	1,601	$16,450,678	1,432	$15,531,017	1,353	$15,086,930
Home-Delivered Meals	2,678	$4,661,210	3,064	$5,779,000	3,162	$6,324,842	2,837	$5,853,810
Home Remodeling	199	$647,452	216	$822,220	6,418	$1,762,172	6,395	$1,757,238
Adult Day Care	260	$1,808,248	267	$1,895,090	265	$2,147,712	263	$2,370,105
Assistive Equipment	658	$574,687	566	$569,418	1,393	$1,649,665	581	$1,193,007
Electronic Home Response	5,386	$1,689,845	5,906	$1,605,874	616	$1,302,749	652	$1,376,249
Brain Injury Services (duplicated)	1,331	$1,464,029	1,428	$1,680,978	263	$1,031,532	187	$869,308
Respite	83	$194,682	487	$586,685	569	$598,675	492	$544,259
Diagnostic Services	1,550	$42,356	1,571	$43,970	2,093	$73,847	1,676	$76,794
PA Background Check /Other	1,447	$69,700	1,459	$70,289	1,704	$46,125	1,738	$50,589
Case Management Services	8,276	$11,179,877	9,109	$12,390,314	9,334	$12,286,243	8,439	$10,807,757
Prescreening	10,144	$923,344	10,631	$965,649	11,735	$1,057,890	10,933	$1,006,710
Total (excl. Prescreening)	32,944	$380,095,153	33,652	$432,320,087	34,309	$475,470,447	33,976	$507,960,379
Total (with Prescreening)	43,088	$381,018,497	44,283	$433,285,736	46,044	$476,528,337	44,909	$508,967,089