Aug 072020
 

This is the draft as of August 7, 2020. Please add your comments at the bottom and we’ll update!

Eldercare has long been the stepchild of society’s pursuit of well-being – shunned by medical care and starved by social arrangements. A century ago, this did not matter much – people did not live so long, families were large and mostly on farms where taking in a relative was not so hard, and medical care did not have much to offer. The situation has changed, but the social arrangements have not kept up. COVID-19 has illuminated a number of the shortcomings. There will be a few short windows of opportunity to change things, but the advocates need to be ready with workable proposals. This blog aims to accumulate proposals that seem worthwhile for use by whoever wants to use them. Please add your comments and suggestions in the comments at the end!

Action Steps

  1. Everywhere that we see an opportunity, encourage broad public and leadership awareness of the high likelihood that each American will live with serious disability for a substantial period and that we are exceedingly poorly prepared to enable late life to be comfortable and meaningful. Write letters to editors, op-eds, and blogs. Call in to radio shows. Ask questions of candidates.
  2. Push to revise how we finance supportive care for elders. Allow pre-tax payment for long-term care insurance. Call for a new social insurance to cover “catastrophic” levels of costs from needing long periods of long-term care. Call for Medicare’s capitated plans (Medicare Advantage) to cover an understandable standard set of supportive services for defined situations.
  3. Generate data that will enable communities to understand how well their community is performing with regard to eldercare and that can monitor efforts to improve. We need visible data about the availability of home-delivered food, adapted housing and transportation, direct service workers, medical care at home, and the quality and reliability of personal care.
  4. Enable some local authority to monitor and manage eldercare on behalf of the community – could be the responsibility of the Area Agency on Aging, the public health office, a coalition of concerned entities, county government, or another approach – – but somehow, we need to create a locus of responsibility for improving performance.
  5. Strategize to reduce reliance on hospitals and nursing homes. They are essential in some circumstances, but many more people could be treated at home or in an outpatient setting, and many more people could go straight home from a hospital stay, IF the community had readily available and fully adequate supports for disabled people living in the community. So – advocate for more adequate funding for the Older Americans Act, which supports meals, care coordination, Area Agencies on Aging, etc. Advocate for more outreach to prevent abuse and neglect. Learn what is not available in your own community and push for that.
  6. Support family caregiving. Employers could seek to be flexible in leave, adjusted hours, and working from home. Respite care could be made available. Family caregivers could be paid in some circumstances and could get social security credits and Obamacare health insurance coverage.
  7. Improve the working conditions for direct care workers. Require a living wage, whether working in facilities or homes. Require conventional workers benefits. Ensure that they have the personal protective equipment and COVID-19 testing (or whatever else arises) that they need. Build career ladders with certifications and opportunities to advance.
  8. Push our organizations to be strong supports – AARP, Alzheimers Association, caregiver groups, professional organizations, provider organizations, political organizations, etc.
  9. Send in suggested questions for televised debates of candidates. Tweet to reporters.
  10. Express outrage over the forced isolation (solitary confinement!) of nursing home residents without even asking them about their tolerance for the risks, or enabling survivors of the infection to be more liberated from restrictions.
  11. Highlight the need for all elders to have comprehensive care planning, including advance care planning for medical care. Nursing homes and assisted living centers should have nearly 100% compliance and failing to undertake this work should be a cause for penalties.
  12. Study and respond to the evident disproportionate impact of COVID-19 on nursing home staff and residents who are African-American, Latinx, or immigrants.
  13. Encourage very limited liability protections for alleged shortcomings arising from COVID-19. The country should avoid a plague of lawsuits, but whatever protections are put in place should be limited in time and scope.

I’ve become quite fond of the hopefulness of this quotation – and a devotee of having good ideas “lying around.” So – let’s get behind them and push them to be politically inevitable!

“Only a crisis – actual or perceived – produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around. That, I believe, is our basic function: to develop alternatives to existing policies, to keep them alive and available until the politically impossible becomes the politically inevitable.” Milton Friedman

This is the draft as of August 7, 2020. Please add your comments at the bottom and we’ll update!

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Nov 132019
 
Dr. Lynn testifying before Congress.
Dr. Joanne Lynn, MD

The Ways & Means Committee of the U.S. House of Representatives heard testimony on “Caring for Aging Americans” on November 14. Dr. Joanne Lynn participated as an expert witness. A video of the hearing can be viewed at https://www.youtube.com/watch?v=20GgbnOMIn4.

Read Dr. Lynn’s comprehensive written testimony by clicking below.

Testimony_JLynn_to_WaysMeans_11-14-2019

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Sep 182019
 
Portrait of Joanne Lynn
Dr. Joanne Lynn, MD

By Joanne Lynn

Within just a dozen years, the U.S. will have nearly double the current number of frail and disabled elderly people needing daily supportive services. Look around! What is being done to prepare for this expectable increase? Already most cities have long waiting lists for home-delivered meals, and no city in the U.S. has adequate affordable disability-adapted housing. We have all sorts of improvements “proven” to work in research or demonstrations, but we have no long-term plan. A recent Health Affairs article showed that most of the people who retired from “middle class” jobs will be unable to afford housing and health care within a decade.

America mostly deals with issues no more than a few years into the future. But private savings for supportive services in old age requires planning more than 30 years ahead – the person at age 50 has to plan for the risks at age 80 and beyond. And the nation has no real plan for how to arrange savings, taxes, and services to keep frail and disabled elders having food, shelter, and personal care. Indeed, even the Presidential candidates don’t debate these issues!

Delaying action until the suffering is so widespread and severe that taxes rise to support more of what is already haphazard and costly “care” would severely weaken the economy and curtail needed investments in other areas, such as childhood development and transportation infrastructure.

One clever proposal calls for federal coverage of long-term care after a period of need that depends upon the person’s lifetime earnings. If low-wage earners had to cover a year and high-wage earners had to cover 5 years, the cost would be less than 1% added to the Medicare tax. And we’d suddenly have long-term-care insurance vehicles that are affordable and widely purchased.

Well-proven improvements in medical care, preventive services, housing, and food delivery are easy to identify – they just need to be demanded and implemented.

In an editorial in the Journal of the American Geriatrics Society, I have called on all of us who serve frail and disabled elderly people to speak up – to push civic leaders for urgent planning and policy improvements. Click here to read the editorial – and then take action! Find a few other people willing to speak up! Get organizations to push for attention to these issues! It’s our future, claim it and make it better! Let us know how to help.

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Dec 032018
 
Nick Macchione, Joanne Lynn
Authors Nick & Joanne

By Nick Macchione and Joanne Lynn

This blog entry was written for the Milbank Memorial Fund and is reposted here with permission.

State and local leaders who aim to improve population health must help older Americans live well with the challenges associated with aging. Given the rapidly rising number of elders, local governments have remarkable opportunities to facilitate improvements in health and quality of life for elderly people living with disabilities and serious illnesses. In March 2016, the county of San Diego joined both the AARP Network of Age-Friendly Communities and the Dementia Friendly America network to create the Age Well San Diego initiative. Age Well San Diego expands on the foundation of the County’s Live Well San Diego vision of a region that is “Building Better Health, Living Safely, and Thriving,” which was first established in 2010.

Age Well San Diego is a five-year collaborative process of assessing needs and working with community partners to develop, implement, and evaluate an action plan. With support from the San Diego Foundation and AARP, the county’s Health and Human Services Agency first held an Aging Summit to introduce the concepts of age-friendly and dementia-friendly communities. Additionally, the county held listening sessions to garner feedback from the public and arranged targeted focus groups to gain input from racial, ethnic, and linguistic communities, which often are not well represented. The planning sessions included a broad array of county departments. Live Well San Diego has long recognized partners, community groups, and other health-related organizations. The variety of input led to a comprehensive “Age Well San Diego Action Plan” that was approved by the County Board of Supervisors in May 2018.

The Age Well San Diego Action Plan identifies five priority themes: health and community support, housing, social participation, transportation, and being dementia-friendly. Goals, action steps, timelines, and metrics to measure success have been developed for each theme, and dementia-friendly strategies are woven through the other four areas. During the next three years, the county will work with community partners, interested stakeholders, and older adults to implement the plan, coming together to build age-friendly, dementia-friendly communities that will benefit residents of all ages. The county will continue to work closely with community partners, government officials, professionals and older adults to build a brighter future for people of all ages.

Guided in part by this Action Plan, San Diego County is making major strides in aging well. For example, the county has one of the lowest rates of hospitalization of elderly people in the nation, a health information exchange that includes data from county services, and much of the county’s public education system has focused on preventing falls, the dangers of inactivity, and hypertension. With the focus on older adults, and an added emphasis on those with Alzheimer’s and dementia, the county is creating an environment in which the elderly are better supported with wrap-around services, thus bolstering and strengthening their ability to remain in their homes and communities throughout their lifespan. Moreover, Age Well initiatives help older residents avoid preventable illnesses, stay engaged in their local communities, and obtain adequate support in the last phase of life.

Despite progress, the county still faces a substantial set of challenges in ensuring supportive care for people living with the disabilities associated with aging. Scores of supportive service organizations serve elders, but their capacities and eligibility requirements vary or change and are not coordinated. Medical care systems are mostly local, and they have cooperated on projects to improve emergency preparedness and care transitions. Most of the MediCal managed care plans, however, are owned outside of the county and are not yet well-connected with local services. Elders and their caregivers are too often left frustrated and anxious, and too many must cope with living without essential services. The county is exploring how to monitor how well elders are doing, both when they are still robust and when they are living with serious illnesses and worsening disabilities. While addressing these ongoing challenges, San Diego County remains an example to others looking at what local governments can do for aging populations.

The Aging Well planning process makes it clear: if a health care financing and service delivery system were designed now for elderly people who might live for years with serious chronic conditions and disabilities, it would not be based on traditional fee-for-service Medicare. Instead, it would prioritize ensuring that adequate food, shelter, personal hygiene, eyeglasses, hearing aids, foot and dental care were all available. The affected population and their families would be involved in deciding which medical services help people live well and need to be readily available, and which services have little impact, given a patient’s age and condition, and need not be readily available. For people who can’t leave their homes, services need to come to them, with appropriately prompt response times.

Optimal policies must go beyond standard preventive health care services and medical care delivery to involve social determinants of health, including education, living or working conditions, and societal connectedness. The built environment, the local workforce, and the services available shape the experience of elders and their families in profound ways. Adapted housing and transportation for the elderly, for example, enable community living, while shortages push elders into nursing homes. When the elderly have access to parks and community spaces, they are more likely to get physical activity and engage with others, reducing isolation and depression.

These ideas are coming together in the MediCaring® Communities reform proposal. The MediCaring® Communities concept proposes additional reforms, including capturing funds saved from avoiding wasted and low-value medical care and instead investing them in community-based services. Currently, health insurance ensures that a frail elderly person can get any costly drug or surgery, but that same person often faces challenges in finding shelter, personal help with bathing, or dental care because these essential services have inadequate funding.

San Diego’s social services and its health care providers have long been committed to enhancing the health of its people, as demonstrated by Age Well San Diego and other collaborative and innovative endeavors. However, the county’s ability to test more fundamental reforms is constrained by established processes and financing. Creating a set of reliable and efficient social arrangements to support a large and rapidly growing number of frail and disabled elderly people will require the opportunity to test substantial innovations. The MediCaring® Communities model provides such an opportunity.

The Center for Medicare & Medicaid Innovation within the Centers for Medicare & Medicaid Services should enable a few communities, like San Diego, to work intensely with their elderly population to demonstrate how a highly reliable and efficient aging care system could be developed for the elders who must live with disabilities and illnesses. Funding should aim to stay within current aggregate costs to elders, families, communities, states, and the federal government, but some funds would be directed to reforms that benefit all elders and their families—such as workforce training, caregiver support, dental care, and so forth. Many communities likely would join and build this future—just in time for the aging of America.

Nick Macchione serves as San Diego County’s director of the Health and Human Services Agency, which serves over 1.3 million people. He is also the architect and strategist of “Live Well San Diego.” He is a fellow of the American College of Healthcare Executives, a Public Health Leadership Scholar with the Public Health Institute/Federal CDC, and a Creating Healthier Communities Fellow of the American Hospital Association. Macchione holds master’s degrees from Columbia University and NYU specializing in leadership, management, and policy. He is a member of the Steering Committee of the Reforming States Group.

Read Joanne Lynn‘s biography.

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Aug 212018
 
Portrait of Christine Stanik
Christine Stanik

By Anne Montgomery, Sarah Slocum and Christine Stanik

What do you need to know in order to remain in your own home as the years advance? Where can you turn for good, reliable services in a costly, chaotic, constantly shifting health care system? One possible answer is PACE (the Program of All-inclusive Care for the Elderly) program. PACE is widely acknowledged to be the “gold standard” of comprehensive geriatric care – which is not just medical care, but also long-term services and supports (LTSS).

But PACE is not yet available in 19 states, and currently has limited capacity, serving about 45,000 beneficiaries (almost entirely elderly persons who are enrolled in both Medicare and Medicaid). Beyond the dually-eligible population, how can we expand PACE to a burgeoning population of Medicare-only beneficiaries, many of whom need some LTSS, and who would very much like to avoid spending down to Medicaid level?

Medicare Advantage

One area of likely growth for PACE is to partner with Medicare Advantage (MA) managed care plans. Recently, the Centers for Medicare and Medicaid Services (CMS) published guidance allowing MA plans to expand the range of supplemental benefits they may wish to offer to include a range of LTSS. MA plans could contract with PACE (or another service organization), to furnish PACE Center attendance and transportation to and from home; meals; and other services to help enrollees avoid hospitalization, emergency department visits, and maintain stability even during periods of decline. For working family caregivers, PACE can be a huge help, serving as a source of reliable respite. And increasingly, evidence is accumulating that such arrangements can reduce in-patient hospitalization and ED costs, and delay or prevent long-stay placement in nursing homes.

To serve current community needs and prepare for larger offerings through MA contracting, some PACE organizations provide services to non-PACE enrollees as a private pay offering. PACE plans have varying levels of experience providing a la carte or service packages to non-PACE enrollees. At the Program to Improve Eldercare, we are developing policy pathways and practical tools to help PACE organizations and MA plans prepare to work together to better serve frail elders. First we need to address the daunting Part D affordability barrier that faces Medicare beneficiaries wishing to enroll in PACE that Sonja Love Felton described in a previous blog. Fortunately, CMS is aware of the problem, and may be open to a system-wide solution. We invite you to encourage them (contact us for guidance at [email protected]).

Medicaid

Another set of challenges to accessing PACE for some Medicare beneficiaries is that they lack the personal resources to pay out of pocket for LTSS. Many in this group have just slightly more income than their state’s Medicaid income eligibility threshold permits. If their monthly medical expenses are high, and this can be documented, some of these beneficiaries can take advantage of the so-called “medically needy spend down” option 33 states have. However, in most states, this option requires a large monthly deductible leaving only small amount of income (as low as $400 per month in some states) to pay for all living expenses. The rest face the “Medicaid cliff” –with an absolute cut off level, usually 300% of the SSI limit, which is $2250 in 2018 and cannot qualify for Medicaid if they are one dollar over the limit. The predictable result is that many families wind up impoverishing themselves to gain access to LTSS – which may only be available in the highest-cost setting – a nursing home. To solve these dilemmas, the Program to Improve Eldercare is working with Medicaid experts to identify practical, workable policy solutions that can be readily implemented, and which can make PACE LTSS services available to many more Medicare beneficiaries. States will ultimately save Medicaid dollars and avoid premature nursing home placement by allowing people to avail themselves instead of lower cost PACE services.

In the course of analyzing these challenges, we have been speaking with Michigan families who generously agreed to tell us their stories. Michigan is a state with an absolute cut-off for Medicaid – if your income is more than $2250 per month, you cannot qualify, even if your medical costs and personal care needs alone are $3000 per month. We relied on family caregivers to speak for elders they are supporting. They provided us insights into what happens to families who find PACE attractive, but who do not qualify for Medicaid and do not think they can afford to pay for long-term services and supports (LTSS) out of pocket. To protect the privacy of those interviewed, we have changed the names below, and details from several individuals are combined in the two composite narratives.

Tom’s Story

We spoke with Tom less than six months after he had contacted PACE on behalf of his octogenarian mother. Because she was becoming increasingly frail and unable to live on her own, Tom moved his mother into his own home. Not yet at retirement age, he soon realized that the demands of caring for her were at odds with a job that kept him away from home for up to 10 hours a day. Tom called PACE to express concern for his mother’s safety when she was home alone, noting that her physical condition was likely to degenerate over time due to several worsening health conditions.

Although Tom and the PACE program concurred that enrolling his mother would be the right solution to an otherwise hazardous situation, the cost of PACE, more than $4000 per month, put it beyond their reach. This left Tom to piece together services as best he could. However, eventually his mother had a fall when he was away from home, breaking her hip. At the time of the follow-up interview, she was convalescing in a nursing home, and Tom was desperately trying to find a better alternative. He was deeply concerned that a lack of adequate rehabilitation at the facility was preventing his mother from regaining her mobility. Although he did not have a plan to keep her safe if she returned home, Tom was exploring options to try to bring his mother home and also obtain therapy that could help her regain strength and the ability to walk. Overall, from a family caregiver’s perspective, the options presented had gone from hazardous to punishing – reliable, ongoing supportive services in a safe environment that would have made both of their lives much better were simply unavailable, because they fell between having a bit too much income for Medicaid, but not enough to pay for PACE.

Sheila’s Story

We spoke with Sheila a couple of months after she had contacted PACE on behalf of her elderly father. After the death of her mother, Sheila became concerned about her father’s social isolation and depression. Declines in physical health and the beginning signs of cognitive impairment were limiting his ability to venture out on his own to see friends and attend medical appointments. Sheila believed the PACE program would be ideal for her father, given that the PACE Center could provide an easy way to access the social interaction he sorely needed, and his medical care would be managed and monitored, alleviating worries about making and tracking various appointments for medical services that created burdens both for him and for her.

Unfortunately, her father’s small pension made Sheila’s father ineligible for Medicaid — without providing enough money to pay the out-of-pocket monthly PACE fee. Given the difficulty of caring for her father’s health needs, and growing concern for his acute loneliness, Shelia made the decision to buy a larger home that would allow her father to live with her family. Unfortunately, this did not work out as well as she had hoped, in part because she and her husband had full-time jobs, and had difficulties transporting her father to various medical appointments that were always scheduled during business hours.

Sheila was also concerned about her father spending most of his days alone. He still drove his own car, but was starting to show signs of forgetting even the most familiar of routes, and she suspected he would soon be unable to drive at all. Sheila was highly motivated to do all she could to help her father maintain a good quality of life in his final years and reported that the PACE Center continued to be the most attractive option for both medical services management and for social interaction. At the time of our last call, she had begun looking into the feasibility of having her father’s pension reduced in order to try to qualify him for Medicaid, so she could enroll him in PACE.

Reflections and Next Steps

Tom and Sheila were both doing their best to care for parents who had reached advanced old age. Both parents worked all of their adult lives and had accumulated some resources for retirement, and the comprehensive care model of PACE was a terrific solution for addressing several concerns. PACE was by far the option – but under current rules, it was beyond their financial means, and no other set of services was adequate or available.

These stories show why we are working on advancing flexibility in PACE, both in Medicare and Medicaid. PACE is well-positioned to serve many more people in a long-lived society if we can get policymakers to agree to implement commonsense solutions that remove current barriers. We hope you will join us in the endeavor, and if you want more information about PACE innovations, please contact us at [email protected].

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Jun 182018
 

The Program to Improve Eldercare (PIE) at Altarum Institute is preparing to award several small contracts to healthcare organizations, Public Health Departments, Area Agencies on Aging, and community-based organizations (CBOs) to carry out guided planning efforts to improve care for frail elders though more effective use of existing data concerning persons living in their catchment areas. The overall goal is to help local management define and generate measures of the local system’s performance concerning eldercare.

The contracts will not require collecting any new data. Each site will work with their own data that is already on hand to conduct aggregated analyses for their own community and region. The results of all funded contracts will form the basis for a national White Paper on how communities across the United States can monitor and manage the arrangements for care for elders living with disabilities and chronic conditions through improved use of aggregated data from multiple sources, such as clinical care, surveys, and use of community services.

Our goal is to empower communities and therefore to fund pilot projects that show high promise using several different approaches to community management of eldercare. Throughout, we aim to work with the sites to identify and document business models in use at the partner sites to support existing or improved system performance for providing adequate supportive care services.

This effort is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute (“Aggregating Care Plans to Manage Supportive Care Services for Elders”), Joanne Lynn, M.D., Principal Investigator.

We invite organizations to contact us to discuss this in order to determine their interest in participating. Please contact us via email to [email protected]. We will be happy to help you determine if your community would be a suitable candidate for these projects.

Contracts will be awarded in two phases.

  1. Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)
  2. Site Pilot Implementation Contracts (to be completed by June 2019)

Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)

  • The Readiness Assessment contract phase will select up to ten geographically-focused organizations (“sites”) to receive a contract of $10,000 to participate in a structured strategic planning process to help the sites evaluate their current uses of data related to service provision for elders in their geographic region. We are looking for sites that at least begin to represent a geographic community’s population and that include at least some attention to both social supports and medical care. We are interested in entire catchment areas as a service delivery setting. With assistance from our national program staff, the sites will prepare a Readiness Assessment and strategic plan for improving quality and reducing cost for their eldercare system through better use of data and management information systems.
  • Our national staff will work with each of the sites to prepare a customized project plan that works backward from the seven strategic planning outputs we are studying for each site. The list of outputs in seven study domains is summarized in Appendix A, below. At the end of the planning process, each site will receive a Readiness Assessment report that will form the basis of our selection process for the next round of contracts, which will provide limited funding toward some costs of actual implementations in some sites.

Site Pilot Implementation Contracts (to be completed by June 2019)

  • This phase will award Pilot Implementation contracts at up to six sites to carry out pilot projects based on their Readiness Assessment results. The amount of the Pilot Implementation Contracts will vary depending on the projects proposed by the sites, but we expect that the minimum awards will be approximately $30,000 per site. Some sites may receive larger awards if their plans are complex. As with the Readiness Assessment contracts, our national staff will provide advisory assistance, but actual work will be done by the sites themselves to ensure that an ongoing capability is built locally in a sustainable manner. The Pilot Implementation contracts will probably not cover all implementation costs for every project. Local participation will be needed to ensure the pilot has some chance of being sustainable.
  • If, at the end of the Pilot Implementation, a site has built a working data flow environment and demonstration management information system and has shown that the analytics coming from it are of actionable value to decisionmakers, our national staff will explore with them ways to seek continuation funding to help them transition the pilot system to an ongoing management reporting system. Continuation funding is not guaranteed as part of this effort, so finding ways to create sustainable business models is an important part of the process.

How to apply to partner in this work

To apply, send Email to [email protected] AND [email protected] with the following information:

  • Subject line – “Community Eldercare Metrics, Planning”
  • State the contact email(s) and phone number(s) of the person or team applying.
  • Define the community you aim to serve.
  • Briefly explain your vision, governance, and data available to the project.
  • Send it soon! We will follow up with the more promising teams on a rolling basis and aim to have all teams identified within July 2018 and to have plans and contracts within August and September 2018, depending upon labor availability at the sites and in our staff.

Appendix A: Overview of Site Readiness Assessment Domains

The site Readiness Assessment planning process will provide sites with a $10,000 contract to work with our national staff to explore seven key domains that are essential to creation of an effective management reporting system for community eldercare. We do not expect that all sites will have advanced information technology capabilities in place. Information for this process is expected to be collected primarily by videoconferencing, with little or no travel expenditures for site personnel. The questions listed in this table will be explored during the Readiness Assessment contract period, and need not be answered as part of a contract application.

You may download a PDF file with details on the seven Site Readiness Assessment Domains.

You may download a PowerPoint presentation with further details on the process for Site Readiness Assessments and information on how to apply.

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May 172018
 
Picture of Sonja Felton
Sonja Love Felton

By Sonja Love Felton, LMSW, MPA
Executive Director of Huron Valley PACE
huronvalleypace.org

Huron Valley PACE, in Ypsilanti, Michigan, is a young PACE organization – we were established only 4 years ago. However, we’ve been moving quickly since the day we opened our doors. Most readers likely know that PACE is an acronym for Program of All-Inclusive Care for the Elderly, a tremendously innovative program that became federal law back in 1997. Today, we provide comprehensive, high-quality, person- and family-centered care, mostly to dually eligible beneficiaries 55 and older – but as the Executive Director of Huron Valley PACE, I can attest that we have larger ambitions.

Here’s how we plan to grow: In March, we broke ground on a new wing that will allow us to enroll an additional 120 participants next year. Today, we serve 162 participants. Beyond enrolling more dually eligible participants, we are tackling the challenge of identifying policy pathways and implementing changes that will allow us to expand to serve a Medicare-only population. With our country’s age wave steadily gathering momentum, we want to build our capacity to enroll seniors who are not Medicaid eligible – either because they do not require a nursing home level of care or because they are not financially eligible (less than $2,250 in gross monthly income and less than $2,000 in assets).

To do this work, we are partnering with Altarum in a project supported by a grant from the Michigan Health Endowment Fund to find innovative ways to expand availability and affordability of PACE services to more elders and people with disabilities in our local service area. In our work to date, we have identified a major barrier for enrollment of Medicare-only participants – the cost of prescription drug coverage. Here’s the dilemma: dually eligible participants have all of their Part D costs covered, but due to conflicting provisions in the original PACE statute and the 2003 law that established the Part D program, Medicare-only participants are now forced to pay exorbitantly high premiums for their drug coverage — $1099 per month in 2018 in our program. That compares to the average $45.15 for a local Part D Prescription Drug Plan (PDP).

To resolve the conflict – which arises because PACE prohibits payment of co-pays and deductibles, and the Part D law requires that co-pays and deductibles be paid to qualify for discounts during the “doughnut hole” coverage gap as well as for catastrophic coverage – Altarum and Huron Valley PACE crafted a PACE and Part D waiver that we have submitted to the Centers for Medicare and Medicaid Services (CMS). In developing a waiver package, we also worked with the actuarial firm Milliman, Inc., to develop a pricing strategy that would allow Medicare-only participants to pay us a premium that covers buying a market-based plan and also covers out-of-pocket copays, deductibles, and over-the-counter medications. The monthly amount would total about $320. We think this is a creative solution that would allow people to keep their Medicare Part D plan and remain enrolled in PACE. We are excited about having the support of the PACE Association of Michigan (PAM), the National PACE Association (NPA), and Representative Debbie Dingell for this waiver.

In 2011, CMS approved a similar waiver for Medicare-eligible veterans, so that they could receive their drug coverage from the VA’s very affordable, high-quality prescription drug coverage program. As of mid-May 2018, we are awaiting news from CMS about our ability to move forward and begin to offer this innovative, lower-cost prescription drug option.

Another exciting development in Michigan that will make PACE more available to frail older adults is a revision to Michigan’s Nursing Facility Transition (NFT) Program which will include PACE as an option for people moving out of nursing homes and back to the community. Much of the NFT work Michigan has done – and thousands of people have already been helped to move back to the community from a nursing home – has been under the federally enacted and funded Money Follows the Person (MFP) program. While the current version of the MFP program is expiring, federal policy makers and advocates are optimistic that a new version of MFP will be forthcoming. Including PACE as an option for people who want to move from nursing homes back to the community will provide a more complete and choice-based set of options for our elders and people with disabilities.

Finally, for people who would be served well in PACE but have a bit too much income to qualify for Medicaid, Huron Valley PACE and Altarum are working with national and state level experts on Medicaid policy to develop a pathway that would enable the participant and Medicaid to share in the costs. Currently, these individuals eventually have to use a nursing home, almost all of their income is paid to the nursing home, and Medicaid picks up the rest. The cost to Medicaid would be lower in PACE and the elderly person would keep living in his or her home much longer.

PACE has been successful in providing comprehensive, coordinated, customized, high quality social and medical care to some of our most vulnerable citizens. Huron Valley PACE is pleased to be a part of this work with Altarum to explore groundbreaking ways to make PACE more available and affordable for a broader array of people who need such support and care in our community. Once we blaze the trail, many other states and PACE programs can make PACE much more broadly available.

For information concerning PACE at the national level, visit the National PACE Association website

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Jan 232018
 
A photograph of a group of Zuni elders
Zuni Elders Community

On December 5, 2017 the “It Takes YOUR Community” symposium was hosted by Altarum’s Center for Elder Care & Advanced Illness in Washington, DC. This post provides an edited videocast of the event and the edited transcript with links to presentation slides as well as a Resource POD. The primary goal of this symposium was to bring together fellow stakeholders and interest groups involved in addressing the needs of the growing elder population at the policy and grassroots level, and to discuss possible strategies as to how we can stay engaged and think about building community-anchored care systems across the country.

Our diverse and dynamic group of speakers and panelists provided in-depth insight, as well as actionable and practical tools of advocacy models necessary to plan for the community-based health and long-term service and support (LTSS) needs of a growing older population.

The Symposium Transcript has been edited for clarity and readability and includes links the background resources that presenters provided [for additional resources see our Resource POD]. Additionally, here is the final agenda, for your reference.

The Full Videocast can be viewed or you can use the individual links to the agenda below (so you can select which panel discussions you wish to watch). Click on the discussion title [blue text] to link to start the recording of that discussion. You can navigate in the whole recording from any of the links below, for example you can view the entire session by clicking the opening link.

0:00 – 6:29 ~ Opening: Communities and the “Age Wave”
6:30 – 1:04:40 ~ Three Communities: What Are the Driving Factors?
1:04:41 – 1:52:52 ~ The Role of the Federal Government in Supporting Community-Anchored Care
1:52:53 – 2:31:46 ~ Panel Discussion: Drilling Down
2:31:47 – 3:10:04 ~ Financing Projections by Communities and Getting a Handle on Services and Costs: How You Can Approach This as a Community Planning Initiative
3:11:46 – 3:47:28 ~ Where Can Communities Go To Find Some Money to Get Started?
3:47:28 – 3:49:44 ~ Leveraging Action

Copyright © 2017 Altarum, All rights reserved.

Altarum is a national nonprofit whose mission is to create a better, more sustainable future through ideas and action that transform health and health care in America. Learn more at www.altarum.org

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Sep 252017
 
Dr. Joanne Lynn Portrait. Photo credit Politico (used with permission)
Dr. Joanne Lynn

by Joanne Lynn

Let’s try a thought experiment.

Imagine that the government assembled a “Medicare Design Commission” that includes not only the usual assorted experts, but at least as many 88-year old women living alone on Social Security in second floor walk-ups, aiming to have them represent the target population of elderly people coming to face the multiple challenges of disabilities, caregiving, and finances. What would emerge as the top priorities for an insurance plan? (Spoiler alert: It would look a lot different from the way Medicare looks today.)

Over the past few years, I’ve polled dozens of audiences on this question. Here are some of the most common rapid responses: dental care, eyeglasses, hearing aids, and podiatry. Accessible affordable housing, transportation, and nutrition services then come up, and many audiences branch out to other social supports — often respite care and help for family caregivers. Then there’s personal care, like help with bathing and with meals, and assistance with shopping and bills and cleaning. Sometimes medications are mentioned. Asked about hospital services, emergency care, and various medical procedures, many in the audiences seem perplexed. Yes, obviously, these need to be covered, but maybe they are not as highly prioritized by elderly people living with multiple chronic conditions and worsening disabilities. Sometimes someone calls out something like, “Save us from doctors!” Yet, Medicare covers those medical interventions and drugs, and none of the other things so readily listed.

When Medicare started, the average age at death was still under 70, and the usual causes were fairly abrupt – heart attacks, strokes, infections. Now, death comes, on average, nearly a decade later, and the usual experience of the last years of life is one of slow decline with substantial self-care disability. Nearly half of us will have cognitive failure in advanced old age[1]. Most people who live past age 65 will have two years or more of needing someone else’s help every day[2]; some will need that help for a decade or more. This is the major cause of personal bankruptcy now. This is the major exploding element in state budgets, as so many people need Medicaid for their long-term care expenses.

Yet, we have not generated a serious and creative discussion of how to support one another in old age. The current cohort of retirees does not generally have savings or insurance to cover their own costs, and the Boomer generation now coming to retirement is even worse, with few pensions, retirement savings lost in the 2008 recession and other stresses, and small and dispersed families unable to provide unpaid care. Older Americans Act funding has been stagnant for years [3], so waiting lists for food delivery are common, and many other supportive services are only occasionally available. Singapore in 1985 mandated that new buildings be adapted for disability living [4], so a person in a wheelchair there has housing options that elderly disabled Americans do not have.

Today, physicians can order up a drug or treatment regimen that costs $100,000. But they can’t order home-delivered meals, or suitable housing, or a hearing aid.

The fact is, Medicare needs some updating. And this invaluable bedrock social insurance program needs to be intelligently adapted and made more flexible so that it can work much more seamlessly with other programs that offer key services – like safe adapted housing and low-cost services that can be delivered at home. These are fundamental to keeping elders out of crisis and preventing elders from cycling repeatedly through costly care settings. The Senate has crafted a solid start – the CHRONIC Care Act (S. 870), which, with luck and some bipartisan cooperation, could be approved later this year. On the administrative front, a more flexible regulatory approach for the Program of All-Inclusive Care for the Elderly (PACE) could enable comprehensive and affordable care for disabled elders, including Medicare-only beneficiaries, who need both medical services and long-term care. Click to see our PACE analysis

The Center for Elder Care & Advanced Illness (CECAI) is calling for testing of a solid, evidence-informed model of care that would free communities to take an active role in monitoring and managing a good eldercare system: MediCaring Communities[5]. (Think “Villages” that are more ambitious and that are designed to take responsibility for all elders across a given area.) For a fast-growing population of elders living with worsening disabilities, the community where they live is their most important resource: It is where they find – or do not find — housing that is suitable for their limitations, home-delivered meals, subsidized accessible transportation, reliable personal care, appropriate medical care and support for family caregivers. Unlike many other countries, the U.S. doesn’t have a tradition yet of giving local communities a major role in ensuring the adequacy of eldercare services at a reasonable cost. The time has come to reconsider.

Multiple studies have already shown reduced use of hospitals and medical interventions from honest and comprehensive care planning, reliable around-the-clock support, and appropriate medical care[6]. If some of the savings from avoided costs on the medical services side of the ledger can be made available for services that communities need to buttress supportive services and the local care workforce, then we would be able to engineer more comprehensive reliable services for elders within current budget constraints[7]. Not only would this improve the lives of the elders and families in the communities that volunteered to try this out — they would provide a path for further reforms.

The partisan debates that are now absorbing most of the attention and running in a seemingly endless congressional loop are avoiding the challenges of long-term care for the rising population of frail and disabled elders that will double in the first half of this century. They ignore the fact that we have less than a decade to be ready for longevity on a mass scale.

So let’s change the channel and do some re-designing! When we’re 88, we’re going to need a different approach to health care – one that emphasizes living meaningfully and comfortably with the health challenges that must be endured, rather than pretending that prevention, cure, and rehabilitation are always available and effective. It’s time to try out much more fundamental changes in Medicare and Medicaid, along with private savings and voluntary caregiving. Living well in advanced old age requires buttressing essential programs such as the Older Americans Act [8], housing programs and workforce training. And having the elderly populations of cities and counties live well with the illnesses and disabilities that accompany their last years of life will require enabling communities to take a hand in measuring their systems’ performance and to manage improvements. In advanced old age, we will need not just medical care that Medicare now covers. We will also need supportive services such as nutritious food, safe housing, accessible transportation, caregiver support, hearing aids and dental care. Now that we know what we need, let’s illuminate the policy path and do the testing and evaluation work to make it possible for our future selves.

[1] Gardner RC, Valcour V, Yaffe K. Dementia in the oldest old: a multifactorial and growing public health issue. Alzheimers Research and Therapy 5 (4):27, 2013.

[2] Favreault M, Dey J. Long-term services and supports for older Americans: Risks and financing research brief. Unban Institute and Milliman. https://aspe.hhs.gov/pdf-report/long-term-services-and-supports-older-americans-risks-and-financing-research-brief (accessed September 24, 2017)

[3] Parikh RB, Montgomery A, Lynn J. The Older Americans Act at 50: Community-based care in a value-driven era. N Engl J Med 373 (5):399-401, 2015.

[4] Graham W C K., Bilger M. (2017), Financing Long-Term Services and Supports: Ideas from Singapore. The Milbank Quarterly, 95: 358–407. doi:10.1111/1468-0009.12264.

[5] Lynn J. MediCaring Communities: Getting what we want and need in frail old age at an affordable cost. Altarum Institute, 2016. https://medicaring.org/book-online/ (accessed September 24, 2017)

[6] Lynn J. MediCaring Communities, pp 57-66.

[7] Bernhardt A, Lynn J, Berger G, Lee J, Reuter K, DaVanzo J, Dobson A. Making it safe to grow old: A financial simulation model for launching MediCaring Communities for frail elderly Medicare beneficiaries. The Milbank Quarterly, 94: 597–625. 2016. doi:10.1111/1468-0009.12199.

[8] New LCAO briefs on OAA:
One-Pager: The Older Americans Act
Issue Brief: The Growing Role of the Aging Network in Improving Health Care and Reducing Costs
(accessed September 26, 2017)

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May 242017
 
Poster showing elder and caregiver

The Center for Elder Care and Advanced Illness is proud to support CARE, a 65-minute documentary about the increasing importance of caregiving in our aging society; the passionate caregivers who often earn poverty wages; and the families who struggle to afford the care they desperately need. We hope you will join the CARE team in support of the work we all do to move towards a more just, and equitable care system for all!

How can you help?

Bring CARE to your church, community organization, campus, or workplace. Local screenings help to spread awareness of eldercare issues, create fundraising opportunities for local care networks, and empower and educate the public about efforts to improve our care system to better support both elders and caregivers. To learn more, reach out to the film team by visiting www.caredocumentary.com or contacting Denae Peters at [email protected].

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