Improving Long-Term Care and Care for Chronic Conditions

Today, millions of Americans who want care at home are struggling. Home- and community-based care is often unaffordable or unavailable.  Another problem is that services and supports are often uncoordinated, so people unnecessarily end up in more costly institutions.  AARP believes all Americans should have the choice to get needed care at home, since 89 percent of Americans 50+ want to remain home as long as possible.

Developing a better system to provide long-term care (LTC) and care for chronic conditions will save money, improve quality of care and life, and help people live at home.  We will need many new, well-educated nurses and other providers to coordinate chronic and long-term care across all settings.  The current problems with the current system include:

Lack of Appropriate Follow-Up and Coordination:  After a hospital visit, lack of appropriate follow-up care and support at home often sends people back to a hospital or a nursing home.  This is especially problematic for people with multiple chronic conditions who often see many providers in many settings, take numerous medications, and have high costs but little care coordination.  This can lead to costly errors, unnecessary tests, and unnecessary hospital and nursing home stays.  Medicare spent $12 billion in 2005 on unnecessary or potentially preventable hospital readmissions.  In fact, 18 percent of the Medicare beneficiaries discharged from the hospital re-enter the hospital within 30 days.
 
Costly Bias:  Many people with multiple chronic conditions and LTC needs rely on Medicaid – the largest payer of LTC in this country.  But Medicaid has an institutional bias.  Nationally 75 percent of Medicaid LTC spending for older people and adults with physical disabilities pays for institutional services, with only 25 percent going to the home- and community-based services (HCBS) that people prefer.  States that invest in HCBS can, over time, slow their rate of Medicaid spending on LTC.

Family Burden:  At any given point, about 34 million family caregivers help loved ones live at home.  These caregivers provide and coordinate care at risk to their own health and financial security. These unpaid contributions were valued at about $375 billion in 2007.  Providing supports to live independently and supporting family caregivers can help people live at home and keep them out of often more costly institutional settings.

Common-Sense Solutions

As part of health care reform, Congress should improve long-term care and care for those with chronic conditions by:  (1) helping people get the services and supports they need to stay in their homes; (2) improving care coordination, especially for people with multiple chronic conditions; and (3) supporting family caregivers.

Targeting Transitions

One way to improve chronic care would be for Congress to establish a Medicare transitional care benefit.  This benefit would be specifically designed to support beneficiaries as they move from the hospital to home or other setting, such as a skilled nursing facility or rehabilitation center. Its goals would include: delivering the services that beneficiaries need; managing their medications; and supporting family caregivers. These steps will reduce hospital readmissions and save money. 

An effective way to structure this benefit has been clinically tested and found to yield positive results.  Targeting the most at-risk individuals, a nurse-led interdisciplinary team would assess the beneficiary (and his or her caregiver) before hospital or nursing home discharge.  The nurse and other providers, in consultation with the beneficiary and caregiver, would develop an individualized plan for appropriate follow-up during and after the transition. 

A transitional care benefit ideally would coordinate among providers, ensure that treatment plans are followed and medications are managed, provide patient and caregiver training, and make referrals to community resources.  Follow-up and coordination would improve patient outcomes and decrease hospital readmissions.

Providing a transitional benefit and improving care coordination will require many new nurses.  To address the nursing shortage, Congress should modernize Medicare Graduate Medical Education nursing education payments to better align them with health reform goals and establish a mandatory funding stream for nurse education.  Improving transitional care will require mechanisms to provide information and referrals to resources for family caregivers upon admission to or discharge from a hospital, post-acute care, or other setting.  One such provision is included in the Retooling the Health Care Workforce for an Aging America Act.

Improving Chronic and Long-Term Care

Efforts to improve chronic care and system coordination include:

• Improve care coordination for individuals with multiple chronic conditions through individualized assessments and care plans, as in the Independence
  at Home Act.
• Improve care coordination for people in both Medicare and Medicaid, the "dual eligibles," by establishing a Medicare and Medicaid pilot to integrate care and financing for "duals" and improving Special Needs Plans, including requiring them to contract with state Medicaid programs. 
• Require or provide incentives for sharing information regarding dual eligibles, such as claims and Part D utilization data, between Medicare, Medicaid and other health plans.

Efforts to improve long-term care include the following Medicaid improvements:

• Raise the income eligibility level, broaden the scope of covered services, and make other improvements in the Medicaid HCBS state plan option;
• Provide an enhanced match to states to expand HCBS and require spousal impoverishment protections for HCBS beneficiaries as in the Empowered at Home Act (S. 434); and,
• Establish a state plan option or requirement to assess all HCBS beneficiaries’ family caregiver needs and connect them to supports, as in the Retooling the Health Care Workforce for an Aging America Act (S. 245/H.R. 468).