Medicaid savings through management of long term care expenses

Special to the Business Times from Mesa County

With the aging of baby boomers, the demand for long term care programs, and the challenge to fund those programs, will continue to grow requiring creative and effective methods of delivering services in a cost effective way, to those in need. Mesa County, Colorado, implemented a project to prevent or delay the need for both nursing home care and Medicaid eligibility. 

            While many seniors retire with adequate income for their daily needs, should a medical need arise that isn’t covered by Medicare, such as in-home services that are considered ‘long term care’, they find themselves in a situation where they don’t have adequate funds to pay for the needed services. Yet because they have adequate income for their daily needs, they often aren’t eligible for Medicaid.

            When this happens, the elderly person often continues living independently, as best as they can, without the in-home care they need, until they finally reach a point where they are so fragile they must go into a nursing home. Since Medicare doesn’t cover nursing home care beyond 100 days, or any other long term care services, the senior must pay the full cost for those services.  At a rate of over $60,000 per year for nursing home care, it doesn’t take long until the individual has no resources left and ultimately becomes Medicaid eligible. This is a significant cost to tax payers, and pushes individuals into nursing homes long before necessary.

            Additionally, low income seniors who do qualify for Medicaid (based on finances), don’t always qualify for the home-based services (based on functional ability/medical need). This is because an individual must meet the same level of functional ability/medical need to receive home-based services as they do to receive nursing home care, in order to receive Medicaid funding.

            In Colorado, some of the largest Medicaid expenditures in the state are for long-term care. Approximately two-thirds of Medicaid dollars provide services to only one-third of all Medicaid clients, those receiving long term care. This continues to drive up the Medicaid budget.

            Mesa County, Colorado implemented a community partnership, Home Connections, to provide “tiered benefits” to frail and elderly clients who were moving towards the need for long-term care. The goal of this project was to prevent or delay the need for both nursing home care and Medicaid eligibility. 

            Partners involved in this pilot included, the Department of Human Services, Area Agency on Aging, local physicians, hospitals and other health care providers, non-profit agencies, and home repair and maintenance businesses, to name a few.  Each of the partners offer in-kind services or contribute money into a pool for purchasing services.  There are currently 36 partners/providers that serve the Home Connections participants.

            There are no financial eligibility requirements, but clients are screened as to need and lack of family or other supports.  All clients are expected to contribute something toward the cost of services they received, and all of them were willing and happy to do so.

            Home Connections serves up to 100 clients per year and the majority of the clients are female. The typical services provided include Homemaker services (Light Housekeeping), Lifeline (Electronic Monitoring), E-Pill Dispenser, laundry services and a free pass for the Life Center at the local hospital.  Additionally, all clients receive case management to better coordinate needed services.

            Let’s use Helen as an example of how Home Connections works. Helen, 76 years old, has been receiving light housekeeping services and electronic monitoring services in her home since March 2009. During a home visit, Helen’s case manager noticed she needed quite a bit of help in the home, but due to her limited income she could not afford to pay for any more help that she was already receiving. After consulting with the Home Connections Collaborative Team, which is made up of community partners that work with seniors and adults with disabilities, a service plan was developed for Helen.

            A member of the Collaborative Team is an Occupational Therapist and offered to provide a free OT evaluation for Helen.  The evaluation revealed that Helen needed some bathroom modifications which included a bath stool, grab bars and a hand held shower.  Helen also needed her front steps repaired and a ramp built in the back of her home so that she could easily and safely access her home.  Supplies were ordered at a discount through Grand Mesa Medical Supply (a member of the Collaborative Team) using funds through the local ARCH (Adult Resources for Care and Help) Program.  The Handyman Project, part of our local RSVP Program (Retired Senior Volunteer Program), installed the equipment in the bathroom, repaired the front steps and built the ramp that was needed in the back of the home. Had these services not been readily available, Helen would likely have been one of the many elderly who experience a serious fall. These types of falls often result in hospitalization and ultimately nursing home care.

            In Mesa County, the average cost per month per client for Medicaid funded nursing home care is $6,650.  With the Home Connections program, the average cost per month per client less than $58. Keeping just one client out of nursing home care saves thousands of dollars annually while keeping people off of Medicaid and delaying the need for nursing home care.