Recently in Aging Category

Money Follows the Person is a cornerstone of the federal government's effort to move Medicaid beneficiaries from nursing homes into the community. But a new study commissioned by Medicaid itself shows how difficult those transitions can be. In the 30 states that have been testing the program over the past three years, only 8,500 people have used MFP to return to their communities.

That's just a tiny fraction of the nearly 1 million people who are eligible, and only about one-quarter of the 35,000 the participating states initially hoped to move. And of the 8,500 who have enrolled in the program, one-third lived in just one state--Texas. By contrast, California has signed up only 186 people since MFP began, and New York only 165, according to the study done by Mathematica Policy Research Inc.  

The concept makes great sense. Move people out of nursing homes, where most don't want to live and where the costs to Medicaid are extremely high, and help them get back to their homes or other community residences. Unfortunately, states have struggled to turn this concept into reality.     

Most troubling for the frail elderly, it turns out that while three out of every four people eligible for the program are age 65 or older, only one-quarter of participants are seniors. Money Follows the Person has been far more successful for younger adults with physical and developmental disabilities than for the frail elderly. 

Mathematica identified several reasons why so few frail elders participate. The biggest may be that they have no home to return to. In the original design, MFP participants had to have been nursing home residents for at least six months. Because many elderly people sold their homes or given up their apartments when they moved into a nursing facility, it was not possible for them to return to their communities. In addition, in many states participants were not allowed to move into assisted living facilities.

Just as troubling, many states don't have enough subsidized rental housing or funding for necessary home and community based services, such as personal aides or transportation. Unfortunately, the growing wave of state budget cuts is likely to make that problem even worse.  

Still, there is some good news. The 2010 health reform law (the Affordable Care Act) allows people to use the program after only 90 days in a nursing facility, instead of six months. That will make another 112,000 people eligible to participate. The health law also promised an additional $1.75 billion in funding, gives states new flexibility in providing community-based services, and continued MFP experiment until 2014.

Long-term care experts and top government officials have had high hopes for Money Follows the Person. They see it as key to helping both the frail elderly and younger people with disabilities receive the supports and services they need at home and not in nursing facilities. But as the Mathematica study suggests, MFP has so far fallen far short of those expectations.   

President Obama's 2012 budget is the latest indication of the growing pressures government-provided aging services will face in coming years.  And as tight as his budget is, spending on assistance for poor and frail seniors is likely to end up much lower than Obama proposed. With congressional Republicans vowing to cut $100 billion from domestic spending over the remaining seven months of the current budget year, and even more from Obama's proposals for next year, the future for federal funding for aging services is grim.

There is some good news for seniors in Obama's fiscal plan. For instance, he has asked for a modest increase in home and community-based supportive services. However, the budgets for many other key programs, including Meals on Wheels and other nutrition programs, would be frozen. Respite care remains grossly underfunded, even though it received a modest budget increase.

On the other hand, Obama proposed cutting the major subsidized senior housing program (called Section 202) by $68 million from the 2010 budget and low-income energy assistance for those living at home by $2.5 billion. The community services block grant program would be funded at $350 million, just half its 2010 level. These are grants for local non-profits that provide housing, nutrition, and other supportive services for very low-income people, including seniors. Overall, Obama would cut the Administration on Aging budget by almost $181 million, or about 8 percent, from 2010 levels.

Keep in mind, though, that once Obama and Congress agree to a final compromise budget (probably sometime next fall) cuts will be deeper than Obama has proposed. Also remember that these cuts so far largely exclude changes in Medicare and Medicaid, which are exempt from the annual budget process but face enormous financial and political pressures of their own. 

Worse, as federal budget pressures grow, these cuts are likely to be only one step in a long and painful process of scaling back government assistance for the elderly. As I have suggested in the past, in such an environment, it will be critically important for state and local governments, senior service providers, non-profits, and advocacy groups to rethink their own future roles in caing for our parents.    

President Obama's 2012 budget is the latest indication of the growing pressures government-provided aging services will face in coming years.  And as tight as his budget is, spending on assistance for poor and frail seniors is likely to end up much lower than Obama proposed. With congressional Republicans vowing to cut $100 billion from domestic spending over the remaining seven months of the current budget year, and even more from Obama's proposals for next year, the future for federal funding for aging services is grim.

There is some good news for seniors in Obama's fiscal plan. For instance, he has asked for a modest increase in home and community-based supportive services. However, the budgets for many other key programs, including Meals on Wheels and other nutrition programs, would be frozen. Respite care remains grossly underfunded, even though it received a modest budget increase.

On the other hand, Obama proposed cutting the major subsidized senior housing program (called Section 202) by $68 million from the 2010 budget and low-income energy assistance for those living at home by $2.5 billion. The community services block grant program would be funded at $350 million, just half its 2010 level. These are grants for local non-profits that provide housing, nutrition, and other supportive services for very low-income people, including seniors. Overall, Obama would cut the Administration on Aging budget by almost $181 million, or about 8 percent, from 2010 levels.

Keep in mind, though, that once Obama and Congress agree to a final compromise budget (probably sometime next fall) cuts will be deeper than Obama has proposed. Also remember that these cuts so far largely exclude changes in Medicare and Medicaid, which are exempt from the annual budget process but face enormous financial and political pressures of their own. 

Worse, as federal budget pressures grow, these cuts are likely to be only one step in a long and painful process of scaling back government assistance for the elderly. As I have suggested in the past, in such an environment, it will be critically important for state and local governments, senior service providers, non-profits, and advocacy groups to rethink their own future roles in caing for our parents.    

It is an article of faith among many in the elder and disability advocacy communities that aging in place is always the best alternative for someone who needs personal care. I don't believe it, and I recently heard an important panel discussion that confirmed that view.

The panel, sponsored by Washington Grantmakers, was especially interesting because the participants were all supporters of community caregiving. But they agreed that, without a strong infrastructure of family, community, and public support, it is not always possible for people to live at home. Indeed, it can often be lonely and even dangerous.

University of Florida professor Stephen Golant, who has written extensively on housing and care alternatives for seniors, reported that his research finds six major challenges to the frail elderly living at home. They include affordability, physical deficiencies of homes, lack of social supports, neighborhood changes, difficulties accessing community assistance (especially in both inner cities and cul de sac suburbs) and vulnerabilities of old age including greater risks of accidents, poorly trained family and paid caregivers, and even abuse.

Golant concluded that those most at risk staying at home are low-income, very frail, poorly educated women who are 85 or older and either living alone or with a frail spouse. This seems obvious, but these are the very people who have the fewest alternatives. For most, high-quality assisted living or even independent living are far beyond their financial means. Golant says those at most risk are not the very poor but the nearly one-third of seniors he calls "tweeners," who do not qualify for public programs but can't afford to private pay for housing with supportive services. 

Golant suggests that addressing these issues requires "changing the aging in place dialogue." Doing this will require society and families to recognize that living at home is not always the answer, and that focusing on group care may make more sense. This can mean thinking about senior villages and other naturally occuring retirement communities where care can be better coordinated and delivered much more efficiently. 

Charles Smith of the Montgomery County (MD) department of aging and disability services said that it is increasingly difficult for government to deliver the services necessary to support people aging at home. Budgets are being slashed and physical distances make it tougher to provide assistance, especially in the suburbs. Smith said that in sprawling Montgomery County, it costs five times at much to deliver a meal to a suburban house as it does to buy it. Transportation services, the single most common need for those at home, face the same difficult combination of smaller budgets and greater distances.

"We are creating expectations that you should age in place,"  Smith says, but government doesn't have the resources necessary to meet those expectations. 

Rev. Joseph Williams, executive director of Emmaus Services for the Aging, a private non-profit in the District of Columbia, added that grassroots community support is essential for people to age at home. "It can't all happpen in the department of aging," he said.   

None of this means those of us caring for our parents should not do all we can to help them stay at home, if it is appropriate. It does mean that just saying the words won't make it happen. Rather, it will require communities and families to work together to back up the sentiment with real resources, including both time and money. It is a fantasy to believe that assistance will come entirely from government, which will be increasingly strapped for funds in coming years. It will also require us all to recognize that some of our parents will be far better off in a congregant care setting.        

The Stanford University Center on Longevity has just released a trove of information on the health, living arrangements, and demographics of an aging America. The study, "New Realities of an Older America" tells the story of an independent, remarkably healthy population, but one that will present unique challenges as it lives well into its 80s and, eventually, reaches frail old age.

For example, authors Adele Hayutin, Miranda Dietz, and Lillian Mitchell paint of picture of serniors increasingly living alone and in the suburbs--housing patterns that will make caregiving especially difficult.These seniors want to age in place, but providing assistance to a population that may become trapped in their own subdivisions will be a huge challenge. Caregivers battling traffic. Elders no longer able to drive to the doctor or the grocery store, or to even visit with friends. These are not pleasant images.

Yet, the current population of elders has made their opinion clear. In 2005, even among those with functional limitations, 85 percent lived at home or with a relative. Just 10 percent lived in skilled nursing facilities and only five percent lived in assisted living facilities. Even among all those 85 or older, three-quarters lived in traditional housing. 

The great challenge will be finding new ways to deliver care to this population--a challenge that will be compounded by the growing prevalence of dementia among those 85 or older. While this study finds that disability rates among the elderly are falling (a conclusion that is disputed by other research), it also estimates that the population with dementia will more than double, to nearly 11.4 million, by mid-century. 

There is lots more to chew over in this paper. Take a look at it.