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October 03, 2007

Creative approaches to caring for seniors in less restrictive settings

Last year, Massachusetts amended its Medicaid laws to require that beneficiaries headed to nursing facilities be screened to see if they could be placed instead in less restrictive settings. The Commonwealth then applied for a so-called Section 1115 waiver from Medicaid rules in order to reallocate federal funds ordinarily devoted to health care facility based care to community based care. The Massachusetts program is called Community First.

This sort of thing is clearly better for beneficiaries, and easier on the public fisc. It also echoes a longstanding effort to keep seniors in community settings, where they can be more active, and to resist medicalizing the normal aging process. The PACE program (aka the Program for All-inclusive Care for the Elderly, begun at the On Lok community health center in San Francisco a couple decades ago) graduated a few years ago from a waiver/demonstration program to a regularly recognized program for federal funding purposes. PACE keeps seniors who are eligible for nursing facility placement out of nursing facilities, arranging for all needed services through community health centers (adult day health, home health, etc.).

Assisted living facilities also sprang up over the past couple of decades as an alternative, or in some cases way-station to, nursing facilities.

There are also programs designed to keep health care facilities from being too much like health care facilities: viz. the Green House model of homelike nursing facilities.

The latest entrant in this field of alternatives to traditional nursing facilities is the Going Home program in Massachusetts, highlighted in today's Boston Globe story about a four-resident home in West Peabody operated by North Shore Elder Services, which plans to add additional sites. The home provides a residence, a live-in aide, meals, and other services as needed. Per the Globe,

Services cost another $3,600 to $4,000 per person a month at West Peabody, covered through the Medicaid and Medicare programs, because the residents have medical and physical conditions that would otherwise qualify them for government-paid nursing home care. The total cost per day is less than the $187 average state payment for nursing home care, but more than the state pays for the least-ill nursing home residents.

The story continues:

Because the houses are not subject to state regulation like nursing homes, some question whether residents would be adequately protected. There have been occasional abuses in state-funded homes for the mentally ill.

Organizers say there are multiple checks and balances in the way the houses are run. One of the regular duties of the elder service agencies is to investigate abuse and neglect for the state. The agencies' staff monitors the care provided in the houses. And other professionals, obligated to report abuse, are regular visitors.

The market for these services is likely robust and it will be interesting to follow the growth of this initiative in Massachusetts and elsewhere.

-- David Harlow

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