Presented by Courtney Burke Nelson A. Rockefeller Institute of Government Health Policy Research Center for the New York State League of Women Voters March 20, 2009

       Explanation of long-term care (LTC) State role in long-term care How LTC is changing Explanation of ‘aging in the community’ How states provide community care Trends and state comparisons in community care Conclusions and suggestions for change 2

   Assistance with essential, routine life tasks Therapies that improve or maintain functioning Special equipment LTC is provided for an undetermined amount of time (i.e., not a one-time intervention) 3

      Millions of Americans use LTC Even more Americans will need LTC as baby boomers age Over $207 billion was spent on LTC in 2005 LTC, especially institutional care, is expensive: U.S. average is $70,900 per year for nursing home and $36,500 a year for four hours/day of a home health aide

(Source: Georgetown University)

There is an opportunity to improve quality and continuity of care Financing care is a burden for states 4

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    Major role in financing state share of Medicaid State-funded supportive services for individuals in need and caregivers Regulatory and quality oversight Administrator and coordinator of services and programs 6

           Home and Community-Based Services (HCBS) waiver Home health services Hospice care Personal care services Private duty nursing services Program of All-Inclusive Care for the Elderly (PACE) Inpatient hospital, nursing facility and intermediate care facility services in institutions for mental diseases, age 65 and older Inpatient psychiatric services, under age 21 Intermediate care facility services for the mentally retarded Nursing facility services, other than in an institution for mental diseases Religious non-medical health care institution and practitioner services 7

Moving toward more community care:

     Care at Home & Home and Community-Based Services waivers (1981) Assistive Technology (1988) Cash and Counseling (1998) Olmstead v L.C. (1999) Federal initiatives – New Freedom, Real Choice Systems Change, Money Follows the Person, Nursing Transition/Diversion 8

  Wikipedia – The ability to live in one’s own home — wherever that might be — for as long as confidently and comfortably possible Journal of Housing for the Elderly – aging in place is not having to move from one’s present residence in order to secure necessary support services in response to changing needs 9

 Within gerontology, sociology and anthropology, aging-in-place is described as “a complex set of processes that is part of the universal and ongoing emergence of the person-place whole, and the creative social effort to reintegrate the whole in a meaningful way when problems arise, compounded by an older adult’s evolving situation.” (Cutchin, 2003) 10

           Personal care Adult day care Assisted living Assistive technology Home care Hospice Rehabilitation services Independent living Respite care for caregivers Continuing care retirement communities Naturally occurring retirement communities 11

     Coordination of care is difficult, i.e., senior centers, AAA, home care providers (licensed & certified), nonprofits, other health care providers, government programs, etc.

Not always a smooth transition between acute care and long-term care Balance between what consumer wants versus needs makes oversight difficult Institutional bias in funding system (e.g., Medicaid does not pay for community-based housing) Administration – Many state agencies involved, e.g., SOFA, OMRDD, OMH, DOH 12

           New Freedom Initiative Real Choice System Change Nursing Facility Transition Initiative Money Follows the Person Community-Integrated Personal Assistance Services and Supports Independence Plus Aging & Disability Resource Centers Quality Assurance and Quality Improvement Rebalancing Initiatives Person-Centered Planning Choices for Independence Initiative 13

    New York Connects – point of entry system Expanded In-home Services for the Elderly Program (EISEP) – (e.g., case management, ancillary services, in-home services) Nursing Home Diversion & Modernization Act (NY one of 14 states) Long-term care restructuring advisory council 14

Type of Service

Nursing Homes HCBS

National Medicaid Participants 1999

1,615,695

2004

1,707,572

# change

+91,877

% change

+6% 935,160 1,337,010 +401,850 +43% 15

State

National # Connecticut Massachusetts New Jersey New York Pennsylvania

Own Your Future

16 X

Aging and Disability Resources Center

43

Cash and Counseling Independence Plus

15 10 X X X X X X X X

PACE

24 X X X 16

     Provide more recognition, support for informal caregiving Make HCBS more accessible, fundable Better integrate acute and LTC to prevent need for nursing home care Provide more state flexibility and federal financial support for evaluations Examine ways to solve the problem at a national level 17

     Policies to allow aging in the community are following disability models Those policies have been slow to diffuse among state Medicaid programs Federal initiatives and support are helping states make needed changes A sizeable proportion of community care is provided outside of government Changing the system is a slow process 18

          DOH – Department of Health EISEP – Expanded In-home Services for the Elderly HCBS – Home and Community-Based Services LTC – Long-term care MA – Medicaid NY – New York OMH – Office of Mental Health OMRDD – Office of Mental Retardation and Developmental Disabilities PACE – Program of All-Inclusive Care for the Elderly SOFA – State Office for the Aging 19

Courtney Burke Rockefeller Institute of Government Director, Health Policy Research Center 411 State Street Albany, NY 12203 (518) 443-5243 [email protected]

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