Most older adults in the US want to age in place, but health policy and clinical experts said they may not be able to afford home-based health care long term, and their communities often lack resources, services and support for patients and caregivers.
The US spends more overall on health care than most other countries but lags in long-term care, with patients and families often responsible for health-related costs until their spending is exhausted and they transition to Medicaid.
“It doesn’t take long, as many of us know, from our own families — whether it’s assisted living, home health care, nursing home care — you very quickly spend out your savings and end up qualifying for Medicaid,” David Grabowski, a professor in the Department of Health Care Policy at Harvard Medical School, said during the webinar, hosted by the National Institute for Health Care Management Foundation.
Medicaid paid for more than half of the $415 billion spent in 2022 on long-term care services, much of it going to home- and community-based care, but the program is heavily regulated, lacks financial transparency and is associated with poor quality of care, low provider reimbursements and workforce shortages, Grabowski said.
Jasmine Travers, a registered nurse and assistant professor at New York University’s Rory Meyers College of Nursing, said 93% of older adults want to age in place at home but end up in nursing homes because available community services do not meet their needs. There also is a “health care bias toward nursing home care” during acute health events, such as a fall or a stroke, said Travers, who noted that older Latino and Black adults, who make up a large proportion of nursing home residents, often face disparities in care and poor outcomes.
Addressing home, community needs
Research shows that communities fall short in key areas such as help with activities of daily living; home maintenance and accommodations; resources for senior centers, day care and meal services; family caregiver support; socialization; and assistance with navigating the health care landscape to ensure access to medical care.
Grabowski and Travers outlined solutions to help more older adults remain at home or to create a more home-like nursing home model. They said overall, more money is needed for home- and community-based services. The nursing home model should shift from large institutional-type facilities to smaller resident-directed homes. Investments are needed across the board to address workforce issues, such as better working conditions, pay and benefits. And there needs to be better integration of clinical care in all of these settings.
Travers said Medicaid needs to cover more hours of care for services such as home health aides. Communities must prioritize aging support, with affordable housing and neighborhoods “that are conducive for older adults to live in and to experience life in.” Travers suggested providing home modification grants that allow people to make changes so they can safely stay at home. Communities also should provide a diverse array of social engagements for older adults.
Grabowski said the Green House model for long-term care is one alternative to institutional nursing homes. Small homes are built in a community setting for eight to 12 older adults. “This is what residents really want,” he said. “They want a more home-like setting, a small setting where it really feels like they’re not living in an institution under someone else’s rules.” Grabowski added that the model is associated with a higher quality of life and lower Medicaid spending.
Increasing connections, resources
Increasing access to clinical care for older adults can include telehealth and providing transportation services to medical appointments. But older adults also need transportation to grocery stores or the pharmacy. Providing more support and education for family caregivers also should be a priority.
Independence Blue Cross began a caregiver support initiative through its Medicare Advantage plans that is focused on adults ages 75 and older, which make up 49% of their MA population. The program grew out of a post-acute program where case managers reached out to people who had been hospitalized or to a patient’s nursing home. The program has expanded to include all members who receive case management services and anyone with a dementia diagnosis.
“We’ve identified ways to enhance management of advanced illness. advanced care planning, focusing on ways to deprescribe, and caregiver support, along with other elements of geriatric medicine,” said Medical Director Dr. Heidi Syropoulos.
The program has led to increased confidence and less isolation among caregivers, fewer hospital readmissions and increased connections for members and caregivers to resources and benefits.
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