This blog is part of our Medicaid Awareness Month series, in which we highlight the ways that Medicaid supports the health of vulnerable populations. Guest bloggers for the series are state advocates who work on behalf of Medicaid from different vantage points.
Medicaid draws accolades for its success in many areas – whether it’s fighting the substance use disorders crisis, providing freedom to people living with disabilities, or supporting children with complex medical needs. But what’s often missed is what Medicaid does for our neighbors, parents and grandparents who need long-term care.
Nationally, and here in Pennsylvania, Medicaid pays for the care of three in every five nursing home residents – people like Harry W. from Beaver County who, at 6’2” and 250 pounds, can no longer be safely cared for by his loving wife, Natalie, in their home. His physical needs require round-the-clock care. Harry and Natalie had good, middle class jobs, but paying the nursing home bill – the average monthly cost for a semi-private nursing home room in Beaver County is $10,230 – quickly exhausted the savings they worked to build over a lifetime. They learned that Medicare doesn’t pay for the kind of long-term, skilled nursing care that Harry needed, and that it would be Medicaid coming to their rescue.
the long-term services and supports (LTSS) a person needs to live independently in their own home or apartment, or with a friend or relative. It’s these kinds of services, and the quality of life they enable, that makes Medicaid the unsung hero of long-term care. Through the provision of LTSS, Medicaid helps to encourage and support more people living in the community – which is often the less expensive and safer option, and, most importantly, the care setting most people prefer.
Pennsylvania’s Medicaid programs for older adults provide senior citizens like 88-year-old William C., who lives in a small town outside Pittsburgh, the day-to-day support he and his wife Beverly need to remain in their home. Debilitating pain from shingles and a degenerative disease that weakens his muscles has made it hard for William to eat and move around the home like he used to. At 86, Beverly is his primary caregiver, but worries about protecting him from falls or other hazards. I had the opportunity to meet with William’s daughter, Linda, and help guide them through the multi-step application process, which includes gathering information to verify both financial and medical eligibility (an assessment of a person’s cognitive ability, functional limitations, and need for ongoing skilled treatment is conducted to determine whether they are “nursing facility clinically eligible” – meaning their needs are such that they require skilled care ).
Once approved for LTSS services, William will have access to a personal care aide to help with things like transferring, bathing, making meals, and managing medicines; transportation to doctor’s appointments; non-medical priorities like religious services or socializing at the local senior center; home modifications such as “grab bars,” a stair glide, or any other changes to make the couple’s home safe; and respite care, to allow Beverly time to rest and recharge.
Reducing fragmentation of care between physical and behavioral health and improving the quality of services are two of the state’s goals in moving to the new Community HealthChoices waiver, a new system of Managed Long-Term Services and Supports (MLTSS) which is being phased in across the state over a three-year period beginning this year in Southwestern PA. Read more on how that transition is going from the consumer perspective here.
In many ways, Community HealthChoices has learned from the success of the popular LIFE program – Living Independence for the Elderly – a model of managed long-term care that supports community-based living for vulnerable older adults covered by both Medicare and Medicaid. LIFE, which nationally is known as the Program of All-Inclusive Care for the Elderly (PACE) model, covers adults ages 55 and older whose health needs require skilled care, but want to remain in their homes and communities. LIFE programs become both the participant’s insurer and provider to deliver comprehensive, whole-person care through an interdisciplinary team that includes preventive and primary care, nursing and home care, mental health, nutrition, vision, hearing, dental care, medicine, social services, recreation, transportation, hospitalization and rehabilitation. The PACE model is lauded for it success reducing preventable hospitalizations and emergency room visits, and improving the quality of life for participants. At age 70, Ms. Lites credits the LIFE program for not only helping her medically, saying “it’s really helped control my blood pressure,” but also for “giving me communication with others and that’s important since I live by myself. I look forward to singing in the choir, playing the games, and doing ceramics here. You need to get out, you can’t just sit home and rock in a chair.”
Telling the story of how #MedicaidWorks for seniors in Pennsylvania is a top priority for the Pennsylvania Health Access Network in the coming year – to evangelize for and help connect people with the benefits of Home and Community-Based services (through LIFE, MLTSS programs like Community HealthChoices, or other Medicaid waiver programs) and make sure that as delivery systems change, they are both centered around, and accountable to, consumers.
Erin Ninehouser, Consumer Engagement Manager, Pennsylvania Health Access Network
Dr. Pamela Z. Cacchione, PhD, CRNP, Associate Professor of Geropsychiatric Nursing-CE, University of Pennsylvania, School of Nursing, Health and Aging Policy Fellow