The National Council on Medicaid Home Care Reports on Final Long Term Care Commission Hearing
August 30, 2013 01:49 PM
The fourth and final public hearing of the Long Term Care Commission (the Commission) was held on Tuesday, August 20, 2013. The hearing featured two panels: the first panel was entitled Service Delivery and ProviderInnovation and Issues while the second was entitled Workforce Innovation and Issues. Michelle Martin, the Council’s policy director, attended the hearing.
All of the witnesses agreed that home care is a growing industry that will require a large workforce and will be a significant expenditure, although the areas of focus and how to accomplish the best service delivery and training varied slightly. A recording of the hearing as well as each witness’ materials can be found here.
Loren Colman, Assistant Commissioner of the Continuing Care Administration at the Minnesota Department of Human Services discussed delivery innovation, offering examples of the interesting and innovative work going on in his state. Minnesota’s current system is the result of more than 25 years of planning and incremental changes made with a consistent vision. The current system has four goals that are designed to promote choice and independence:
To manage an equitable and sustainable long-term care system that maximizes value;
To continuously support how services are administered;
To promote professional excellence and engagement; and
To support and enhance quality of life for older people and people with disabilities.
Mr. Coleman outlined several elements that support Minnesota’s delivery system and while some are common to many programs—new and improved ways to provide information to empower people in need of care, helping people remain in or return to the community, downsizing institutions and improving institutional care, strengthening protective services—others stood out as unique to Minnesota. In effort to leave valuable space available in waiver programs, Minnesota has redefined the level of care required to be eligible for Medicaid services.
Instead of leaving those with lower needs to fend for themselves, the state has a smaller set of state-funded essential services and supports to assist those with lower needs. To make sure each person in need of assistance is receiving the appropriate level of care, Minnesota has implemented a uniform assessment instrument and process for use with all older adults and persons with disabilities.
Another element that is unique to Minnesota is the implementation of a comprehensive report card to measure and report quality for HCBS services. The state is basing the report card on their successful nursing home report card that has been in use for some time. Minnesota is now modifying the report card for use in HCBS, recognizing the difficulties that arise when measuring and reporting quality HCBS due to the variety of services provided.
A final important element of Minnesota’s system is the focus on partnerships with stakeholders. State officials meet regularly with a group of stakeholders to discuss initiatives that affect them and offer feedback and advice. So far, the work going on in Minnesota has bent the cost curve for HCBS and has kept nursing home spending flat.
The remaining speakers focused on the need to increase the size of the direct care workforce and to improve training requirements. Tracy Lustig, a study director for the Committee on the Future Health Care Workforce for Older Americans at the Institute of Medicine said that the health care workforce is woefully unprepared for the challenges ahead.
Ms. Lustig’s remarks first focused on the lack of health care professionals who specialize in geriatrics and soon identified direct care workers as the “linchpin of the formal health care delivery system,” but noted that Federal training requirements only exist for some types of direct care workers. Even for those direct care workers who do have training requirements, those requirements have not changed in more than 25 years.
For more than a decade, the Institute of Medicine has cautioned that the combination of a shortage of workers coupled with a lack of training will limit the expansion of HCBS.
To avoid a workforce crisis, Ms. Lustig offered the following recommendations:
Increase the competence of virtually all members of the health care workforce in the basic care of older adults;
Increase the number of providers with expertise in caring for older adults;
Increase recruitment and retention; and
Improve models of care.
When addressing recruitment and retention, Ms. Lustig pointed out the need to provide workers with improved education, training, competitive wages, and career development opportunities, as was recommended in a 2001 Institute of Medicine report. Ms. Lustig also explained that direct care workers are typically poorly paid and rely on government programs for food stamps and often Medicaid. What Ms. Lusting, or the IOM’s 2001 report, didn’t offer is how to pay for any of the items she recommended.
Charissa Raynor, Executive Director of the SEIU Healthcare NW Training Partnership (the Training Partnership), was the last witness to discuss the challenges facing the workforce. The Training Partnership is a non-profit school in Washington State training more than 40,000 home cares workers annually.
The school was created and sponsored by a labor-management partnership including the State of Washington, SEIU, and 20 home care agencies. Ms. Raynor echoed many of Ms. Lustig’s points in terms of the need to train a diverse workforce and compensate those individuals well. The Training Partnership is offering a solution to the education need and emphasizes five key areas as part of training:
Mastering core skills to support ADLs and IADLs effectively;
Individualizing those core skills to the unique needs of the consumer;
Care context including applied understanding of mental illness, dementia, chronic disease, developmental disabilities, spinal cord injuries, and traumatic brain injury;
Connecting to the care team.
In conclusion, Ms. Raynor offered two recommendations—the first was to have a federal minimum training standard and the second was a three-part process that would assist in determining what initiatives are and are not working:
Enlist the U.S. Department of Labor to develop a data management system for collecting and reporting on HCBS workforce trends like turnover and vacancy rates;
Enlist U.S. Department of Health and Human Services to develop a data management system for collecting and reporting on quality of care and quality of life measurement for HCBS delivery; and
Allocate more funding to evaluate specific best practice models that exist.
The witnesses agreed that the workforce needs to be strengthened and innovative care delivery models are necessary. The dilemma for the Commission is that while there is no shortage of recommendations to “fix” the long term care system, there is a severe shortage of recommendations to pay for all of the suggested improvements.
The question and answer session that followed each panel primarily revolved around a possible return on investment. How to get to that initial investment, regardless of the size of the investment, is the real question. The State of Minnesota determined that investing state dollars in supports before requiring an individual to spend down to Medicaid eligibility paid dividends in other areas. The recipients of the lower level supports maintain their health in a way that keeps them from applying for Medicaid and becoming eligible for a wider range of services, a method that is allowing the state to provide the needed care to a higher-need population while ensuring that lower need individuals are care for appropriately and, importantly, the method is saving money for the state.
The State of Washington made a $15 million per year investment in training in an attempt to grow and strengthen the work force. Workers in the State of Washington are required to go through more training than their counterparts in other states and, as a result, receive higher wages than their untrained (or less trained) counterparts in other states. While these investments have garnered returns and successes, the opportunities for collaboration and investment do not exist in every state. Questions remain as to how states can translate success from other states to their own workforces.
The Commission will now spend the next several weeks focusing on completing the recommendations that will be sent to Congress by September 12, 2013. The Commission is continuing to accept comments and recommendations from any and all interested stakeholders.