For long-term care, shift to community- based services gains momentum
For long-term care, shift to community- based services gains momentum
Some experts suggest that there is no question that programs transitioning nursing home patients to community-based services save money and are better for patients. For most Medicaid programs, community services are limited and waiting lists are long, but a growing number are doing something about this long-standing problem.
To date, 30 state Medicaid programs have received grants from the Money Follows the Person Demonstration (MFP), a Medicaid initiative enacted into law in 2006. States receive enhanced federal support for Medicaid long-term care programs by providing more services in the community and fewer in institutional settings.
"While the 'Is home and community-based service cost-effective?' question is 25 years old, there is no disagreement that the nursing home transition programs are cost-effective," says Leslie Hendrickson, PhD, principal of East Windsor, NJ-based Hendrickson Development, a consulting firm that provides information to develop and strengthen long-term care programs for Medicaid and other state-funded programs.
The MFP program is based on the premise that many Medicaid beneficiaries currently residing in institutions want to live in the community and could do so if they had adequate support-and at less cost to Medicaid than is currently spent for institutional care.
"While the number of MFP transitions to date has been modest, it is still a clear achievement that the program has already enabled hundreds of people who had been living in a nursing home to return to the community," says Molly O'Malley, a senior policy analyst with the Henry J. Kaiser Family Foundation in Menlo Park, CA. "Going forward, we expect states to continue to transition more people back to the community. This program fits into the broader context of state efforts to promote greater access to Medicaid home and community-based services."
Challenges are many
In a June 2009 report from the Kaiser Commission on Medicaid and the Uninsured, "Money Follows the Person: An Early Implementation Snapshot," states reported their biggest challenges were gaining approval from the Centers for Medicare & Medicaid Services (CMS) for their operational protocol and identifying appropriate housing for individuals transitioning back to the community.
"They also reported challenges working with numerous internal and external stakeholders to coordinate transitions," says Ms. O'Malley. This was a necessary step in the process, though, in order to form collaborative partnerships with stakeholders.
"A program such as MFP is needed. Medicaid programs are not structured as well as they might be for supporting transitions from institutional care to the community," says Carol Irvin, PhD, a senior researcher at Mathematica Policy Research in Princeton, NJ. "Several factors pose challenges to transitioning institutionalized people to the community." Ms. Irvin says that some of these challenges include:
-One-time supports that are not long-term care in nature but are critical to help transition someone into a home or community setting may not always be reliably available. This is because a state's Medicaid program or other social programs often do not adequately cover these services. These include rental or utility deposits, basic furnishings, vehicle modification, and other help with transportation or housing.
-Existing home- and community-based waiver programs are frequently capped. Some programs have long waiting lists that deny some beneficiaries timely access to necessary home and community-based services.
-The range of long-term care services covered by a state's optional benefit or waiver program is often limited.
-Regulations typically restrict the hours of care per week that a Medicaid beneficiary can receive. It may not be enough for the beneficiary, especially when first transitioning from an institution to the community.
-Housing options are frequently limited, particularly if a beneficiary's home was sold after entering the institution or modifications are needed to make available housing accessible. "The housing piece seems to be the most common challenge," says Dr. Irvin.
"At this point in time, all states with MFP grants have established their programs and have started to transition a wide variety of people from institutional to community care," says Dr. Irvin. "Several have been transitioning individuals for more than a year. Others are just now starting their transition programs."
According to Kaiser's June 2009 report, 11 states reported that they had completed 349 transitions, and 13 states reported that 465 transitions were in progress.
When Dr. Hendrickson contacted all the state MFP programs in early 2009, he found that most don't use systematic methods to select residents. Methods vary, with some programs relying on referrals from agency staff and others planning on contacting all nursing home residents periodically. For example, Maryland plans to contact all residents every six months. According to data from Mathematica Policy Research, most programs target less than 1% of MFP eligibles.
As for the recession's impact on these programs, Dr. Hendrickson says, "Whether states are doing this well, or not doing it at all, has nothing to do with the recent economic downturn. It is really more to do with the policy that states use with their long-term care programs."
When Dr. Hendrickson was responsible for Medicaid long-term care programs as Assistant Commissioner in the New Jersey Department of Health and Social Services, he worked on New Jersey's transition program, Community Choice. The statewide program, implemented in 1998, provided nursing home residents with information about home and community-based services and housing alternatives and assistance to those who wanted to move out of a nursing home.
More than 3,400 people left nursing homes with the help of Community Choice counseling between state fiscal years 1998 and 2001, and the state's total nursing home population declined by 5% during this period. Despite this success, however, the program was not continued. "After we left, the program lapsed for two years, since the policy-makers that followed us were not interested in transition," says Dr. Hendrickson. "In contrast, Pennsylvania has had a well-operating transition program that has continuously expanded since 2001."
In Kaiser's June 2009 report, nearly all states reported not having to make budget cuts or changes to MFP programs as a result of the downturn. Ms. Irvin says, however, that some MFP programs have been affected by state hiring freezes and furloughs. These have slowed down some of their implementation plans. "Several states have been thinking about scaling back the number of people they will transition as a result," says Dr. Irvin. "But several have expanded their transition goals."
Greatest long-term challenge
An independent analysis found that Wisconsin's Family Care program saved an average of $452 per person, per month in total medical assistance expenditures. "The program offers people a choice about long-term care. It's helping seniors and people with disabilities live in dignity by giving them the choice to stay in their own home," says Stephanie Marquis, spokeswoman for the Department of Health Services in Madison, WI.
Ohio has two complementary initiatives that expand community living options for consumers in institutional settings-HOME Choice (Helping Ohioans Move-Expanding Choice) and the Unified Long-Term Care Budget (ULTCB).
HOME Choice is a transition program created through an MFP grant that Ohio was awarded in January 2007. The Ohio Department of Jobs and Family Services administers HOME Choice, which will relocate up to 2,200 people residing in nursing facilities and intermediate care facilities for mental retardation to community care. "The project must also meet CMS-approved targets that begin to shift spending on institutional and community care options into balance," according to Erika Robbins, Ohio's MFP Project Director. "As demand for community care is expanded through the ULTCB, nursing facilities spending is expected to flatten or decrease, thus freeing up revenue for expansion of additional community care options."
According to Jerry Fuller, Alaska's Medicaid director, the cost of long-term care is "always a challenge." Unlike many states, Alaska did not permit a huge growth in nursing home beds, and has been focused on community care for many years.
"We are not facing a big challenge now of transitioning from nursing homes and reducing beds, but rather providing sufficient quality community care for our rapidly growing senior and disabled population that becomes eligible for Medicaid," says Mr. Fuller.
According to a February 2006 report from the Lewin Group in Falls Church, VA, on Medicaid spending for the state of Alaska, "Long-Term Forecast of Medicaid Enrollment and Spending, 2005-2025," estimated Medicaid costs will more than quadruple over 25 years. About half of the increase was attributed to the growing need for long-term care services.
"Pacific Health Policy Group did a study and report for our legislature in 2006 that emphasized this issue," says Mr. Fuller. In addition, a 2008 report by Baltimore-based HCBS Strategies provided an in-depth review of Alaska's current programs to improve their long-term care system. "They made many very good suggestions on how to position the state for the future growth and make the Medicaid program more fiscally sustainable," says Mr. Fuller. The department is in the process of determining what changes to make and when.
"I believe finding ways to improve community-based services, develop and maintain a work force to provide these services, and implement efficiencies to help make the Medicaid long-term care services more sustainable are the greatest long-term challenges facing the Alaska Medicaid program," says Mr. Fuller.
Contact Mr. Fuller at (907) 269-3495; [email protected], Dr. Hendrickson at (609) 443-1809 or [email protected], Dr. Irvin at (617) 491-7900, ext. 232 or [email protected], Ms. Marquis at (608) 266.1683 or [email protected], Ms. O'Malley at (202) 347-5270 or [email protected], and Ms. Robbins at [email protected].
Some experts suggest that there is no question that programs transitioning nursing home patients to community-based services save money and are better for patients.Subscribe Now for Access
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