Verma: Older Adults Must Have a ‘More Robust’ Set of Home Care Options

The U.S. Centers for Medicare & Medicaid Services (CMS) on Monday touted several tools designed to help states rebalance their long-term care ecosystem toward home- and community-based services. 

The development is the latest in a series of CMS efforts aimed at strengthening home- and community-based services amid the COVID-19 pandemic, with the ultimate goal of decreasing America’s reliance on nursing home care.

“The COVID-19 crisis has shone a harsh light on the human costs of a long-term care system that relies too heavily on institutional services like nursing homes,” CMS Administrator Seema Verma said in a statement included in Monday’s announcement. “Too often, they are seen as the default option, even for those who may not require round-the-clock care.”

Broadly, Monday’s “toolkit” offers examples of innovative state models and best practices to rebalance long-term services and supports programs toward in-home care. Examples largely focus on Medicaid, the primary funder of long-term services and supports nationally.

One specific example highlighted in the toolkit is Pennsylvania’s managed care policy that requires plans to implement a home care workforce innovation component within their programs, utilizing person-centered planning principles to improve the recruitment, retention and skills of direct care workers.

Another is Vermont’s Medicaid section 1115 demonstration to increase access to home- and community-based services for adults at risk for nursing home admission who may not be eligible for Medicaid and who do not meet level-of-care criteria for a nursing home.

“While nursing homes will always be an important part of a complete care continuum, many elderly individuals and their families should have access to a more robust set of home care and community-based care options,” Verma’s statement continued.

In FY 2018, 79% of total Medicaid long-term care spending for individuals with intellectual and developmental disabilities (I/DD) was tied to home- and community-based services. Nearly half of long-term care spending for individuals with mental health and substance use disorders was tied to home-base care.

Meanwhile, just 33% of long-term care spending for older adults and individuals with physical disabilities was tied to home- and community-based services in FY 2018.

Contextually, CMS issued its toolkit on the same day The American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) released a report revealing that new COVID-19 cases are increasing in nursing homes in the U.S., mostly due to the community spread among the general population.

Weekly new COVID-19 cases in the general population rose by 61% to 391,527 new cases the week of Oct. 18, according to data from Johns Hopkins University.

A correlating uptick in new cases in nursing homes occurred when cases in the surrounding community started rising back in mid-September.

Source: AHCA/NCAL

“As we feared, the sheer volume of rising cases in communities across the U.S., combined with the asymptomatic and pre-symptomatic spread of this virus, has unfortunately led to an increase in new COVID cases in nursing homes.” Mark Parkinson, president and CEO of AHCA and NCAL, said in a press release. “It is incredibly frustrating as we had made tremendous progress to reduce COVID rates in nursing homes after the spike this summer in Sun Belt states. If everybody would wear a mask and social distance to reduce the level of COVID in the community, we know we would dramatically reduce these rates in long term care facilities.”

The full long-term services and supports rebalancing toolkit is available here.

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With 40% of Nursing Homes Close to Shutting Down, the ‘Shift to Home’ Is Likely to Accelerate

Across the country, home health nurses and therapists continue to struggle with restrictions around seeing their patients in nursing homes, assisted living communities and other long-term care facilities.

Unfortunately, those restrictions aren’t likely to go away anytime soon, especially when it comes to facilities located in Sun Belt states.

According to a new report from the American Health Care Association (AHCA) and National Center for Assisted Living (NCAL), the nursing home sector is currently in the midst of a major spike of new COVID-19 cases — one that surpasses the previous peak level set at the end of May.

Washington, D.C.-based AHCA and NCAL represent more than 14,000 nursing homes and assisted living communities nationwide.

The latest spike is a direct result of spikes in the general population.

“With the recent major spikes of COVID cases in many states across the country, we were very concerned this trend would lead to an increase in cases in nursing homes — and unfortunately it has,” AHCA and NCAL President Mark Parkinson said in a statement. “This is especially troubling since many nursing homes and other long-term care facilities are still unable to acquire the personal protective equipment (PPE) and testing they need to fully combat this virus.”

Long-term care facilities began limiting in-person visits from outside home health agencies very early on in the public health emergency. In doing so, operators believed they could better control and screen for the coronavirus in their buildings, keeping their residents safer in the process.

Yet many assisted living and nursing home residents have critical home health needs. Limiting residents’ access to home health services could unintentionally cause their health status to worsen, providers argue, ultimately leading to a trip to the hospital or emergency room.

“[We’ve been trying to] fight back to make sure that we have access to assisted living facilities and skilled nursing facilities,” Brent Korte, chief home care officer at EvergreenHealth, said during a recent webinar hosted by Blacktree Healthcare Consulting.

Home care agencies and hospice providers have similarly been restricted from seeing patients in long-term care facilities.

“The biggest challenge is related to delivering care within facilities, where many of our patients reside,” Ken Albert, president and CEO of Androscoggin Home Healthcare + Hospice, told HHCN during a July Disrupt conversation. “For example, 50% of our hospice patients reside in either assisted living or long-term care facilities. Right, wrong or indifferent, the facilities essentially locked their door and prevented access to care.”

The number of new cases in nursing homes, in particular, hit a low of about 5,480 during the week of June 21, according to federal data cited by AHCA and NCAL in their report. That climbed to 9,715 for the week of July 26, the last week with available data.

As of the end of July, nearly 80% of new COVID-19 cases in U.S. nursing homes were coming from Sun Belt states.

‘Substantial doubt’

As a result of the COVID-19 virus, skyrocketing PPE prices and staffing demands, the cost of operating a long-term care facility has drastically increased. That new financial reality is making it much harder for some operators to stay in business. 

In a separate AHCA survey of more than 460 nursing home providers conducted in August, 72% of respondents said they’ll likely be unable to sustain operations at their current pace for another year. Another 40% said they’re unlikely to last six months.

Meanwhile, 55% of survey respondents said they are currently operating at a loss, with 97% of nursing homes saying they’ve lost revenue because of COVID-19.

Nursing home giant Genesis HealthCare (NYSE: GEN) is among the operators to express concern about its financial future.

“Without giving effect to the prospect, timing and adequacy of future governmental funding support and other mitigating plans, many of which are beyond the company’s control, it is unlikely that the company will be able to generate sufficient cash flows to meet its required financial obligations, including its rent obligations, its debt service obligations and other obligations due to third parties,” the Kennett Square, Pennsylvania-based operator announced in a second-quarter earnings release.

The earnings release went on to say that COVID-19 has cast “substantial doubt” about Genesis’s ability to survive the next year.

While home health providers may be struggling to see their facility-based patients in the present, that financial distress may shift more care into the home on a long-term basis.

It’s a point that several providers have made in recent weeks.

April Anthony, CEO of Encompass Health’s home health and hospice business, touched on caring for patients who may have otherwise been directed to a skilled nursing facility (SNF) during a Q2 earnings call in July.

“We’re getting some SNF patients that we wouldn’t have otherwise gotten, particularly directly from physicians,” Anthony said on the call. “But it’s a hard thing to prove what could have, might have, should have happened or would have happened in the prior world.”

Bruce Greenstein, chief strategy and innovation officer at LHC Group, also touched on SNF trends during his company’s Q2 call.

“SNF diversion has become an exceedingly hot topic since COVID started, and it’s something that we’ve been talking about for at least the last 2 years at [LHC Group],” Greenstein said on Aug. 8.

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