long-term care infrastructure op-ed in The Hill

America’s long-term care infrastructure: A road to nowhere – Op-ed in the Hill co-authored by Nexus Insights

In a recent op-ed in The Hill, Nexus Insights Fellows Anne Tumlinson, David Grabowski and Robert Kramer, raise an important point that has been missing from recent discussions around transforming long-term care following the pandemic. The Biden Administration has proposed a $400B investment in home- and community-based services (HCBS). We assert this investment is necessary but not sufficient. Without additional spending on services to help families navigate and manage long-term care services, this HCBS investment is basically a “road to nowhere.” We argue for the need to create a network of long-term care service hubs across the country to help families navigate services.

As you know, there have been A LOT of thought pieces around improving long-term care going forward, but we have not seen this point made elsewhere. Thus, we believe it would be an ideal time to make this point as policymakers consider the Biden proposal.

Excerpt:

Long-term care is complex. Few Americans plan ahead and most wait until a crisis pushes them into a frantic search for solutions. It doesn’t have to be this way.

Every day older adults lose their ability to care for themselves. Often, they are discharged from the hospital too weak or confused to be left alone or care for themselves. Now what? Who will take care of them? Is home- or facility-based care the best option? How much will it cost and who will pay? Does Medicare cover it? Does Medicaid? If home care is the answer, how do you find a qualified and affordable caregiver? Where do you even start? Life-changing decisions must be made, and fast.

Read the full op-ed in The Hill.


Anne Tumlinson is CEO of ATI Advisory and the Founder of Daughterhood. David Grabowski is Professor in the Department of Health Care Policy, Harvard Medical School. Robert Kramer is the founder of Nexus Insights, and the co-founder and Strategic Advisor & former CEO of the National Investment Center for Seniors Housing & Care (NIC).

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David Grabowski presents a podcast on rethinking long-term care

Grabowski Spotlighted on Disrupt Podcast: Rethinking Long-Term Care in the US

The nation’s infrastructure has become a hot topic, as the Biden administration lays out its infrastructure plan. Long-term care for the growing senior population is one of the areas for proposed investment, which may be a surprise to some, but not to those in the industry. Rethinking long-term care for our nation’s rapidly aging population is an urgent problem, but addressing it effectively is a complex one.

David Grabowski, Professor of Health Care Policy at Harvard Medical School and a Nexus Insights Fellow, was interviewed recently on his thoughts and recommendations for the reformation of long-term care in the United States. Grabowski is a key figure in the research, policy and media world, with expertise in the economics of aging, Medicare, and the integration and coordination of care for dually-eligible beneficiaries. He’s a member of the Medicare Payment Advisory Commission (MEDPAC), a well-known expert in the post-acute care services realm and a leading speaker on industry publications and newscasts around the world. 

Grabowski’s recommendations range from a unified post-acute payment system to changing up the traditional nursing home model and investing more heavily in home-based care. He compares the United States to other developed countries for home and community-based services spending, considers why investment in nursing homes and home care services is not an either-or proposition, and explores the future of SNF-at-home programs.

Listen to Grabowski’s Interview: A part of the Home Health Care News podcast series Disrupt. 

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Bob Kramer and Anne Tumlinson discuss HCBS

Foresight TV: Bob Kramer & Anne Tumlinson – What Does HCBS Mean For LTC?

With the federal government considering an investment in the country’s infrastructure, a new light has been shed on the importance of infrastructure. And from the resulting discussion, a broader understanding of what is vital infrastructure is emerging. That infrastructure necessarily includes a system of long-term care for the nation’s aging population and a trained workforce to deliver that care.

“We have an outdated, crumbling infrastructure in nursing homes. We have non-existent infrastructure in home and community-based services (HCBS). And we have millions of older adults living longer, many of whom will need services and supports,” said Bob Kramer, Founder and Fellow for Nexus Insights, and Co-Founder and Strategic Advisor for the National Investment Center for Seniors Housing & Care (NIC).

Kramer recently interviewed long-term care expert Anne Tumlinson about the importance of long-term care and changes needed in how it’s delivered and how it’s paid for. Tumlinson, the Founder and CEO of ATI Advisory, and Founder of daughterhood.org, offered recommendations for the policy changes needed to make long-term care financially viable for more seniors and their families. Her recommendations also addressed the critical need for a living wage for the shrinking pool of caregivers who work in long-term care, and the important role of HCBS in helping seniors thrive.

“We don’t have a system; instead, every single family has to create their own system, over and over again. What is out there that could help me? How do I find it, set it up, coordinate it? There is currently no system or function in our society to handle that,“ said Tumlinson.

The interview was hosted by Senior Living Foresight. View the entire discussion.

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LTSS caregiver and patient

ATI Advisory Issues Recommendations for Expanding Access to Home and Community-Based Services

Long-term services and supports (LTSS) when provided in the community as home and community-based services (HCBS) can be a lifeline to help a person live safely at home and age with dignity. In a position paper on HCBS, A Blueprint for Reforming Medicaid Long-Term Services and Supports and Creating Good Caregiving Jobs, ATI Advisory CEO, and Nexus Fellow, Anne Tumlinson offered three recommendations for legislators and regulators to expand access to home-based care services sustainably and equitably. 

1 – Providing states with better financial support, assurances and predictability

Medicaid accounts for 29% of total state spending across all funding sources, and LTSS is a substantial portion of this spend. This creates financial pressures, resulting in cuts to the Medicaid program during times of budget pressure, and reluctance to provide or expand services that are optional, such as HCBS LTSS. 

IMMEDIATE RECOMMENDATIONS: Several policy and financing approaches (e.g., enhanced federal match for HCBS, state education on HCBS financial controls) increase access to HCBS by increasing funding and alleviating immediate state financial concerns.

LONGER-TERM RECOMMENDATIONS: Financing reform could include federalizing some portion of LTSS or creating a shared risk model between states and the federal government. 

Read the full recommendation

2 – Modernizing long-standing Medicaid eligibility policies

Long-standing Medicaid eligibility policy creates a bias toward institutional care, making it difficult for individuals to remain in their home or the community when they have LTSS needs. 

IMMEDIATE RECOMMENDATIONS: Several eligibility regulatory changes would increase access to HCBS and help ensure individuals have access to LTSS in the most appropriate setting of care. 

LONGER-TERM RECOMMENDATIONS: National minimum eligibility standards applied across states would reduce inequity and improve access.

Read the full recommendation

3 – Investing in the direct care workforce delivering HCBS

Immediate and longer-term recommendations for increasing access to home and community-based services (HCBS), reducing institutional bias in Medicaid long-term services and supports (LTSS), and creating good caregiving jobs: 

ISSUE: Direct care worker pay is relatively low and the work is demanding. Policymakers should take a comprehensive approach to fairly compensate; elevate; and retain, engage, and develop workers. 

SHORT-TERM RECOMMENDATIONS: Increase the minimum wage, create a high-level HCBS and Direct Care Workforce coordinating office, make targeted investments in training, and launch a public service campaign to help address key workforce issues. 

LONGER-TERM RECOMMENDATIONS: Improve jobs by enacting policies to support affordable childcare, healthcare, and paid sick leave; modernize training; and create a permanent federal Center for Direct Care Excellence. 

Read the full recommendation

 

See the full Position paper

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meaningful reform in nursing homes

Seize the moment: Bob Kramer lays out path for meaningful reform in nursing homes in new Health Affairs blog

“The American long-term care system, particularly in skilled nursing facilities, has been exposed as deeply flawed, chronically underfunded, and in need of reform.” This bold statement is from Robert Kramer, Founder and Fellow of Nexus Insights, and Co-Founder and Strategic Advisor for NIC. It’s the opening line of his recent blog in Health Affairs.

Kramer delves deeply into the urgent problems facing nursing homes that have been spotlighted on the national stage by the pandemic and its tragic death toll among nursing home residents and staff. Kramer predicts the likely responses we can expect to see from nursing home operators, federal and state regulators and policy makers, and seniors and their families. But he urges, instead, a more thoughtful, complex and multi-faceted approach to solving the challenges of long-term care in nursing homes that involves dispensing with out-of-date assumptions, acknowledging the problems, and aligning the different stakeholders involved.

The problems he sees stem from undervaluing and undercompensating the work of caregivers, and the too-narrow focus of regulatory metrics on physical care needs, rather than the personal goals and aspirations of the residents themselves, and their quality of life. Other challenging problems include the long-term shortage of caregivers for a rapidly growing population of seniors, the lack of financial transparency, inadequate reimbursement models that incentivize the wrong behaviors, the age of nursing home infrastructure, and the financial impact of the COVID-19-related lawsuits that are certain to hit the beleaguered industry as the pandemic winds down.

“Every stakeholder must understand that this is a disruptive moment.” – Bob Kramer

The solutions Kramer proposes will require thoughtful cooperation and coordination among all the players in the industry, including industry providers, organized labor, consumer advocates, investors, and regulators. And it won’t be easy. But as Kramer points out, “Every stakeholder must understand that this is a disruptive moment. SNFs and long-term care are, for a moment, center stage. Those of us who care about this sector, and the millions of Americans it serves, must seize this moment.”

Link to full blog

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