Expand Coverage for a Comprehensive Range of AT/HM in Public Programs
Funding in health and long-term care programs to cover the costs of AT/HM was a major problem noted in both the literature and discussions with experts and stakeholders. Panel participants discussed the need to better align public programs, including Medicare, Medicaid, and HUD, to work together in supporting access to AT/HM, in addition to addressing challenges within each program.
TEP and CAP panelists discussed that the long-term care financing system will pay for certain solutions, which may not be the best solution. Generally, devices must fit in a medical category and be provided by an authorized provider in order to be covered. Another limitation is that Medicaid covers solutions that benefit the care recipient, but not the caregiver.
In the TEP discussion, the experts agreed that reimbursement for AT/HM and one-on-one work with caregivers in the home is difficult to obtain and that advocacy is needed to increase reimbursement for AT/HM. Additionally, TEP members noted that, for many caregivers, the decision to spend money on AT/HM can be difficult. Many caregivers become caregivers in a crisis situation and are unsure what caregiving expenses they may need to pay in the future, whether the person's condition might change, and how long the person will be able to continue living at home. eCAPmembers also discussed caregiver concern of the AT/HM costs as a barrier to their implementation. In cases where coverage is available through private insurance, many caregivers and care recipients have expressed reluctance to adopt these technologies due to potentially high co-payments.
Although many sources provide some funding for AT or HM, reimbursement varies across states and is typically limited to certain allowable products and services from participating providers. A January 2011, analysis of state payment for aging services technologies by the LeadingAge CAST found that 44 states reimburse for Personal Emergency Response Systems, which was the most commonly reimbursed technology (Peifer, 2011). An increasing number of states also reimbursed for other technologies, such as medication management (16 states), and telemonitoring/home telehealth (seven states). Other sources of funding include Title III of the Older American's Act and Medicaid state plan services (including Programs of All-Inclusive Care for the Elderly). In addition, the U.S. Department of Veterans Affairs (VA) programs in the states operate an extensive telehealth program for veterans.
TEP members discussed that many interventions can be provided relatively inexpensively. On average, the cost of the intervention in Maryland was in the hundreds of dollars. However, some older people may need major modifications or repairs in order to continue living in their homes, such as fixing a roof or installing a first-floor bathroom. Staff at one of the visited sites commented that many homes in their area are in poor condition, and this has significant health impacts, but resources are insufficient to help. Many homes do not have a half-bathroom on the first floor, and many older people with chronic illness are unable to safely walk up and down stairs.
In addition, TEP members commented on the importance of considering home and vehicle modifications and technologies to help people get outside of the home. Although much attention has focused on AT/HM for inside the home, getting in and out of the house and vehicles can be very problematic for someone who needs assistance, indicating the need to think beyond the front door.
Also noted was the importance of home repairs in conjunction with HM to improve accessibility. Dr. Gitlin commented that many provide care in very unsafe home conditions -- an average of eight home hazards, such as a lack of handrails in good repair and slippery floors. The American Occupational Therapy Association states, "Home modifications are used in conjunction with assistive devices and home repairs" (2011). Some HM may not be possible without home repair. A member of the TEP pointed out the importance of considering home repair first, in some instances, before installing HM. For example, installing handrails in a home to help an individual maneuver the stairs may not be as important as first fixing the stairs. Oftentimes, AT may not be possible to use in the home without HM or repairs (e.g., installation of ramps to a home and widening doorways to accommodate a wheelchair).
Increase involvement of occupational therapists and physical therapists
Discussion with one TEP member emphasized that reducing physical strain among family caregivers requires a multi-prong approach, with OT and PT as critically important components. CMs and other staff in the Aging Network can be trained to identify family caregiver risks and home hazards, but identifying specific technologies and training caregivers in specific techniques requires the involvement of trained health professionals. Some very simple techniques, accompanied by assistive devices, could provide family members with better back protection and reduce the strain they experience. Many people with chronic illness/disability and their families also need hands-on training in the use of new technologies, regardless of the size or complexity of the device.
The working group noted that occupational therapists are critical because they are the most skilled at assessing home safety issues, but noted that families can do their own assessments as well. A suggested model was to include communication with occupational therapists about more complicated issues, but not necessarily include them in each assessment. CMs or SWs could conduct assessments, with occupational therapist involvement achieved through telehealth applications, remote interactive videos, or "telepresence," in which a robotic video camera can be remotely controlled via the Internet, to help occupational therapists interact with people remotely.
The issue is not only about cost, but identifying the correct types of AT, which is an area where occupational therapists can help. Staff at one of the visited NFCSP sites noted that CMs can "plant the seed" by identifying issues and making referrals. Occupational therapists can then help increase function and increase community participation.
Panel participants mentioned several studies involving occupational therapists that found evidence of success; these are included in the literature review (Part I).
Encourage housing designs that support aging in place and family caregiving
To support multi-generational housing, "visitability", accessibility, and universal design are integral to ensuring individuals can age in place. In Connecticut, the Hartford area CIL succeeded in the passage of no-cost legislation to encourage "visitability" of new homes; that is, housing designs that are accessible to visitors with disabilities. The Hawaii State Unit on Aging is involved in a task force that is a partnership between the private sector and county and state governments to promote physical structures that support aging in place and multi-generational living (Home for Life Task Force, 2011). One working group is focused on providing information about HM and aging in place through ADRC services, including an educational website, options counseling that includes AT/HM options, intake and assessment forms. The second working group is providing recommendations for zoning legislation and accessory dwelling unit rules.
Montgomery County, Maryland has developed Design for Life Montgomery, a voluntary certification program for Visit-Ability and Live-Ability in single family attached and detached homes in the county. There was a Zoning Text amendment 06-17 approved by the Montgomery County Council establishing this program.9