Last September, the U.S. Department of Veterans Affairs kicked off a project in Maryland with far-reaching implications. It chose five former U.S. Army soldiers — all veterans with disabilities — to receive monthly stipends for services that enable them to live at home rather than in a VA facility.
David Silver is one of them. Silver, 95, a retired salesman and World War II vet who suffered a hearing loss in combat, and his wife, Gertrude, 94, live at home with the help of a full-time caregiver. Under the Veterans-Directed Home and Community Based Program, a joint VA and U.S. Department of Aging project, veterans are eligible for gross monthly stipends of $1,630, $2,454 and $3,300.
Silver’s monthly stipend goes toward his caregiver’s salary, $6,000 per month. The family had been paying it out of pocket until, as his daughter and official representative, Rodni Edelson, put it, “The money runs out.”
The VA payments don’t defray the entire cost. “But they’re a tremendous help,” Edelson said. “For the VA to do this for the vets, it’s wonderful. It’s a blessing.”
Ilene Rosenthal, deputy secretary of the state’s Department of Aging, which oversees the program, said that for the first year, the VA has enough funding for another 40 or so participants. Nonetheless, as small-scale and experimental as it is, the VA project hints at the kinds of initiatives happening in Maryland generally — from a database of providers to affordable housing.
For at least a decade, the state has been moving to rebalance the long-term services and support (LTSS) spending in Medicaid, the health insurance program for low-income individuals and people with disabilities. Now, thanks to federal funding, the pace has quickened and deadlines are looming.
In 2009, the most current data, the state’s total LTSS Medicaid budget was $2.1 billion. Of that, about 63 percent, or $1.35 billion, went to nursing homes; the rest, or $784 million, to home/community-based services.
By 2015, the state is aiming for a 50/50 split between nursing homes and home/community, says Mark Leeds, director of long-term services and support at the Maryland Department of Health and Mental Hygiene.
Not only are home/community services more cost effective, but consumers prefer them, said Leeds, whose department is spearheading the effort.
“Our emphasis has long been on increasing the proportion of long-term-care options in community programs versus institutional programs,” said Leeds, noting that the department does not have a dollar figure for savings as a goal.
Rather, the way he sees it, “This is not about savings. It’s about spending smarter and serving more people with the same amount of dollars.”
Rosenthal echoed the sentiment. The idea behind the VA project is autonomy. “The veterans make the key decisions,” said Rosenthal, whose department last fall won two federal grants — a total of $3.3 million — to foster community services.
“We want to give people more choices and control,” she said of the shifting focus in long-term care. “Continuing what we’ve done for the past 30 years — having people go into nursing homes— is not sustainable. People don’t want it, and it’s not affordable.”
Although rebalancing is not a federal mandate, financial incentives encourage states in that direction. A key federal program to do so is 2007’s Money Follows the Person.
By 2016, the state plans to move 3,889 people from institutions into community settings, the proviso being that services are available for independent living. The Centers for Medicare & Medicaid Services initially projected that Maryland would receive $67 million under Money Follows the Person, but that figure was based on fewer people being relocated. Leeds does not have a revised figure that accounts for updated relocation numbers.
Another key program, separate from Money Follows the Person and enacted later, in 2011, is the Balancing Incentive Payments Program, an enhanced Medicaid match for a specified period to build a network of home/community providers. Maryland’s match period runs from April 2012 through Sept. 30, 2015.
The standard federal/state Medicaid match is 50/50. With the Balancing Incentive Payments Program, the state would get 52 percent of the match. The additional 2 percent amounts to $106 million.
States competed for the payments program. Maryland was the second state in the country to be accepted and, based on projections, is on track to receive it, Leeds said.
“We have initiatives to reach enhanced community goals. We have put out RFPs [requests for proposals] to outside contractors and providers. We are looking for new ideas,” said Lorraine Nawara, deputy director for community integration with the Department of Health and Mental Hygiene.
But services are only part of the equation. The other part is low-cost housing. “The biggest obstacle to moving people out [of institutions] is [having] affordable places for them to live,” Nawara said.
To that end, the department currently is waiting to hear — probably next spring — about an award from the U.S. Housing and Urban Development. The amount, to be determined by a competitive process, will financially assist developers in building 150 affordable housing units for the disabled in the Baltimore-Washington, D.C., corridor.
Kim Burton, co-chair of the Maryland Senior Action Network, an advocacy group, has been following the state’s Medicaid activity for years. She is familiar with the programs and can rattle off their acronyms with ease. To Burton, the long-term services and support rebalancing is nothing short of “inspired.”
For one example, she talks about Maryland Access Point (MAP), a website the Department of Aging has been working on since 2003 and that went operational statewide this year. It is a “one-stop shop” in each county of local services and providers for the elderly and disabled. But MAP is supposed to be more than a mere listing of phone numbers.
“There are high expectations for what a MAP website and MAP staffers will do for citizens,” Burton said. “Maryland seized the federal opportunities, but the state’s progress is because rebalancing is a priority.”
For the most part, the industry appears to accept the state’s long-term services and support efforts. Joseph DeMattos Jr., president of Health Facilities Association of Maryland, the state’s oldest and largest trade group of nursing homes and assisted-living facilities, is a member of the Maryland Medicaid Advisory Committee that is overseeing the changes.
Instead of the term “nursing homes,” DeMattos prefers “skilled nursing and rehabilitation centers” because it better describes their range of care — from transitional to rehabilitation to long term.
“Community rebalancing is not so much a policy change than an acknowledgement that, moving forward, for any state to be successful it must have robust capacity across the continuum of care,” DeMattos said.
Likewise, Isabella Firth, president of LifeSpan, a trade association of diverse facilities from nursing homes to assisted-living retirement communities to senior housing, is active on the long-term services and support frontlines.
Although LifeSpan supports the rebalancing, Firth acknowledged that some members do not.
“They take a narrow view. They feel threatened,” she said, although most understand that “it’s not a question of if it’s going to happen.
“There is a political will on the part of government. Consumers want more options, and the market is changing. Members are making the changes they need for the future.”