Watch out for the Medicaid Cliff!

 Posted by on November 19, 2018  No Responses »  Tagged with: ,
Nov 192018
 
Cliff part of Medicaid Cliff Image
Oh No! Watch Out!

By Sarah Slocum

You’re 65 and you’ve worked all of your adult life, saved up a nest egg, earned a pension, saved in a retirement account, and paid into Social Security and Medicare. You have a pretty nice retirement income and lifestyle. Now suppose you need long term supports and services (LTSS) at some point in your later years, as most of us will. Very likely, you face disaster! Many otherwise well-informed Americans don’t realize that Medicare does not pay for LTSS; it only covers short term stays after hospitalization in a skilled nursing facility and limited periods of skilled home health and hospice care. That means if you live a couple of years needing paid daily help, you will have to pay for that all out-of-pocket – or spend down to Medicaid. And that means you will forfeit essentially almost all of your assets and income.

Medicaid pays for about two-thirds of all long term nursing home stays. Although the default is care in a nursing home, most states increasingly provide home and community-based services (HCBS) and are taking steps to shift funding toward in-home LTSS. But Medicaid is complicated and varies state by state, with complex, changing rules on functional and financial eligibility. Federal law sets some rules that states must follow in designing their Medicaid plans, but many crucial decisions are up to each state. The range and scope of LTSS options that states offer, like the Program for All-Inclusive Care for the Elderly (PACE) and various HCBS initiatives vary enormously, since they are optional and states can choose whether and how to offer them.

For people who need LTSS, one of the most difficult aspects of understanding Medicaid is that in many states, including Michigan, there are stricter (lower) income amounts that are required to qualify for community-based options as compared to nursing home care. Right now, Michigan has a strict cap on income for PACE and HCBS that is set at $2,250 per month. This amount is 300% of the income limit for the federal Supplemental Security Income (SSI). It is treated as a hard cap, meaning that a person who has even one dollar more than $2,250 from all retirement income sources combined is not eligible for Medicaid covered PACE and HCBS services. This is also known as the Medicaid cliff. The result is that if your income is below that amount, you can get a range of services that are adequate for your support. If it’s above $2,250, you have to “make do” with inadequate services and serious risks to health and life, or give up virtually all of your income and enter a nursing home. It makes little sense that someone with income over $2,250 per month can still get Medicaid support for an in-patient nursing home stay, but not for staying at home, usually at less cost to the state. According to David Goldfarb of the National Academy of Elderlaw Attorneys, “Experts often talk about the importance of generating lifetime-income in retirement. Unfortunately, our long-term services and supports system is in direct conflict with this goal. Some individuals learn the hard way that doing the right thing leaves you with no choice but the nursing home.”

Some states mitigate this pressure by allowing special arrangements to set aside excess income through trust mechanisms like Miller Trusts, Pooled Trusts, or Special Needs Trusts. New Jersey received a waiver from CMS a few years ago to allow people with excess income to set aside enough to become eligible and use those funds later for non-covered medical and LTSS expenses. Many states, though, have failed to address the disparity, leaving people who have just a little more income than the limit with no real choice but to move into a nursing home to get basic supportive care. This means that if you had savings enough for your first year or two of disability, but if your income is just a little above the Medicaid limit – you could find yourself having to cope without critical services like adequate food, heat and hygiene. Or you might have to give up your home and income, and enter a nursing home.

Below is a graphic that illustrate these points. It applies to a great many states, though some have learned to enable HCBS services in a way that eases the cliff.

The Medicaid Cliff Diagram

The Medicaid Cliff Diagram

In addition to allowing various trust arrangements to set aside excess income, other possible solutions include allowing people to participate in cost sharing for their services, so that Medicare beneficiaries would pay for LTSS with the portion of their income that is over the hard cap, and Medicaid would pay for the rest of the month’s LTSS. This would allow people to participate in Medicaid programs through paying a premium to the state, or establishing a deductible that is based on the amount of income the individual has above the cap. None of these options seem terribly difficult — what has been lacking so far is the political will to change Medicaid policies in states that have an artificially low Medicaid cliff.

Altarum is researching these possible options and working to build public momentum to address the disparity in income caps that exist for institutional care vs. HCBS. We think that newly elected state leaders may want to join their colleagues in exploring ideas and taking action to make it possible for those who want to age in place through to the end of life. To make this a reality, we need to extend access to PACE and HCBS as a win-win for elders who need LTSS and for state budgets.

Is your state like Michigan, with a low income cap for HCBS? If you’re not sure, ask your Medicaid office or a geriatric social worker. Are you interested in joining our efforts to influence states that to stop tolerating a Medicaid cliff? Reach out to us at Altarum, by sending an email to [email protected]. We want to support your efforts and join them with ours to make policy changes that create more rational and accessible LTSS options.

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States Move to Chart a Path for More Reliable, Affordable LTSS

 Posted by on September 25, 2018  1 Response »  Tagged with: , ,
Sep 252018
 
portraits of Anne Montgomery and Sarah Slocum
Authors Anne and Sarah

By Anne Montgomery and Sarah Slocum

On May 4, 2018, the Michigan State Legislature voted to “just do it:” to assemble a group of experts to craft a blueprint for taking the Wolverine State deep into the future of Michigan’s age wave – all the way through the mid-21st century.

Specifically, the language requires the Michigan Department of Health and Human Services (MDHHS) to contract for: “an independent feasibility study and actuarial model of public, private, and public-private hybrid options to help individuals prepare for, access, and afford long-term services and supports.” The study will take 9 months. It is meant to squarely address the fact that current options for individuals to fund their long term supports and services (LTSS) needs have been unworkable and have often resulted in impoverishment and bankruptcy for Michigan families.

Since Medicare doesn’t pay for LTSS and less than 10% of Americans have purchased private long term care insurance, most people have to pay out-of-pocket when they need in-home care, assisted living, or nursing home care. This continues until the disabled person qualifies for Medicaid, which picks up the cost of nursing home care. Or, if there is an available program for home and community-based services (HCBS) that doesn’t have a waiting list, families may be able to tap into Medicaid for in-home services and other types of assistance.

Along the way, thousands of formerly middle-class families in Michigan are forced to impoverish themselves every year in order to qualify for Medicaid LTSS coverage. This “spend down” process is anguishing for many, who would prefer to have more control over their lives and perhaps to leave some of their accumulated resources to children and grandchildren. Recognizing this, the Michigan legislature, led by Rep. John Hoadley (D-Kalamazoo) and Sen. Margaret O’Brien (R-Portage), went to work last year — along with a coalition of concerned organizations led by Michigan United and including Altarum’s Program to Improve Eldercare – to ensure that the study bill would become law.

The Michigan budget for fiscal year 2019, which begins in October, includes language directing the Department of Health and Human Services (MDHHS) to draw up a workable, practical plan that will make LTSS available to middle-class Michigan families. MDHHS has $100,000 in state funds that will be matched with at least that much in private philanthropic funds – and possibly far more — to take a hard look at LTSS financing possibilities, workforce development capacity and future needs. The study will assess the current landscape of long-term care needs including:

  • What private and public services exist;
  • What the costs for current services are;
  • Who is accessing them and who is not;
  • What are the challenges to accessing care, including the gaps in services;
  • The impact that care has on the care workforce and family caregivers.
  • The primary goal of this study is to assess the cost and impact of three main financing proposals:

    • o A long-term care benefit for all Michiganders;
    o A public-private risk-sharing insurance program that reimburses insurers;
    o A long-term care benefit for those who do not qualify for Medicaid.

Today, Michigan Medicaid spends almost $3 billion per year on LTSS — and the cost goes up each year. But Michigan families spend more. AARP Michigan reports that Michigan families provide $15 billion worth of uncompensated care each year. New options are needed to keep both the state budget and Michigan families healthy during the state’s “age wave” era.

On the workforce side, Michigan is already facing shortages of people able and willing to fill direct caregiving jobs. MDHHS will engage experts to examine what supports current workers need to remain in the LTSS workforce: e.g., career ladders, benefits and wages to make LTSS jobs more attractive, and workplace conditions to make LTSS jobs safer and valued to attract candidates and keep them. Overtime and turnover due to stressed staff are major cost centers and major causes of staff shortages. The LTSS study will examine all of these factors and create new solutions to make LTSS jobs a career option for many more people.

Similar studies in the states of Washington and Hawaii have resulted in major changes to how LTSS is delivered and paid for in those states. The AARP Long Term Supports and Services Scorecard ranks these states respectively first and seventh in the nation on an array of measures. Washington and Hawaii have used results of LTSS studies to develop much better options for individuals and workers. Michigan is overdue for a serious examination of issues in financing and staffing LTSS, and this opportunity will jump-start major innovations. In the absence of a national strategy or plan for affordable high quality LTSS, several additional states are pursuing state level action. The chart below provides some current examples:

The current environment of long term care in Michigan includes over 40,000 nursing home beds in about 430 facilities, another 40,000 beds in about 4,500 Adult Foster Care Homes, and 10,000 beds in about 190 Homes for the Aged. An unknown number of unlicensed Assisted Living facilities operate in Michigan, serving an unknown number of people. In addition, another unknown number of people are getting care through visiting nursing services, private duty home care, and other unlicensed businesses offering various services. Medicaid also funds 11,000 Medicaid HCBS beneficiaries through the “MI Choice” program, and over 3,000 beneficiaries (the vast majority are dually eligible) through 10 PACE organizations (Program for All Inclusive Care for the Elderly). Michigan is home to nearly 1.9 million Medicare beneficiaries, of whom almost 300,000 are also eligible for Medicaid.

Experts estimate that 50% of the Medicare population will need long term care at some point in their lives. In Michigan and around the country, elders are the fastest growing segment of our population – so the need for LTSS, which seems high today, is set to increase steeply over the coming years.

To put some financial parameters around this discussion, nursing home care costs Michigan’s Medicaid budget $1.7 billion dollars per year; private pay rates in nursing homes range from $9,000 to $11,000 per month. Adult Foster Care and Home for the Aged monthly rates range from $800 to $5,000 for those able to pay privately. Michigan spends another $350 million on MI Choice and PACE, both of which have lower monthly costs than nursing home care. Area Agencies on Aging and other community organizations provide supportive community services, but their budgets are quite limited and have not seen the significant budget increases needed to keep pace with the growing aging population.

The costs to individuals and families of unplanned, poorly coordinated LTSS are also very high: First there are substantial “out-of-pocket” costs associated with in-home services, equipment, medications and more medical procedures and visits; second are the high costs to family caregivers, who may face the loss of their jobs and their own livelihoods as care needs increase. Some families may also find it necessary to move to different housing that can accommodate an ill or disabled family member’s needs for disability access, thus incurring the costs of moving. Many families struggle and figure out how to cope for a while, and later give up – leading to costly nursing home admissions. Others simply go bankrupt.

Like other states, Michigan must devise ways to stretch publicly financed health care dollars further to support LTSS. For families, LTSS must be made more affordable and reliable – and delivery systems must shift to services that can readily be delivered at home. The workforce that delivers this care must be well-trained, supported, and paid a living wage to assure quality and continuity of services. With advocates, researchers, policymakers and funders at the table, the Michigan LTC study is a prime opportunity to create smart adaptations to existing programs, and to create new and more efficient initiatives. Both will serve as investments in the future.

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Pick up the PACE to a New World of Eldercare

 Posted by on August 21, 2018  1 Response »  Tagged with: , , , , ,
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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Expanding PACE Opportunities in Our Community

 Posted by on May 17, 2018  No Responses »  Tagged with: , , , ,
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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Through a Glass Darkly: The Community-Based Care Transitions Program Evaluation

 Posted by on February 22, 2018  No Responses »  Tagged with: , , , , ,
Feb 222018
 
Photographs of Joanne Lynn and Sarah Slocum
Authors Joanne & Sarah

By Joanne Lynn and Sarah Slocum

“All models are wrong, but some are useful”. – George Box

In late November, the Centers for Medicare and Medicaid Services (CMS) released an extensive evaluation of the Community-based Care Transitions Program (CCTP). (https://downloads.cms.gov/files/cmmi/cctp-final-eval-rpt.pdf)

While the report has some useful points, the primary metrics used to measure performance – re-hospitalization/discharge rates, are seriously deficient. To start with, reducing hospital readmissions – or, for that matter, reducing admissions – is not always good for patients. More importantly, the CCTP evaluation presumed that the relevant part of the patient’s journey starts in the hospital at discharge, and that the main issues revolve around having and adhering to the correct discharge instructions, especially for medications, which then lead to engaging the patient in his or her outpatient medical care. These are certainly important, but the evaluation’s narrow focus on short-term transitions of care leaves out much of what happens in the lives of seriously ill persons that reflect the capacity of their community to provide ongoing supportive services – disability-adapted housing, home-delivered nutritional food, the adequacy of the personal care workforce, employer flexibility for family caregiving, and more.

The CCTP was part of a larger innovation effort sponsored by CMS, the Partnership for Patients, which had an overall goal of a 20% reduction in Medicare fee-for-service (FFS) hospital readmission rates. The agency was given $500 million to implement CCTP in 101 sites around the country. Most project sites applied basic commonsense transitions of care protocols, for which there is substantial evidence, i.e., ensuring that newly discharged patients received the right medications and were engaged with their community-based physicians in order to prevent avoidable hospital readmissions within 30 days after discharge. Yet the focus on medical services provided at and for a short while following hospital discharge, as well as the metric that applied to hospital rates, distorted the endeavor and put a good number of participating community-based organizations at serious financial risk.

The original Quality Improvement Organization (QIO) project that preceded the CCTP measured the effect of improvement activities on entire communities (rather than specific hospitals), and aimed to reduce readmissions per 1,000 Medicare FFS beneficiaries across the entire population, https://jamanetwork.com/journals/jama/fullarticle/1558278. That model accepted the need not only to address medical errors and mobilize patient self-care, but also to focus on what it takes to successfully shift the support of very sick and disabled persons to community service providers and reduce the challenges of living with ongoing serious illness.

In the QIO project, most Medicare beneficiaries who were re-hospitalized within 30 days were known to be very sick and disabled prior to the initial hospitalization. This meant that the hospitalization episode represented a few somewhat worse days in the course of living with a serious condition, such as an organ system failure, neuromuscular degenerative disease, or frailty. That understanding broadened the focus of reforms to include examining the capacity of the person’s community to support very sick and disabled persons with reliability and competence. The interventions aimed to optimize the overall course of disease and disability and to ensure that the individual and family (and other caregivers) felt well supported. For example, they worked to ensure the adequacy of the care plan, prompt availability of supportive and personal care services, and realistic planning for decline and death.

However, in building on the QIO results, CMS shifted the focus to a hospital-centric design and evaluated performance on a hospital-specific basis. This creates the problem that we reported in a previous blog, https://medicaring.org/2014/12/08/lynn-evidence/, which is that good practices in the community reduce the number of admissions at about the same rate as the number of readmissions, is ignored. In turn, this makes the hospital-based readmissions/admissions metric misleading. Perhaps more important, structuring the CCTP to measure the impact only on the hospital leaves out the importance of how effective community-based providers were in providing supportive services over time to frail elders living at home and in other community settings.

Some community services providers nevertheless managed to help their partnering hospitals make impressive gains in reducing re-admissions. For example, the Eastern Virginia Care Transitions Program (EVCTP) brought together five Area Agencies on Aging that improved support and smoothed transitions across 20% of the state. Five health systems and 69 skilled nursing facilities joined. Re-hospitalizations for the whole area declined from 18.2% of all FFS Medicare discharges in 2013 to 8.9% in 2015, resulting in a $17 million savings to Medicare and a great deal of avoided suffering by patients, families, and caregivers. EVCTP used the Coleman Care Transitions Intervention© and offered enhanced services as part of the admissions process for certain segments of the Medicare population. It also prompted formation of a coalition of all 25 Area Agencies on Aging in Virginia to infuse best practices in subsequent partnerships across the state, http://www.chcs.org/media/EVCTP-Case-Study_101217.pdf/.

In Akron, Ohio, “Direction Home,” the Area Agency on Aging’s program, first began embedding coaches (either nurses or social workers) in local hospitals in 1998 to assist patients through connecting them to various community services, including home care and home delivered meals. That history of collaboration between health care providers and social services providers gave Akron a head start in reducing hospital use by Medicare beneficiaries with ongoing serious chronic conditions. Between 2010 and 2016, hospital readmissions fell from 19.6% of Medicare FFS hospital discharges to 11.7%. Akron leaders attribute much of this success to intentional relationship building, which extends to having health system professionals on the boards of community organizations, http://www.commonwealthfund.org/publications/case-studies/2017/aug/akron-ohio-health-care. However, CMS did not allow community-based organizations to use CCTP funds for training, overhead, data development, administration, or outreach – only for the patient-facing services. This meant that some of the community-based organizations encountered major difficulties and high costs in trying to forge initial connections and close working relationships with hospitals in their area.

Other findings in the evaluation point to well-documented challenges for some CCTP sites, including incorrect (or poorly understood) discharge instructions on medications and dietary restrictions; under-resourced community-based services; fragmentation between social services and health care systems; and a lack of data at the individual level for high-value individual care planning, and at the aggregate level for geographically-based system planning.

Every model leaves out a great deal of complexity. What matters is what we retain and take forward in subsequent work. We can accept that high re-hospitalization rates are probably evidence of shortcomings in a hospital’s discharge processes, and that mobilization of patients to take care of themselves gets us partway toward a better model of care. However, we should also include how communities and their social support organizations can improve access to adequate safe housing, nutritious food, reliable personal care, and other key services. That more complex model requires the involvement of multiple stakeholders, and measuring the performance of a complex, multi-faceted care system that serves similarly situated individuals across a geographic community — rather than just the re-hospitalization rates of certain hospitals.

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It Takes YOUR Community Symposium

 Posted by on January 23, 2018  1 Response »  Tagged with: , , , , , ,
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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Caregiving in Politics and Policy: A Data Chartbook

 Posted by on September 26, 2017  No Responses »  Tagged with: , , ,
Sep 262017
 
Red Image of America Cares Chartbook

The America CARES Forum was held on November 14, 2016, a week after the national election. Sponsored by Altarum with Caring Across Generations, the forum featured national polling data from Lake Research Partners and The Tarrance Group. The polling showed strong support for major policy advances for both family caregivers and direct care workers, as demonstrated in the data from the Chartbook for America CARES [click to download the PowerPoint file]. Voters of all stripes ranked caregiving as a major concern and all endorsed substantial policies to make caregiving more possible and less burdensome.

Overall, the number of older adults over the age of 65 will nearly double by 2050 and the 80+ population is projected to increase 79% from 2010 to 2030 and 44% from between 2030 and 2040. These changes, coupled with falling birthrates, will create a care gap, with less than 3 people of working age (potential caregivers) for each older adult in need — compared with a 7:1 ratio in 2010. Meanwhile, labor force participation among women ages 25 to 64, who currently make up 73% of the home care workforce, will increase by only 2 million in the next decade, compared to 6.3 million in the previous decade.

Caregiving issues will shape the politics and policies of the coming decades.

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Re-Designing Society for Our Future Selves

 Posted by on September 25, 2017  No Responses »  Tagged with: , , , ,
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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The America CARES Forum

 Posted by on January 10, 2017  No Responses »  Tagged with: , , , ,
Jan 102017
 

By Anne Montgomery and Josie Kalipeni, Caring Across Generations

The Public Attitude on Caregiving in 2016: The America CARES Forum

On November 14, 2016, six days after the election, Altarum Institute’s Center for Elder Care and Advanced Illness and Caring Across Generations (CAG) hosted a national forum: America CARES. As participants, we talked broadly about what voters signaled they wanted; what implications the election may have for our work looking ahead; and what our primary objectives are as our country hurtles into the longevity era.

As the morning progressed, it became clear that our core, collective work of moving initiatives forward to help family caregivers and care workers who provide assistance in the home, is precisely in line with what all of us want—both for ourselves and our aging family members. We found evidence of this when we looked at exit polling data from voters who were interviewed on election eve and election day; when we reviewed what advocates and experts said was important; when we took into account recommendations from the National Academy of Sciences, Engineering, and Medicine’s recent report on caregiving; and when we examined our own advocacy.

Responses to poll from Lake Research Partners on policies to help people who are ill, elderly, or disabled.

Polling Data from Lake Research Partners on policies to help people who are ill, elderly, or disabled.

We talked about how our current health care system typically treats only immediate, pressing health care issues, while ignoring those for which ongoing management is the best solution. And, we discussed what we can do to move initiatives forward that will improve the economic security of tens of millions of caregiving Americans in communities across the country, while also boosting the fortunes of the four million workers who care professionally.

“As a nation we really are at a crossroads right now,” noted Sarita Gupta of Caring Across Generations. “We can stay with the status quo patchwork system and let the next economic crisis take place in our homes; or we can take advantage of this tremendous opportunity to build the care infrastructure we need, and support the realities of 21st century families [by] meeting the country’s soaring needs for home-based care and more affordable childcare.” That involves, she added, “making major investments in our ‘people’ infrastructure.”

“On a fundamental level what we have in common is that we want to create a much stronger care economy,” Anne Montgomery of Altarum said. “There is no doubt that we have it within our power to create change that is wanted and needed, and to take that forward. Our system is designed to make that possible, and we know that money does not produce the best ideas. Collective work does.”

To push such an agenda forward, America CARES forum participants worked to distill the day’s deliberations and conversations around a set of principles:

  • Providing better financial assistance to family caregivers—in the form of tax credits, direct payments, flexible paid family leave that includes both child care and elder care, and substantially improved access to coverage options that incorporate high-quality, affordable long-term care services;
  • Providing improved skills training and advancement opportunities for care workers, along with access to retirement savings and other standard employment benefits; and
  • Establishing creative new ways of prioritizing and paying for adapted housing that enables people with disabilities and other types of limitations to live as independently as possible.

Along the way we hope to be able to widen the base of support for tens of millions of Americans who are caring today, as well as the roughly three-quarters of us who—if we live long enough—will need support. The truth is that very few people can pull this off entirely by themselves—either the caregiving or the arranging of and paying for care. The odds of success are much better if we work together in complementary and interdependent ways to organize caring systems in our communities. Josephine Kalipeni, director of policy at Caring Across Generations said, “Building support, the ‘caring majority’ if you will, is critical to moving forward what we want to see. The voice of the caring majority can demand improving and expanding existing programs, creating new needed programs, and holding elected officials accountable for what we all really need—an affordable, accessible system that works for everyone.”

As we grow older, we want our health care system to provide the “right care at the right time guaranteeing an organized continuum of services that are adjusted for each person’s unique needs, goals and preferences. This is the essence of person and family-centered care, and there is already considerable evidence that it is both attainable and cost-effective. The question we have to ask ourselves is, if we had the opportunity to do it all over, would we rebuild the system of acute care interventions that was the blueprint in the 1960’s, or would we build something different that works for the 21st century family?

At the November 14 forum, Gupta noted that “the more opportunities we have to come together to share updates on our work and look for the opportunities to cross-collaborate, the stronger our organizing, and the stronger the care agenda will be.” Affirming this, CAG political director Kevin Simowitz emphasized that “we have to talk about care as an economic issue and not solely as a moral imperative.”

At a national level, the Trump Administration and the 115th Congress will be required to address hundreds of challenges every day. Competition for the attention of policymakers will be fierce, and multiple proposals representing a wide range of interests will be aggressively pushed and lobbied. In the public sector, the fate of national health care programs that serve frail elders and people with disabilities is highly uncertain—notably in the case of Medicaid, which could be transformed into a series of divergent state programs if funding caps are approved and longstanding quality and accountability rules are erased. But there is no doubt that amplifying the voices and advocating on behalf of more than 90 million Americans who voluntarily step up to support someone who needs care is a high honor. Our New Year’s prediction for 2017 is that increasingly, policymakers will recognize that supporting family caregivers and care workers is simply the right thing to do. But we know recognizing this isn’t enough. We need action.

Toward that end, we hope you will join our efforts as we strive to help build an even stronger movement dedicated to improving how we care for each other in old age and during times of illness and disability.

Are you a member of the caring majority who is receiving or providing care? Add your voice to this growing movement. Share your story with us. Send us materials to post at the link above. We’ll also be out on January 21 bringing a message of inclusiveness to the Women’s March on Washington from family caregivers and direct care workers who cannot be there. Please email [email protected] if you would like to march with us, and we will send you the details.

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America CARES: An Emerging Consensus-Based Approach to Moving a Family-Focused Caregiving Agenda Forward

 Posted by on December 6, 2016  No Responses »  Tagged with: , , , , , , , ,
Dec 062016
 

By CECAI and Caring Across Generations Staff

Caring for others has become the defining issue of our time, and grows increasingly salient in political campaigns with each passing day. This emerged as the defining theme of a November 14th forum, “America CARES,” which was headlined by Altarum Institute’s Center for Elder Care and Advanced Illness and Caring Across Generations.

Coming less than one week after the national election, more than 200 caregivers, researchers, analysts, and advocates gathered online and in person in Washington, D.C., to discuss voter preferences, share information about what stakeholders and advocates are prioritizing, and focus on what can be moved forward through deliberate collaborative work.
Much attention was paid to what voters think, as measured in bipartisan national polling conducted on election eve and election day by Lake Research Partners (LRP):

Responses to poll from Lake Research Partners on policies to help people who are ill, elderly, or disabled.

As both LRP principal Celinda Lake, a Democratic pollster, and Brian Nienaber of The Tarrance Group, a GOP pollster emphasized, the most striking finding is that both Trump and Clinton voters overwhelmingly chose “all of the above.”

“When you look across these demographics, this [caregiving] issue is of major salience to groups in both coalitions,” Lake said. Women care particularly intensely about this issue, [and] so do seniors.” She continued: “This issue needs to be embedded in a broader economic frame. We are talking about it in too minor a way.” Nienaber added: “When you get people volunteering ‘all of the above’ that is huge…[It] is one indicator that [voters] grasp the depth of the problem, and I think too an indicator that they are just not sort of fully versed in what the most appropriate or easiest bite-sized solution is.”

For this reason, Lake suggested that messaging on this issue should always be “1/3 problem, 2/3 solution.” As Josie Kalipeni of Caring Across put it, “[It] creates an umbrella to say that we need a system that works for all…and to have a unified message while bringing expertise of what [each organization] is advocating for to the table.” Moreover, a third of respondents favored all three options presented for expanding the number of direct care workers: increasing wages to $15 per hour, benefits including paid time off and retirement savings, and opportunities for skills training and career advancement.

What voters say they want are the things we don’t have in place in our health care system today—except for in-home services—and these are not reliably available or affordable for many people. The system that we have in place today, in other words, is effectively not the one we need in a rapidly aging society.

But there is also good news: Kevin Simowitz of Caring Across Generations pointed out, “caregiving entered the presidential campaigns this year in a way we haven’t seen it enter before,” with care appearing on both the Republican and Democratic national party platforms (for more on how this happened, see the Family Caregiver Platform Project). Multiple speakers reiterated the need to make an economic case for care policy in combination with stories about the people impacted. As Ben Chin of the Maine People’s Alliance pointed out, “the public is with us on tax fairness right now. “Maine People’s Alliance managed to get a measure on the ballot in 2016 that provided 3% surcharge on income over $200,000 to fund education. “In districts where many voted for a right wing populist, they did vote for this,” he said. This dynamic can be used again, he argued, noting that polling from Caring Across Generations has found broad bipartisan support for universal family care funded by tax increases on those making more than $100,000.

In a new long-term care white paper, Caring Across Generations recommends the creation of a state level public long-term services and supports benefit that is accessible to all who need it regardless of income. “We continue to see tremendous opportunities in the states, and we believe that states can and must take intermediate steps to expand access to affordable and accessible long-term care until federal improvements are made,” said Sarita Gupta, co-director of Caring Across Generations. “State-based programs can address the unique care problems faced within each individual state, yield invaluable insights into what works and what does not, and build momentum for an eventual federal solution.”

The fact that people want much more integrated and well-coordinated care was also clearly reflected in responses to an online survey of registered participants fielded by Altarum. Participants were asked to rate their support for a number of policies. Of the 5 most that were most strongly supported, 4 out of 5 related to coordination of support: 1) ensuring availability of adapted housing; 2) development of a comprehensive repository of social resources and the community level; 3) caregiver assessment in Medicaid, Medicare, and the VA; 4) flexible workplace policies; and 5) expansion of integrated, community-based programs such as the Program of All-Inclusive Care for the Elderly (PACE).

To establish a system that is effective, we need to adapt, re-engineer and redesign to include health-related social services and supports in the array of services that are available on a reliable basis. Roughly 70% of us will spend several years—and for some it will be many years—living with both multiple chronic conditions and functional limitations.

We know that 34 million family caregivers and 2.2 million care workers provide care to older adults and people with disabilities in the community. Both groups struggle to maintain financial stability, to coordinate care, to maintain physical and mental well-being, and to balance their work and family responsibilities, and are becoming increasingly active as political groups. One of the goals of this event was to unite family caregivers and care workers with a common care agenda.

The most prominent theme of the forum was that care is a unifying issue that provides a blueprint for tailoring positive advocacy in a more populist era. Again and again, speakers emphasized the universality of the need for care. Noting that there will be 47 mayoral elections and 36 gubernatorial elections in 2018, Lake suggested that advocates, analysts, stakeholders and their allies have a solid opportunity to make caregiving actionable at the ballot box. Participants also highlighted the Caregiver Advise, Record, Enable (CARE) Act as evidence of what can be accomplished at the state level, in addition to the ways in which care transcends partisan politics. This bill would require that hospitals record the name of the caregiver in the medical record, inform them if the loved one is transferred, and provide instructions and training on tasks that the caregiver will be expected to perform at home. The traditionally red state of Oklahoma, John Schall of Caregiver Action Network noted, was the first state to pass the CARE Act.

Voters have provided a green light to move forward—at the national level, the state level, and the local level. And we look forward to working with all of you to do that. Together we have a clear opportunity to shape policy and to ensure that those who care, whether as unpaid family members or as workers, live in dignity and have the tools they need to support those for whom they care.

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