GRANITE CARE INCREASES HOME- AND COMMUNITY-BASED CARE

Anna C. Spencer

On Jan. 1, 2006, New Hampshire took its place among the many states that have implemented home- and community-based care (HCBC) in an effort to give elderly and disabled Medicaid beneficiaries more choices, while reducing Medicaid spending. Under “Granite Care,” made possible by a federal waiver and the enactment of HB691, patients who are eligible for institutional care have the option to receive long-term care services in their homes, assisted living facilities or other sites, provided that such care is available and does not cost more than it would in a nursing home.

The law mandates that only state-employed RNs will evaluate whether individuals are eligible for Medicaid-reimbursed institutional care. In the past, individuals were assessed by community social workers, hospital discharge personnel and others. The RN-only restriction is an effort to give the state more control over who is deemed eligible for nursing home care. In addition to intake evaluations, the RNs develop individualized budgets, provide information and referral services, and supply oversight or case management.

At first glance, it appears that the reforms have reduced the number of individuals who choose nursing home care and have produced cost savings. Between January 2006 and June 2006, 67 more Medicaid beneficiaries began receiving care at home and 42 more began receiving care at assisted living facilities, compared to the same time period during the preceding year. “When you compare the average cost of $60,000 a year for institutional care with $32,000 for home-based care, of course we’re seeing savings,” said Rep. Peter Batula. And those savings will mean that “more people [will be] offered coverage.”

“Without a doubt, the program is working,” John Stephen, the state health commissioner and architect of the Medicaid reforms told the Concord Monitor. As in the rest of the country, “it was critical for New Hampshire to move toward home- and community-based care. We simply cannot continue to afford to support the Medicaid nursing-home population.”

The trend toward HCBC predated the implementation of the Medicaid reforms. Since 2002, there “has been a growing trend toward home-based care and a gradual reduction in the number of Medicaid recipients on Medicaid in nursing homes,” said John Poirier, president of the New Hampshire Health Care Association. From 2000 to 2004, the number of individuals who entered nursing homes in New Hampshire dropped by about 50 persons per year. In 2005, 90 fewer individuals received Medicaid-financed care in nursing homes than in 2004. While the state’s numbers are notable, Poirier said, “There is no way to know for certain that the change was directly linked to Granite Care.” Poirier also questions whether the state will save money in the long run because it now must employ RNs to conduct intake interviews.

Regardless, the move towards HCBC seems to be unstoppable. First, there is data that demonstrates that some forms of home-based care save much needed state dollars. Second, the federal government is providing encouragement to states to adopt systems of care that offer more choices for seniors and persons with disabilities. Finally, beginning in January 2007, states will be able to provide HCBC to certain beneficiaries without submitting waiver applications, thanks to the Deficit Reduction Act of 2005 (DRA).

Other Programs Show Results

A recent study published in the journal Medical Care shows that “Cash and Counseling,” a form of consumer-directed care that allows elderly and disabled Medicaid beneficiaries to control their own care, may play a role in diminishing reliance on institutional care.

Tested in Arkansas beginning in December 1998, and later in Florida and New Jersey, Cash and Counseling provides qualifying beneficiaries with a monthly allowance equal to the expected cost of receiving needed services from home-care agencies. Beneficiaries may use these funds to hire workers (including relatives) to provide care, as well as to modify their home or purchase disability-related goods and services.

Researchers found that Cash and Counseling participants had higher costs of personal care, but those costs were at least partly offset by the fact that program participants had 18 percent fewer nursing home admissions than the control group. Also, states are developing measures to reduce the increase in costs. Cash and Counseling reduced the physical, emotional and financial burdens on unpaid family caregivers—a potentially important factor in reducing nursing home placements.

Recognizing the promise in HCBC, on July 26, 2006, the Centers for Medicare and Medicaid Services announced the implementation of the “Money Follows the Person” initiative. Authorized by the DRA, the program will give states a total of $1.75 billion over five years to develop HCBC services. For one year, participating states will receive one and one half times the normal federal Medicaid matching rate to pay for long-term care services for individuals who transfer from an institution into the community.

In addition to covering alternatives to institutional care services, the grant money can be used for home modifications, respite services for informal or unpaid caregivers, personal care and assistive devices. The deadline for the first year’s applications is Nov. 1, 2006. Demonstration grants will be competitively awarded to states from Jan. 1, 2007 through Sept. 30, 2011. Funds will be available for a five-year period; however, states must participate in the demonstration for a minimum of two consecutive years.