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Advisory Council November 2020 Meeting Presentation: Expand Access to LTSS

Tuesday, November 10, 2020

Printer Friendly Version in PDF Format (10 PDF pages)


Past Efforts to Expand Access to Long-Term Services & Supports

Gretchen Alkema, Ph.D., Vice President, Policy and Communications, The SCAN Foundation

U.S. Aging Policy Milestones

  • Daily Living Security
    • Public:
      • ACA Opportunities (2010)
      • Medicaid (1965)
      • Older Americans Act (1965)
    • Private:
      • LTC Insurance (1970s)
      • Family / Friends / Neighbors
  • Income Security
    • Public:
      • Social Security (1935)
      • SSDI/SSI (1956/1972)
    • Private:
      • Defined Benefit
      • 401K -- 403B
      • Private Disability Ins.
      • Earned Income
  • Health Security
    • Public:
      • ACA (2010)
      • Medicare/ Medicaid (1965)
      • VA (1930)
    • Private:
      • Medigap (1965)
      • Retiree Health Insurance
    • Pub/Priv:
      • Medicare Managed Care (1982; 1997; 2003)

2013 Commission on Long-Term Care

  • Commission's charge: To create a plan to...
    • Establish, implement, and finance a comprehensive, coordinated, and high-quality LTSS system
    • Ensure availability of LTSS to:
      • Older adults
      • People with substantial cognitive or functional limitations
      • Others needing ADL assistance
      • Those who plan for future needs

Call to Action

  • 12+ million need LTSS
    • Diverse population: almost half under age 65
    • Most living in their homes and in the community
    • Most are assisted by family caregivers
    • Many get their needs met
  • Key problems more severe with population aging:
    • Paid LTSS is expensive & long periods can be catastrophic
    • Most retirees not adequately prepared for costs
    • Family caregivers provide most care
      • Financially and emotionally stressful
      • Availability will decline in the future
  • Direct care workforce capacity, quality, & training
  • Paid LTSS: highly fragmented & difficult to access
    • lack focus/coordination to get best outcomes
    • can be expensive and inefficient
  • Future growth in LTSS need with population aging
    • Major strain on federal/state budgets

Population Needing LTSS, by Age Group and Level of Need

Stacked Bar Chart: Children total 0.6; Working Age total 5.4; Elderly total 6.7.
SOURCE: S. Kaye, data from 2012 NHIS, 2010 Census, Nursing Home Data Compendium 2010.

The Number of Americans Needing Long-Term Care Will More than Double by 2050

Bar Chart: 2010 12 million; 2050 27 million.
SOURCE: S. Kaye, C. Harrington, and M. Laplante (2010), Analysis of 2005 SIPP, 2007 NHIS, 2007 ACS, 2004 NHHS, and the 2005-2006 Medical Expenditure Survey.

Call to Action

  • Projected increase in LTSS need will confront significant resource constraints due to current & projected fiscal challenges
    • New care integration, technology, & innovative workforce strategies needed to reduce costs & improve outcomes
    • Creative financing solutions needed to insure risk & encourage savings
    • More accessible & sustainable Medicaid safety net needed

Vision for Future LTSS System

  • Service Delivery
    • Person- & family-centered
    • Balance of options: HCBS/Institutional
    • Integrated medical & LTSS
    • Effective: outcomes focused
    • Efficient: financially sustainable
  • Financing
    • Full array of LTSS financing options
    • Balance of public/private financing
    • Protects against catastrophic costs
    • Enables individual preparation
    • Safety net for those in most need
  • Workforce
    • Attracts & retains trained workers
    • Adequately-sized
    • High quality, person-centered care across LTSS settings

Recommendations: Service Delivery

  • Rebalancing: incentivize states to balance HCBS & institutional care
  • Care Integration
    • Align incentives to integrate person-centered care
    • Establish a single point of contact for LTSS.
    • Use technology to mobilize and integrate resources
    • Create livable communities
  • Uniform Assessment: implement a standardized assessment tool to produce a single care plan

Recommendations: Service Delivery

  • Consumer Access: expand "No Wrong Door" to provide enhanced options counseling
  • Quality: accelerate development of LTSS quality measures for HCBS and make them available to consumers
  • Payment Reform: promote payment based on the service rather than the setting

Recommendations: Workforce

  • Family Caregiving
    • National strategy to maintain & strengthen family caregiving
    • Include family caregivers in needs assessment & care planning
    • Encourage expansion of caregiver interventions
  • Paid Workforce
    • Encourage revision of scope of practice to permit delegation with supervision to direct care workers
    • Enable criminal background checks for LTSS workforce
  • Direct Care Workforce
    • Create meaningful ladders & lattices for career advancement
    • Integrate direct workers in care teams
    • Collect detailed data on LTSS workforce
    • Encourage standards & certification for home care workers

Financing: Vision and Alternative Approaches

  • Common Vision: A balance of public and private financing to insure the most catastrophic expenses, encourage savings and insurance for more immediate LTSS costs, and provide a strong safety net for those without resources.
  • LTC Commission did not agree on a single approach, but offered two approaches that might achieve the common vision
    • Private options to strengthen financing
    • Social insurance

Recommendations: Financing

  • Medicaid Improvement
    • Demo to provide LTSS to those w/ disabilities to stay employed
    • Assist states to achieve greater uniformity in Medicaid buy-in programs
  • Medicare Improvement
    • Eliminate 3-day prior hospitalization requirement for skilled nursing facility stay
    • Reconsider "homebound" requirement for home health care
  • Savings
    • Allow individuals with disabilities & their families to set up section 529 savings funds

Long-Term Services & Supports State Scorecard, 2020 Edition

High-Performing LTSS System

  • Five dimensions of LTSS performance, constructed from 26 individual indicators.
    • Affordability and Access
      1. Nursing Home Cost
      2. Home Care Cost
      3. Long-Term Care Insurance
      4. Low-Income PWD with Medicaid
      5. PWD with Medicaid LTSS
      6. ADRC/NWD Functions
    • Choice of Setting and Provider
      1. Medicaid LTSS Balance: Spending
      2. Medicaid LTSS Balance: Users
      3. Self-Direction
      4. Home Health Aide Supply
      5. Assisted Living Supply
      6. Adult Day Services Supply
      7. Subsidized Housing Opportunities
    • Quality of Life and Quality of Care
      1. PWD Rate of Employment
      2. Nursing Home Residents with Pressure Sores
      3. Nursing Home Antipsychotic Use
      4. HCBS Quality Benchmarking
    • Support for Family Caregivers*
      1. Supporting Working Family Caregivers
      2. Person- and Family-Centered Care
      3. Nurse Delegation and Scope of Practice
      4. Transportation Policies
    • Effective Transitions
      1. Nursing Home Residents with Low Care Needs
      2. Home Health Hospital Admissions
      3. Nursing Home Hospital Admissions
      4. Burdensome Transitions
      5. Successful Discharge to Community

ADRC/NWD - Aging and Disability Resource Center/No Wrong Door
HCBS - Home- and Community-Based Services
LTSS - Long-Term Services and Supports
PWD - People with Disabilities
* Support for Family Caregivers Dimension evaluated across 12 individual policies, which are grouped into four broad categories.

SOURCE: Long-Term Services and Supports State Scorecard, 2020.

State Rankings Overall, 2020

State Map colored according to Top, Second, Third, or Bottom Quartile.

Key 2020 Scorecard Findings

  • States made progress since 2017, but status quo dominates
  • Even highest-performing states have room for improvement
  • Top- & bottom-ranked states have remained consistent
  • States showed significant decline in long-term care insurance policies
  • Affordable/accessible housing remain significant unmet need

The SCAN Foundation