State aging programs headed for overhaul

In her Louisville home adorned with family photos, Fyrne Gentry is waging a battle with pain and weakness over where to spend the rest of her life — and at 87, she's ceded ground.

The ache radiating down her back and legs makes housekeeping impossible. She can't drive. She needs help stepping into the shower, and some days, just getting out of bed is a challenge.

But even as the pain robs her freedom of movement, Gentry says the assistance she receives through a state program on aging at least gives her flexibility over housing.

"I have this theory that if I decide to go into the nursing home and it's terrible, I won't be quite so depressed because I put myself in there," she said. "If somebody else put me in there, I would be angry. I really, really want to stay out."

With baby boomers growing older and most seniors wishing to remain independent, Kentucky is undertaking a broad overhaul of elderly services in a bid to stretch resources and help older generations have the same choice as Gentry — to live out their final years at home rather than in an institution.

But it's an area where the state has struggled to keep up with demand, forcing many to remain on waiting lists for critical programs or enter nursing homes earlier than necessary, and experts say those challenges are only expected to grow as baby boomers advance in age.

"Nationally, I don't think anybody is prepared for what is going to happen with the boomers," said Deborah Anderson, commissioner of the state Department for Aging and Independent Living, which spends about $857 million from Medicaid each year on institutional care.

That's more than 81 percent of the total Medicaid dollars earmarked for the elderly and disabled in Kentucky. The other 19 percent – about $198 million – goes to the type of home and community-based services that can help people avoid nursing facilities at about one-third the cost.

Officials and advocates for the elderly say that ratio needs improvement.

"What we want is that when someone goes to the nursing home, then it is because they absolutely need skilled nursing, not because they don't have anyone there to help them take a bath," Anderson said.

Jim Kimbrough, president of AARP Kentucky, predicts the department's new approach will make a big difference in elderly care, but he also warns that the state needs to find more long-term funding strategy to shore up services in coming years.

"There is a huge, huge challenge about how we are going to continue this over the next decade," he said.

Kentucky's low rankings

Many states began the transition years ago.

In June, the AARP ranked Kentucky behind every other state on the availability of long-term support services for seniors, people with disabilities and family caregivers.

Forty-three others do a better job channeling Medicaid and state funding to programs that allow people to stay in their homes, the group said.

Meanwhile, more than 13,000 people remain on waiting lists at the Department for Aging for meals, transportation, home-based services and caregiver services, with some applicants as long as five years.

And census figures indicate that, from 2015 to 2030, the number of Kentuckians aged between 70 and 74 will climb from around 166,460 people to 262,534 — a 58 percent increase.

All this comes at a time when the department has, since 2009, faced a 26 percent reduction in its $72 million budget.

Anderson said officials decided to undertake the revamp after hearing concerns from advocates and recognizing that funds are likely to remain stagnant in the near term.

"Every program, just about, in this department has a waiting list," said Anderson. "There is not enough money to cover the need."

Changing direction

The department has worked with advocates and care providers for the past year on ways to rebalance funding and focus more money, both Medicaid and state general funds, on home-based care instead of nursing homes.

Officials aim to have regulations rewritten and approved by next spring.

Part of the discussion has centered on integrating services like Meals on Wheels and nursing support, into Kentucky's Home and Community-Based Waiver program, which allows the state to use Medicaid funds for non-medical assistance.

Kentucky's Medicaid cost for a nursing home bed is around $48,000 per year, while the cost of maintaining someone at home with waiver services is only $15,000 annually.

The waiver has enough capacity to serve 17,050 people but has remained under utilized because the eligible services have not historically matched people's needs, Anderson said.

Only about 11,000 people are in the waiver now, but filling up the empty slots is one goal of the department's overhaul.

Additionally, officials want to streamline similar programs that non-Medicaid clients receive thorough the department, often free of charge or at a discounted rate depending on their income.

That could help people avoid the cost of a nursing facility and free up money to reinvest back into home-based programs, Anderson said.

"We know that there will be savings, but is it enough to cover all the people on waiting lists — no," she said.

States have seen savings

Virtually every state has made at least some effort to rebalance Medicaid dollars, according to H. Stephen Kaye, a professor at the Institute for Health and Aging at the University of California, San Francisco.

Kaye authored an analysis in 2012, which found that states can reduce costs by about 15 percent over a decade if they gradually shift money — around 2 percentage points a year — from institutional care toward home and community-based waiver programs.

But savings are not automatic, and states must avoid pitfalls, such as increasing reimbursement rates for nursing homes just to compensate them for lost revenues, he warned.

"It is at least no more expensive," Kaye said. "States rarely end up spending more money because they have shifted to a home and community-based services system, and often, they end up spending less money."

Kimbrough, from the AARP, also argues that a successful transition will require the state to consider ideas like tax credits for caregivers and reforms that will allow family members to take over more medical practices, such as administering shots to loved ones.

The AARP estimates that Kentucky could accommodate 31,000 additional low- and moderate-income adults on Medicaid if officials improved performance to that of the best states.

Likewise, around 2,100 people who have remained in a nursing home for at least 90 days could return to the community, the group said.

The politics of transition

Rep. Tom Burch, D-Louisville and chairman of the House Health and Welfare Committee, said he has supported reforms to improve home-based care for more than a decade. But both he and Kimbrough said the nursing home industry has played a role in stalling change.

The Kentucky Association of Health Care Facilities, for instance, has spent more than $309,000 on legislative lobbying and has doled out $106,500 in campaign contributions since the beginning of 2011.

KAHCF represents more than 220 facilities across the state, including corporate members, non-profits and independent owners.

But the group's president, Betsy Johnson, said the spending has gone to support tort reform and legislation to create medical review panels, not to influence long-term care policies.

"Politicians don't make level-of-care decisions," she said. "Giving campaign contributions to a candidate would not incentivize anybody to discharge or send anybody to a nursing home."

Johnson also disagrees with measuring nursing home costs against home-based care, calling it an "apples to oranges comparison."

"The services just don't look the same," she said.

Spending down retirement

According to the Kentucky Department of Insurance, the average cost for a semi-private room at a nursing home in 2012 was $70,445 annually, while assisted living facilities charge around $33,912 each year.

Meanwhile, the average cost for homemaker services in 2012 was about $18 per hour.

The department does not keep figures on how many Kentucky residents have long-term care insurance, but officials warn that Medicare will not cover the services.

Anderson said its common for people to end up relying on Medicaid and income-based services at the department as they spend down their wealth in their final years.

"Even ...upper middle class people, if something catastrophic health wise happens to them, health care is so expensive it just doesn't take long," she said.

In Gentry's case, she started out using private pay, but now her fee is waived based on her income and state funds make up the difference.

She receives services through the Kentuckiana Regional Planning and Development Agency, which contracts with a program called ElderServce in Louisville.

For 2 1/2 hours each week, it provides a personal assistant who performs light housekeeping, picks up groceries and medicines and aids Gentry is tasks like taking a shower.

Gentry said has been getting the service for about a year, but was placed on a waiting list for nearly a year beforehand.

And as she watched her assistant, Delcie Birts, dust around her picture frames on a recent summer afternoon, she was unequivocal about her dependance on the program.

"I don't know what I would do without it," she said. "I couldn't stay here alone."

Reporter Mike Wynn can be reached at (502) 875-5136. Follow him on Twitter at @MikeWynn_CJ.