This is an exciting month for AARP’s Public Policy Institute. We’re set to release our third Long-Term Services and Supports (LTSS) State Scorecard Report on June 14, and this powerful tool is far more interactive and comprehensive than the 2011 and 2014 installments.
A lot has changed since 2011 when we first partnered with the Commonwealth Fund and the SCAN Foundation to conceive of the idea for a scorecard that would measure long-term services and supports for older adults as well as people with physical disabilities and family caregivers on a state-by-state basis.
At the time, I concluded in an article that, based on the report’s findings, even the best performing states had a long way to go to create a high-performing system of long-term services and supports. Certainly many states have made progress since then, and no doubt the 2017 Scorecard will continue to highlight that progress. But there’s also little doubt that the Scorecard will uncover a list of shortcomings and areas for improvement. That’s what the Scorecard was all about in its 2011 and 2014 iterations, and that’s what the 2017 Scorecard promises to illuminate.
Of course, the actual Scorecard release is not the most exciting part. What’s truly exciting is the impact it can have after its release. We’re encouraged by how policymakers and advocates viewed the 2014 Scorecard for what it was: a call to action. Many used the information in the report as a tool to make positive change in their states. With Americans living longer and LTSS demand continually growing, our call to action must be louder and more pronounced than ever.
Thanks to the efforts of all involved in compiling and organizing data for the 2017 Scorecard, I’m proud to say that—no question—it tops the 2014 installment in value as a key tool in the field. So, what’s the same and what’s different this time around? Like the first two installments, the 2017 Scorecard examines state performance across five key categories, or dimensions:
- Affordability and access
- Choice of setting and provider
- Quality of life and quality of care
- Support for family caregivers
- Effective transitions
But this year, we’ve placed an emphasis more than ever on how the results are presented. The information on our website will be truly interactive and engaging than in years past. (The new version of the site, http://www.longtermscorecard.org/, will appear June 14.) Users can easily customize data to suit their needs, no matter what role they play in LTSS and where they’re located. While our accompanying report remains an invaluable source of information, the interactive website has become the true centerpiece of the offering.
Other new additions of which we’re extremely proud: Visitors to the site will have access to videos, called Impact Stories, that show how improving on the Scorecard can impact the lives of real people. Users can also download Promising Practices such as this one as well as Emerging Innovations that states can use as they work to improve the lives of older adults, those with physical disabilities, and family caregivers. Better still, new and groundbreaking content will not stop with the June 14 Scorecard release. We’ll continue to bring you more Promising Practices and Emerging Innovations, as well as releases in our Impact Story video series, throughout the year.
My colleague Jean Accius, vice president for Independent Living/Long-term Services and Supports, who was instrumental in spearheading these changes, summed up their value succinctly when he said, “These concrete tools and innovative practices will help states improve their performance and, ultimately, the lives and well-being of others.” As for the addition of the Impact Story videos this year, he added that they “literally complete the picture—putting a face to the diversity of individuals whom the Scorecard examines.”
Will this year’s Scorecard illuminate shortcomings and challenges in LTSS as it has in the past? Absolutely. (Here’s a teaser: we’ve got a long way to go.) But I’m extremely excited that we’ll also shine a light on a path forward for all caregiving stakeholders.
Susan Reinhard is a senior vice president at AARP, directing its Public Policy Institute, the focal point for AARP’s public policy research and analysis. She also serves as the chief strategist for the Center to Champion Nursing in America, a resource center to ensure the nation has the nurses it needs.
Photo courtesy of Sullivan County New Hampshire ServiceLink
Most of us will need long-term services and supports (LTSS), either for ourselves or our family members. However, most of us do not know about our options and how to pay for these services. That is why the LTSS State Scorecard—created by the AARP Public Policy Institute and funded by The Scan Foundation and The Commonwealth Fund—ranks states on their Aging and Disability Resource Centers. These Centers are an important feature of a high performing LTSS system.
Aging and Disability Resource Centers can serve as the gateway for helping individuals and their families find and access LTSS, including light housekeeping, transportation, and respite care to give family caregivers a break, just to name a few. States have these “one-stop-shopping” models to help people receive public and private services regardless of which organization they contact. Therefore, they are sometimes called “no wrong door.” If people contact an organization within this system, they can be connected with information, referrals, and supports, resulting in “no wrong door” to services irrespective of their age, income, or disability. Area Agencies on Aging, Centers for Independent Living, and state agencies such as Medicaid agencies and state units on aging work together to make up this no wrong door system. While the states have these centers, the operations and functions of each center vary greatly, which is why the Scorecard ranks them.
Although the previous two Scorecards included an indicator on these Centers, the upcoming third edition contains an updated indicator to reflect published guidance on key elements of no wrong door systems from the federal government. AARP, in collaboration with the U.S. Administration for Community Living and The Lewin Group, collected information for this indicator from a survey of state administrators. Then, they followed up by interviewing administrators from states that had scored well or demonstrated innovation to produce a newly released promising practices and toolkit paper on person- and family-centered practices.
This first in a series of promising practices and toolkit papers provides concrete examples of how six states—Connecticut, Michigan, New Hampshire, Virginia, Washington, and Wisconsin—plus the District of Columbia promote person- and family-centered practices in their no wrong door systems. These Centers are using an interactive process directed by individuals and family members to support decision making. They also help to develop a plan of support that reflects an individual’s and family’s strengths, preferences, needs, and values. It affirms the core principle that each person is the expert in his or her own life rather than simply plugging people into programs based on their eligibility.
The promising practices are:
- Ensuring leadership support for these practices (with examples from the District of Columbia’s mayor-led cross-population task force, Michigan’s broad support for change, and Virginia’s state legislation on this practice);
- Creating standards for these practices (with examples from Washington’s statewide standards of practice, Virginia’s co-employment model between aging and disability organizations, the District of Columbia’s intake to better listen to people and families, and Wisconsin’s follow-up);
- Training the “no wrong door” workforce (with examples from New Hampshire’s training and certification, the District of Columbia’s training for all, New Hampshire’s peer support model, Virginia’s person-centered advocates, and Connecticut’s essay exam); and
- Helping people maximize use of private resources (with an example from Wisconsin that has been a leader in serving private pay clients).
This promising practices and toolkit paper includes resources and contacts for state and federal administrators, providers, and advocates to learn about—and even replicate—these practices. This paper also provides a checklist of what is needed to move toward more person- and family-centered practices.
NOTE: The third edition of the Scorecard will be released soon … on June 14th. Promising practices and toolkits are a new feature of the Scorecard project. More papers—such as promising practices in preventing long-term nursing home stays—will be forthcoming. For the new Scorecard, the promising practices and toolkit papers, and more, please go to the LTSS State Scorecard interactive website at www.longtermscorecard.org.
Wendy Fox-Grage is a Senior Strategic Policy Advisor for the AARP Public Policy Institute. She works on state long-term services and supports issues, including Medicaid and home- and community-based services.
Courtesy of Greg Kahn
An important AARP study shows that an overwhelming majority of people would like to remain in their homes and communities for as long as possible. Personal care services, such as assistance with bathing, eating, and dressing, are critically important to helping older adults and people with disabilities of all ages live independently and avoid costly nursing facility placements.
Medicaid plays a critical role in providing this support. It is the largest payer of long-term services and supports (LTSS), including home and community-based services (HCBS) like personal care. While there has been an increase in funding for HCBS over the years, institutional care still accounts for 59 percent of Medicaid LTSS spending for older adults and people with physical disabilities. Nevertheless, through such programs as Community First Choice (CFC), the trend has continued toward greater availability of HCBS across all populations. And with HCBS being both cost effective and a means of enabling greater independence, it’s a trend that needs to continue.
Yet the recently released American Health Care Act (AHCA), the proposed legislation to replace the Affordable Care Act (ACA), puts the future of CFC in jeopardy. With a provision that repeals the program, if enacted the AHCA could disrupt services for older adults and people with disabilities covered through CFC.
How Does Community First Choice Work?
Community First Choice is a provision of the ACA that offers additional federal funding to states to provide personal care and assist individuals with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks. States may also leverage CFC funds to cover transition services to help people leave nursing facilities and return to their homes and communities.
The CFC option empowers older adults and people with disabilities through its emphasis on self-direction. Unlike some other types of Medicaid programs, individuals enrolled in CFC and their families are guaranteed the right to self-direct their services and oversee the people that provide their personal care.
Community First Choice and the States
As of 2016, eight states offer this option in their respective Medicaid programs. An analysis of just four of the states (California, Oregon, Washington, and Montana) showed that the program has served more than 500,000 people since its inception. States that offer CFC must offer the program to all populations, and the analysis found that 40 percent of CFC enrollees were adults 65+ and 55 percent were people with disabilities under age 65.
While a more recent enrollment count is not available, the current total is likely much higher today due to the increased number of states offering this option.
The Financial Impact of Personal Care and Community First Choice
Numerous studies and analyses reveal that providing people LTSS in their homes and communities is generally less expensive than doing so in a nursing facility. A 2016 analysis from Genworth, for example, shows the median annual cost for a private room in a nursing facility exceeds $92,000, while the cost for 30 hours of personal care is $32,000. AARP research on Medicaid-funded HCBS also found that Medicaid pays nearly three times as much for each person served in institutional settings as it does for each person served in the community. Additional studies found annual cost savings of $11,912 per older adult who transitioned from a nursing facility back to the community through Medicaid’s Money Follows the Person Rebalancing Demonstration. In short, redirecting more resources to provide Medicaid HCBS is cost-effective compared with nursing facilities.
Given the lower expenses associated with personal care and the full spectrum of home and community-based services, increasing the portion of Medicaid LTSS dollars spent on these services could yield significant long-term cost-savings to states and the federal government. We are already moving in that direction. The most recent data on Medicaid LTSS expenditures shows that 53.1% of all Medicaid LTSS dollars go towards HCBS for all populations, up from 51.3% the previous year. Since its inception, Community First Choice has become an important tool to help states continue balancing Medicaid LTSS toward HCBS.
The Future of Community First Choice
The CFC option is an important piece of the puzzle for helping states provide services that enable people to live independently in their homes and communities. It also has the potential to help states and the federal government improve and expand access to LTSS while containing costs.
Including a repeal of Community First Choice through the AHCA, therefore, could hinder the progress made toward balancing long-term services and supports and limit access to home and community-based services for the growing number of states that have embraced the program. Given CFC’s current role in expanding HCBS, and the potential for cost savings to Medicaid through increasing access to HCBS more broadly, it would be wise for policymakers to preserve CFC and allowing state governments to continue offering HCBS through this mechanism.
Brendan Flinn is a policy research senior analyst for the AARP Public Policy Institute. He works on Medicaid, long-term services and supports, and family caregiving issues.