State gets failing grade on long-term care support

By Brian Goslow

We’ve got world-class hospitals and medical schools. We are the first state to have mandatory health care insurance, a program that has expanded the level of care to low-income and handicapped residents. And we are the first state to have systems in place to assist consumers in the selection of health-related services.

So why did a recently released report from AARP and the SCAN Foundation rank us 30th in being prepared to deliver our aging population’s long-term services and health care needs?

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“Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers” is the first-ever attempt to gauge these programs and services on a multi-dimensional, nationwide scale.

Its goal is to give states the opportunity to improve their long-term services and support programs by providing them with hard factual evidence on how they’re faring currently and giving them the example of other states that are doing better to learn from. 

“Seventy percent of the people over 65 will likely need some form of long-term services and support during their lifetime,” said SCAN Foundation President and CEO Bruce Chernof, during a press conference announcing the findings. “On average a person will need three years of support. That’s not necessarily in a nursing home; a lot of those services are actually delivered in the home and in the community. That’s a significant amount of time and a significant amount of need.”

Massachusetts scored respectably well overall in affordability and access (17th) and in choice of setting and provider (14th), two of the four main areas of consideration. That was offset by low scores in quality of life and quality of care (34th) and in support for family caregivers (39th), the other two main areas.

The state failed miserably in median annual nursing home private pay cost as a percentage of median household income age 65 and older (329 percent) and median annual home care private pay cost as a percentage of median household income age 65 and older (108 percent), ranking 47th in each.

The high cost of residing in nursing homes is partially due to higher cost of labor in the east, according to W. Scott Plumb, senior vice president for the Massachusetts Senior Care Association.

“If you look at affordability, you’ll see that the four states with higher costs than Massachusetts are Maine, Connecticut, Rhode Island and New York,” Plumb said. “Private rates are a function of labor costs and New England and New York have the highest labor costs. If we didn’t pay higher salaries for care, we wouldn’t have the nurses we need.”

Another reason for the higher costs, Plumb said, is the high number of seniors residing in state nursing homes through Medicaid. Medicaid payments are currently $32 below the nursing homes’ daily operational cost. To stay in business, the nursing homes have to make up the difference through higher commercial rates. “It’s not fair to ask the private consumer to offset that cost, but that’s the reality we’re working with,” he said.

Though the state ranked 34^th place for quality of care, Plumb said, “We did extremely well in everything except for restraints,” Plumb said. “We’re trying to get better. It’s a very difficult issue. Nursing home workers get a lot of pressure from families to restrain loved ones they perceive to be at risk. Some family members want the bed rails up for their loved one to be safer.”

Restraints are only used on nursing home residents through doctor’s orders. “Keeping people safe is a priority as is maximizing their independence,” Plumb said.

Perhaps the biggest area health care advocates feel the state needs to improve on is reducing the number of new Medicaid long-term services and supports (LTSS) users who are introduced to its services in an institutional setting. As of 2007, only 31 percent of Medicaid users received their initial services in the community.

The state’s Medicaid program, Mass Health, allocates 39 percent of long-term care dollars to community care and 61 percent to institutional care. Those states with the highest scores flip the percentages in favor of community care. “The report showed we are doing a very poor job getting people services at home first, as opposed to an institutional setting,” Deborah Banda, state director of AARP Massachusetts said. “We know from our research that people want to remain in their own homes and communities as they age.”

Al Norman, executive director of Mass Home Care, said the AARP Scorecard’s results paint an unflattering picture of the state’s ability to put its “Community First” program — which allows individuals the opportunity to choose home care before nursing home care — in place.

Dr. JudyAnn Bigby, the state’s Secretary of Health and Human Services, said in a statement, “The Patrick-Murray Administration is committed to making significant strides in these areas in the years ahead.” She said the percentage spent on long-term care funding on community-based services has gone up about 10 percent since 2007. “This funding has helped ensure that seniors and people with disabilities who want to live in their own homes and communities have the support they need to do so successfully.”

In the four main areas studied, Massachusetts was 39th in the country in providing support for family caregivers, with 77.7 percent of caregivers usually or always getting needed support; Oregon was on top with 84 percent.

When it comes to assisting caregivers in the number of health maintenance tasks that are able to be delegated to certified home health aides, out of 16 named health maintenance tasks, Massachusetts only allows two — the administering of glaucoma tests and performing of ostomy care (which includes skin care and appliance changing).

“The only ones able to give oral medications in the home are nurses — we’re talking just pills, putting them in the hands of people so they can take them, not injections,” said Norman.

“Similarly, we have people here who have cataract surgery that are told to put drops in their eyes twice a day. Who is supposed to put in those drops if the person can’t see? If we allow families to do it, why not home health aides?”

Norman noted most people cannot afford to have a nurse come to their home to administer this kind of care and will remain impediments to keeping people at home until the roster of professional medical workers is expanded to assist them.

Five states — Oregon, Nebraska, Iowa, Missouri and Colorado — allow all 16 listed health maintenance tasks to be carried out by certified health aides.

Legislation that was introduced to remedy the situation has failed numerous times. Norman said the state’s lack of action in making these services available in a home setting is an example of how it makes it difficult for people to get help in their home.

When it came to providing legal and system supports for caregivers, Massachusetts scored 3.17 out of a possible 12. Among the measures considered were:

•state family medical leave laws;

•mandatory paid family and sick leave;

•protection of caregivers from employment discrimination;

•the extent of financial protection for the spouse of Medicaid beneficiaries who receive long-term care services and supports; and

•state assessment of family caregiver needs such as -— depression, physical health, level of strain they experience, development of a care plan, education and training to provide care, authorization of services to caregivers and authorization of respite care.

When caregivers don’t get the services they need, it makes it harder for them to provide the assistance their loved ones need to stay in their homes, according to Banda.

Massachusetts scored third nationwide in the number of adults with disability or low-income adults who are getting Medicaid or other health insurance assistance. “That is the first prong of our health care reform efforts in this state — to get people enrolled,” Banda said. “We wanted to get people covered and we’ve done a great job of that.”

The state ranked 10th in providing the tools and programs needed to facilitate consumer choice of health services. The majority of new Medicaid LTSS users choosing not to get their initial services in a community setting temper the score, however. Banda felt the state and others around the country need to do a better job of alerting the public to what services are available outside of institutional settings.

“We all know we’ve got an extremely fragmented system of long-term service and supports not only in this state, but the country and I think one of the pieces that most states, including us, have to do better is making sure people know what’s available so that they can utilize those services that are out there,” she said.

There are a lot of good things being done in Massachusetts when it comes to long-term services and supports, Banda said, but the affordability piece is a big factor that is hampering efforts to move forward as fast as some other states. “If we can tackle that payment reform piece and get some of the health care costs in this state down, I would hope that we would see more programs and more services become available for people,” she said.

Mass Home Care’s Norman is skeptical about the payment plan that’ll be put in place and who’ll be in charge of overseeing it. He said one of the plans state legislators are considering would put state health insurance monies into a single plan that would be overseen by the large health networks — the same hospitals and doctors that have been institutionalizing people for years.

“We’re heading in absolutely the wrong direction,” Norman said. “We’ve asked the state for an independent care coordinator on each elder’s team — someone with no interest in benefiting from the (recommended) services.”

While much of the information released in the Scorecard report is individually state-based, Susan Reinhard, Senior Vice President for Public Policy, AARP, noted states cannot be expected to financially support the changes necessary to improve long term care services and supports programs on their own.

“Some things they have direct control or say over or they can encourage changes on a national public policy level,” she said. “Others in the private sector and even consumers will make the difference here. We hope this scorecard will engage and start discussion and dialogue within each state will all of those different stakeholders in long-term services and support and target areas for improvement.”