University of Pittsburgh psychiatry professor Richard Schulz has been one of the nation’s foremost researchers on caregiving stress for
Ed Ricketts spent 2005-08 in a Shadyside nursing home, as a sedentary double leg amputee in his mid-60s who figured he’d never again have the privacy and autonomy taken for granted by those living at home.
“Living there is hard to describe,” the 73-year-old says of the nursing facility, which he had been forced into by a series of medical crises he had overcome, but which cost him his mobility and strength. “It’s like being in prison or something. ... I think I became oblivious to it though. I don’t think I understood the gravity of it.”
Only when a rehabilitation counselor handed Mr. Ricketts a brochure about the state’s Nursing Home Transition Program did he realize the government actually provided support for people like him to return to the community, if he had the desire.
After he called the number on the brochure to connect with an Allegheny County Area Agency on Aging caseworker, she used knowledge of resources and a $4,000 budget to find an available HUD-subsidized apartment in Penn Hills, pay initial rent and security deposit, furnish it and stock it with food. The AAA found a home aide to help him several hours a day, plus set him up with home-delivered meals, transportation services and other assistance.
The ongoing services today for Mr. Ricketts — whose long-running exercise regimen now has him able to walk on prosthetic legs with a cane — cost Medicaid about $30,000 a year instead of more than $70,000 for a nursing home.
Mr. Ricketts’ transition predated the start of Pennsylvania’s Community HealthChoices program by a decade, but it represents what the Wolf administration’s managed care initiative hopes to achieve. The state has spent the 21st century gradually trying to rebalance its long-term care spending by diverting more people and resources to home support instead of institutional care, and the CHC program is intended to deepen that effort.
Through a variety of what are known as waiver programs for frail, older individuals or younger ones with disabilities, the state used Medicaid dollars on home-related services in 2015-16 for some 68,000 individuals whose health conditions would have qualified them for subsidized nursing home care. That was more than twice the number of seven years earlier. Meanwhile, it was paying the far higher cost of nursing home living for about 84,000 individuals — also an increase, but of just 3,000 over seven years.
Now those waiver individuals, including Mr. Ricketts — in addition to Medicaid-funded nursing home residents and healthier people who qualify by age and income for both Medicare and Medicaid but don’t yet require subsidized services — are mandated to join Community HealthChoices in 14 southwestern counties on Jan. 1. The state is asking them by Nov. 13 to choose one of three state-contracted managed care organizations that will coordinate their long-term care support and medical services, or else one of those MCOs will be assigned to them.
A goal of the MCOs, with financial incentives that make it worth their while, is to move any capable clients out of nursing homes — and even more, to help people whenever possible to avoid those facilities in the first place. That is to be accomplished through the work of service coordinators who will monitor and assist individuals in the program more closely than was the case a dozen years ago for Mr. Ricketts, who was largely on his own when he entered and got stuck in his nursing home.
Mr. Ricketts was fortunate to be handed a brochure about the Nursing Home Transition Program, which has been helping about 1,400 Pennsylvanians a year move out of nursing homes, including several hundred annually in Allegheny County. The MCOs will be taking over much of that nursing home transition work and adding their own resources to the $4,000 allotment the state provides to help people move back into the community.
“This is all about emphasizing and supporting a person’s choice of where they want to live and where they want to receive their services,” said Sharon Alexander, president of long-term services and supports for AmeriHealth Caritas, one of the three MCOs. She said service coordinators will be making personal visits initially to each Community HealthChoices participant, including those in nursing homes to gauge their interest in relocating. None can be forced to move.
“We’ll want to look at people that have the ability to be successful in the community,” she said. “It’s partly driven by a person’s own functional abilities, their caregiver and family network, and their own desire and willingness.”
What this all means for the nursing home industry is complicated. Providers and trade association representatives complain on the one hand that Medicaid rates are set too low to cover the true cost of caring for those residents; still, they rely on those government-subsidized individuals for nearly two-third of their patients on average, and empty beds are a worse alternative.
Nursing home officials also question how many of their existing residents can return to the community in a safe and cost-effective manner, in that about 10 hours of paid home care a day at home can equal the cost of a nursing home.
“If you walk through a nursing home and ask who among them would like to be at home, obviously the vast majority would prefer to receive care at home if they can,” said Steven Tack, CEO of Butler-based Quality Life Services, which operates 11 nursing homes. “For some, that’s not necessarily realistic.”
Officials with the state and county agencies that handle the existing Nursing Home Transition Program say difficulty finding quality, affordable housing for aging and disabled individuals can be the biggest barrier to relocating people to the community. It’s unclear how the Community HealthChoices MCOs will be able to address that, although helping people find suitable housing and making home modifications when it would assist those residents are among the insurers’ responsibilities.
While nursing homes could lose some potential residents from the CHC initiative, they have not publicly questioned its goals or expressed concern for their own long-term future under it. The nursing home occupancy rate — currently close to 90 percent among Pennsylvania’s 88,000 beds — has dropped in some states that previously adopted Medicaid long-term managed care. Pennsylvania’s atypically old demographics may offset that, as evidenced by how its Medicaid-funded nursing home population has grown modestly in recent years despite the huge spurt in government-funded home services.
“You look at our growing demographic of seniors, and yes, many will be able to receive services at home, but there are many who won’t and will need the services of a nursing facility,” said Anne Henry, senior vice president of LeadingAge Pennsylvania, which represents nonprofit long-term care providers. “It’s like we need more of everything.”
In the short term, nursing homes have concerns about how much and how quickly they will be paid by the MCOs starting Jan. 1 compared to their current relationship with the state. Those and other unanswered operational questions about Community HealthChoices have caused a smaller percentage of nursing homes to sign agreements to join the three MCO networks thus far than is the case with other providers crucial to the program.
LeadingAge and the Pennsylvania Health Care Association set up a meeting Monday for area nursing homes to meet with the MCOs to resolve snags and move forward so CHC participants will have wide-ranging options of nursing homes by Jan. 1 in each MCO’s network, if and when they need them — though the state and MCOs hope to have people need them less.
Gary Rotstein: firstname.lastname@example.org or 412-263-1255.
First Published November 6, 2017 10:50 AM