Just in Time?

We know we promised you a series on operational/organizational effectiveness, accuracy/consistency/efficiency (ACE), and going beyond compliance, but something happened this week that reminded us why doing these things is so important.  We will get back to our series with our next entry.

My brother’s wife is now somewhat frantically trying to arrange care for her Aunt K.  Aunt K lives in Indiana – my brother and sister-in-law just moved to Florida.  Aunt K has been in a rehabilitation facility, paying out of pocket because her Medicare Advantage plan said that she no longer qualified for therapy and the facility says they have to discharge her.  Aunt K has suffered some cognitive decline while in the facility and the rehab staff are referring her to assisted living, saying that Aunt K won’t be safe going home alone which is how she lived until her recent surgery.

My brother expressed to me “Our top priority is Aunt K’s safety. We want her to be 100% safe.”  I suggested that if she doesn’t want to be in a facility, perhaps they might want to listen to what she wanted and work to find a way to balance that with the safety considerations.  I was shocked when he said “that might be fine for now, but at what point, does what shewants just go out the window?”  Suddenly, Aunt K is no longer a grown woman, retired teacher, who just a few weeks ago was independent with a rich and active social life. So often in the midst of a crisis, the person ceases to be a person and becomes a problem or a situation that has to be handled. Now everybody just wants to “put” her somewhere where she will be safe, and they want it to happen quickly.

Aunt K has some money in the bank and income from a pension.  She owns her own home free and clear.  She’s not in immediate danger of requiring Medicaid assistance, so in theory at least, the state has no interest in Aunt K’s outcome. But is that really true?  Why should state systems care about people like Aunt K? Let’s break this down (in a somewhat oversimplified fashion):

  • If my sister-in-law really wanted to ensure only that Aunt K was “100% safe” one option would be to admit her to a nursing facility as a private pay resident.While the appeal has been pending, she’s been paying $372/day.  Assuming no rate changes, $100,000 would buy her about 268 days, about nine months in the nursing facility.
  • One can’t guarantee 100% safety in an assisted living community, but there is staff presence 24/7. If we assume the Genworth average cost of assisted living (~$3900/month), $100,000 would buy about 25 months of care.
  • If Aunt K would prefer to stay at home and can do so in an acceptably safe fashion with a few hours a day of personal assistance and support from her active network of friends, that care would cost around $100/day and $100,000 dollars will last about a thousand days, or 3 years.

Medicaid is the largest payer of LTSS in the country, and LTSS is becoming a larger and larger portion of those expenditures as lifespans increase. It is in the state’s best interest to help people access good information about what’s available to them and how they can use their personal resources in the way that best balances what is important to them with what is important for them.  A person in this situation with $100,000 available to pay for care potentially delays running out of funds and becoming Medicaid eligible for up to a year.  Even better, that person and their circle of support retains the ability to manage their own affairs and make choices that are congruent with their goals and preferences.

Long term care is not easy for people to navigate and way too often, they are trying to do so while they are in a crisis.  Most people say that they would prefer to remain in their own home, but don’t always know what they need to do to identify and set up services they might need. When there is no access to unbiased, person-centered options counseling, the pathway to LTSS becomes rather narrow. For decades, that pathway led straight to nursing facilities. Now the path is shifting to assisted living. That sector is seeing burgeoning demand for their services, but it is unclear if that is reflective of overall demand or just that AL is the only pathway people think they have.  Assisted living operators work hard to make their services a very visible option to individuals and their families. If people had equal access to information about the range of service options available to them, they might make different choices,

No Wrong Door systems are intended to promote access to unbiased information and resources that people need to make their own best decisions regarding LTSS.  No Wrong Door systems require investment on the part of the state and federal governments, for technology, marketing and outreach, training, and funding high quality options counseling for people, regardless of payer.  To date, it’s been very difficult to quantify the benefits of this investment because it’s hard to measure.  People like Aunt K do not show up in a lot of the data decision makers use until they are eligible for Medicaid, although the consequences for Medicaid are great, if there is no No Wrong Door system of access to help people like Aunt K.

ACL recently funded ten states for the purpose of measuring the return on investment in the establishment of No Wrong Door systems.  This is an exciting opportunity for both ACL and states to start to learn what should be measured, what systems need to be in place to capture the data related to those measures, and to validate what types of processes or interventions are most likely to lead to desired outcomes, one of which is mostly certainly delaying the need to access publicly funded services.  It might be a little late for Aunt K, but for the millions coming behind her, it might be just in time.

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