Home and Community-Based Services for Older People and Younger Persons with Physical Disabilities in Washington

HOME AND COMMUNITY-BASEDSERVICES FOR OLDER PEOPLEAND YOUNGER PERSONS WITHPHYSICAL DISABILITIES INWASHINGTONFinal ReportPrepared for:U.S. Department of Health and Human ServicesHealth Care Financing AdministrationPrepared by:Joshua M. Wiener, Ph.D.The Urban InstituteandSteven M. Lutzky, Ph.D.The Lewin GroupJune 5, 2001 HOME AND COMMUNITY-BASEDSERVICES FOR OLDER PEOPLE ANDYOUNGER PERSONS WITH PHYSICALDISABILITIES IN WASHINGTONFinal ReportPrepared for:U.S. Department of Health and Human ServicesHealth Care Financing AdministrationPrepared by:Joshua M. Wiener, Ph.D.The Urban InstituteandSteven M. Lutzky, Ph.D.The Lewin GroupJune 5, 2001 This research was supported by Health Care Financing Administration ContractNo. 500-96-0005. In this contract, the Urban Institute is a subcontractor to the LewinGroup. The opinions expressed in this report are those of the authors and do notnecessarily reflect the views of the Health Care Financing Administration, the UrbanInstitute, or the Lewin Group. We gratefully acknowledge the many people in Washingtonwho generously answered our many questions. Final Report219722Table of ContentsHOME AND COMMUNITY-BASED SERVICES FOR OLDER PEOPLE AND YOUNGERPERSONS WITH DISABILITIES IN WASHINGTON.......................................................................................1THE LONG-TERM CARE SYSTEM IN WASHINGTON.................................................................................2ADMINISTRATIVE STRUCTURE...........................................................................................................................8ELIGIBILITY CRITERIA AND ASSESSMENT..................................................................................................9CASE MANAGEMENT...............................................................................................................................................10SERVICES.......................................................................................................................................................................11NONMEDICAL RESIDENTIAL CARE................................................................................................................12CONSUMER DIRECTION........................................................................................................................................14COST CONTAINMENT..............................................................................................................................................18QUALITY ASSURANCE............................................................................................................................................23CHALLENGES FOR THE FUTURE......................................................................................................................28 Final Report1219722HOME AND COMMUNITY-BASED SERVICES FOR OLDER PEOPLE ANDYOUNGER PERSONS WITH DISABILITIES IN WASHINGTONWashington is a relatively small northwestern state with 5.8 million people in 1999,about 11.5 percent of whom were age 65 and over.1 The state is doing well economically andonly about 8.9 percent of the population lives in poverty, well below the national average.Washington provides home and community services to a very substantial number of beneficiariesthrough the Medicaid personal care program, a large Medicaid home and community-basedservices waiver, and some small and shrinking state-funded programs. Washington has anational reputation as a leader in innovative home and community services and relies heavily onconsumer-directed home care and nonmedical residential services, such as assisted living andadult family homes. In fiscal year 1999, almost twice as many people received home andcommunity-based services as received Medicaid-funded nursing home care, making Washingtonone of the most balanced long-term care delivery systems in the country.The long-term care policy environment in Washington is shaped by five factors. First,the state is strongly committed to a policy of "aging in place" and to developing an array of homeand community-based services (mostly social rather than medical) to meet consumer needs.Second, although the state has a well-organized and politically effective nursing home industry,strong consumer advocates, especially for older people, have provided an effectivecounterbalance. Consumer advocates have provided much of the political will to redesign thelong-term care system and have worked closely with state officials to do so.2 Third, there hasbeen a consistent vision and stable leadership for over 20 years, with one state governmentofficial. His recent retirement and that of another long-time administrator signals a chang