By Gema G. Hernández

Once upon a time in 1999 there was a Secretary of the Florida Department of Elder Affairs that instituted a program called the Nursing Home Diversion Program. The idea behind the program was very simple; prevent the placement of frail elders in Nursing Homes. The idea was also for the program to survive for years to come, if possible improving with the passage of time and gained experience.

Since the conceptualization of the program until the program was fully implemented, the Nursing Home Diversion program has several challenges: First, it was important that only agencies with solid audit reports be able to participate, Second, it was equally important that those agencies selected for the program possess the financial solvency to support all levels of care of all participants from the time of enrollment until the time of death. This was an extremely important point because we wanted to have a Diversion Program not only for two or five years, but for years to come. Third, because the Diversion Program was new it was unclear as to how many of these frail individuals would eventually require Nursing Home placement nor did we know how soon that placement may occur, therefore, the payment methodology was based on a set of unknown factors. Fourth, the safety of the patient was important. Keeping the patient in the least restricted environment was the primary goal as long as the safety of the patient and the caregivers were not in jeopardy.

To make sure the agencies participating in the Diversion Program met the financial criteria, the fiscal responsibility, and were able to offer the entire spectrum of services from meals to Nursing Home coverage, Florida legislators drafted the law identifying the types of agencies that could be Diversion providers. It is important to know that even though legislators could have identified Area Agencies on Aging, Council of Aging or Community Care for the Elder Lead Agencies also known as CCE, as Diversion providers they did not. At the last minute before the passage of the law a lobbyist managed to add four words “and other qualified providers” leaving behind a little open crack for other agencies that perhaps in the future wanted to become Nursing Home Diversion Providers.

The Nursing Home Diversion Pilot became so successful that after my departure the legislators began expanding the program from the 2 original sites to now 4 or 6 sites. But as any successful program can attest if you expand one program the other programs will decrease in volume and funding.

Now let us imagine that the programs that are being impacted by the success of the Diversion providers are not happy with the fact the Diversion providers have managed to survive for several years despite predictions this will never happen. Let us say that in the minds of the non Nursing Home Diversion CEOs they deserve not a piece of the pie but the entire pie. After all Community Care providers (CCE) were created also by the Florida Legislators to monopolize community care for the elders fund and these Nursing Home Diversion Providers have invaded their territory with no warning. What can be done to gain total control again?

The answer is simple; you make sure the State of Florida buys into a Managed Care type approach to deliver community and institutional based services under the control of one Lead agency per geographical area. You make sure that that line in the law which refers to “other qualified providers” applies to your organization. You hire a lobbyist that has inside connections to the department and avoid any reference to “other qualified providers” to refer to issues such as financial solvency, comprehensive offering of services including Nursing Home and Assisted Living Facilities and never being fined for billing inadequacy or fraud . Of course there is the issue of those existing Nursing Home Diversion providers, those agencies that have the financial solvency, the accurate financial reporting and the infrastructure and resources in place. What can be done to make them the issue and not your desire to control?

The answer is also simple; you make sure the capitation rate per person per month becomes “the issue”. This way the legislators, OPPAGA and Medicaid Budget groups focus their attention on the capitation rate on the Nursing Home Diversion Providers and not on the fact that Community Care Lead agencies have tripled, maybe even quadrupled, their unit costs since 1999 at the expense of thousands of elders. The increases in their unit prices have forced some Area Agencies on Aging to overspend their budgets, in some cases as high as 1.5 million in one year.

The attention is now on the monthly Capitated rate and those Nursing Home Diversion Providers are in a no “win” situation unless they realize the strategy and change the game plan. They are in a no win situation because if they argue the monthly rate is no longer able to properly support accepting total financial risk for the frail persons’ lives the spin doctors would say this agency only cares about money. If they continue to accept lower capitation rates per person per month on a year to year basis they would reach a point of no return and the quality of care would suffer.