# Presentation: 912511

## DEVELOPMENT OF THE OREGON LTC SYSTEM

***MAKING THE SYSTEM WORK IN HARD TIMES***
**INDIANAPOLIS---MAY 6, 2002**
**Richard Ladd, Ed.M.**
**Ladd and Associates**
**Salem, OR**

**Notes:**
Development of the Oregon LTC System:  Making the System Work in Hard Times, a presentation by Richard Ladd of Ladd and Associates. Presented at the AHRQ-NGA meeting, State Long Term Care Systems: Reducing Cost, Quality and Access, held in Indianapolis, IN May 6-8, 2002.

## Pre-implementaiton

- Joint HCFA-AOA demonstration
- State integration proposal
- Advocates’ ad-hoc committee
- State policy on aging

**Notes:**
Twenty two years ago we started changing the Oregon system. We started in four counties in Oregon to test whether if additional funding for HCBS helped lower total spending, or if you simply helped agencies work together, could you improve the system? One county received additional money, another tried coordination, one did both and a fourth was a control county. Just providing more money didn’t make a difference. The county that didn’t get more money but got agencies together did well. But money and coordination worked best. 

The project worked so well it was expanded statewide. We also reorganized agencies by combining Medicaid, eligibility, food stamps and the Senior Service agency in October 1981. We prepared a plan but we didn’t involve consumers and that was a mistake. Our planned was shelved and a task force was formed to develop one that expanded HCBS services. Although similar to the internal plan, it passed the legislature because it  had support from advocacy groups. 

## IMPLEMENTATION

- First home and community based based waiver (1915(c))
- Decentralization
- Implementation of the state policy on aging

**Notes:**
The new program was premised on the basis that a growing elderly population demands services be delivered in a coordinated manner and in the least restrictive setting. Funds from nursing home services were reallocated to alternative care (in home, assisted living, adult foster care).  All funds were combined in a single appropriation. 

## HARD TIMES

- Special session
- Plan to cut 20% of each agency’s budget
- Relocation
- Pre-admission screening
- No waiting lists

**Notes:**
In 1981, there was a major recession and the governor called on each agency to cut 20 percent of the budget. When reorganizing the system, we first developed a mission, and all our decisions were compared to the mission. Our goals were the right of consumers to choose their preferred service, to offer access to a full range of LTC services, and to stay at home if they so chose. We hired 25 people and assigned them to work with nursing home residents to help anyone who wanted to move. We did not find relocation trauma. The program moved 7,000 persons back into the community in the first year.  There were plenty of arguments about needing training and a provider structure before helping people move.  Having the infrastructure in place is a chicken and egg argument – but some big mistakes were made, especially in paying attention to quality.  Oregon has done a better job maintaining quality since the program started.  

## RESULTS

**Notes:**
We now place  85% of the long term care clients in HCBS programs.  Oregon and Washington are the two States that spend more on HCBS than institutional care. We believe it is still possible to serve as few as 15% of all long term care beneficiaries in nursing homes. 

## Lessons from the Oregon experience

- Get the advocates on your side
- Must go to war with the nursing homes
- Need nurse delegation
- Need a working philosophy

**Notes:**
Based on our experience, it’s important to get the advocates on your side – don’t work against them. They can get things done that no one else can. You can’t balanced a system without going to war with someone. First, we had to oppose the nursing home lobby, and later the nurses. You can’t be friends with everyone. Your aims and their aims are entirely different.You have to have  nurse delegation because paying for nursing care at home nurse is costly and sometimes not necessary if there are other people there who can be trained to perform the tasks. 

## Lessons learned...

- Need to limit services to those most in need
- Transfer those in less need out of Medicaid
- Development of out-of-home placements
- Need to review all Medicaid nursing home residents

**Notes:**
You can’t take care of everyone – you must target services to persons in most need.  You have to have a mechanism to target services to the most needy, or you will spend a lot more. You also need out of home placements other than nursing homes.  There are people who can’t have care out of their own home but don’t have to be served in nursing homes. Foster homes and assisted living are good alternatives. Foster homes usually serve 5 or fewer.  One final thing – don’t take the nursing home’s word that everyone there needs to be there. See the people themselves, and leave the decision up to the person – offer to help them move to another setting.