Ohio Department of Aging
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Publisher: Scripps Gerontology Center
Published Date: May 15, 2007
Executive Summary
PASSPORT, Ohio’s Home- and Community-Based Services (HCBS) waiver program for older people, provides in-home services to Medicaid consumers who would otherwise qualify for placement in a nursing home. The intent of the program is to support disabled community-dwelling older people in their efforts to remain at home for as long as is reasonably possible and to be fiscally responsible to Ohio taxpayers. PASSPORT services include personal care, homemaker, medical transportation, and home-delivered meals, emergency response systems, adult day services, chore, home medical equipment, minor home modification, independent living assistance, nutrition consultation, and social work counseling.
In the twenty plus years since it began as a regional demonstration program, the PASSPORT program has grown considerably in both size and scope. It is certainly the biggest waiver program in Ohio and one of the largest waiver programs in the United States. In SFY 2006, PASSPORT provided a variety services to nearly 35,000 Ohioans over age 60; the average daily census of the program was 26,000 clients. These services along with the informal/ unpaid care (which comes from a variety of family and community sources) have allowed many disabled Ohioans to remain in their communities longer than might otherwise have been possible.
The Ohio General Assembly called for an independent evaluation of the PASSPORT program. The Ohio Department of Aging, which administers the program pursuant to an agreement with the Ohio Department of Job and Family Services (Ohio’s Medicaid agency), and an Advisory Council for the project specified the topics and questions to be addressed in the evaluation. Following are the key findings and recommendations related to those areas of investigation. These findings and recommendations are discussed briefly in this report, and in much more detail in the six topical reports that support this document.
Key Findings
The people getting PASSPORT services need them and are financially eligible for the program. The majority of consumers met level of care eligibility by virtue of having either two ADL impairments or on the basis of multiple criteria. The remainder were eligible based on single criterion specified by program standards. The average gross monthly income of PASSPORT consumers was $719, well below the allowable income of $1,692. Only 69% of PASSPORT consumers had any assets; the average value of their assets was $434.
PASSPORT is less expensive than nursing home care. The average yearly Medicaid expenditure for a nursing home resident was $55,751, compared to $23,702 for a PASSPORT client. The average per-person value of all non-Medicaid public assistance to PASSPORT consumers is $2,830, compared to $480 per year for nursing home residents. When Medicaid and other public costs are totaled, the cost of caring for a person in the community is a little less than one-half the cost of caring for a person in a nursing home.
PASSPORT providers meet certification standards set for in the Ohio Administrative Code. The PASSPORT Administrative Agencies use a pre-certification visit with providers to give technical assistance on the certification process, and to make sure that the provider is in compliance with standards. If a provider is out of compliance, the certification process does not move forward.
On average, providers have been with the PASSPORT program for nine years or more. About one-quarter of current PASSPORT providers have been in business five years or less. Current providers rate the likelihood of continuing with PASSPORT at 8.7 (on a scale of 1 to 10, with 10 being very likely). The major reason that providers discontinue involvement with PASSPORT is financial—low reimbursement rates, low numbers of referrals, or both.
The initial and ongoing PASSPORT assessment process adequately captures consumer needs and contributes to an appropriate service plan. Case management and case management supervision are linchpins of the PASSPORT program. The case management system is highly effective and widely praised by consumers and their caregivers.
While there is consistent commitment to the principle of informed choice, there are several threats to consumers’ exercise of informed choice. Some of the factors inhibiting informed choice are the vulnerabilities that bring consumers to PASSPORT in the first place. Another threat is related to the lack of information available to consumers (such as provider quality).
Delays in service onset were a problem in some cases. Whether due to Medicaid eligibility determination or due to waiting lists (now obsolete), these delays put people at risk of declines in health and premature nursing home placement. Medicaid eligibility determination delays are variable by county and by workers within counties.
Consumers seek a level of services that best meets their needs and do not demand excessive services. Caregivers continue to provide essential care and support.
PASSPORT has quality assurance processes in place and working to safeguard the health and welfare of participants. The numerous quality assurance processes include annual structural compliance reviews of providers by the PAAs, monitoring of the PAAs by ODA and of ODA by ODJFS, incident reporting and follow-up, interviews and surveys with consumers, and PAA-specific quality assurance/quality management strategies. All of these processes center on the health and well-being of participants.
ODA has undertaken a concerted effort to fully operationalize and implement the CMS Quality Framework. ODA’s adaptation of the CMS framework is the Quality Management and Improvement System (QMIS). Regularly scheduled teleconferences with PAA staff are a vehicle for communication about, refinement of, and implementation of the system. One of the challenges in implementing the quality management system is striking the appropriate balance between the effectiveness of standardization and the local responsiveness of PAA flexibility.
The fiscal accountability of the PASSPORT program is ensured through multiple levels of monitoring and audits. Providers, PAAs, and ODA fiscal processes and records are monitored routinely. Assessment of the fairness and adequacy of the contracting process revealed serious concerns about low reimbursement rates and rate setting that is not linked to quality.
Overall, this evaluation found that PASSPORT is a cost-neutral, effectively targeted, quality-oriented, thoroughly monitored, consumer-responsive home care program.
Download and read the full evaluation report
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PASSPORT Evaluation Summary Report (259kb)
Additional Topic Reports:
Ohio Department of Aging