By Joanne Lynn
The time has come to seek cooperation from the Centers for Medicare and Medicaid Services (CMS) so MediCaring Communities can get underway in many parts of the country. These programs are as necessary to an aging society as pediatrics and obstetrics are for children and maternal care. Empowering communities to take care of their own residents who aim to age in place and eventually live with frailty is a challenge we can meet without impoverishing younger people or stalling the economy. But it will take some action now. Can you and your community be among the pioneers?
The core ideas are simple and well-proven. Now is the time to pull them together into a workable and affordable system of care. First, we have to be willing to acknowledge that becoming old and frail—having two or more limitations in Activities of Daily Living, presence of cognitive impairment, or being older than 85—is now an expectable part of life for most Americans. When this period arrives, we usually need a more supportive and adaptable care system. The arrangements we have now for health care and supportive services are frustrating, wasteful, and a serious misfit for providing the comfort, meaningfulness, personalization, and reliability that are so greatly desired at that point in our lives. Critically important, we become more and more individual as we grow old: each of us has a unique set of relationships, values, resources, aspirations and fears, as well as a particular medical situation. This demands that frail elderly people have a thoughtful care plan for the services needed across time—one that fits their individual preferences and priorities.
Medical care for frail elderly Medicare beneficiaries also needs to fit their situation. Screening to prevent illnesses that are unlikely to become a serious problem for a decade or more is a good example of low-value care that should be avoided, while preventing falls and delirium assumes a very high priority. Going to the hospital may sometimes be essential; however, for frail elders, this entails much more risk (e.g., infections and falls) than it did earlier in life, so hospitalization decisions need to be carefully considered. More medical services should be provided in the person’s home once it becomes very difficult and disorienting to go to a doctor’s office or clinic.
Here’s another key point: For the mainly homebound frail elderly Medicare population, supportive services are critically important to daily well-being and must be readily available and reliable. Some frail elders need food delivered or housing adaptations. Others need ongoing personal care or supervision. The great majority hopes to stay in their homes and not have to move to institutions, and most want to keep up relationships with neighbors, family, religious groups, and others. Family caregivers of the future will be both less available and will face more substantial challenges than in the past, and we need to support them.
Scores of improved practices are known to achieve better care, but to date all have been small projects, hard to sustain and difficult to scale up and spread. The current funding rules in the United States encourage overuse of medical care while providing scant supportive services and almost no tools for communities to evaluate local needs and priorities. It is bizarre that any physician can write a prescription for a drug costing $100,000 that has been found to be only a little helpful for only a few potential patients, but neither the doctor nor anyone else can order up a substitute caregiver when the spouse is ill or find a way to get food delivered when there is a long waiting list for Meals on Wheels. Most families and elderly people find this strange as well, once they experience the situation. But most people are only gradually realizing that this sort of distortion is a direct result of policy choices—and that we could choose differently.
MediCaring Communities is a way to choose differently. Here’s how: Each community would develop a way to reflect the voice for its frail elders, which we’ll call a “Community Board,” though it could have a number of names and organizational features. The important thing is that it would help guide providers in the local system toward achieving and maintaining high-value care. For example, the Community Board would work with health care, public health, and social services providers to monitor performance metrics that reflect the priorities of frail elders in the area, including the preferences of individuals, and help decide on priorities for investments and improvements.
Where would funding for investment and system management come from? The funding would come from savings arising from much-improved coordinated services that are adapted appropriately for the population of frail elderly Medicare beneficiaries, follow their preferences, and adhere to the principles of geriatrics, and that reduce overutilized, low-value services in Medicare! The potential for savings varies, but an average of about 30% is plausible for almost any MediCaring Community program. Even saving 10% would enhance the ability of communities to make supportive services that are needed by elders—and which are the mainstay of long-term care—much more available. A program could be built on a managed care platform, an Accountable Care Organization arrangement, or a Program of All-Inclusive Care for the Elderly (PACE) program.
Recent legislation has made a new avenue possible through the PACE program, the most established, community-based service delivery model for older adults. The PACE Innovation Act (P.L. 114-85), signed into law on November 5 2015, provides the Centers for Medicare & Medicaid Services (CMS) with the authority to loosen the rigidity of the PACE program. CMS’ Center for Medicare & Medicaid Innovation (CMMI) can now pilot expanded PACE models to serve a broader population. For the first time, the program can be readily adapted to serve Medicare-only beneficiaries who have a need for some LTSS but are not yet functionally at their states’ nursing home level of care and have incomes above their state’s Medicaid financial eligibility threshold. Building MediCaring Communities on an ACO, MA plan, or PACE platform will require some cooperation with CMS.
That’s where your help is needed. The time has come to ask CMS to take up the challenge of working with willing applicants, starting by opening the door to allow pioneer MediCaring Community programs, including willing PACE programs, to move ahead.
Here’s what we have found likely to be important in the first set of communities, enabling them to lead in building reliable, sustainable services for frail elders in the MediCaring Communities model:
- A history of cooperation in the public interest;
- Implementation of some improvements already in frail elder care, such as some experience with models like PACE, GRACE, INTERACT, local support of nutrition and transportation services, age-friendly environments, or similar models and programs;
- Leaders who are concerned about the future effects of increases in the numbers of persons needing daily help in old age;
- Enough frail elders to field a convincing project but still small enough to be able to make improvements quickly (perhaps 500–10,000 is a reasonable range, and frail elders are about one-tenth of all persons older than 65);
- Reasonably self-contained area, with boundaries that are well-known, that is, the health care and supportive services to people who live in the area are generally provided by services anchored in the area.
There will be other considerations, but none are as important as commitment and leadership. We invite you to think on it and talk it over with others, and if building the elder care system of the future is plausible and appealing in your community, city, or county, please let us know! We are planning some webinars and perhaps some meetings to spell out details, answer questions, and shape up our request before we head to CMS to get approval for leadership communities to get underway.
Serving a far larger population of elders is a solvable problem—it is only made difficult by protocols and regulations that were developed for a different (younger) demographic reality. Let’s modernize our care system for our old age and create a trustworthy set of arrangements that generate pride instead of waste and frustration. Send us an email today.
What do you think? Can you help to make this happen? Write to us at [email protected] if you can see a good opportunity in a community that you know. Also encourage support from the leadership of professional and advocacy organizations, political leaders, and CMS. Let us know if you are doing this and what progress you are making. If you contact us, we’ll be in touch and will aim to include your community in the list of potential pioneer communities to help persuade CMS to let us proceed.
I have studied the public national Long-term Care Insurance program in Japan. I have also worked as a geriatric social worker for many years in Michigan. I really think a national program is the best solution with the same guidelines for eligibility in the country and with funding for the necessary services. I can’t see this happening within the current U.S. system. Everything is too fragmented and dependent on Medicare and Medicaid funding. Long-term care is not medical care and needs to have a separate system.