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!

Jan 272020
Anne Mongomery & Nils Franco
Authors Anne and Nils

By Anne Montgomery and Nils Franco

As the age wave rapidly transforms Medicare and the wider U.S. health care sector during the 2020s, policymakers and stakeholders are starting to pay much closer attention to including supportive services as part of the continuum of health care delivery. A growing number of Medicare Advantage (MA) plans are now offering certain limited supplemental long-term services and supports, such as transportation and personal care. Community-based organizations (CBOs) are eager to expand to provide these and other services, and more Area Agencies on Aging (AAAs) are forming networks in order to contract with a range of health care organizations. And in the Medicare fee-for-service (FFS) sector, an expanding array of Alternative Payment Models (APMs), starting with Medicare Accountable Care Organizations (ACOs), are being developed and implemented to incentivize both practitioners and beneficiaries to shift toward more coordinated models of service delivery and tighter financial integration.

Following is an examination of an array of models that are aiming to foster better coordination, quality oversight, and efficiency in care for tens of millions of Medicare beneficiaries who need both medical care and supportive services.

Current Transformative Models in Medicare

At their core, Medicare ACOs are hubs of doctors, hospital(s), and other medical care providers that share financial and clinical responsibility for providing good care while also limiting unnecessary spending. Where successful, ACOs receive incentive payments that reflect a share of Medicare spending reductions for patients attributed to them. They can take on various structures of ownership, risk and decision-making power held by constituent medical practices. The Direct Contracting (DC) model recently announced by the Center for Medicare and Medicaid Innovation (CMMI) may prove attractive to a subset of ACOs, because it offers greater flexibility for contracting with non-medical organizations, and it lets participating entities capture a larger share of savings (by taking on more downside risk). Direct contracting may attract other types of health care organizations, including some PACE (Program of All-Inclusive Care for the Elderly) plans.‎

In related work, CMMI is encouraging more comprehensive care planning and service provision by primary care practices through medical home models. The Comprehensive Primary Care Plus (CPC+) initiative, for example, pays medical home practitioners to coordinate their patients’ primary care and their referrals for certain tests and specialists. Medical home practitioners are also eligible to receive a modest bonus tied to achieving benchmark quality measures such as lower preventable hospital readmissions or patient-reported care coordination. Notably, the CPC+ model requires participants to “identify patients’ high-priority health-related social needs and resources available in your community to meet those needs.”

Starting in 2021, CPC+ will evolve into the higher-risk Primary Care First (PCF) model, in which primary care practices will help their patients follow through on all services for which they are referred. Both clinical quality and patient experience measures – including use of advance care planning as well as patients’ survey responses, blood pressure and glucose levels, and cancer screening rates – will be used to determine which PCF practices are eligible for bonuses. The PCF model also ties payment to attributed beneficiaries’ overall Medicare spending. To succeed in this model, therefore, practitioners must be able to effectively track their patients across multiple care settings.

A more specialized PCF model for seriously ill beneficiaries whose care is hard to predict – those who frequently use the emergency room and incur high hospital costs, and who lack a consistent primary doctor – will also be implemented. PCF practices must change seriously ill beneficiaries’ pattern of health care, and they must establish a cohesive plan to link and track these patients with other medical and social services providers.

Together, these CMMI models, especially newer forms that pay flat amounts per beneficiary, have the potential to provide a new source of referrals to CBOs and to thereby expand the reach of supportive services to the frail and chronically ill elderly. For the medical sector, the new models are making physicians and hospitals more aware of the social needs of beneficiaries they see. In ACOs and in MA plans, screening for social determinants of health (SDOH) has translated to only modest growth in referrals for supportive services to date. But actually connecting patients to a reliable source of supportive services is key to keeping beneficiaries with multiple chronic conditions out of crisis. Closer business and service delivery relationships between CBOs and medical providers are needed to reduce costs and improve care.

Partnered Efforts for Population Health in the Community

Screenings are fundamental to the Accountable Communities for Health (ACHs). The movement gained steam through CMMI’s State Innovation Models, and AHCs now have funding for screening for supportive care needs and navigating Medicare and/or Medicaid enrollees to community resources under a demonstration that runs from 2017 through 2022 (the Accountable Health Communities Model). In general, ACHs are local collaborations that ask the public health, social services, and medical sectors to act together in order to address social issues that face their constituents and affect their health. A medical partner or other “bridge organization” conducts screenings, and the ACH works with supportive services providers to try to ensure that referred clients are linked to follow-on services.

While ACOs and primary-care medical homes receive medical system dollars to conduct screenings and to send referrals to CBOs, CMMI’s model for ACHs includes public health agencies, LTSS providers, and CBOs, and investments in IT infrastructure and capacity can be shared among participating organizations. The demonstration’s bridge organizations include a broad range of medical and non-medical groups: they include hospital systems, public health departments, and direct service nonprofits. There are also ACHs with other sources of funding. Overall, ACHs aim to create change “through integration with delivery and payment system reform, and funded by both private and public payers,” according to a 2017 survey, which notes that to date, some ACHs have been slowed by the capacity of partners to raise start-up funds and to communicate across organizations.

Catalysts Needed to Continue Innovation and Coordination

Additional reforms are needed, as illustrated by a 2018 survey (Bleser et al, Health Affairs, June 2019) of ACOs serving seriously ill Medicare beneficiaries, which identified significant infrastructure deficits in data, analytics, social supports and workforce. Surveys of CBOs and AAAs about their contracts with the health care sector have identified persistent barriers to collaboration, as documented by the Scripps Gerontology Center and the Aging and Disability Business Institute at the National Association of Area Agencies on Aging (n4a). Both financial risks and the “time it takes to establish a contract” were cited as barriers, and CBOs cited a need for more sophisticated data systems to contract with health care partners. The survey also found that CBOs seeking new business opportunities in the health care sector have often opted to join a “coordinated group of community-based organizations that pursues a regional or statewide contract with a health care entity” (Kunkel et al., 2017, and Kunkel et al., 2018). This shows a path forward to improve community infrastructure and financing opportunities for programs, attractive to both grantmakers and investors.

Building on new incentives and referral sources in the health care system, entrepreneurial community-anchored delivery systems can be flexibly designed to serve larger numbers of older and disabled adults – before the full impact of the age wave arrives. This could be done by encouraging partnerships among interested health care organizations, such as PACE and D-SNPs, to partner with CBOs in order to create linked networks that serve Medicare beneficiaries who need both health care and supportive services. Locally focused arrangements of this sort, which we refer to as Community-Based Health Organizations (CBHOs), could be developed and built out in grants for planning, piloting and dissemination.

Lawmakers Wrestle with Financing and Capacity Needs

On Capitol Hill, policymakers are continuing to become more aware of the role of supportive services in eldercare. For example, in a November 2019 hearing before the U.S. House Ways & Means Committee, witnesses testified about improving nursing home and hospice quality, family caregiving, the growing number of older Americans with Alzheimer’s, and taking steps to build out long-term services and supports (LTSS). Altarum Senior Policy Analyst Joanne Lynn highlighted work conducted by UMass Boston and the Urban Institute that could undergird development of federal legislation that covers the “tail end” of long-term care risk using a social insurance model that could be financed by an additional 1 percentage-point increase in the Medicare payroll tax for workers older than 40. To cover “front end” risks, Dr. Lynn suggested testing a variety of options, including adding limited supportive services coverage to Medigap plans serving FFS beneficiaries, as is being considered in Minnesota.

Kickstarting New Collaboration

Over the next 10 years, Medicare service providers seem likely to move much further in the direction of integrating more services across settings and time, aligning with incentives provided by various contractual arrangements, bundles, and initiatives that pay health systems based on overall costs to Medicare. For community service organizations that serve the frail elderly population in traditional Medicare, new partnerships are now encouraged that can unlock new opportunities to expand service capacity and infrastructure. The question, for funders and entrepreneurs, is how to kickstart and optimize those collaborations among interested CBOs and health care organizations.

Varying configurations of CBOs and health care organizations are possible, allowing communities to design linkages for their needs. For example, some CBHOs might involve PACE programs, Medicare special needs plans (D-SNPs or C-SNPs), Medicare Advantage plans, larger health care systems, and Federally Qualified Health Centers and/or Rural Health Clinics. Fundamentally, such collaborations would have an anchor institution – one that has expertise in serving Medicare beneficiaries and a predictable source of revenue from CMS. The institution would collaborate with AAAs and CBOs to address the needs of high-risk Medicare and dually eligible beneficiaries who are identified as needing ongoing assistance and supportive services to remain at home (or other setting of choice). Contracts between an anchor organization and CBOs could be designed to both organize packages of services for older adults and to grow and gradually expand the number of older adults able to benefit from highly coordinated and comprehensive services. In addition to the satisfaction of improving care, organizations participating in a CBHO-type partnership might benefit financially through contractually apportioned shares of any savings realized.

For both health care organizations and CBOs, a new era is afoot. CBOs are poised to address health-related social needs for older adults with upstream interventions at much lower cost. This may spur health care innovators to see that investing (or reinvesting) in supportive services for aligned or enrolled Medicare beneficiaries makes good business sense, and where referrals to CBOs position medical practice to reap incentive payments, lower net business costs, and/or gain access to a share of savings. These insights, among others, are embedded in CMMI’s PCF and DC models, which are taking steps to encourage innovators to enter into formal relationships with CBOs. Similar relationships have already been fostered under private insurance plans and through Medicaid, but new flexibility in the approach to FFS Medicare beneficiaries with complex needs means that this important group of seniors is likely to be at the center of a new wave of contracting.

In the process, CBOs will need to make an accurate case for the value of their services; and, they will need to rapidly develop the capacity to both analyze and to share information with health care providers. Beyond that, they may find it in their interest to participate in organizational hub CBHO-type arrangements that handle financing, referrals, contracts and ongoing operational activities. From the beneficiary or client’s perspective, a CBHO could mean that services might be coordinated and delivered more reliably. CBHOs could also promote partnerships, not unlike ACOs, which act as hubs for various medical practices that are striving for improved coordination between settings and for greater efficiency.

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

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


Oct 222019
Logo of National Community Care Corps

By Sarah Slocum, Altarum Program to Improve Eldercare

We live in a country of neighborhoods. Our geographic neighborhoods often bond around a common ethnicity, a religion, similar economic status, or a group of occupations or employers. In large cities, perhaps it’s a school district. Across urban, suburban and rural areas, these factors that identify neighborhoods and communities are part of what helps us define where we live. This is particularly true of many frail elders and people with disabilities who often manage their daily needs with help from informal networks of individuals living nearby. A new initiative, funded by the federal Administration for Community Living (ACL), will create a formal network of volunteers ready to provide supports at the community level.

This brand-new effort, the Community Care Corps, will work with local organizations across the country to identify and develop tools that will be available to anyone wishing to start or strengthen a formal network of local volunteers. The project aims to develop the methods to support and enable these neighborly arrangements and create a network of volunteers who provide non-medical support to older and disabled people living in our communities — thereby enabling them to stay in their homes and remain connected to their neighborhoods. The Community Care Corps will identify best practices, standardize elements of high-performing volunteer programs in many different types of communities, and make starting and sustaining a volunteer support program much easier for any local organization to accomplish.

ACL has awarded St. Louis, Missouri-based Oasis Institute a five-year grant, with $3,800,578 in first-year funding ($19.7 million over 5 years) to stand up the Community Care Corps. In partnership with the Caregiver Action Network (CAN), the National Association of Area Agencies on Aging (n4a) and Altarum’s Program to Improve Eldercare, Oasis will help to develop and refine innovative models for volunteers to assist family caregivers, older adults and people with disabilities. Oasis will serve as the administrator of the project, awarding grants to communities nationwide. Community organizations will propose various creative ways of serving different populations, and a range of non-medical services, such as food, transportation, and other supports. The four lead organizations are eager to see what innovations they propose.

“This is a unique opportunity for Oasis to embrace a new role on the national stage as a grant maker for innovative caregiving projects,” said Paul Weiss, president of The Oasis Institute. “As a pioneer in healthy aging for more than 35 years, we recognize caregiving as a challenge that impacts families in ways that can limit quality of life tremendously. We are excited to be partnering with some of the most knowledgeable organizations in this sector to encourage creative approaches that can improve the lives of those who find themselves in the position of providing ongoing care for loved ones.”

Oasis will disseminate an RFP through multiple channels in late 2019, with anticipated grant announcements for the first year of funded pilot programs to be announced in spring 2020. Local funded programs will implement innovative approaches to recruit, train, and sustain volunteers who will provide neighborly help to disabled adults and their experiences will generate a toolkit of best practices for use nationwide.

“Volunteers have long played a key role in the reach and success of programs and services supported by the aging and disability networks,” said Edwin Walker, Deputy Assistant Secretary for Aging at the Administration for Community Living. “ACL is pleased to have this opportunity to further strengthen the important role of volunteers and looks forward to working with the Oasis Institute and its partners to achieve this goal.” An excellent article in the Kaiser Health News details this national initiative.

A local project is already underway in Livingston County, Michigan, where Livingston County Catholic Charities (LCCC) and Altarum are working to expand and update their volunteer services to elders and people with disabilities in their homes. LCCC was awarded a one year grant from the Michigan Health Endowment Fund to create a toolkit that will be available to any other organization that wants to set up a similar program to provide transportation, shopping, light housekeeping, companionship, and a number of other non-medical services to community members in need. LCCC is already well known for their volunteer services and this Care Corps project will enhance their ability to expand and provide more volunteer hours of service, as well as formalizing their volunteer recruitment, training, and retention strategies. The LCCC/Altarum project is one example of the type of community based effort Altarum will evaluate local efforts and will help identify best practices and ideas that are ripe for replication. The experience of people receiving support will be crucial in identifying the most effective strategies for delivering non-medical support and volunteers will be able to tell us a great deal about how well the program meets their needs. We expect many different and creative models arising from local projects and do not expect one model to fit all locales. As with the particular identity of a neighborhood, groups of volunteers and care recipients will have varying cultural and geographic characteristics and the Community Care Corps in their area will need to meet those needs.

The Community Care Corps is arriving at a time when a shortage of paid caregivers is putting a lot of pressure on community based care systems. Many service providers already report great difficulty filling jobs and retaining workers to provide care. Some worker advocates view volunteer efforts as competition, but the Community Care Corps partners see the roles volunteers will fill as part of a set of solutions that will support family caregivers and perform certain tasks that will lighten the load on paid caregivers. The same groups setting up the Community Care Corps are also highly interested in better wages, training, and career opportunities for direct care workers. Pursuing improvements in both the paid and unpaid caregivers’ situations will relieve some of the pressure on systems that will only intensify as our nation ages and more and more of us need care.

The Community Care Corps request for proposals will be available later this fall. What can you do? Make sure your local volunteer organizations know about this opportunity and encourage them to apply. Organizations that want to apply or would like more information should sign up for communications for an announcement by clicking here.

Once the first round of projects start, make sure elected officials know about this great innovation happening in their district and are invited to visit with volunteers and the organizations that support them. Speak up publicly to state and federal officials about the need for renewed social structures that promote neighborliness.

We can’t wait to get started!

Oct 212019
Community Living Policy Center Logo

by Anne Montgomery

What it would take to harness the energies of states to take big leaps forward in key areas – housing supports, transportation supports, workforce supports, family caregiver supports, and employment supports for individuals with disabilities?

The answer is, policy that motivates Members of Congress to organize funding and a framework to help make infrastructure investment a reality! And in that regard, it’s good news that an issue brief, Improving Home and Community-Based Infrastructure: A Policy Proposal, has just been published by the Community Living Policy Center at the University of California, San Francisco (UCSF).

HCBS Infrastructure Brief 10.21.19

The thesis of the issue brief – and of evolving policy that is now being discussed in both the House and the Senate — is that what we most need to do in order to get ready for 2030 — when more than a fifth of all Americans will be 65 and older – is to make a one-time serious investment in state capacity in order to get ready. This investment needs to be in the form of a great deal more accessible housing; much more extensive networks of accessible and affordable transportation for those who move around in wheelchairs; and a far more robust workforce of personal care assistants and other types of direct care workers – who will only stay in these jobs if there are meaningful career ladders and positions with benefits. We need to also make much more possible for family caregivers to provide voluntary assistance – which means regular respite and various kinds of ancillary support that is ongoing. And we need to make it possible for those with disabilities to work and to support themselves.

There’s yet another reason we need to build out this capacity – and that is, the health care system won’t work very well without it. It’s a bit like roads and bridges and sidewalks and curb cuts – infrastructure is what allows everything else to work.

We think that these are exactly the kinds of investments that Members of Congress from both parties and across the spectrum can readily understand the need for and get behind.

Stay tuned for more on this front!

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.

May 082019
Portrait of Dr. Joanne Lynn
Dr. Joanne Lynn MD

By Joanne Lynn

May 7, 2019

CMMI has announced that they will soon call for proposals for a bevy of new payment models, aiming to reduce hospitalization without harming quality by allowing a great deal of flexibility by practicing primary care clinicians for Part A and Part B services in Medicare and by allowing contracting for services for larger groups of beneficiaries. Effectively, CMMI is offering practitioners and other stakeholders a group of models that blend capitation and fee-for-service, with payments generally depending upon lowering hospital use, meeting quality standards, and making certain continuity services available (e.g., 24/7 on-call with the record and electronic records with interoperability). While many of the details are not yet clear, I believe that these models could offer some important opportunities for moving toward optimal care for elders living with serious illnesses and disabilities.
The publications so far have not really dealt with long-term care, supportive services in the community, or integration with Medicaid. But they also have not made these things any more difficult.
As a very brief overview, CMMI is offering two groups of models: Primary Care First and Direct Contracting. This table summarizes what I’ve been able to learn as to the characteristics of the proposed models. All models appear to require having some experience with value-based payments, having certified electronic records with interoperability and connection to the local HIE – and providing primary care. From one perspective, Primary Care First is a successor and spread of CPC+, and Direct Contracting is a successor and spread of NextGen ACOs. More information can be found on these URLs:

And here is an introductory table.

2019 CMMI Proposals Table

Note that practices now participating in CPC+ cannot join Primary Care First until 2021. The areas where Primary Care First will be allowed in 2020 are these:

Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

The RFI for the Geographic Direct Contracting Model is at DATES: Comment Date: To be assured consideration, comments must be received by Thursday, May 23, 2019 at 11:59 pm EST. ADDRESSES: Comments should be submitted electronically to [email protected].

There are dozens of ways to implement these, and I hope that CMMI will allow diversity and will be clever in the evaluations, aiming to harvest insight and wisdom as well as comparisons with past performance and unaffected beneficiaries. However, if they allow contractors to put together the geographic and the serious illness endeavor, we could have a model that would fit the seriously disabled or slowly dying elder well. We could have communities with exemplary performance within a few years, and tremendous experience to build upon.

I would very much like to know whether you, the reader, are in a position to encourage potential sites to be ready to submit a letter of intent soon after the RFPs come out in June (for all except the Geographic Direct Contracting). If you are interested in shaping the RFP for Geographic Direct Contracting, the deadline for comments is May 23, 2019. If our coordinating information is useful to you or a colleague, please be in touch with us at [email protected]. We aim to put together communications as appropriate in order to accumulate best practice ideas concerning eldercare and to devise approaches that might allow optimization of local care systems quickly! We are happy to help any organization focusing on elders who are living with frailty, disabilities, and illnesses that need long-term supports and services and generally are eventually contributing to the end of life.

Dec 182018
Portrait of Dr. Joanne Lynn
Dr. Joanne Lynn, MD

By Joanne Lynn

“Starting in 2020, we are going to be expanding that range of [Medicare Advantage] benefits…to include home modifications, home-delivered meals, and more.” — Alex Azar, Secretary of HHS [The Root of the Problem: America’s Social Determinants of Health, November 14, 2018, as prepared for delivery]

Aha! Medicare leadership is awakening to the fact that elderly people living with disabling conditions need comprehensive care that includes supportive services. Without those, frail elders run up unnecessary expenses for Medicare, particularly when the only way to get help is to go the emergency room. People who can’t get out and about need nutritious food delivered to their homes – and we need homes where wheelchairs can get into the bathroom, and from which disabled persons can escape during an emergency. When we can’t take care of our daily needs, we need help with meals, hygiene and transportation. Virtually all of us will need this help for at least a couple of years if we live to advanced old age, for ourselves or for those we love and honor. There are sound ways we can provide for this through policy and adaptation of current care systems. One way is through newly expanded MA supplemental benefits which enable MA plans to offer partial coverage for long-term services and supports (LTSS).

The CHRONIC Act, part of the Bipartisan Budget Act of 2018, frees Medicare to start allowing MA plans to offer supplemental benefits in conjunction with a personal care plan in calendar year 2020, which requires that the proposals be submitted to the Centers for Medicare and Medicaid Services (CMS) by the end of June 2019. Already, MA plans that chose to submit bids for 2019 including some LTSS services may offer a narrower range of supplemental benefits to all with designated conditions in a particular county. In general, MA plans can choose to offer supplemental benefits if they decide they can do so for less than the capitation that Medicare is expecting to pay. In the past, these benefits have been limited to services that are tightly tied to health care, including eyeglasses, and diabetes supplies, and those services had to be available to all beneficiaries in the plan.

Secretary Azar and others are pleased to point out the merits of avoiding hospitalizations and skilled nursing facility stays for beneficiaries who can be served at lower cost with additional support “at home.” It’s a good thing for Medicare to take note of the urgent need for the basics of daily living – food, hygiene, clothing, shelter, socialization, and mobility. People who need help with these basics in old age also need caregiving, and Medicare is making efforts to help caregivers, for example, by redefining respite and in-home support services to be included in permissible supplemental benefits. In addition, policy changes should allow Medicare to help volunteer and paid caregiving by including requirements for reasonable training and support for communities providing adequate back-up for caregivers.

Gaps are Wide Today

Yet there is still more we must do. How is it that this prosperous country can publish a study of home-delivered food that randomized 626 people in 8 cities who were on waiting lists longer than 6 months, needing home-delivered food? The three groups received
(1) 5 meals delivered daily on weekdays,
(2) 5 frozen meals delivered each week, or
(3) nothing
(Thomas KS, Dosa D. More than a Meal Pilot Research Study: March 2015. at—march-2-2015.pdf ) How does it not count as a scandal that one-third of the study participants were left without food? Indeed, how does it not count as a scandal that the study could readily find 8 cities with more than 6 months waiting for home-delivered food?

MA plan supplemental benefits might help reduce the inadequate supply of supportive services, but there are risks to using medical care to address social needs. To start, getting housing through a physician has to be an expensive way to provide housing. Perhaps more important, who will get supplemental services in a capitated medical care system? Surely, it will be people who are likely to spend less on medical care if they have the services. These will be enrollees who have established a track record of high-cost medical care, or who are reliably predicted to do so. But over time, many people will realize that the way to get urgently needed LTSS services is to go to the emergency room a few more times. Perhaps before that, they will sign up for MA plans that have these supplemental services. Inadequate risk adjustment may therefore pose a risk of adverse selection for plans, while promoting perverse behaviors on the part of beneficiaries.

Even more troubling is the moral question of feeding (or housing or otherwise supporting) people mainly because they are costly, rather than because they are very much in need. Imagine two neighbors, Ida and Emma, both 90 years old, hearing-impaired and visually limited, and who use wheelchairs to get around their small apartments due to failing hearts and bad hips. Ida is very nervous about her health and has a physician whose response to any urgent call is, “Go to the ER.” She ends up in the hospital every few months. Emma, on the other hand, believes that things will take their course and you should only use a hospital when there’s something specific that hospital care can fix. Her primary care physician also serves the local hospice program and does house calls when needed. She hasn’t been in the hospital since having her last child 50 years ago. Indeed, she has not seen her physician for some years, relying instead on telephone advice from the office.

Both women live on Social Security at just above the Medicaid income eligibility threshold, and they juggle the cost of rent, pills, co-pays, heat, and food. Neither has family nearby and all their old friends have died. Recently, both of them have become sufficiently disabled that they cannot shop for food and can only heat things up in the oven or microwave. Is it really acceptable that the supplemental benefits from the MA plan ensures that Ida gets home-delivered food regularly, but Emma does not, and that Emma’s life may be shortened due to lack of good nutrition (and socialization, as the More than a Meal study showed)? We don’t calculate the impact of a deficit of supportive services at this point: Rather, earlier death is attributed to age and various maladies. Not acknowledged are the months Emma spends hungry and alone. This is poor care, and we need Medicare to take additional steps to address LTSS – both for enrollees of MA plans, and the millions of Medicare beneficiaries who prefer to be in the fee-for-service system or other non-MA care arrangements.

In addition to supportive services, good eldercare arrangements make physician coverage much more reasonable. Both of these ladies are likely to need ongoing personal care at some point. MA plans are not likely to provide more than short-term help with in-home aides – it is just too expensive and doesn’t save hospital care much. Instead, good care at home saves on nursing home care, but that is not covered by Medicare. Ida and Emma are therefore likely to end up spending down quickly to Medicaid and having to move from their homes to a nursing home (and giving up all but a pittance of their income). Even in states with managed Medicaid LTSS for elderly persons, those plans are often not the same as the MA plans, and concern for spending down and nursing home placement is not often a pressing concern for the MA plan.

Things are even more challenging when it comes to family support. What should we expect of family? What if Ida had multiple attentive family members willing and able to bring in food, help with household repairs, provide transportation, and so on – while Emma had only the grudging support of a small group of elderly relatives living some distance away? What if the situation is even more complicated by a history of abuse? This country has had little discussion of what can reasonably be expected of relatives or neighbors when a person becomes disabled and needs help.

Another major issue that is rarely spoken about is this: how can we account for the effects of our choices on our lifespans, given that survival is expensive once you need near-constant help from another person? This and family support are among the elephants in the room, with too little honest discussion to shape good public policy.

How can we adopt a more useful and accurate vision of what it takes to ensure adequate supportive services for all elderly people? One way to do this is to start with the simple premise that individual people have varying needs that evolve over time, and addressing them requires that they be connected to local entities that have a mission of addressing those needs. In other words, services must be organized to be adequate by geographic community. No physician can conjure up housing that is affordable and adapted for a disabled elderly patient if that sort of housing is not available in the area where that elder lives. If there is a long waiting list for home-delivered meals, there is virtually no opportunity to ensure that what a particular person needs can be met. No one physician, nurse or other provider, or family member or friend, can generate the trained workforce needed, or convince area employers to have flexibility to enable family caregiving.

To get a handle on whether a particular community has adequate service capacity, we need metrics that can gather information about and publicly display what a local system’s overall performance is vis-à-vis eldercare, and its ability to improve. We also need examples of governance arrangements that develop into entities that can take on the responsibility of monitoring and managing the performance of a local eldercare system. This entity needs data and the authority to prioritize the use of some resources.

Some MA plans could do this, for example in areas where an MA plan dominates the local health care market or where the various providers and payers learn to cooperate in the public interest of better eldercare. Under current policy, an initial “demonstration” phase could take place in designated counties where payers, providers, and civic leaders are willing to measure and monitor their eldercare system’s performance according to selected dimensions and are able to establish an entity that is charged with setting priorities and taking action. If we can get a dozen counties to test this approach, we can quickly learn what reliable and effective eldercare looks like, and how efficient it can actually be. In a locally driven framework, the new MA supplemental benefit availability would become part of achieving better eldercare across the community.

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 serves vice chair of the Milbank Memorial Funds’ Reforming States Group.

Read Joanne Lynn‘s biography.

Nov 282018
Photo of Anne Montgomery and Aging Today Logo
Anne Montgomery

By Anne Montgomery

Originally published in AgingToday Volume xxxix: Number 6; November–December 2018 and is reposted here with permission.

In America and worldwide, the “age wave” has gathered in force—no more so than in Japan, where 27 percent of the population is already older than age 65, a number that will rise to 40 percent by 2060. Policymakers, spurred by widespread public interest in Gratton and Scott’s influential book, “The 100-Year Life” (London, UK: Bloomsbury Publishing, 2016), recently em¬braced this stark demographic fact.

International Efforts to Help Family Caregivers

Japan’s Prime Minister Shinzo Abe in 2017 convened a “Council for Designing 100-Year Life Soci¬ety,” directing members to expand “social security for people across all generations,” and institute free early childhood education and daycare and other “measures to secure the necessary caregiv¬ing personnel for reducing the number of people who leave employment to provide nursing care to zero.” The Council has met nine times, each time chaired by Abe.

A relatively new advocacy community that has sprung up to support family caregivers wel¬comed Abe’s efforts. Founded in 2010, the nonprofit organization Carers Japan has developed ini¬tiatives and objectives, notably enactment of a law to outline carers’ rights. The organization is helping and advising the Liberal Democratic Party, and others, to set up a parliamentary group for carers. Carers Japan also is sponsoring study groups for local politicians interested in amending city regulations to champion carers’ needs and priorities.

In the labor sector, advocates are pressing for added employment flexibility, to make it possible for carers to both work and support an ill or disabled loved one living at home. A recent change al¬lows Japanese workers supporting family members who need full-time medical care to take unpaid leave in up to three installments ( The maximum leave for years has been 93 days, and the legal entitlement belongs to the cared-for person, who has that amount of time to spend across his or her lifetime, which family members may use ( Japanese companies are not required to pay employees during family care leave; if no wages are paid or only a partial wage below 80 percent of the worker’s base wage is paid, an employee can draw 40 percent to 80 percent of his or her base pay from unemployment insurance (

These issues are becoming more prominent in many other countries. In the Middle East, Care¬givers Israel, launched in 2014, formed solid corporate relationships, and sponsors advocacy ini¬tiatives focused on paid and sick leave, new social security support for those caring for an ill family member and severance pay for people who must leave employment to care for a disabled family member.

In Asia, Carers Hong Kong formed to engage the government on pressing challenges—the need to invest in building a much larger workforce of paid aides, nurses and other personnel to support older adults and individuals with disabilities. In Europe, Carers Denmark organized in 2014 around a “Carers Charter,” which includes developing standardized caregiver training; creating caregiver consultants in all local municipalities to organize respite and daycare, and to conduct outreach to families and carers; and promulgating policies for political parties that speak to carers’ “rights and circumstances.”

Progress Being Made, but Challenges Remain

Making sustained gains that support family caregivers requires investing in more reliable communi¬ty services, and realizing a clearer understanding of family caregiver needs and wants. Underfunded community care and fragmented medical and community services across multiple providers and siloed settings could easily thwart significant progress. This is a particular challenge for America, where accountability for “whole person care” remains diffuse and elusive. Further reforms to promote employment flexibility—unpaid leave and teleworking—are needed, along with more focused pol¬icy discussions about the importance of paid leave to support family caregivers and people strug¬gling to cope with unexpected periods of illness and disability.

Among Organisation of Economic Co-operation and Development (OECD) nations, the U.K. has the richest history of advocacy and political work on behalf of carers. Founded in 1988, Carers UK is a continuation of earlier organizations, including the National Council for the Single Woman and Her Dependants, which secured the first tax benefit for carers in 1967, the Dependant Relative Tax Allowance. Following devolution 30 years later, Carers UK expanded into associated organiza¬tions—Carers Wales, Carers Scotland and Carers Northern Ireland.

Today, Carers UK champions rights to paid care leave and increased flexibility in the labor mar¬ket. Its 2013 report, The Case for Care Leave (, notes that “with the public expenditure costs of carers feeling unable to continue to work estimated at £1.3 billion a year, it is crucial that we take steps to help carers in work. There is an opportunity to turn these losses into economic gains, with public finances seeing an estimated £1 billion in additional tax revenues if car¬ers can be supported back into the workplace.”

The report argued that “a statutory entitlement to care leave would help many carers to juggle their caring responsibilities with work in a sustainable and manageable way, making them more productive and less stressed, and saving businesses and the economy money in the long run.”

In the healthcare sector, policymakers are preparing to issue in November 2018 a new Long-Term Plan for England’s National Health Service (NHS), which will extend until 2028 ( Carers UK and other advocacy and political organizations are consulting with government officials to help shape the NHS plan with regard to carers.

New Policies on “Caregiver Strategies”

Though “caregiver strategies” are being developed in various countries, a 2016 OECD chart (; p. 5-12) makes clear that countries are all over the map on how they structure care¬giver leave rights. Italy allows two years of paid leave over an employee’s lifetime, at 100 percent of earnings up to a ceiling, and Sweden provides paid leave at 80 percent of earnings up to a ceiling in episodes that can be up to 100 days. Cyprus allows only seven days of unpaid leave per year. The United States, under the Family Medical Leave Act, provides up to 12 weeks of unpaid leave for employees who have a year’s worth of service and work for medium-size and large firms.

Currently pending in the U.S. Congress is the Family and Medical Insurance Leave Act, which would provide paid leave for up to 60 days a year. Several states, including California, New Jersey, Hawaii, Rhode Island, New York and the District of Columbia, have already enacted state paid leave programs (

In recent developments, the Progressive Policy Think Tank’s 2016 report, Caring for Our Carers: An International Perspective on Policy Developments in the UK (, notes that “Australia’s and Canada’s Human Rights Commissions are leading the way in emphasising what a human rights approach to care and caring can bring, in starting to articulate a right to care, and in setting out the frameworks needed to make caring a real choice for carers and those needing sup-port.” The report also notes that “Japan, Germany, France, Belgium, Sweden and other countries are now using their long-term-care insurance schemes and tax systems to stimulate the develop¬ment of a wider range of care, household and personal services to ensure there is good support for care at home.” In America, there are plans to craft a federal blueprint for action following enact¬ment of the RAISE Family Caregivers Act in early 2018 (

In Europe today, there are an estimated 100 million caregivers, according to Carers UK. In Amer¬ica, though estimates vary, the number of family caregivers supporting older adults is reported to be about 44 million. In other surveys, four in 10 Americans report they are caregivers (; in Canada, half of the population reports having provided support to a chronically ill or disabled loved one or friend at some point during their life ( The reach of politically organized family caregivers seems primed to grow—and for families across the globe, that’s good news.

Anne Montgomery, M.S., is deputy director at Altarum Institute’s Program to Improve Eldercare, in Washington, D.C.