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Home » Info Center » News & Announcements » Legislative Testimony

Budget Testimony for the Ohio Department of Aging
Ohio House Finance Human Services Subcommittee
Barbara E. Riley, Director

April 3, 2007

Chairman Stewart, and members of the House Finance Human Services Subcommittee, I am Barbara Riley, Director of the Ohio Department of Aging (ODA). Thank you for the opportunity to appear before you today in support of the Governor's Executive budget for the Ohio Department of Aging.

Our mission is to serve and represent the more than two million Ohioans age 60 and older, as we strive to help them live high quality, active, healthy and independent lives. It also is our charge to promote positive attitudes toward aging and older people, to advocate for their needs and to work to create the linkages necessary to assure effective service delivery. We do not do this work alone. The Ohio aging network includes ODA, other state departments, 12 Area Agencies on Aging, over 400 senior centers and county and municipal organizations, and hundreds of private providers and not-for-profit agencies which working together serve over 500,000 individuals, or one quarter of all older Ohioans.

Part of what drew me to this position is the changing face of aging and its universal impact on all of us - regardless of economic status, race, or geography - we all are aging. Each month, 12,000 Ohioans celebrate their 60th birthdays. These are the oldest, the first wave, of the Baby Boom generation. Their sheer numbers alone will tax our service systems, but this generation also is well known for having strong opinions and preferences and their changing expectations and influence will alter how we must plan for the future. To put this into perspective, I would like to share some basic facts. Facts that may frighten us, but clearly set the stage:

• In 2000 there were 1.96 million Ohioans age 60 or older;
• In 2020 the forecast is for 2.82 million of us to be 60 or older, a growth of 44%.
• In 2000 167,000 older Ohioans were severely disabled, or 8.5 % of all those 60 or over;
• In 2020 we anticipate 220,000 severely disabled older Ohioans, an increase of 32%, and 7.8 % of those 60 or over.

There is good news embedded in this, as the proportion of our aged who are disabled is forecast to decrease, but again, the raw number surely points to an ever increasing service demand.

This increasing need has to be addressed at the very time our state is encountering growing revenue pressures, requiring a creative but thoughtful approach to how we tackle what we are facing. Built on Governor Strickland's Turnaround Ohio initiatives, this budget proposal does exactly that by focusing on: consumer choice, independence and self-care, promoting home and community based care, reducing costs, and addressing quality.

Our aim is to:

• Provide cost-effective, high-quality home and community-based care to help seniors remain safely independent.
• Expand the capacity of PASSPORT and Ohio's other community-based services to give Ohioans true choice in long-term care.
• Promote consumer choice by providing an array of home-and community-based services and by providing information about these options to Ohioans in need of long-term care.
• Develop the framework and protocols needed to support a unified budget for long-term care.
• Promote and disseminate evidence-based disease prevention programs for seniors.
• Respond to workforce challenges and opportunities presented by an aging society.

To carry out this administration's goals, the Department of Aging's budget includes a number of specific proposals and provisions that support the vision for enhanced and effective service delivery.

PASSPORT

Spotlighted within our proposed budget is the expansion of PASSPORT, one of our most economical ways to support older Ohioans in settings they prefer. With the expansion of PASSPORT, we will be able to provide an additional 5600 older individuals with choices in how their long term care needs are met in their communities. At this funding level, ODA would be able to serve the projected natural enrollment for the program. This initiative, coupled with the Governor's recent directive to clear the previously existing waiting lists, will serve all those eligible individuals we anticipate requiring PASSPORT services in the upcoming biennium. A report by AARP cites that 90% of those over 60 would prefer to choose the setting in which they receive care, whenever they can, and the PASSPORT waiver program is one option the Department of Aging offers those dependent on Medicaid.

In order to assess the success of PASSPORT in serving the 33,291 Ohioans enrolled in 2006, and at the request of the General Assembly, ODA has contracted for an outside evaluation of the PASSPORT program. Over the next two months, we will be releasing a series of six detailed reports on the results of this thorough evaluation, but now that all of the fieldwork has been completed, I want to share a few of the evaluation highlights with you.

• The average annual cost of home and community-based services for PASSPORT consumers was $13,310 - well below the "cost cap" for participation.
• On average Medicaid costs for nursing home residents were 2.3 times more than for those receiving services through PASSPORT (even taking into account traditional Medicaid state plan services used by the PASSPORT recipients).
• PASSPORT consumers are very poor. Their average gross monthly income was $797 per month and they have average liquid assets of only $341.
• Due to this rate of poverty, PASSPORT consumers may receive additional public benefits; 44% of PASSPORT consumers received food stamps ($624 per year) and 23.4% received home energy assistance ($242.48 per year).
• An extended length of time on the PASSPORT program is positively associated with being female, being older, having a higher level of impairment and taking a higher number of medications. This is likely due to the "aging in place" of PASSPORT consumers who do not enter institutional care.
• On the other hand, shorter time on PASSPORT has a direct correlation with dementia, chronic obstructive pulmonary disease, an informal caregiver unable to continue support at the needed level of care, and the need for assistance with medication. Apparent in these findings is that family and other informal caregivers are critical to the success of keeping a PASSPORT consumer at home, and if they are unable to do so, that consumer is more likely to move into an institutional setting.
• 30% of PASSPORT consumers leave the program to enter a nursing home - consumers age 83 and over with dementia are most likely to disenroll from PASSPORT and enter a nursing home.
• PASSPORT has a number of quality assurance processes in place and these are working.
• Case management is very effective in sustaining a good fit between consumer needs and services provided.
• PASSPORT consumers actively sought a service plan that best matched their needs and did not insist on excessive services.
• PASSPORT consumers are highly satisfied with the program.
• The financial integrity of the program is well guarded by multiple levels of review.
• Areas of needed improvement for PASSPORT include shortening the length of the Medicaid eligibility determination process, reducing program choice complexity for consumers, improving the assessment of informal caregiver capacity, improving communication with service providers, and continuing to improve the PIMS software used by ODA and its PASSPORT Administrative Agencies to manage the program.

Since the inception of PASSPORT in 1993, we also have learned something about long term care supply and demand that is crucial to understand as we work to expand consumer choice. At its beginning, 33.7 of every 1000 Ohioans age 60 and over were using either PASSPORT or were in a nursing facility, 2.9 of those 33.7 individuals were in PASSPORT, and 30.8 were in nursing facilities. By 2005, 32.7 of every 1000 were in one of the two settings, but 11.4 were in PASSPORT. (See attachment A.) There was no apparent woodwork effect.

Instead, we see many more Medicaid consumers of long term care in their own homes and communities, while nursing facilities are serving many more who need rehabilitation services, or who have a more intense level of care need. Indeed, we must be certain that we have all care settings available, as there is a place in this system for all.

Assisted Living

Also included in the Executive budget proposal is funding to support the federally authorized 1800 assisted living waiver slots. On July 1, 2006, ODA assumed administration of the Assisted Living Waiver Program which is open only to individuals currently residing in a nursing facility or enrolled on another home and community-based waiver program, such as PASSPORT. Unfortunately, this greatly limits the population eligible for assisted living services, and only 132 older Ohioans were enrolled as of March 19th. In spite of this, we also are experiencing the anomaly of a waiting list of 180 people. Why the waiting list? Simply stated, we need additional providers willing to participate, and we need to more effectively link eligible consumers with willing providers that will meet their service needs.

There are two components required to make the Assisted Living Waiver Program work. Not only must individuals meet the same eligibility requirements as for the PASSPORT program, assisted living facilities must meet specific requirements and be certified to become a provider. However, of the nearly 500 residential care facilities serving Ohio, only 279 facilities meet all the required criteria to qualify for the program. Of that number, at present 50 facilities are participating. Based on the experience of other states with new waivers, Ohio's slow start up experiences are not unique. Regardless, we believe it is essential for us and our state and local partners to work together with potential facilities to determine what the barriers are, and how we might circumvent them.

Understandably, potential providers have expressed their reluctance to move an established resident, who is occupying a room that meets the certification criteria, in order to make space for someone who wants to shift from a nursing home. In addition, the ORC requires a person who has been a private pay resident, but who has exhausted his or her income, to move out of their assisted living home and into a nursing facility or onto a Medicaid waiver before they can re-enter assisted living. This forced move is not conducive to continuity of care or quality of life for the consumer, and it is not financially feasible for the provider to leave that bed empty while they await the resident's return. S.B. 5, currently referred to the House Finance and Appropriations Committee, does address this factor, and we are hopeful that with its enactment we will resolve some of those issues.

PACE

Requested funding levels support the two existing PACE sites providing services to 735 participants in Cleveland and Cincinnati. In 2006, ODA assumed responsibility for the Program of All-Inclusive Care for the Elderly, or PACE. PACE is a managed care model that provides participants with all of their needed health care, medical care and ancillary services in acute, sub-acute, institutional and community settings. PACE sites receive two monthly capitated payments, one from Medicare and one from Medicaid. Each of the two PACE sites pool those resources to pay for whatever services an individual needs, including services not otherwise covered by Medicare or Medicaid. This flexibility allows them to be proactive in their care of participants.

Choices

The Choices Medicaid waiver program, available in two areas of the state (central Ohio and rural southern Ohio), allows a qualified PASSPORT participant to employ service providers in his or her home, allowing the participant to self direct his or her plan of care. In 2006, 236 individuals enrolled. CHOICES is funded as a component of PASSPORT.

Residential State Supplement (RSS)

The Residential State Supplement program provides funds to low-income adults with disabilities who do not require nursing home care. The supplement, along with the consumer's income, pays for an approved living arrangement in a certified and licensed facility. This funding request retains housing subsidies for 2000 low-income adults age 21 and over.

HB 119 also contains language that seeks to improve the quality of RSS living arrangements through certification standards to be adopted in rule by ODA and additionally sets forth a new priority for the RSS waiting list that will allow us first to serve those who receive Supplemental Security Income. These changes are in line with federal requirements for RSS programs.

Homestead Exemption

As you are aware, the budget would remove existing income limitations on the homestead exemption and make property tax relief available to all senior citizens and disabled homeowners. This will increase the number of eligible recipients for homestead relief from the current 220,000 to 775,000, which is about one-quarter of all homeowners, and will save older home owners an average of $400 a year. Although HB 119 removes the income test for the Homestead exemption, implementation will provide a proportionately more substantial deduction for the low-income elderly homeowner. By exempting the first $25,000 of home value from property taxes, the older or disabled homeowner in Gallia County, with a $50,000 home (Gallia County's median home price), will experience a 50% cut in their property taxes. The owner of a $500,000 home would experience only a 5% savings. In addition, we believe this will help ameliorate one reason often cited by older Ohioans as a deterrent to passing local levies, their perception of ever increasing property taxes.

Kinship Care

Although not in the ODA budget, I want to go on record as supporting the provision in the Ohio Department of Job and Family Services budget which expands eligibility and support for our grandparents who are raising their grandchildren. In Ohio, there are an estimated 86,000 grandparents who are providing care, and the newly configured program will allow us to serve many more of those who are most financially in need of assistance.

State Ombudsman Program

Ohio can be particularly proud of our Long Term Care Ombudsman program. This service is available to all long term care consumers, regardless of income or payment source, who need to resolve complaints they might have related to nursing facilities, physician services, Medicare and Medicaid eligibility, guardianship, and other consumer rights. In an average year we receive over 10,000 such complaints. There are 88 paid ombudsmen, who along with 255 volunteers, field these complaints and work for resolution. In addition we provide extensive public education and information about the choices available in long term care, publish an on-line consumer guide, conduct resident and family satisfaction surveys, provide legal assistance, elder abuse protection, and as mandated by the federal Older Americans Act, advocate for older Ohioans.

Unified Long Term Care Budget

In order to move Ohio forward in providing consumer choice and to achieve better balance within our long term care system, H.B. 119 assigns to ODA the responsibility for establishing a process that will lead to the creation of a unified long term care budget by June 1, 2008. Other states are finding this to be an essential facet of a more rational long term care system. The Ohio Commission to Reform Medicaid and the Ohio Medicaid Administrative Study Council previously have addressed the need for a unified budget, and this proposal supports that recommendation.

I believe there are three underlying principles for why a long term care budget should be developed. The first is flexibility, achieved by allocating the dollars to the individual to be expended on their care, rather than allocating dollars to a particular service category. In an ideal system, there are no waiting lists for any particular setting, be it a nursing facility, assisted living facility, or an individual's own home. Instead, for those eligible for long-term services and supports, the setting is determined by consumer choice and differing levels of service need. Some will need the more intensive medical setting of a nursing facility; others will need assistance with the activities of daily living, which they can safely continue to receive in their own homes. The Department of Job and Family Services recently received a federal "Money Follows the Person" grant, which is an excellent example of how this principle can work.

The second rationale is transparency. As members of the General Assembly, you should not have to examine the budgets of several different state agencies to determine how much Ohio spends on long-term services and supports. Currently funding for these services is fairly opaque, as evidenced by the effort expended by OMASC staff to establish a current base line for long-term care spending.

The third, and perhaps not so well recognized, reason for a unified budget is civility. For many years the debates on long-term care funding have pitted provider against consumer, provider against provider, and consumers and providers together against state agencies. The process of creating a unified budget will require us all to work together for the common good.

But I believe the success of a unified long-term care budget is dependent on first developing a unified long-term care strategy for Ohio, a step that has proven to be elusive over the years. But the time to address these issues is now, because the status quo is unsustainable as the baby boomers age. In 2050 more than one million Ohioans will be over age 85, and so we must build the system that we want for them, and let's be candid, for ourselves and those we care about.

As set forth in H.B. 119, ODA is to create a workgroup of consumers, providers, advocates, and state and local policymakers who are charged with developing a budget that:

• Provides consumers a choice of services that meet the consumer's health care needs and improve the consumer's quality of life;
• Provides an array of services that meet the needs of a consumer throughout life;
• Consolidates policymaking authority and the associated budgets in a single entity to simplify the consumer's decision making and maximize the state's flexibility in meeting the consumer's needs; and
• Assures the state has a system that is cost-effective and links disparate services across agencies and jurisdictions.

This will be a massive task and we will have to grapple with many issues:

• How inclusive should we be? All Ohioans who need long term care, including our seniors, our disabled, those with MR/DD or mental health diagnoses? A subset of these vulnerable Ohioans?
• Should there be a single point of entry?
• Who will do financial eligibility and level of care assessments?
• Will we provide case management for all those receiving long term care regardless of the setting?
• Do we do assessment only of those who are Medicaid eligible, or do we assess everyone to avoid folks having to move to Medicaid as their payee?

Obviously, there are a myriad of details to be discussed. What we do know is that consumers choose wisely, and that the average cost of care varies greatly, from about $1100 a month for PASSPORT to around $5000 a month for nursing facility care. We also know that we need a full array of services, including those delivered in both home and facility-based settings. I believe success in this effort is fundamental to our successfully providing services and controlling Medicaid costs in this state. You have my commitment to be fully inclusive and to make this process as painless as possible.

To conclude on a more general note, and to better understand how all of these pieces fit together to form the patchwork quilt that serves and protects Ohioans, I want to share some of the principles that drive our department.

ODA programs are designed to assist older Ohioans at every stage of aging to help mature adults live active, healthy and independent lives. For that older Ohioan, the key to maintaining good health is to remain active, both physically and mentally - to be their best in body, mind and spirit. ODA and the aging network provide many opportunities to work, learn, volunteer, contribute to our communities, and generally enjoy life. Volunteer programs, like the Long-Term Care Ombudsman program, RSVP, Foster Grandparents and others, keep interested older Ohioans engaged in meaningful activities. Approximately 400 senior centers throughout the state also engage the older members of their communities. We also work with employers, Ohio's workforce systems and the Department of Labor's Senior Community Services Employment Program to help older Ohioans contribute to the fiscal prosperity of their communities through employment and independence.

Perhaps our best known and most popular program is the Golden Buckeye Card which is in the pockets of approximately 2 million Ohioans and is honored at more at more than 20,000 businesses statewide. Golden Buckeye cardholders have saved an estimated $2 billion since 1976 through voluntary discounts at participating merchants. We are constantly seeking new ways to partner with business leaders to not only increase the value of the Golden Buckeye Card, but also to help businesses take full advantage of the benefits of courting older Ohioans as consumers and employees.

As a result of HB 468, on July 1, 2007, the Ohio Best Rx and Golden Buckeye Prescription Drug Savings Program will merge under the auspices of ODA, and we will be able to offer Ohioans the best of both worlds. While the Golden Buckeye program gives seniors a discount at many participating businesses, Best Rx offers a better prescription deal than the Golden Buckeye Prescription Drug Savings program allowing the state to serve more people with a more valuable benefit.

The aging network also provides an array of home and community supports to enable older Ohioans to remain in their homes. Through such programs and services as Meals On Wheels, transportation services, home repair, adult day care, respite programs, and even support services for caregivers, older Ohioans and their caregivers receive the support they need to maintain their health and independence in their own homes and communities.

Many of these services fall under our administration of the Older Americans Act in Ohio, ultimately serving 500,000 individuals. Funding for these services, which are not supported by Medicaid, include $49 million in federal funds, $16 million in state funds and $57 million in local general revenue and levy funds. Federal Title XX funds also support some of these services as detailed in each county's Title XX plan.

As I previously stated, we cannot carry out these responsibilities alone. Regionally, Ohio has 12 Area Agencies on Aging, which make up the backbone of aging services delivery in Ohio. Each area agency serves a unique geographic area and coordinates with local human and social service networks, including service providers, to plan and deliver aging services. Similarly, 12 Regional Long-term Care Ombudsman Programs work within their communities to safeguard consumers of care services, advocating for quality care, investigating complaints and giving them a voice.

County and local offices on aging throughout the state extend the reach of the aging network and tailor services to their specific community and have their own offices on aging to support and enhance the efforts of the state and regional offices. County and Municipal Senior Centers offer people age 60 and older a place to go for nutritious meals, social activities, volunteer opportunities, health screenings, health and consumer education, creative arts, exercise and more.

Local law enforcement, colleges and universities, non-profit charities, fraternal and benevolent organizations, chambers of commerce and other community resources are also part of the virtually endless aging network.

Something that is less well known, but important, is that ODA also serves younger adults through many of our programs. I previously mentioned the merger of Ohio Best Rx and the Golden Buckeye Prescription Drug Program, which will target uninsured Ohioans up to 300% of poverty. Other ODA programs that serve Ohioans under the age of 60 include the new assisted living Medicaid waiver, the Residential State Supplement program, PACE, the Senior Community Services Employment program, the long-term care ombudsman program, our family caregiver support program, the Golden Buckeye Card program, and the "PASS" (preadmission screening) part of our PASSPORT program.

I am proud of our ability, with only 102 qualified and competent staff, to facilitate services for so many of our most vulnerable Ohioans, and look forward to working with you to build a more strategic and effective system in the future. I would be happy to answer any questions you might have.