Bringing Health Care Services into the Homes of the Elderly
Guy and his wife, both in their late 70s, enthusiastically volunteered for their northwest Vermont public school system. Even Guy’s lymphedema, a swelling of the legs, could not slow him down. Every morning, his wife would wrap his legs so he would not be incapacitated. When she got sick and could no longer care for him, Guy realized he did not want to move into an expensive nursing home. Their limited transportation would interfere with his daily volunteer work, so he began to seek other options.
“We got together and looked at everything,” says Nancy Eldridge, former executive director of the Cathedral Square Corporation in Vermont and now executive director of the National Center for Healthy Housing. Cathedral Square, a nonprofit that operates communities for seniors and people with special needs, helped Guy figure out the best solution for his needs, which in the end was applying for long-term Medicaid that enabled him to afford nurse’s visits at home.
Guy is not alone in looking for a better way to deal with the health effects of growing old. With the aging of the nation’s 76 million baby boomers and a tendency toward longer lifespans, the U.S. can expect millions more people to need long-term care.
The problem with helping people age healthfully becomes trickier as adults are increasingly expected to pass their 80th birthday, when rates of dementia increase. Less than 1 percent of people under age 65 have dementia; by age 85, the condition hits two in five people. In total, by 2050, the annual number of new Alzheimer’s cases is expected to more than double.
Because the physical and cognitive impairments associated with an aging population require years of comprehensive care, experts say people need better alternatives to nursing homes, which cost an average of $87,600 a year. Bringing needed services and preventive care to the elderly and coordinating their care at home can reduce their use of costly health care services, such as emergency room visits, and help save money overall.
“If you look at volume and extension of elderly lives, you realize you need a decentralized, community-based care system,” says Eldridge.
Aging at Home
Approaches that keep the elderly out of nursing homes are also the preference of many people entering their golden years, like Guy.
“I hear from many people that they go to a nursing home to visit somebody and they can’t wait to get out,” says Kim Fitzgerald, current chief executive officer of Cathedral Square. “They feel like it’s just people waiting to die.”
That is aside from the cost, which is beyond what many older Americans can afford. Just over 9 percent of the population has a long-term-care insurance policy. Neither private health insurance nor Medicare, the federally funded health insurance for older Americans, covers the majority of services provided by long-term care facilities; Medicare only covers short-term skilled nursing, rehabilitation, and end-of-life care. Medicaid, the federally funded health insurance for low-income people, covers long-term care for low-income disabled individuals who qualify as “medically needy”—a category under which some, but far from all, senior citizens fall. Those who qualify for Medicaid long-term care may find that their options are limited. Not all states, for example, allow Medicaid to pay for assisted living.
Supports that assist with aging at home offer a more affordable solution. A federal Medicare demonstration, Independence at Home, provides in-home primary care services to chronically ill Medicare beneficiaries through an initial group of participating medical providers. The home visits allow physicians, nurses, pharmacists, social workers, and other primary care team staff to keep tabs on patients’ health, for example by helping them adjust their medication and record their blood pressure to prevent future medical emergencies. Providers that demonstrate effectiveness at offering high-quality care at a lower-than-targeted cost to Medicare receive a financial incentive.
In its first year, the program saved $25 million in Medicare expenses across 14 practices or consortia. This equates to more than $3,000 in avoided Medicare costs per person. If the program were expanded nationwide, it could save $4.5 billion a year for an estimated 1.5 million participants, according to the American Academy of Home Care Medicine.
“For many individuals, it’s challenging to get out and get services in the community,” says Alisha Sanders, managing director of the Center for Housing Plus Services at LeadingAge, a nonprofit association that addresses aging issues through research, policies, and practices. “When you can bring the services to the property, that increases access to services.”
Coordinating housing and health
Some apartment communities for seniors have paired housing with health care and other services to better serve their elderly residents. In 2008, Cathedral Square established the Support and Services at Home (SASH) program. Funded by Medicare and now available in many Vermont communities, SASH provides health care overseen by a care coordinator and wellness nurse who work with a team of community providers. Residents also can take advantage of transportation and fitness and wellness activities.
At Cathedral Square, the combination of services has boosted residents’ well-being substantially. According to a LeadingAge case study, in the program’s first year, falls decreased by 22 percent, hospital admissions decreased by 19 percent, and more residents became physically active.
The program is cutting costs, too. Fitzgerald says SASH reduced health care expenses in Cathedral Square communities by just over $1,700 per person. Vermont recently predicted that the SASH program and the state’s health reform initiative would save Medicare $40 million by reducing older consumers’ use of inpatient hospital and physician services, outpatient hospital and emergency room services, and nursing home stays.
Fitzgerald says, “We’re more efficient in our delivery of care because the entire team is at the table and knows who’s doing what, so there’s not duplication, and we know where we can have impact and where the participant wants to make a difference in their own health needs.”
For the growing care needs of an aging population, the solution may be bringing health care services home.