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An Alternative to a Nursing Home

Choices enrolls 7,000 Medicaid patients in first year of providing home-based care

Betty Caldwell and her mother faced a painful dilemma. Caldwell, 64, had developed a heart condition that left her so exhausted she felt barely able to make the daily trip to her mother's nearby apartment in Kingsport.

Her mother, Elsie King, 90, a widow for almost 60 years, had raised three children on her own while working in a factory nearly all her adult life, and was fiercely independent. But she'd come to rely on her only daughter for help with meals, medications, cleaning and errands.

"We had gotten to this very difficult point," Caldwell said. "I was sick. My mom needs care, but she's not ready for a nursing home where she would be in a bed in a room."

They found a solution in Choices, a program implemented a year ago that provides in-home services as an alternative to nursing home care through Tennessee's Medicaid program, TennCare.

Choices represents an overhaul of how the state responds to the needs of older or physically disabled residents needing daily care. For years, Tennessee ranked at or next to the bottom among the states in providing home- and community-based services.

During the program's first nine months, enrollment in home- and community-based services jumped from 18 to 25 percent, which is about 7,000 people.

That includes 256 who went directly from nursing homes to home care. The program allows up to 9,500 people to be enrolled at any time.

The program began in Middle Tennessee last March and went statewide in August.

The Choices program provides a broad menu of services to those who would otherwise qualify for nursing home care based on their income and health, but who can safely live in their own homes. Services include installing wheelchair ramps and arm rails, providing in-home health care, bathing services, transportation, homemaker services, and, in certain cases, helping pay the monthly bills at assisted living facilities.

At-home services in the Choices program cannot exceed the average cost of nursing home care. So far, the average participant costs about $15,000 to $20,000 per year compared with the average annual cost of nursing home care, about $52,000, said Steve Witt, director of the Southeast Tennessee Area Agency on Aging and Disability, based in Chattanooga.

"If you can make it possible for people to stay at home — which is what most people want — it's better for the individual, the family and the taxpayer," Witt said.

Advocates are hoping to build on the early success of the program by adding other options — such as adult residential homes for people unable to live alone — while preparing to defend the program from any potential cutbacks.

"It's a very difficult time for federal and state budgets, and we'll be working to ensure there's not a disproportionate share of cuts just as more people need these services," said Rebecca Kelly, AARP Tennessee state director.

The number of people who will require long-term services is expected to triple in Tennessee in the coming decades, but the biggest challenge for the program, which has no waiting list, is getting the word out to those who could benefit, said Margot Seay, AARP state president.

In King's case, the program sends someone once a week to clean and perform household chores. It delivers one meal a day, Monday through Friday.

The program has also installed a personal emergency response system, which allows King to press a button if she needs assistance, and the service will contact Caldwell or emergency responders.

Some weeks, when needed, Choices provides more assistance in helping with daily dressing or other activities.

In the future, it may provide respite care for Caldwell, a grandmother who rarely leaves their hometown because of her caregiver responsibilities for her mother.

Choices "doesn't replace the care we're giving her," Caldwell said. "It just helps her and eases the burden a little for me and my husband. The people in the Choices program have been a blessing to us."

For more information, call 1-866-836-6678 toll-free.

Anita Wadhwani is a reporter based in Nashville.

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