USAging and the American Society on Aging convened their seventh Managed Care Summit, addressing Managed Long-term Services and Supports, hosted by the Aging and Disability Business Institute in April, as a lead-up to the On Aging conference. Funders including Rani Snyder, vice president, program, of The John A. Hartford Foundation and Erin Westphal, program officer with The SCAN Foundation lauded the work and innovations that have happened up to this point with the goal of improving and ensuring a better quality of life for older adults and people with disabilities, and then a slate of speakers from organizations fostering collaborations between healthcare entities and community-based organizations (CBOs) laid out details and plans.
Camille Dobson, deputy executive director of ADvancing States explained its work representing states and territorial agencies on aging and disabilities and long-term services and supports (LTSS) directors, emphasizing how states’ Medicaid budgets are always the largest item in a state’s budget, outstripping education and public policy. The Managed LTSS system is heavily unbalanced toward institutional care and only recently is it shifting toward spending more on home- and community-based services (HCBS), which is what the bulk of the speakers addressed—how to improve on that shift. Now states are struggling to return to regular business as COVID-19 calms and partnering with plans to implement American Rescue Plan Act and HCBS spending, Dobson said.
Senior Analyst Megan Burke from The SCAN Foundation spoke on her organization’s scorecard recognizing states that perform well on LTSS, focusing this year on New Jersey, which greatly increased access to healthcare by requiring enrollment in a Managed Care program, raising its HCBS use rate from 30% to 50%. Ohio received the same prize for its effective transition to Home Choice, a Money Follows the Person program. Ohio made Home Choice sustainable by requiring it be part of the duals demonstration program.
“Enrollment in integrated models of care does increase access,” Burke said, “but enrollment remains low.” People dually eligible for Medicare and Medicaid are more likely to sign onto programs if they can continue to see preferred providers and if they are given information about new programming that’s easy to understand and in their preferred language.
Sarah Steenhausen, deputy director of Aging Policy, Research and Equity at California’s Department on Aging addressed that state’s path forward to integrated care via Cal MediConnect and MLTSS. After describing the history of managed care in California, Steenhausen said for now MLTSS in her state means only adult day health and institutional long-term services and supports; other services are provided through Medi-Cal, and HCBS has been carved out.
The Cal MediConnect program has a high rate of eligible people opting out and lots of confusion surrounding the program. People wanted to keep the same providers, so if Medicare providers are not engaging with the program, that meant lots of duals chose not to enroll. The state is improving education materials, simplifying enrollment, and standardizing assessments for LTSS, as well as increasing provider education and outreach.
‘Our society does not value work in the home.’
California renewed its 1115 Medicaid demonstration waiver under CalAIM, and it identified and managed comprehensive needs through a whole person approach to care, which recognizes the social drivers of health. That improved quality outcomes, reduced disparities, transformed the delivery system through value-based initiatives, modernization and payment reform. Steenhausen’s department is trying to make Medi-Cal consistent statewide and seamless for enrollees.
CalAIM is funding critical community supports, Steenhausen said, including housing, transition services, short-term and post-hospitalization housing, recuperative care, sobering centers, asthma remediation and more. “It’s really exciting that California invested in a program called Providing Access and Transforming Health. CBOs don’t have the resources to build capacity to contract with healthcare. We [the state] don’t have statewide availability of all of those supports, so millions of dollars have been invested into CBOs to enhance provider capacity, and enhance delivery system infrastructure,” she added.
A Spotlight on MLTSS Workforce Innovations
Courtney Roman, senior program officer at the Center for Healthcare Strategies, spoke first in the next panel, defining the direct care worker job and its severe and ongoing challenges, particularly that, “our society does not value work in the home.” In 2020 the median wage for this work was $13 an hour and most direct care workers made less than $20,000 per year, which means they live below the poverty line and rely upon state and federal help to survive.
Roman offered multiple ways to strengthen this critical workforce, including: convene direct care worker advisory committees; use federal funding and flexibilities to improve wages; prioritize direct care worker–related goals in Medicaid Managed Care contracts; build out a centralized training infrastructure; develop an online direct care worker career platform; and whenever possible talk about the direct care worker job differently.
LeadingAge’s Natasha Bryant, senior director of workforce research and strategy, continued in the same vein, laying out the immense challenges facing this workforce, including insufficient training requirements and a lack of professional career advancement opportunities. To make direct care work more desirable, Bryant suggested thinking about alternative career paths beyond nursing that tap into relationships direct care workers have built with social workers, care managers, activity directors, care coordinators and management, to entice them up the ladder. Bryant also bemoaned the lack of diversity at the top of care organizations.
She suggested employing Diversity, Equity and Inclusion efforts such as partnering with the United Negro College Fund (UNCF) and Historically Black Colleges and Universities (HBCU) (as LeadingAge is), which made a nice segue to the next speakers, Julian Thompson, strategist at UNCF and Victoria Smith, strategy analyst with the UNCF Institute for Capacity Building.
Thompson detailed why UNCF partnered with LeadingAge, as an “overabundance” of individuals find their way into HCBUs to be reskilled and upskilled for the 21st century workforce, and the UNCF is building career paths that engage traditional and nontraditional learners. He also stressed a need to transition from the current mindset of helping vulnerable populations to a mindset of resilience that builds on humanity, welcomes new voices and works to develop ways to share power.
Smith lauded the heightened interest in HCBUs but noted confusion over where large companies can begin to engage students from these institutions. Boeing, Apple and Zoom have invested in internships and new campuses, and with LeadingAge UNCF is going to “provide transformative work in aging,” she said.
The partnership’s plan is to create aging services leadership and management programs; create career transition fellowships for people interested in aging; expose students to aging services at provider organizations and partner with faculty to develop curriculum aligned with the needs of aging services careers. So far UNCF and LeadingAge have engaged in partnerships with 9 HCBUs and begun conversations with 8 providers, Smith said.
‘Fifty percent of people with LTSS needs have a behavioral issue, not including dementia.’
Senior Director, Strategies Elizabeth Cozzi with The United Way of Tucson shared a pilot project formed with Pima Home Care, in which the United Way received funding to address the direct care workforce shortage, as they knew a collective solution would have a greater impact. Arizona’s state Medicaid plan established a mandate to make a significant investment in workforce development and the Mercy Care health plan chose avenues through which it could recruit and retain direct care workers.
Community health workers were hired and an automated intake process was designed through which direct care worker candidates could quickly receive pre-employment information. “We were trying to place a high value on direct care workers receiving good quality training, which resulted in our partnership with Pima Home Care,” Cozzi said.
Rebekah McGee, Pima Home Care’s vice president of Population Health Strategies said the Home Care company provided an extensive direct care worker training of 20 to 40 hours, which covered the basics, but was still found to be lacking. McGee said they heard from direct care workers who didn’t think the basic training properly prepared them for the physical, emotional and social aspects of the job, especially the physical needs of clients.
Pima Care invested in a skills lab that simulates care situations in homes and in which one could experiment as clients or as direct care workers with equipment like Hoyer lifts. They also provided training on intergenerational relationships, LGBTQI cultural competency, palliative care and dementia.
“Building upon the United Way’s campaign for recruiting, coaching and screening direct care workers, we’ll be launching a large campaign to help,” said McGee.
Integrating Behavioral Health with MLTSS
The final segment of the Summit was a conversation between ASA’s Vice President, Programs and Thought Leadership Leanne Clark-Shirley, Alice Dembner, senior policy analyst at Community Catalyst and Jennifer Raymond, chief strategy officer for AgeSpan, addressing the integration of behavioral health into MLTSS.
Dembner works with local and state advocacy organizations to explore what those who are most harmed by the healthcare system want from it, including people who are fighting substance use disorders, and are severely stigmatized. At least 25% of the population older than age 65 has a mental health or substance use diagnosis and that number is growing as Baby Boomers age. Also 50% of people with LTSS needs have a behavioral issue, not including dementia. Most of these people get no treatment, and as they age they are more at risk for falls, other ailments and suicide, which is why integrating behavioral health into MLTSS is so critical.
Raymond said we’ve finally reached a place where people are beginning to understand behavioral health issues. AgeSpan is in northeastern Massachusetts, and for the past 45 years has been working in 28 cities and towns, including the poorest and most affluent communities in the state. It takes what Raymond called a “behavioral health lite” approach, using geriatric service coordinators, and geriatric core teams, which perform assessments across agencies and refer people to interventions, whether counseling to manage depression, stress and anxiety or to programming that helps with housing.
“The biggest impact folks have when we use the lite touch of behavioral health expertise is it often creates a readiness to more fully engage in other types of services,” said Raymond. She expects to see data in another five years from mandatory partnerships with behavioral health as models continue to emerge, and if the data is positive, it’ll be time for strong policy advocacy for more behavioral help.
“ASA members can encourage their agencies to do just what Jennifer’s agency has done,” said Dembner, “to look internally at how to collaborate more with behavioral health services.”
“They need to support policy initiatives that expand telehealth, which can destigmatize mental health issues, and think about how Medicare falls short in covering mental health and substance use. Congress is considering a massive bill on mental health, and you can educate Congress by saying we need to think about older adults.”