Reinvesting in home and community-based services

How the Biden Administration’s $1.9 trillion relief bill will impact Medicaid in Massachusetts

The American Rescue Plan Act (ARPA) — a COVID-19 relief and recovery package — was signed into law by President Joseph Biden last month. Among the $1.9 trillion relief bill’s provisions is a temporary enhanced federal matching percentage (FMAP) for Medicaid home and community-based services. The FMAP is the proportion of every Medicaid dollar spent paid for by the Federal government. Massachusetts could receive as much as $409.2 million during the one-year period covered.

Prof. Miller discusses COVID-19 relief bill

“One of ARPA’s goals is to strengthen state efforts to help seniors and people with disabilities live in their homes and communities rather than in nursing homes or other institutional settings,” said Edward Alan Miller, PhD, a fellow at the Gerontology Institute at UMass Boston and professor in the university’s Department of Gerontology. “The imperative to do so has been underlined by the COVID-19 pandemic which increased demand for safe, high quality alternatives to institutional settings where morbidity and mortality threats from the virus are greatest.”

Organizations serving vulnerable populations — AARP Massachusetts, the Dignity Alliance of Massachusetts and Disability Advocates Advancing our Healthcare Rights — gathered stakeholders statewide recently to look at how this new funding could be directed in Massachusetts and, in particular, expanding and strengthening home and community-based services. Miller was among the speakers to address the group.

The Centers for Medicaid and Medicare Services (CMS) had already allowed states certain flexibilities in meeting the COVID-19 crisis through the option to adopt temporary changes to their Medicaid programs covering home and community-based services. Furthermore, prior legislation had increased the federal matching rate by 6.2 percentage points across Medicaid services for the duration of the Coronavirus emergency. ARPA increased the federal matching rate by an additional 10 percentage points for home and community-based services (HCBS), specifically. The federal government typically pays for half of Massachusetts Medicaid costs. Combined with the early increase, 66.2% of the Commonwealth’s HCBS costs would be paid for by the federal government under ARPA for one year.

“Key stakeholders see the value of the flexibility ARPA provides to address needs across a range of services and populations needing home and community-based support,” says Miller. “There is particular interest in improving the work conditions of direct care workers, including raising wages and benefits to increase their quality of life and improve recruitment and retention. These are issues that directly impact the quality of care delivered.”

In addition, care recipients and advocates view the ARAP legislation as an opportunity to fund the additional services and supports necessary to maintain older adults and younger people with physical disabilities, developmental disabilities, and severe mental illness at home and in the community, not just during the pandemic but beyond.

One key area the legislation does not detail is whether changes considered by states need to be shared, reviewed, or approved in advance by the federal government. The Massachusetts Office of Health and Human Services is waiting for guidance from CMS before finalizing or implementing plans to take advantage of the enhanced federal match. Although the funding period began April 1, 2021, the state would not lose money if plans were not implemented by that date.

 “Developing strategies and processes that best enable states to take advantage of ARPA’s enhanced federal matching funds would give them a leg up should substantial additional resources become available through the American Jobs Plan and other potentially forthcoming federal legislation,” said Miller. Critical to success is consultation with community stakeholders to outline plans on how to expend the additional revenues in the most effective way possible to the greatest benefit of care recipients, their families, and the front-line staff who care for them.”

Nursing Home Reimbursement: A case study

The current financing structure of Pennsylvania nursing homes is not sustainable

Nursing homes play a critical role delivering long-term services and supports (LTSS) to older adults and individuals under the age of 65 with disabilities. Despite this, these facilities face serious threats to their financial viability. A new report documents the increasingly important role nursing homes play in Pennsylvania, the key demand and supply factors affecting nursing home performance, and highlight implications for the financial viability of nursing homes going forward.

Edward Alan Miller

Editor-in-chief Edward A. Miller

Using data from a variety of sources, the researchers demonstrate that the demand for nursing home care is expected to increase, but the reimbursement level from Medicaid — the growing source of payment for nursing home residents — is causing a financial strain on these institutions. The report, “The Case for Funding: What is Happening to Pennsylvania’s Nursing Homes,” was written by researchers with the LeadingAge LTSS Center @ UMass Boston and funded by The Jewish Healthcare Foundation.

Data between 2010 and 2018 indicate that nursing homes are serving lower income individuals with more challenging diagnoses, including more severe cognitive impairment and psychiatric illness, as length of stay and occupancy has declined. Coupled with Medicaid as a payment source for increasing numbers of residents, the researchers expect to see more nursing homes face financial challenges in the coming years.

“The current financing structure supporting nursing home care in Pennsylvania is not sustainable,” says Edward Alan Miller, PhD, one of the report’s authors and Professor of Gerontology at UMass Boston. “Unless the reimbursement rates paid by the Medicaid program are brought more in alignment with the costs of providing high quality care in a safe manner, providers will face increasing challenges caring for Pennsylvania’s most vulnerable residents.”

Data on professional and support staff in nursing homes also indicate a concerning trend:

  • Even as patients are presenting with more challenging diagnoses, overall staff hours among direct care workers have remained relatively unchanged over the last ten years and RN hours have declined slightly.
  • Compensation for direct care workers has remained relatively flat, increasing by only 1.9% per year from 2012 to 2019. When adjusted for the medical consumer price index, real wages have declined an average of .78% annually during the time examined.
  • While certain individual quality metrics have improved — such as declines in the numbers of bed sores — overall aggregated quality scores have not.Marc Cohen, PhD

“The growing gap between what facilities need, as reflected in charges, and the Medicaid reimbursement rate has come at a time when nursing homes are being asked to care for an increasingly complex and frail mix of residents,” says Marc Cohen, PhD, one of the report’s authors and Co-Director of the LeadingAge LTSS Center @ UMass Boston. “The result has been increased cost shifting to individuals and families who must pay for care privately or take on additional caregiving responsibilities. Nursing home services represent a critical component in Pennsylvania’s continuum of care. Our study demonstrates that more needs to be done to support them.”

Journal Special Edition Dedicated to COVID-19 and Older Adults: Lessons From the Pandemic

Edward Alan Miller

Editor-in-chief Edward Alan Miller

The impact of the COVID-19 pandemic on older adults around the world has been nothing short of breathtaking. Like any sudden crisis, it begs a few common questions: What actually happened and how did we respond? What lessons should we take from that experience? And, most importantly, what do we do now?

In a special double-issue of the Journal of Aging and Social Policy, dedicated to the COVID-19 pandemic crisis, leading gerontology researchers tackle those questions from a wide range of perspectives. The issue, Older Adults and COVID-19: Implications for Aging Policy and Practice, offers 28 scholarly articles available online free of charge.

“The COVID-19 pandemic has devastated populations and economies globally but older adults have been particularly hard hit, due both to direct exposure to the virus itself and to the adverse consequences of efforts taken to mitigate its effects,” said Edward Alan Miller, a University of Massachusetts Boston gerontology professor and JASP’s editor-in-chief. Continue reading

Institute Director Len Fishman: Ease Direct-Care Health Workforce Shortage by Improving Jobs

Len Fishman testifies before Legislative committee

Gerontology Institute Director Len Fishman testifies Feb. 5 before the Legislature’s Joint Committee on Elder Affairs

Gerontology Institute Director Len Fishman offered a simple suggestion to state legislators wrestling with the critical shortage of low-paid direct-care health workers: Make the jobs more attractive.

Fishman told the Legislature’s Joint Committee on Elder Services that two things – more money and a legitimate career path to better jobs – were overwhelmingly the most important factors that would attract more workers to the field.

“How can we convince more people to accept and remain in jobs that are physically and emotionally demanding, provide poor benefits, low wages and offer virtually no opportunity for career advancement? When you ask the question honestly, it answers itself,” he told the legislators at a Feb. 5 hearing. Continue reading

Institute Talk: A Conversation With Vince Mor on Alzheimer’s Care and the State of Nursing Homes

Len Fishman and Vince Mor

Len Fishman, left, and Vince Mor

Vincent Mor is a leading academic expert on eldercare issues and a national authority on research related to nursing homes. The Brown University professor has been principal investigator in more than 40 grants funded by the National Institutes of Health that focus on the use of health services and the outcomes experienced by frail and chronically ill persons.

Mor and Susan Mitchell of Hebrew SeniorLife are leading an ambitious new collaborative research incubator for “pragmatic clinical trials” that test and evaluate interventions for Alzheimer’s disease and related dementias. Last month, they received a grant from the National Institute on Aging expected to total $53.4 million to fund that work over the next five years. It was one of the largest federal grants ever awarded for Alzheimer’s care.

Gerontology Institute Director Len Fishman recently spoke with Mor to talk about his new project and discuss the state of the struggling nursing home industry. The following is an edited version of their conversation. Continue reading

Gerontology Institute Research Team Completes Report on Healthy Aging in New Hampshire

Mass. Heatlhy Aging Team

The Healthy Aging team, left to right: Wendy Wang PhD, Bon Kim, Nina Silverstein PhD, Jay Lee PhD, Sae Hwang Han, Shiva Prisad, Frank Porell PhD, Haowei Wang, Beth Dugan PhD. Team members not in photo: Natalie Pitheckoff and Evan Chunga.

A research team from the University of Massachusetts Boston has delivered a comprehensive new report on the health of older people in New Hampshire, along with detailed profiles of 244 communities in their state.

The first-ever New Hampshire Healthy Aging Data Report was prepared by researchers at the McCormack Graduate School’s Gerontology Institute, led by associate professor Beth Dugan. The report, funded by the Tufts Health Plan Foundation, was released April 2 at a legislative breakfast at the New Hampshire statehouse.

“We are all aging,” said Dugan. “Identifying and understanding the gaps in healthy aging will allow communities to continue to adapt, improving quality of life for all New Hampshire residents.” Continue reading

Gerontology PhD Student Shiva Prasad Studies How to Create Ideal LGBT Online Senior Center

By Caitlin Connelly

Imagine an online LGBT senior center. What would that look like and how would it serve visitors?

These are questions on Shiva Prasad’s mind. The third-year gerontology PhD student at UMass Boston recently presented preliminary research findings on the subject at the LGBT Elders in an Ever Changing World conference in Salem, Mass.

Nearly 200 people attended the one-day conference held to discuss the needs and desires of older adults and caregivers who are lesbian, gay, bisexual, or transgender. Organizations helping put on the event included the LGBT Aging Project, North Shore Elder Services and the Over the Rainbow LGBT Coalition, Salem State University School of Social Work, Care Dimensions, and AARP Massachusetts. Continue reading

Institute Talk: A Conversation with Senior Housing Design Authority Victor Regnier

Victor Regnier is, perhaps, the nation’s leading authority on the design and development of senior housing with service across the LTSS continuum. A joint professor at USC’s School of Architecture and Leonard Davis School of Gerontology, Regnier is the only person to achieve fellowship status in both the American Institute of Architects and the Gerontological Society of America.

As a designer and practicing architect, he has provided consulting advice on more than 400 building projects in 38 states and several foreign countries. As an academic, he has written 10 books or monographs and directed more than 20 research projects. Regnier’s latest book, Housing Design for an Increasingly Older Population, was published in September 2018.

Gerontology Institute Director Len Fishman recently talked with Regnier about  northern European models of senior housing with supportive services and their influence on housing for older adults in the United States. The following is an edited version of their conversation.


Len FishmanLen Fishman:
Your view of housing and services for older adults has been deeply influenced by models from Northern Europe, especially Denmark, Sweden, Finland and the Netherlands. How did this happen?

 

Victor Regnier: I had been working on a research project with the head of geriatric medicine at UCLA in the late ‘80s, early ‘90s. I wanted to examine new housing models and had an upcoming sabbatical. He said I should go to northern Europe. He had been impressed by their attitudes and perspective on creating non-institutional circumstances for older people, especially older frail people. I ended up going to five countries. I asked to see the most non-institutional or residential housing for the frailest individuals and visited 100 buildings.

LF: You were coming from a country where, at that point, there was no assisted living to speak of and the idea of housing with supportive services hadn’t emerged yet. What were your impressions? Continue reading

News Flash: UMass Boston Gerontology Makes Headlines in 2018

By Taryn Hojlo

UMass Boston’s gerontology faculty and students produced exciting new research findings and achieved remarkable public service achievements in 2018. The news media took notice.

Associate professor Beth Dugan and her Gerontology Institute colleagues published the 2018 edition of the Massachusetts Healthy Aging Data Report in December.The comprehensive report examined a vast array of health indicators on a community-by-community basis, creating an essential resource for policymakers and local leaders to better serve Massachusetts seniors. News coverage by WBUR in Boston looked at seven key takeaways from the report. The Boston Globe dove into the healthy aging data and produced a front-page story examining the impact of depression among elders. Dugan and her team ended the year at work on a similar report profiling the health status of seniors in New Hampshire. Continue reading

New Reports Explore Global Expansion of Foreign-Born LTSS Workforce

By Natasha S. Bryant

Foreign-born nurses and personal care assistants make up an increasingly significant percentage of workers in the field of long-term services and supports (LTSS) around the world, according to new research from the Global Ageing Network and the LeadingAge LTSS Center @UMass Boston.

These immigrant/migrant workers, who come primarily from developing countries, bring myriad benefits to the LTSS organizations that employ them and the care recipients they serve, according to findings from a 2018 study by the LTSS Center.

Three new reports explore those benefits, in addition to identifying challenges associated with hiring foreign-born LTSS workers, exploring strategies to address those challenges, and providing an overview of global migration patterns and policies. Continue reading