Proposal Presented for the Master Plan for Aging (#85)
Disclaimer
Throughout the MPA process, more than 100 proposals were developed thanks in particular to thousands of hours of work by external stakeholders and members of the public. These proposals and the MPA Council commentary are being submitted to the Governor and shared with policymakers and the public to inform policymaking. These proposals represent a starting point for discussion. Further discussion is necessary between relevant state agencies and stakeholders to both refine these proposals and assess which may be appropriate to adopt and implement.
Summary
Create a demonstration program for individuals being discharged from hospitals participating in the evidence-based care transition demonstration. The demonstration would coordinate home care and aging services for individuals with co-occurring LTC and mental health and/or substance use needs who are transitioning back to or newly being transitioned to community-based OMH housing.
Justification
Individuals with co-occurring LTC and mental health and/or substance use needs who are transitioning to community-based OMH housing need immediate access to home care and aging network services. Implementation of a parallel demonstration project that coordinates home care and aging services for individuals being discharged from hospitals participating in the evidence base care transition demonstration will allow for a more seamless transition and better care coordination for this vulnerable population.
Full Proposal
Building off the Cross System Care Coordination through the 1115 Medicaid Waiver proposal and adding components of the Supporting Community Housing Models and the Interagency Integration of Social and Healthcare Services proposals, implement a parallel demonstration project that coordinates home care and aging services with individuals being discharged from hospitals participating in the evidence base care transition demonstration. The focus of the this demonstration would be individuals with co-occurring LTC and mental health and/or substance use needs who are transitioning back to or are newly transitioning to community-based OMH housing and needing immediate access to home care (personal care and/or skilled home health services, medical case management) and aging network services (time-limited review of aging service and managed care enrollment options, social engagement services, food needs, chronic disease self-management classes in local area, etc.) upon discharge. Regardless of payer source and managed care enrollment, individuals and their OMH housing program providers would be required to be plugged into the local SCN of Medicaid and Medicare LTC providers and aging network services based on their needs and preferences.
MPA Council Commentary
This proposal is categorized as long-term. The current iteration of the 1115 Medicaid Waiver that has been approved by the Center for Medicare and Medicaid Services is in process. While a focus on the care transition needs of individuals moving from inpatient hospital settings to the OMH housing is critical for the provision and parity of care, this demonstration program would need to be developed and proposed for a future iteration of the waiver. The State is continuously evaluating potential additional changes to the waiver that could be negotiated with the federal government as part of future waiver renewals. Accomplishing this proposal would require resources that would be subject to the annual budget process and the availability of resources. If the subject demonstration were to be otherwise approved, DOH would work with OMH to integrate the program with existing data systems. New York AAAs may continue to develop relationships with health care organizations and technology companies to keep older adults healthy, support aging in place, and connect older adults to community-based services to prevent higher levels of care.