State of Alaska Division of Legislative Audit

Long Term Care Performance Review

Improving Service

Summary: The report includes a number of recommendations that highlight areas in which the department can improve existing services. The department could implement changes that directly improve service. It could also implement internal improvements that, while not as apparent to the outside observer, could have a measurable effect on the department’s ability to provide quality services.

Click here for the table of all recommendations to improve service

Key Findings for Improving Service

  1. Alaska has been successful in developing all three types of Long Term Care: institutional care, in-home services, and residential programs. Alaska scores fifth in the nation on the Association of American Retired Persons score card of Long Term Services and Support based on 26 indicators. (pg. 64)
  1. The department is not currently meeting the needs of the growing Alzheimer’s disease and related dementia population. In 2014, an estimated 6,100 Alaskans had Alzheimer’s or a related disease. The lack of services for persons with Alzheimer’s disease and related dementia was frequently mentioned during interviews with Department of Health and Social Services (DHSS or department) employees and key stake holders. (pg. 53)
  1. The population of seniors in need of services will expand rapidly, especially between 2022 and 2032. The leading edge of the baby boomers will turn 75 in 2021-2022, and the following decade will see considerable growth in populations that require increased assistance with daily living activities. (pg. 85)
  1. Current Medicaid assisted living reimbursement rates discourage the treatment of people with high acuity because the rates are tied to the number of beds in the facility rather than related to the characteristics of persons receiving care. (pg. 87)

 

Key Recommendations for Improving Service

  1. The department should expand the use of small privately-owned residential programs to gradually add residential capacity for individuals who would meet the Alaska Pioneer Homes level of care.
    (Recommendation 2.8)

The population size of persons using residential services is projected to increase by 50 percent in the next 10 years and more than double the current residential services population by 2032. With a fixed bed count, the Pioneer Homes will not be able to absorb any of this utilization increase. If the State wishes to provide more residential opportunities, it can either build pioneer homes, incentivize the growth of other residential providers, or do both. Incentivizing small privately-owned residential programs is more cost effective than building a pioneer home with large downstream funding commitments.

  1. An Alaska Pioneer Home should be devoted to become a center of excellence for Alzheimer’s disease and related dementia services in the state.
    (Recommendation 2.10)

In 2014, an estimated 6,100 Alaskans had Alzheimer’s disease and related dementia. The lack of services for this population was a frequently mentioned subject of conversation in interviews. It is also a major priority of the Alaska Commission on Aging. A January 2011 study of persons in Alaska Pioneer Homes found that 57 percent had dementia. By devoting a Pioneer Home to Alzheimer’s disease related dementia services, the State would be able to provide better care to individuals with high acuity and issues with Alzheimer’s disease and related dementias. Currently, many individuals with severe Alzheimer’s disease and related dementia are left to use costly state emergency services, or end up in the Alaska Psychiatric Institute.

  1. Adjustments to the calculation of cognition on the Consumer Assessment Tool (CAT) should be made.
    (Recommendation 6.3)

The CAT is used to assess an individual’s ability to take care of him or herself. Applicants take the assessment to determine if they are eligible for personal care services or an Older Alaskans/Adults with Physical Disabilities waiver. Eligibility for waiver services allows Medicaid to be used to provide a nursing home level of care to those who live outside of a nursing home. Strict eligibility screening limits the number of individuals eligible for services through Medicaid waivers. Adjustments in screening criteria could allow more individuals with dementia and related disorders to obtain access to assisted living, chore, respite and other services provided through Medicaid waivers rather than using services financed entirely by the general fund. Adjusting CAT scoring is an alternative to going through the time and expense involved with a 1915(i) waiver.

  1. The State should routinely review services provided in assisted living programs to ensure that they are provided to recipients consistent with their plan of care.
    (Recommendation 10.4)

The State lacks a system of impartial, conflict-free, care coordinators that is characteristic of other states’ home and community based services programs. For example, in Oregon and Washington, a federally established membership association that does grassroots management of community needs for aging populations along with state staff provides care coordination management to recipients and monitors whether appropriate care is rendered.