Most older adults want to remain in their homes as they age — a sentiment that has strengthened during the COVID-19 pandemic. But to do this, many will eventually require Medicaid-funded home- and community-based services (HCBS) to meet functional needs such as bathing, dressing, meal preparation, and medication management. This is particularly true for people who are dually eligible for Medicare and Medicaid, more than one-third of whom rely on HCBS to live independently at home. For them, the fragmentation of coverage between Medicare and Medicaid can make it difficult to coordinate their medical, social, and behavioral health care. COVID-19 has exacerbated these challenges.

Through support from Arnold Ventures, the Center for Health Care Strategies (CHCS) is producing a blog series that explores the impact of COVID-19 on different sub-populations of dually eligible individuals. To better understand how COVID-19 has impacted dually eligible individuals who use HCBS, CHCS spoke with several experts:  Cindi Jones, senior vice president of Government Relations, InnovAge and former Virginia state Medicaid director; Luz Ramos, MD, regional medical director, InnovAge; Denny Chan, senior staff attorney, Justice in Aging; and Michael Monson, former senior vice president for Medicaid and Complex Care, Centene Corporation.

Challenges for Home-and Community-Based Populations amid COVID-19

COVID-19 has created numerous challenges for HCBS users. Now that individuals have limited opportunities to leave home due to social distancing, activities like filling prescriptions, going to the doctor, or getting groceries are increasingly challenging for a population that has a high rate of multiple chronic conditions along with functional limitations. Food insecurity may now be an issue for individuals who had been receiving meals at a day program or senior center that had to shut down because of the pandemic. Basic care needs may be going unmet because people are afraid to let personal care attendants into their homes or because aides stay away due to illness or fear of infection. Without transportation, people may not be going to medical appointments. In many cases, family caregivers are trying to pick up the slack, but are doing so without training, personal protective equipment (PPE), or opportunities for respite from new responsibilities. Furthermore, many families have removed or are less likely to send family members to nursing homes and other institutional care facilities after a hospital admission, given the high risk of the virus spreading among older, frail residents. This requires families to provide more supports for their family members in the home.

Individuals who are dually eligible often receive fragmented, uncoordinated care with little communication between Medicare- (e.g., hospitals and skilled nursing facilities) and Medicaid-funded (e.g., HCBS) providers. This makes transitions of care — from a skilled nursing facility back to an individual’s home, for example — particularly challenging. Even pre-COVID, dually eligible individuals had 30-day hospital readmission rates that were 10 to 31 percent higher than Medicare-only beneficiaries. Dual eligibility is associated with both higher rates of COVID-19 infection and hospitalization, and while multiple factors are involved, lack of coordinated care likely plays a role.

Benefits of Integrated Programs for Dually Eligible Individuals

Integrated care programs — in which all or most Medicaid and Medicare covered services are managed by the same entity — can support coordinated, whole-person care for dually eligible individuals. These programs use care management models that work across siloed systems to coordinate HCBS with medical and other social services. Blended, capitated payments can allow integrated care programs the flexibility to offer additional benefits to better meet members’ needs in the community. Within integrated programs, the use of an interdisciplinary care team encourages a holistic approach to address the full range of an individual’s needs. Importantly, program care managers have “eyes and ears” on individuals in the home allowing them to quickly respond to changes in an individual’s health status or emerging care needs.

One integrated care model, the Program of All-Inclusive Care for the Elderly (PACE), primarily uses an adult day health center model and employs an interdisciplinary care team to serve its participants, more than 90 percent of whom are dually eligible. This approach allowed several PACE organizations to mount an all-hands-on-deck response to COVID-19. The experiences of InnovAge, a PACE organization that serves more than 6,500 individuals in five states, highlights the benefits that a flexible, integrated model can bring to adults who are dual eligible.

InnovAge pivoted quickly from a center to a home-based, telehealth-supported model within a few weeks. It credits its nimble response to a combination of its provider-led structure and integrated financing model. InnovAge redeployed staff to meet evolving needs of members in the community. Drivers and schedulers assumed new outreach responsibilities, checking in on individuals to identify those who were isolated or experiencing medical issues, or to deliver food to participants’ homes. PACE dentists are providing at-home oral health kits, and recreational therapists are helping individuals with self-care needs at home. PACE staff interacting with members in their homes alerted care teams to participants’ increasing levels of isolation and depression as the pandemic stretched on. In response, behavioral health specialists used wellness calls to screen for mental health concerns and make referrals to services.

Policy and Program Changes in Response to COVID-19

Several new federal policy flexibilities and state programmatic changes in response to COVID-19 help address the needs of HCBS users and providers and provide expanded support for HCBS:

  • Telehealth. One of the most significant policy changes is the expansion of telehealth. Telehealth visits allow care managers to check on members while keeping physically distant and using staffing resources efficiently. Many states, health plans, and providers are very interested in making these flexibilities permanent and examining the impact of this expansion on quality or program costs outside of the context of a pandemic.
    While telehealth has been beneficial to many, access to telehealth is not equitable. Older or high-need individuals may have less access to the technologies needed for these services. In particular, non-white older adults face more challenges related to less familiarity with telehealth and unequal broadband access, and a lack of computers or smartphones is an additional barrier for many older adults. Many integrated health plans have prioritized outreach to familiarize members with telehealth features and connected them with resources for subsidized internet access. It will be important to ensure alignment between Medicare and Medicaid telehealth coverage policies over the long-term to ensure these strategies are seamless to beneficiaries.
  • Resources for providers. Many states have enacted provisions through Appendix K for Home- and Community-Based 1915(c) waivers. This standalone waiver appendix allows states to quickly enact provisions in response to emergencies in approved waivers to better support beneficiaries. Provisions enacted in response to COVID-19 can include but are not limited to: increasing flexibilities to create emergency person-centered plans, expanding provider qualifications or settings in which HCBS may be provided, and paying family caregivers for providing services that would otherwise be performed by formal workers. Strategies to expand the number of family caregivers, particularly women of color who represent a majority of paid and unpaid caregivers, should include ensuring that they have the necessary supplies and PPE they need to feel safe.
    Due to state restrictions on businesses that serve individuals in congregate settings and fear of and limitations on in-person gatherings to limit the spread of the virus, some HCBS providers such as adult day health providers have temporarily or permanently closed due to lack of revenue. Other organizations like InnovAge have increased investments in technology, new home-based service models, and PPE. More broadly, home health and personal care providers are seeing increased expenses for overtime due to workforce reductions, and hazard and sick pay for direct care workers. There are already major shortages in the direct care workforce due to low payment and retention rates. As demands for HCBS continue to grow, states and the federal government may need to consider how to support HCBS providers to ensure their long-term financial viability.
  • Housing. During the COVID-19 pandemic, eviction and foreclosure moratoriums have helped to ensure individuals can remain at home or return home after hospital or skilled nursing facility stays. While the long-term impact of COVID-19 on the economy remains unseen, the need for housing supports will likely remain for some time, particularly for dually eligible individuals who are by definition, mostly low-income.

The Way Forward

HCBS play a vital role in helping individuals receive holistic, person-centered care in their own homes. Although dually eligible individuals often have greater care needs than individuals covered by only Medicare or Medicaid, they have the same desire to live at home. COVID-19 has created numerous challenges to the delivery of HCBS, but integrated care programs and their intensive care management models are well-positioned to respond. Many of the policy and programmatic changes implemented to address COVID-19 could be continued to strengthen HCBS delivery and enhance integrated care models.

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