We all know the toll that COVID-19 has taken on older adults in institutional settings. It’s prompted many aging advocates and policymakers to rethink how we deliver care to the frail elderly and whether the traditional nursing home model needs to change.
Many experts agree that more care should occur in community and home settings, but we lack enough clinicians to provide it and many states lack the resources to pay for it. However, home and community-based services (HCBS) can save money in the long term, studies have shown, and this care approach can work on many levels.
For example, “house calls” programs enable clinicians to directly deliver primary care in a patient’s home. Such services can be a critical lifeline for homebound older adults, especially during this pandemic, according to the nonprofit Home Centered Care Institute (HCCI), which provides education, consulting, research, and other assistance needed to expand home-based primary care nationally. With at least 2 million vulnerable older adults in the U.S., experts say house calls can improve access to care for those most at risk and in need of undisrupted care.
Physicians, nurse practitioners or physician assistants can perform examinations during house call visits, prescribe treatments, and provide needed immunizations and tests. They also review patients’ prescriptions, check that older adults are receiving adequate nutrition, identify potential fall hazards, screen for signs of elder abuse and offer caregivers an opportunity to learn how to perform care tasks, among other responsibilities.
Thomas Cornwell, M.D., executive chairman of the Home Centered Care Institute (HCCI), pointed out some of the benefits:
“House calls dramatically improve patient outcomes, lower health care costs, and help family caregivers correctly provide homebound, and often immunocompromised, older adults with complex care without having to leave their homes. … This can also save older adults from needless and expensive visits to the hospital, which is especially critical in the midst of a pandemic.”
Data from the Agency for Healthcare Research and Quality’s (AHRQ) Medical Expenditure Panel Survey show that half of Medicare spending is driven by just 5% of its beneficiaries — those who are frail, disabled, medically complex, chronically ill and often homebound. According to Cornwell, this group typically needs a disproportionately level of hospital or emergency room care, but house calls can dramatically reduce such expenses.
A Centers for Medicare & Medicaid Services (CMS) initiative, which tested home-based primary care for the frailest and more costly Medicare beneficiaries to see whether it would reduce Medicare costs and help patients age at home, confirmed these cost savings, according to this Commonwealth Fund report and follow-up studies. Providing primary care at home for the 50,000 older adults in the study saved Medicare more than $100 million in the initiative’s first five years.
“Given the cost savings and health outcomes, house calls provide a great opportunity for the healthcare system to improve care for older adults and save taxpayers money,” said Cornwell. “Home-based primary care should be the national standard for treating medically complex patients.”
The catch? A shortage of doctors, physician assistants and nurse practitioners in the U.S. who provide this level of care, according to this Health Affairs article. According to the authors, an estimated 2 million to 4 million people needed these services, but most homebound people lived more than 30 miles from a high-volume provider (based on 2013 data).
“There are at least 2 million homebound frail people and fewer than 2 million nursing home patients in the United States,” the authors write. “However, about seven times more primary care providers (34,000 of them) visited nursing facilities than visited patients at home. The volume of nursing facility visits also greatly exceeds that of home visits.”
Nearly 5,000 primary care providers made 1.7 million home visits to Medicare fee-for-service beneficiaries annually in 2012–13, accounting for 70 % of all home-based medical visits, according to the article. “About 9–10% of these providers performed almost half of these home visits, making them the highest-volume providers of home-based medical care in the country.” Yet, at least 53% of Americans lived more than 30 miles from any of the high-volume or full-time providers of home-based medical care (more than 1,000 visits annually). Alaska, Hawaii, Maine, Mississippi, New Hampshire, and Vermont were among the states which did not have any health care professionals who made more than 500 home visits a year.
COVID-19 has shed new light on the challenges of housing frail elderly in congregate, institutional settings. This recent commentary in Albany Times Union calls for rethinking nursing home care and shifting residents, whenever possible, to home and community services. “The real problem is not how nursing homes are run or regulated, but how they are being used. The continuing practice of relegating seniors to institutions because they can no longer live independently is long overdue for change.”
Home and community-based care require strong federal-state partnerships since Medicaid is the primary payer of long-term services and supports. CMS recently released a Long Services and Supports toolkit to help states expand and enhance home and community-based services and rebalance the long-term care from institutional to community focus. While many states have temporarily expanded HCBS during the pandemic, COVID-19 has also left most state budgets with serious shortfalls and likely cuts to Medicaid budgets.
It’s still not certain what the latest COVID relief bill will include — assuming it passes — but lack of additional funding for Medicaid will directly impact the cost and cost-savings of long-term care, as well as the lives of millions of older adults.
Journalists: How are your states faring on supporting any or all of these home- and community-based programs? Will funding be cut as states grapple with budgets?
- PACE: Program of All Inclusive Care for the Elderly is a comprehensive long-term care program for elders through Medicare and Medicaid. For most participants, care is delivered in the home. Contact the National PACE Association to find a local program.
- MFP-Money Follows the Person: A program to encourage transitioning out of institutional care and into home and community settings. A tribal MFP program increases funding available for tribal communities.
- Independence at Home is a CMS demonstration program that allows providers to deliver primary care in the person’s home, currently underway in 14 locations.
- The CAPABLE program is a home-based care program developed at Johns Hopkins that allows medically-needy older adults to remain at home. It incorporates appropriate home modifications to ease aging in place; an R.N. and an occupational therapist deliver care. See previous AHCJ coverage.
- Check out this Kaiser Family Foundation Issue Brief on State Actions to Sustain Medicaid Long-Term Services and Supports During COVID-19.
- On Dec. 3, Sen. Bob Casey (D-PA) and Rep. Debbie Dingell (D-MI) introduced the COVID HCBS Relief Act ( 4957/H.R. 8871) to provide a 10% increase in the Federal Medical Assistance Percentage (FMAP) to states for Home and Community-Based Services (HCBS). States would be able to use the funds to support direct care workers with hazard pay, paid leave, and personal protective equipment, to recruit and train additional direct care workers, support family caregivers, and provide services to individuals on waiting lists. A summary of the bill is here.