Chapter 3.5Coordinated System of Care

Section § 9250

Explanation

This law is about improving long-term care services in California, focusing on making these services more coordinated and personalized for individuals. The current system is fragmented, which makes it hard for people to get the care they need when they need it. The law aims to make care more holistic and accessible in the community, rather than institutional settings like nursing homes. This approach is not only more humane but also more cost-effective. Efforts are being made to use technology and better information systems to link individuals to the services they require.

The legislation intends to make sure that individuals can connect with the right services for them, improve the coordination of long-term care, make it affordable, and use both public and private funding effectively.

(a)CA Welfare and Institutions Code § 9250(a) The Legislature finds and declares all of the following:
(1)CA Welfare and Institutions Code § 9250(a)(1) Our delivery of long-term care needs to be vastly improved in order to coordinate services that are appropriate to each individual’s functional needs and financial situation. Care services should be holistic and address the needs of the entire person, including the person’s mental, physical, social, and emotional needs.
(2)CA Welfare and Institutions Code § 9250(a)(2) The coming age wave will bankrupt California if we maintain the current uncoordinated system of long-term care.
(3)CA Welfare and Institutions Code § 9250(a)(3) The new generation of aging Californians will desire, expect, and demand a much more responsive, coherent, and human-dignified system of care services.
(4)CA Welfare and Institutions Code § 9250(a)(4) Multiple funding streams and varied eligibility criteria have created “silos” of services, making it difficult for consumers to move with ease from one service or program to another.
(5)CA Welfare and Institutions Code § 9250(a)(5) Separate funding streams and uncoordinated services for older adults and adults with disabilities have created barriers in services for these populations. Adults with disabilities often receive long-term care services designed to support and protect the institutionalized older population. Instead, services need to be individualized to empower older adults and persons with disabilities to live in the community.
(6)CA Welfare and Institutions Code § 9250(a)(6) Historically, two delivery systems, referred to as the medical model and the social model of care, have evolved with little or no coordination between the two.
(7)CA Welfare and Institutions Code § 9250(a)(7) A high percentage of consumers enter the long-term care system after a hospitalization. Assistance and support following hospitalization would reduce the number of nursing home placements.
(8)CA Welfare and Institutions Code § 9250(a)(8) The Legislature affirms the notion that individuals should be able to receive care in the least restrictive environment.
(9)CA Welfare and Institutions Code § 9250(a)(9) Skilled nursing facilities account for 5 percent of the long-term care caseload and 52 percent of the long-term care expenditures. Home and community-based services account for 78 percent of the long-term care caseload, and 13 percent of long-term care expenditures. It is, therefore, more cost-effective to connect consumers with services in the community than to continue to place individuals in institutions.
(10)CA Welfare and Institutions Code § 9250(a)(10) A number of counties and programs have developed and implemented innovative Internet-based information systems. Some of these systems are designed to help consumers access information regarding long-term care services, and others are designed to help providers track client information.
(11)CA Welfare and Institutions Code § 9250(a)(11) The California Health and Human Services Agency is developing the “CalCareNet” Web site, which is designed to help the consumer find state-licensed providers of health services, social services, mental health services, alcohol and other drug services, and disability services, and also to find state-licensed care facilities.
(b)CA Welfare and Institutions Code § 9250(b) It the intent of the Legislature to enact legislation to do all of the following:
(1)CA Welfare and Institutions Code § 9250(b)(1) Ensure that each consumer is able to connect with the appropriate services necessary to meet individual needs.
(2)CA Welfare and Institutions Code § 9250(b)(2) Better coordinate long-term care delivery, recognizing the elements that are already in place, and expand the availability of long-term care.
(3)CA Welfare and Institutions Code § 9250(b)(3) Deliver long-term care services in the most cost-effective manner.
(4)CA Welfare and Institutions Code § 9250(b)(4) Access multiple public and private funding streams, without supplanting existing funding for programs and services.
long-term care holistic care services coordinated care functional needs financial situation age wave funding streams community-based services institutional care medical model social model post-hospitalization support least restrictive environment CalCareNet information systems
(Added by Stats. 2002, Ch. 541, Sec. 14. Effective January 1, 2003.)

Section § 9251

Explanation

This section defines key terms related to long-term care for older adults and adults with disabilities. Long-term care includes supportive health and social services aimed not at curing illnesses but helping individuals live their best lives at home or in their community. "Care navigation" involves helping individuals access information, referrals, and short-term assistance to coordinate care, often through various agencies or centers. A "care navigator" is someone who works with individuals to find the most suitable services based on their medical, financial, and social needs.

Lastly, "CalCareNet" is an online tool designed to connect consumers with licensed health and social service providers in California, helping them navigate the long-term care system.

For purposes of this chapter, the following definitions apply:
(a)CA Welfare and Institutions Code § 9251(a) The term “long-term care” refers to a wide range of supportive and health and social services for older adults and adults with disabilities. Long-term care differs from other types of care in that the goal of long-term care is not to cure illnesses, but to allow individuals to attain and maintain optimal levels of functioning in their homes or in their communities. The provision of long-term services involves a continuum of health and social services in a variety of home- and community-based settings.
(b)CA Welfare and Institutions Code § 9251(b) The term “care navigation” describes any of the following services, performed in multiple settings, including, but not limited to, area agencies on aging, hospitals, caregiver resource centers, independent living centers, and senior centers:
(1)CA Welfare and Institutions Code § 9251(b)(1) Consumer information delivered over the Internet, by telephone, including a statewide information hotline, or in person.
(2)CA Welfare and Institutions Code § 9251(b)(2) Referral to programs or services delivered over the Internet, by telephone, including a statewide information telephone hotline, or in person.
(3)CA Welfare and Institutions Code § 9251(b)(3) Short-term assistance for the consumer or caregiver, provided by persons qualified to work with the consumer to define needs, to refer the consumer to services that are free of charge or that may be purchased by the consumer, and to develop a plan of coordinated care.
(4)CA Welfare and Institutions Code § 9251(b)(4) Recognition of the need for ongoing assistance, with the ability to link consumers to ongoing assistance, care coordination, services coordination, or case management.
(c)Copy CA Welfare and Institutions Code § 9251(c)
(1)Copy CA Welfare and Institutions Code § 9251(c)(1) The term “care navigator” describes an individual who provides care navigation to older persons or persons with disabilities in need of long-term care services, or to caregivers. Care navigators consider an individual’s medical and functional needs, financial resources, and social support, in order to partner with the individual and, together, determine which services offered in the community are most appropriate for the consumer. The intervention with the consumer may be limited, depending on the consumer’s needs.
(2)CA Welfare and Institutions Code § 9251(c)(2) Care navigation may be performed within existing programs and at multiple points of entry, including, but not limited to, area agencies on aging, independent living centers, county welfare departments, hospitals, caregiver resource centers, and senior centers.
(d)CA Welfare and Institutions Code § 9251(d) The term “CalCareNet” describes a self-directed statewide, Internet-based application using the State of California Internet portal to link local Internet information systems. The CalCareNet Web site is designed to help the consumer find state-licensed providers of health services, social services, mental health services, alcohol and other drug services, and disability services, and also to find state-licensed care facilities. The purpose of CalCareNet is to enable the consumer to better navigate the long-term care system.
long-term care supportive services care navigation care navigator older adults adults with disabilities consumer information referral services coordinated care community-based settings senior centers independent living centers statewide information hotline programs and services CalCareNet
(Added by Stats. 2002, Ch. 541, Sec. 14. Effective January 1, 2003.)

Section § 9252

Explanation

This section emphasizes that the services provided under this chapter should prioritize a home-like setting, considering the health condition and needs of each person. They should be easily accessible from various entry points, so they can cater to the diverse needs of the elderly and people with disabilities. Additionally, these services must be available directly from the hospital and should encompass a broad range of support options to meet different consumer needs.

Implementation of this chapter shall be grounded on the following principles:
(a)CA Welfare and Institutions Code § 9252(a) Services shall be provided in the least restrictive, most home-based environment compatible with the health condition, mental status, and long-term needs of each consumer.
(b)CA Welfare and Institutions Code § 9252(b) Services shall be accessible through multiple points of entry into a continuum of long-term care services that meet a wide range of needs of the aging population and for persons with disabilities.
(c)CA Welfare and Institutions Code § 9252(c) Home- and community-based long-term care services shall be readily accessible from the hospital.
(d)CA Welfare and Institutions Code § 9252(d) Home- and community-based long-term care services that meet a wide range of consumer needs shall be available.
least restrictive environment home-based care aging population needs disabilities continuum of care accessible services hospital discharge planning community-based services long-term care consumer needs health condition mental status entry points home care services hospital accessibility
(Added by Stats. 2002, Ch. 541, Sec. 14. Effective January 1, 2003.)

Section § 9253.5

Explanation

This section of the law emphasizes that long-term care programs in California, like skilled nursing and adult day care, face burdensome regulation from multiple agencies, leading to conflicting interpretations and wasted time. To address this, by March 1, 2005, the California Health and Human Services Agency was tasked with deciding on a single entity to oversee adult day health care center standards. Additionally, the State Department of Health Services must determine a suitable percentage of reviews for multipurpose senior services conducted by the California Department of Aging to ensure proper oversight without unnecessary duplication.

(a)CA Welfare and Institutions Code § 9253.5(a) The Legislature finds and declares all of the following:
(1)CA Welfare and Institutions Code § 9253.5(a)(1) Providers of long-term care programs, including, but not limited to, programs of all-inclusive care for the elderly, skilled nursing facilities, adult day care, adult day services, Alzheimer’s day care centers, and multipurpose senior services programs, are regulated by numerous state and local agencies.
(2)CA Welfare and Institutions Code § 9253.5(a)(2) Overlapping and duplicative oversight of long-term care programs often results in conflicting interpretations of statutes and regulations. Also, oversight by multiple agencies creates an operational burden that ultimately deprives residents or clients of valuable staff time.
(3)CA Welfare and Institutions Code § 9253.5(a)(3) The State Auditor has completed an audit investigation of the duplicative overlapping regulatory oversight of long-term care programs.
(b)CA Welfare and Institutions Code § 9253.5(b) By March 1, 2005, the California Health and Human Services Agency shall determine the appropriate single entity to provide oversight of the waiver standards for adult day health care centers.
(c)CA Welfare and Institutions Code § 9253.5(c) The State Department of Health Services shall determine a percentage of the number of oversight reviews it conducts of the Multipurpose Senior Services Program (MSSP) utilization surveys that are conducted by the California Department of Aging. The percentage of surveys reviewed shall be sufficient to ensure effective oversight, but small enough to avoid unnecessary duplication of effort.
long-term care programs regulatory oversight adult day health care centers skilled nursing facilities California Health and Human Services Agency State Department of Health Services Multipurpose Senior Services Program California Department of Aging operational burden conflicting interpretations waiver standards oversight duplication of effort audit investigation elderly care regulation oversight reviews
(Added by Stats. 2004, Ch. 455, Sec. 1. Effective January 1, 2005.)

Section § 9254

Explanation

This law aimed to create standards for CalCareNet, a website offering information on long-term care services in California, with design flexibility for local entities. The site should be linked to county systems by January 1, 2004. Local entities can keep their systems if they meet CalCareNet's guidelines. Importantly, any shared information must maintain client confidentiality.

The Long-Term Care Council must involve various stakeholders in developing guidelines, such as consumer groups, senior services, veteran services, and disability programs. The agency is not required to perform new tasks without federal or private funding. No state funds will be allocated for this development.

(a)CA Welfare and Institutions Code § 9254(a) By January 1, 2005, the agency, with recommendations from the Long-Term Care Council, shall set standards for CalCareNet, with the goal of creating an Internet site that links to counties and planning service areas, and that provides information on long-term care services that are available to the consumer. The agency shall recommend guidelines for local Internet information systems, allowing for flexibility in design and structure. The local entities with existing systems are encouraged to maintain existing systems, assuming CalCareNet guidelines are met.
(b)CA Welfare and Institutions Code § 9254(b) State funds shall not be appropriated for purposes of this section. The agency is not required to undertake any new task described in this section unless it receives federal or private funds for that purpose.
(c)CA Welfare and Institutions Code § 9254(c) Information shared between, and tracked by, providers through CalCareNet may in no way violate Section 15633, pertaining to client confidentiality, or any other statute requiring that client information be kept confidential, unless otherwise exempted by law.
(d)CA Welfare and Institutions Code § 9254(d) In crafting its guidelines for the local-level information systems, the Long-Term Care Council shall seek input from interested stakeholders, including, but not limited to, all of the following:
(1)CA Welfare and Institutions Code § 9254(d)(1) Consumers.
(2)CA Welfare and Institutions Code § 9254(d)(2) Consumer advocacy organizations.
(3)CA Welfare and Institutions Code § 9254(d)(3) Area agencies on aging.
(4)CA Welfare and Institutions Code § 9254(d)(4) Senior legal services.
(5)CA Welfare and Institutions Code § 9254(d)(5) The California Commission on Aging.
(6)CA Welfare and Institutions Code § 9254(d)(6) Caregiver resource centers.
(7)CA Welfare and Institutions Code § 9254(d)(7) Veterans’ services.
(8)CA Welfare and Institutions Code § 9254(d)(8) Senior centers.
(9)CA Welfare and Institutions Code § 9254(d)(9) PACE (Program for All Inclusive Care for the Elderly).
(10)CA Welfare and Institutions Code § 9254(d)(10) The Senior Care Action Network (SCAN).
(11)CA Welfare and Institutions Code § 9254(d)(11) The Multipurpose Senior Services Program (MSSP) services.
(12)CA Welfare and Institutions Code § 9254(d)(12) Ombudspersons.
(13)CA Welfare and Institutions Code § 9254(d)(13) County-level programs, including, but not limited to, In-Home Supportive Services (IHSS), county welfare departments, public health departments, and adult protective services agencies.
(14)CA Welfare and Institutions Code § 9254(d)(14) Programs for persons with disabilities, including, but not limited to, independent living centers.
(15)CA Welfare and Institutions Code § 9254(d)(15) Other social service programs, including, but not limited to, employment development programs.
(e)CA Welfare and Institutions Code § 9254(e) By January 1, 2004, the agency shall link the CalCareNet Web site to local Internet information systems. The agency shall permit counties and planning service areas to design local information systems, contingent upon the availability of funding and resources for these purposes.
CalCareNet long-term care services Internet information systems client confidentiality Long-Term Care Council local information systems consumer advocacy area agencies on aging senior legal services caregiver resource centers veterans' services programs for persons with disabilities In-Home Supportive Services (IHSS) county welfare departments stakeholder input
(Added by Stats. 2002, Ch. 541, Sec. 14. Effective January 1, 2003.)

Section § 9255

Explanation

This law outlines a plan for recommending standards for care navigation within the long-term care system. By January 1, 2004, an agency, guided by the Long-Term Care Council's advice, must suggest how consumers can be better guided from acute care to long-term care.

The recommendations should cover training requirements for care navigators, where they fit in the care system, and funding impacts. It should also look at improving connections between acute and long-term care, enhancing home- and community-based services, and discuss collaborating with healthcare providers across various facilities.

These plans should incorporate input from relevant stakeholders and align with the goal of ensuring people can access needed care through existing systems. Importantly, state funds are not allocated for this initiative, and federal or private funds are needed to make these recommendations actionable.

(b)CA Welfare and Institutions Code § 9255(b) In its recommendations to the Legislature, the agency shall address care navigator educational and training requirements, the care navigator location within the long-term care continuum, licensure and oversight requirements, and potential funding impact. In its recommendations, the agency shall discuss the need for waivers, enhancing access to home- and community-based services for private payers, connecting the acute care system with the long-term care system, and obtaining private and public funding. The agency shall also discuss means for the cooperative participation of insurance companies, physicians, hospitals, assisted living facilities, home health agencies, and skilled nursing facilities.
(c)CA Welfare and Institutions Code § 9255(c) In crafting its recommendations to the agency, the Long-Term Care Council shall seek input from interested stakeholders, including, but not limited to, those stakeholders described in subdivision (d) of Section 9254.
(d)CA Welfare and Institutions Code § 9255(d) Care navigation must be consistent with the goal of developing a program that is based on the existing state and local systems, to ensure that consumers are connected to the necessary care and services.
(e)CA Welfare and Institutions Code § 9255(e) State funds shall not be appropriated for the purpose of implementing this section. The agency is not required to undertake any new task specified in this section unless it receives federal or private funds for that purpose.
care navigation long-term care care navigator training licensure and oversight funding impact home and community-based services acute care connection healthcare stakeholder input cooperative participation insurance companies assisted living facilities home health agencies skilled nursing facilities Long-Term Care Council federal or private funding
(Added by Stats. 2002, Ch. 541, Sec. 14. Effective January 1, 2003.)

Section § 9256

Explanation

This law states that a care navigation program can only be put into place if new legislation is passed that mandates its implementation.

The implementation of a care navigation program, as described in Section 9255, shall be subject to the enactment of legislation requiring implementation.
care navigation program legislation enactment program implementation future legislation requirement program activation condition subject to legislation implementation requirement California welfare Section 9255 care program legislative mandate healthcare navigation care services program government program activation legislative approval legal condition for programs
(Added by Stats. 2002, Ch. 541, Sec. 14. Effective January 1, 2003.)