Addressing the Long-Term Care Crisis

Control of Care | Community Solutions | Managed Community-Based Care | Recipient Characteristics | Workplace Shortages |

Growth in the population of disabled and elderly people in recent years has put pressure on the long-term care system and its funding. Mathematica's work in this area began with the landmark evaluation of the National Long-Term Care Channeling Demonstration in the 1980s. Since then, we have gone on to evaluate community-based and institutional models of long-term care for people of all ages with chronic conditions. Our recent work on consumer direction casts light on models that promote independence and choice of providers for disabled children and adults. As the baby-boom generation ages, issues of where services are received, who pays for them, and how they are managed are growing in importance.

Increasing Consumer Control of Care

Our Cash and Counseling study is the most comprehensive to date of consumer-directed care for Medicaid beneficiaries who are frail or have disabilities. Cash and Counseling participants in three states received a monthly cash allowance to purchase personal assistance services and related goods. In one state, children were also included. Participants received counseling to help plan their purchases. The program sought to expand consumer control over personal care, increase satisfaction, and meet needs for care without increasing Medicaid costs. Our evaluation found that beneficiaries who directed their own disability-related personal care had better access to services, and greater satisfaction with services, paid workers, and the way they were spending their lives, compared with traditional Medicaid beneficiaries. Cash and Counseling also had many positive effects on the satisfaction and well-being of primary informal caregivers. In one state, Cash and Counseling reduced nursing home use by 18 percent.

In the area of AIDS care, the disease has gone from an acute and fatal condition to a complex chronic condition, as a result of better understanding of the disease and new pharmaceutical treatments. These changes have helped to prolong the life of people with AIDS and increased the need for long-term supportive services. We developed a research agenda for studying the current and future status of home- and community-based service use by people with AIDS.

Increasing Awareness

Community solutions to long-term care needs are more popular than institutional solutions. We are examining strategies for developing coalitions of local stakeholders to improve care and develop a coordinated system. We have surveyed 13 communities to identify gaps in services and public awareness of long-term care issues and options. The study is identifying promising models and disseminating information about what works.

Managed Community-Based Care for Elderly People

Because policymakers need accurate information on models for coordinating care and managing chronic illness for elderly Medicare and Medicaid recipients, we are evaluating the Program of All-Inclusive Care for the Elderly (PACE). This unique, capitated managed care benefit for the frail elderly seeks to provide better care and cost savings by integrating preventive, acute, and long-term care into one package. For most participants, the program provides needed services through an adult day care center to enable them to live at home, rather than in a nursing home or other institution. We are estimating the program's impact on beneficiaries during their enrollment, as well as describing how the program has changed now that it is a permanent component of Medicare.

Mathematica has a long history of investigating service delivery models to help elderly people maintain independence and dignity in their daily lives. Recent work explores the promise of new models, such as social HMOs, which aim to improve care for frail Medicare beneficiaries in the community. Combining managed care and expanded home- and community-based services, social HMOs enroll a broad spectrum of Medicare beneficiaries. Extra services are targeted to those at greatest risk of nursing home admission, or those with significant health care needs. Although social HMOs provide enhanced services, our research has shown that member satisfaction with them is about the same as with regular Medicare HMOs.

To understand Medicare's latest offerings, we are evaluating Medicare Advantage special needs plans—capitated arrangements to provide services to specialized target populations, including dual eligibles, nursing home residents, and people with severe chronic illnesses or disabilities. These studies continue Mathematica's long tradition of researching high-profile long-term care issues that began with our groundbreaking evaluation of the National Long-Term Care Channeling Demonstration in the early 1980s. This study tested whether intensive case management of community-based long-term care and flexibility in the use of Medicare and Medicaid dollars could enable elderly persons with physical or cognitive impairments to remain in the community rather than enter a nursing home. The research showed that neither the more expensive and extensive channeling model nor the basic model reduced nursing home use or Medicare and Medicaid costs. However, the program did increase the quality of life for elderly clients and their primary caregivers, as well as their satisfaction with service arrangements.

Characteristics of Recipients

Medicare beneficiaries who are also eligible for Medicaid, the so-called “dual eligibles,” are vulnerable because of their high medical and long-term care needs and their low incomes. They are also more likely than other Medicare beneficiaries to live in poverty and have severe health conditions. But little is known about their characteristics and the respective roles of Medicare and Medicaid in paying for their care. We have provided state-level descriptive statistics on dual eligibles, reported on their risk adjustment in managed care, and examined their use of Medicaid pharmacy benefits. We are studying the role of Medicare and Medicaid in financing home health care for dual eligibles and analyzing each program's share of expenditures for this population in nursing homes.

Solving Shortages of Long-Term Care Workers

Attracting and retaining sufficient certified nurse aides (CNAs) and home health aides to care for elderly, disabled, and chronically ill patients in long-term care settings is a growing concern. At the same time, Temporary Assistance for Needy Families (TANF) recipients need jobs as they struggle to move from welfare to work in an environment marked by strict work requirements and time limits. Our study examined the suitability of TANF recipients for employment as CNAs or home health aides and the approaches used to train TANF recipients for jobs in the long-term care industry. We also designed surveys to understand more about certified nursing assistants' and home health aides' roles in the long-term care setting.

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