Florida's Community-Based Diversion Pilot Project

Project Overview

General Approach: The Community-Based Diversion Project is designed to demonstrate the integration of medical and long-term care through the application of managed care principles and reimbursement. Under the authority of a Medicaid 1915(c) waiver, participating HMOs are paid a monthly capitation rate to provide, manage, and coordinate a comprehensive array of long-term care services and medical services for persons who are dually eligible. Enrollment is voluntary and limited to very frail persons who are at a high risk of nursing home placement.

Implementation Date: December 1, 1998

Waiver: 1915(c)

Eligible Population: Project enrollment is limited to persons 65 years of age or older, Medicaid eligible up to 300% of SSI, Medicare eligible for Parts A & B, who reside in the project service area counties, are determined to be at risk of nursing home placement, and meet one or more of the following clinical criteria:

• Require some help with five or more activities of daily living (ADLs)
• Require some help with four ADLs plus require supervision or administration of medication
• Require total help with two or more ADLs
• Have a diagnosis of Alzheimer's disease or another type of dementia and require some help with three or more ADLs
• Have a diagnosis of a degenerative or chronic condition requiring daily nursing services.

Benefit Package: Long-term care services include adult companion services, adult day health services, assisted living services, case management services, chore services, consumable medical supply services, environmental accessibility adaptation services, escort services, family training services, financial assessment/risk reduction services, home delivered meals, homemaker services, nutritional assessment/risk reduction services, personal care services, personal emergency response systems (PERS), respite care services, occupational, physical, and speech therapy services, and nursing facility services (unlimited). Acute-care services include community mental health services, dental services, hearing services, home health care services, Medicare co-insurance and deductibles, prescribed drug services, visual services, and transportation.

Delivery System: Within broad parameters, the project allows the contractor flexibility in the service delivery system design. The project contract includes requirements regarding coordination of long-term care and acute care services, the development of individualized care plans, and subcontract provider qualifications. Contractors are expected to propose a service delivery system that meets the needs of enrollees and the requirements in the contract. It is expected that the service delivery systems will vary from contractor to contractor.

Quality Assurance Activities: The contract requires that the contractor have a formal quality assurance program and specifies certain criteria to be met. It is anticipated that contractors will use their existing quality assurance programs for the Diversion Project. These programs must, however, be modified to specifically address the long-term care needs of project enrollees. The contractor is also required to conduct quality of care studies that address such issues as the appropriateness and timeliness of care, and the comprehensiveness of and compliance with the plan of care.

The contractors are monitored by the State on an ongoing basis. Monitoring activities include client record and financial record reviews. A disenrollment survey will be sent to each enrollee who disenrolls from a plan. An annual independent quality review is also required and the development of outcome measures is planned.

Technical Assistance Activities: The current focus is on implementation and evaluation issues. The State, the contractor, and aging network staff conduct monthly meetings to resolve issues relating to coordination of benefits, service delivery, marketing, and enrollment.

Current Status

Enrollment: To date, the Diversion Project has enrolled overall 1,254 individuals. The number in each health plan is: 181 in Beacon Health Plan, 420 in Summit Care Plan, and 653 in Health and Home Connection.

Recent Accomplishments: An evaluation was recently performed that compared the Diversion Project with Medicaid eligible/disabled adults in the State's ADA Waiver. The evaluation results indicated that seniors have greater satisfaction with the Diversion Project. The care coordination provided in the Project results in more seniors being satisfied with the services and the case management they receive.

In addition, the State of Florida is working on two other managed long-term care initiatives. The initiatives, the Program for All-Inclusive Care of the Elderly (PACE), and the Social Health Maintenance Organization (SHMO) Initiative, are intended to provide home and community-based long-term care as an alternative to nursing home placement, and to integrate the delivery of acute and long-term care.

The 1998 Florida Legislature authorized financing and contracting for a PACE site. The PACE model is similar to the Community Diversion Pilot Project in that it targets individuals who meet nursing home level of care criteria and it integrates acute and long-term care services. However, PACE services are delivered through adult day care centers and case management by multi-disciplinary teams. In addition, PACE sites receive an enhanced capitation payment from Medicare, beyond that of a traditional Medicare HMO. In July, 1998, Miami Jewish Home and Hospital applied for an exemption from HMO licensure created by the legislature to allow a non-HMO to operate a PACE site. While the Department and the Miami Jewish Home have begun implementation planning, this process was limited by a delay in the promulgation of federal PACE regulations. The Miami Jewish Home and Hospital hopes to be able to implement PACE shortly.

In 1998, the Florida Department of Elder Affairs was awarded a planning grant by HCFA to develop several SHMO demonstrations designed especially to deal with the acute and long-term care needs of the dually eligible. The service delivery and financing model developed under the grant will build on the foundation of Florida's current Community Diversion Pilot Project. The new model will incorporate additional reforms and waivers developed as part of the Medicare SHMO II demonstration to enable beneficiaries to realize the benefits of a higher level of integrated health care delivery

The SHMO initiative will focus on all Medicare beneficiaries who choose to enroll in participating Medicare+Choice plans. The model will integrate acute and long-term care services through managed care for all Medicare eligibles, including the dually eligible. The Florida SHMO initiative will build on the Medicare SHMO model by integrating Medicare and Medicaid to address the needs of the dually eligible population, including those who are very frail and/or chronically ill. Thus, dually eligible beneficiaries electing to participate in the SHMO will receive the full continuum of medical and long-term care services, including home and community-based and institutional services, through one managed care organization.

Contact Information

Judith Royce
Florida Department of Elder Affairs
Long-Term Care Community
Diversion Pilot Project
4040 Esplanade Way, Suite 335
Tallahassee, FL, 32399-9000

Phone: (850) 414-2308
Fax: (850) 414-2008
Email: roycej@elderaffairs.org
Website: http://fcn.state.fl.us/doea/Home/home.html