As state ages, governor presents a plan for expanding home care

Gov. Dannel P. Malloy this morning will unveil a plan to dramatically shift the way seniors and people with disabilities receive services by increasing the availability of home care while offering funds for the nursing home industry to eliminate beds and change their business models, according to documents obtained by The Mirror.

The effort has significant implications for the state's growing population of seniors and for Connecticut's finances. More than 10 percent of the state's budget is now spent on long-term care paid for through Medicaid, and the number of people getting the services is expected to rise by more than 20 percent by 2025.

The plan is the product of more than a year of work by state officials, consumers, advocates, and the home care and nursing home industries, and builds on more than a decade of policy goals. It's intended to address several major barriers that policymakers say make it significantly harder to get care at home than to get a bed in a nursing home. Those include a fragmented system of getting coverage for home care, workforce shortages, the lack of accessible and affordable housing and transportation, and the discharge of patients from hospitals to nursing homes, where they often stay.

nursing facilities chart

Connecticut has one of the highest rates of seniors in nursing homes in the country, and more of them are considered to have lower levels of needs than in other states, according to the plan. Research suggests that most people would prefer to live in their own homes rather than go to nursing homes when they need long-term care.

Home-based care also tends to be less costly. Although 24-hour care and other intensive services can be more expensive to deliver to patients living in the community, workforce costs are lower for home care workers, and people at home often do more for themselves than they would in a nursing home and rely more on family and community supports.

But for the state to accommodate a massive shift to home care, those community supports need to be available and reliable. The plan Malloy will present, called the Strategic Plan to Rebalance Long-Term Services and Supports, will include a town-by-town analysis of the projected demand for long-term care services, according to sources briefed on the governor's proposal.

$2.8 billion on long-term care

Some of the changes will be funded by $72.8 million from the federal government through a grant program for states making structural changes in long-term care. Through 2015, Connecticut will receive additional federal reimbursement for Medicaid money spent on non-institutional care, and those funds must be spent on new or expanded home- and community-based long-term care services.

To qualify for the funds, at least half of the state's spending on long-term care must go toward non-institutional care by Sept. 30, 2015. Already, the majority of Connecticut's long-term care clients are served at home or in community-based settings, but their care represents less than half of the state's total Medicaid long-term care spending.

Long-term care is by far the most costly piece of the state's Medicaid program; in the previous fiscal year, the state spent nearly $2.8 billion on long-term care in Medicaid. Many people who would not have qualified financially for Medicaid medical coverage come to rely on the program to cover nursing home or other long-term care costs.

Lawmakers included funds in this fiscal year's budget for nursing homes that want to diversify their business plans. The strategic plan describes possible changes for nursing homes that include physical changes to make them more home-like, and developing the ability to provide home-based services such as therapies, home health, delivered meals, hospice, respite and adult day care. The state is expected to issue a request for proposals from nursing homes in the coming weeks, with $13 million in operating and bond funds available.

Why is it easier to get nursing home care?

If barriers that prevent people from choosing where to get care are removed, the plan projects, the state could have a surplus of 5,000 nursing home beds -- nearly one of every five in the state.

The plan includes a number of recommendations aimed at removing those barriers.

For years, advocates have argued that one major problem is that anyone who meets the physical need and income requirements can get Medicaid coverage for nursing home care, while getting home care requires qualifying for one of several specific programs, many of which have waiting lists. The plan doesn't endorse changing that -- state officials have raised concerns that it could increase state costs -- but calls for exploring ways to reduce the fragmentation of the system, including broader Medicaid home care coverage.

The plan includes the development of a website as part of a way to make sure people have better access to information about long-term care options.

It also calls for redesigning respite for unpaid caregivers, who make up the backbone of the long-term care system and who often face high levels of stress and potential burnout. Recommendations will come from a focus group of caregivers; one option mentioned in the plan is to give caregivers options for respite that include having the person they're caring for stay briefly in a nursing home or getting short-term in-home support.

The lack of available home-care workers is considered another major barrier to expanding home care. The field often has high rates of turnover, and workers typically receive lower wages than nursing home workers, with no benefits. The plan recommends creating a statewide list of workforce needs and promising initiatives; promoting retraining programs for nursing home workers who want to provide home care; partnering with workforce investment boards; collaborating with community colleges to design curriculum; increasing the ability to hire family members as paid caregivers; and creating a set of core competencies for home care workers that emphasize communication and relational skills, but that wouldn't infringe on the rights of the people getting services to train their workers and direct their own care.

Training for home care workers has been controversial; many people with disabilities who have home care workers prefer to do their own training, and they say centralized training could interfere with the individualized nature of home care.

To address the need for housing and transportation, the plan calls for increasing coordination between state housing and Medicaid officials and exploring the use of Zipcar-like rental services, school buses or other forms of transportation that could be covered through Medicaid. It also recommends using bonding money for affordable housing and allowing nursing homes to modernize by having more home-like environments and more common space.

State officials have already been working to move people out of nursing homes as part of a program known as Money Follows the Person. But so far, fewer people have moved out of nursing homes than had been projected or counted on in the current fiscal year's budget.

Related:

"Right-sizing" nursing homes

Demand for home care workers soaring, but will there be enough takers?

Caring, long term: A way of life for 1 in 8 Connecticut residents

As baby-boomers hit 65, state told to prepare for "silver tsunami"

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