Faced with burgeoning populations of elderly citizens dealing with the dementia and behavioral disturbances characteristic of Alzheimer’s disease, state departments of health responsible for dispersing Medicare and Medicaid funds are shopping for better, and cheaper, ways to care for the disabled and elderly in their communities.
Several states now agree with many patients and their advocates that not only are home- and community-based services preferable to nursing homes, but they can also save the state money as well.
"People vastly prefer alternatives to nursing home care," Larry Polivka, Ph.D., stated at the 10th annual National Alzheimer’s Disease Education Conference, sponsored by the Alzheimer’s Association in Chicago in July. "And alternatives, like home- and community-based residential programs, if properly funded and administered, are cost effective. All of the research done since 1992 leads to this conclusion." Polivka, a sociologist, is now the director of the University of South Florida’s Center on Aging. Prior to his joining the university, he was Florida’s assistant secretary of health for aging and adult services.
The problem, Polivka told Psychiatric News, is that about 80 percent, of all public funds spent on patients with dementia are spent on nursing homes, while only 35 percent to 40 percent of total expenditures for developmentally disabled persons are spent on institutional care. That is, "In most states, we do a much better job of taking care of developmentally disabled patients in home and community programs than we do in taking care of dementia patients, including those with Alzheimer’s disease," he explained.
According to Polivka, at most only 12 states have made substantial progress toward balancing their overall long-term-care systems between nursing homes and home- and community-based systems.
Ideally, according to Polivka, a state should find a balance in which 45 percent to 65 percent of funds are spent on institutional care, and 35 percent to 55 percent are spent on home- and community-based care. Florida officials, he noted, are working to achieve a 60 percent/40 percent balance after several years of crisis in the funding stream as more and more of the funds were "eaten up" by what Polivka characterized as inappropriate institutional care.
Reforming a state system to work toward that balance takes time, said Polivka. "On average, a state needs to devote five to 10 years in order to achieve that balance," he explained. "You have to develop systems and methods of shifting the state’s resources, and you cannot neglect home- and community-based programs while you are working on the institutional realignment."
It is also important, Polivka told Psychiatric News, to develop rigorous management systems for home- and community-based systems and aging services networks, including managed long-term-care systems. States must also work to promote and expand private-pay options within the new system.
"At the same time," Polivka concluded, "you must constantly work toward improving quality of care and quality of life for patients who are in long-term-care facilities." A major component of ensuring high-quality care in the changing nursing home environment, Polivka said, is addressing workforce issues, including compensation, working conditions, and training.
Several states are ahead of Florida in successfully reforming their long-term-care systems, including California, Arizona, Oregon, and Michigan.
Since 1986 Michigan has been working to reform the way it cares for the disabled and elderly, paying particular attention to patients with Alzheimer’s disease.
"Alzheimer’s disease is a specific line item in our $8.7 billion budget," said James K. Haveman, Jr., director of Michigan’s department of community health. "And the only reason it is a specific part is because of dedicated patients and advocates who worked hard to make it so. Three years ago a patient with Alzheimer’s disease appeared before the [state legislature’s] appropriations committee, telling the members that it was extremely important for her to testify because she probably would not be capable of doing so the following year." That, Haveman said, got legislators’ attention, and ever since, specific funds have been earmarked for Alzheimer’s care.
Michigan found that in its quest to reform the way it cared for its rapidly increasing disabled and elderly population, it would literally have to scrap its current system and build a new system from the ground up.
In 1991, when Haveman began as director of the state’s mental health department, the state had an unwieldy five geographic divisions, and services and care were splintered.
"After an intensive review, Governor John Engler in 1996 gave me 30 days to completely redesign health care in the state," Haveman told Psychiatric News. He responded by doing something drastic. He bucked the trend toward decentralized systems and brought the five health divisions back into one department of community health. That required some serious streamlining, paring down 13,000 employees to about 6,000 today.
The result was a single, much larger revenue stream that could be more specifically earmarked and dedicated toward improving long-term care. Haveman also closed 15 state institutions for the developmentally disabled and mentally ill and shifted the care back to home- and community-based programs.
"I am a firm believer in comprehensive community efforts, building on private agency efforts to perfect the work that really makes a difference," Haveman told the plenary session attendees. "Everyone with Alzheimer’s disease will require long-term care. On average, patients and their families endure 10 years of progressively worsening symptoms, with the majority of care occurring in the home. After about seven or eight years, a majority of patients will need some kind of out-of-home care."
Providing strong support systems to families, Haveman said, has a direct impact on the length of time they are able to provide care for individuals with Alzheimer’s disease at home. It is important for coordinated service delivery systems to recognize that there are effective drug, environmental, and social interventions that can delay the need for out of home care. But the key, Haveman emphasized, is early identification and intervention.
"A priority for reforming a system must be a focus on helping people who already have a place to live to keep their housing and be able to receive care there," Haveman concluded. "Care from spouses, relatives, friends, and neighbors represents the bulk of services provided to persons who need long-term care. A work group that looked at the problem in Michigan recommended a significant expansion of services to support these caregivers as the most important means of increasing the overall quality of care, the patients’ and their caregivers’ quality of life, and making state programs more cost effective."
Although a work in progress, the state’s reforms are already seeing an effect in reduced expenditures to nursing homes, increased decision making at the community level, and much greater access to care across the state, Haveman said.
More information about Michigan’s long-term-care system is available on the Department of Community Health’s Web site at www.mdch.state.mi.us. ▪