How a Managed Care Plan Helped a Young Man Move Out of a Nursing Home

Getting your Trinity Audio player ready…

OJ had been living in a nursing home for about 10 years when Jesse Aires got him as a client. One of Aires’ tasks as a case manager with the Institute on Aging, a Bay Area nonprofit agency providing home care and case management services, is to identify nursing home residents who might be eligible to live in a different care setting.

“The first time I saw OJ, I knew he could transition out of the nursing facility and into the community,” Aires said. “He is one of my youngest clients, and he doesn’t belong in a nursing home with centennials.”

OJ, 34 years old with severe disabilities and unable to talk after a traumatic brain injury, was residing in a San Mateo County, California, nursing home. He was eager to make the switch. Aires made it happen.

Today OJ lives in a residential care facility in Daly City, just south of San Francisco. With his motorized wheelchair, he can leave his home and get around his neighborhood, using his iPad to communicate with others. It’s a major lifestyle upgrade from living in a nursing home with two roommates in a remote corner of the county. And the new situation is also much less expensive for the Medi-Cal program that supports his care.

Soon many more Californians will be eligible for this kind of transition. Effective January 1, 2023, policy and payment changes will make it easier for long-term nursing home patients to transition back to the community. Helping more people who need ongoing care to live successfully outside of nursing homes is part of the plan behind the state’s comprehensive reform of Medi-Cal services, known as CalAIM (California Advancing and Innovating Medi-Cal). Medi-Cal covers 14.6 million Californians — about a third of state residents — and more than two-thirds of nursing home days.

In Medi-Cal, long-term nursing home care has been paid for and administered under separate rules and policies from coverage of either short nursing home stays or physical health care.

Many Thousands of Californians Could Move Out of Nursing Homes

Compared to other states, nursing home residents in California are more likely to experience one or more hospital stays, and Californians have a lower success rate for transitioning back to a community home after a short hospital stay. On a state-by-state scorecard, California ranks 35th for effective transitions.

And a report by the AARP Foundation found that nearly 1 in 10 California nursing home residents — or roughly 37,000 people — have lower-level care needs and potentially could live successfully in the community.

CalAIM innovations started rolling out earlier this year and will continue phasing in through 2027. Next month, Medi-Cal managed care plans statewide will be responsible for organizing and funding long-term care in nursing homes. In addition, nearly all seniors and people with disabilities, including those also eligible for Medicare, will be enrolled in Medi-Cal managed care.

Health Plan of San Mateo (HPSM) is the Medi-Cal managed care plan responsible for OJ’s care. San Mateo is one of the state’s 27 counties where Medi-Cal managed care plans have had responsibility for long-term nursing home care for several years. HPSM has been a pioneer in the movement to transition qualified patients out of nursing homes and back into the community. It contracts with the Institute on Aging, Aires’ employer, to organize transitions and community-living plans for members like OJ.

I am the same age as him. I also was involved in a motorcycle accident. I was in a nursing facility for a couple months. I really sympathize with OJ. I know how it is to be young and in these places.

—Jesse Aires, OJ’s care manager

“We have people sitting in nursing home beds who don’t want to be there,” said Amy Scribner, chief health officer of HPSM. “We want people to live successfully in the community with supports if they want that.”

Most of the people affected by this change in state policy will be older adults who need support to live independently. But some of them, like OJ, are younger people with disabilities who are not likely to thrive in a nursing home setting designed to meet the needs of the extreme elderly.

“Keep in mind that this population of focus includes a wide range of clinical profiles,” said Dustin Harper, chief strategy officer for the Institute on Aging. It includes “a 25-year-old trying to return to the community after a traumatic accident who needs a different set of services or mobility adaptations than an 85-year-old who has a cognitive impairment.” But that doesn’t mean that elderly people with impairments should necessarily be placed in a nursing home. There are some who may not be able to live safely at home by themselves due to cognitive or functional needs but don’t have an ongoing need for skilled nursing. An assisted living setting, for example, might better meet their needs.

Surviving a Motorcycle Crash

OJ, formally known as Ofisi Latu, is a Pacific Islander who was so severely injured in a motorcycle accident in Hawaii in his 20s that he was not expected to survive.

“He has gone through a lot,” Aires said. “He was pronounced dead at the scene. He came back with CPR. He is a success story. He has gone through so many challenges where he was unable to voice yes or no, unable to sit in a wheelchair. . . . Now he is able to do both of those. A strong guy.”

After a lengthy recovery and rehabilitation, he is mentally aware but physically incapacitated. He is paralyzed on his right side and can’t walk. He has severe aphasia, which is to say, he can understand conversation and indicate assent by a rough “yeah” and a thumbs-up. To express himself more fully he uses his left hand to type with one finger on an iPad.

OJ is rated at the highest level of need for caregiving. “OJ is my first client being so young with this high level of needs,” Aires said in an interview. “But OJ is quite special not just because of his age, but because he’s come far with his recovery and wants to strive for the ability to talk again and regain life in the community again. As I was conducting his assessment, he reported that he still has many goals and isn’t done doing what he wants to do — to be with family and continue learning.”

It wasn’t easy to find a care home that would take OJ. Several establishments turned him down, and the first place he did go to didn’t work out. Aires had to find another alternative. At the new home, the situation is more favorable in part because the caregivers give OJ enough time to type out his responses on the iPad.

Part of the reason Aires feels so eager to advocate for OJ is personal history: He and OJ are both 34 and share some experiences. “It did affect me at first. I am the same age as him. I also was involved in a motorcycle accident. I was in a nursing facility for a couple months. I really sympathize with OJ. I know how it is to be young and in these places.”

How CalAIM Helps

The nursing home reforms in CalAIM include two overarching benefits for those who qualify:

• Enhanced Care Management is a new benefit that provides a care coordinator for the patient, in effect a navigator or concierge, who acts on the patient’s behalf to obtain and coordinate the needed services. This benefit is what compensates the Institute of Aging for Aires’ time and skill.
• Community Supports are specialized services the patient needs to live outside a nursing home. They might include the wraparound caregiver services for someone with complex needs like OJ to thrive in a group home or assisted living facility, the installation of a wheelchair ramp, or delivery of meals. These services help turn the care coordinator’s plan into a reality. They make it possible for OJ to live in a care facility instead of a nursing home. These supports have been available through special programs for years, but they were administered by a patchwork of agencies and often had capped enrollment. CalAIM simplifies these services by giving plans the option to offer them — and get paid for them — in the same manner as Medi-Cal would pay for a doctor’s visit or a hospitalization.

There are plenty of reasons to believe this transformation will be a good thing in the long run. “It will provide more opportunity for people in nursing homes throughout the state to receive more services,” said Harper.

In the short run, however, bringing new services into managed care represents a hefty administrative challenge to providers and managed care plans. Migrating to this new model affects almost everybody: care coordinators in hospitals, nursing homes and plans, finance and billing departments, and patients and their caregivers. Everyone must adapt their systems and ways of working together to this new framework. It’s a big lift.

But for case managers and others who work directly with the patients and families, the rewards are ample.

“I love it,” Aires said about his work. “Having clients like OJ and getting them out of the nursing facilities and having them thrive in the community — that makes my job that much better.”

Authors & Contributors