Caregiver pushing senior female sitting on wheelchair. Mid adult nurse is with disabled senior female. They are in bedroom at home.
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A tool to help states increase long-term services and supports rebalancing could lead to more business for assisted living providers.

In an effort to contain LTSS spending, some states use managed LTSS models to shift long-term care delivery from Medicaid-funded skilled nursing facilities to more affordable community-based settings such as assisted living. California created a plan that plays off of the In Lieu of Services, or ILOS, tool introduced by the Centers for Medicare & Medicaid Services to create new pathways for those transitions. Today’s Geriatric Medicine noted that California’s plan could provide a roadmap for other states to create their own programs.

In December, CMS approved the Golden State’s request for a five-year extension of both its Medicaid demonstration and Medicaid managed care waiver — collectively renamed the California Advancing and Innovating Medi-Cal, or CalAIM, program. CalAIM includes provisions designed to advance health equity, fund services such as home- and community-based services, and improve access to care.

CalAIM is intended to identify and manage needs through a whole-person care approach, improve quality outcomes and reduce health disparities. According to the California Department of Health Care Services, CalAIM is moving the state’s Medi-Cal program toward a population health approach that prioritizes prevention and whole-person care. 

CalAIM will allow the state to create a new path to support Medicaid beneficiaries by integrating health services into Medicaid service delivery and financing using the ILOS tool. ILOS allows health plans to pay for nonmedical services in “medically appropriate and cost effective” situations. 

California Assisted Living Association President and CEO Sally Michael told McKnight’s Senior Living that it’s still early in the process, and CALA members have not had much opportunity to engage with the program, but she applauded the state for “seeking solutions that will expand options for older adults, allowing them to access the most appropriate care setting for their needs.”

“We are optimistic that this effort will be a positive development for residents and providers,” Michael said. “We see the ILOS tool as something really beneficial that will help older adults who are receiving care to preserve as much of their independence as possible.”

Using the ILOS tool, Medi-Cal managed care plan partners can offer up to 14 community supports to meet the social needs of members, including housing services, personal care services, medically tailored meals and nursing facility transition / diversion to assisted living facilities. 

More than 9% of California skilled nursing residents have low level care needs that could be met in assisted living, according to the 2020 LTSS report card from the AARP Public Policy Institute, the SCAN Foundation and the Commonwealth Fund. 

Doing so can save the healthcare system money. Data from the state’s assisted living waiver program showed that every skilled nursing transition to assisted living saves the state $27,000 annually in Medicaid dollars. Shifting 10% of LTSS recipients from skilled nursing to assisted living would generate $99 million in annual Medicaid cost savings, according to Today’s Geriatric Medicine.