Ohio May Let Elderly Have More Control Over Their Care

By Jim DeBrosse, The Dayton Daily News

March 8, 2009

If home health care agencies can't find enough reliable, compassionate caregivers to tend to the growing number of elderly and disabled, why not pay clients to hire their own relatives or friends to provide their in-home care?

More than a dozen states, including Ohio, are exploring that choice as a way to head off a looming shortage of home health aides and to help control skyrocketing Medicaid costs for nursing home care.

Home care typically costs less than a third of what states pay for nursing homes. But at current wage scales of $10 to $12 an hour, the turnover rate among home health agency staff is high — 90 percent of aides leave their jobs within the first two years, according to the Institute of Medicine.

Would friends and family do a better job while also saving states hard-pressed Medicaid dollars?

Initial reports from states that allow elderly clients to hire and fire their own in-home workers, including family and friends, suggest it may be one solution.

In a 2006 report, Arkansas found it reduced nursing home admissions 18 percent over a three-year period through a program called Cash and Counseling. The program gives elderly clients the option to employ their own caregivers, direct their own mix of services and pay aides through a budget they control. Case managers advise clients and monitor care.

While the program raised the state's costs for in-home care, higher costs were offset by savings in reduced nursing home admissions and other long-term care costs, Arkansas found.

Cash and Counseling, a joint program of the Robert Wood Johnson Foundation and the U.S. Dept. of Health and Human Services, is now being tested in 15 states, including Michigan and Kentucky.

Ohio launched its own version of Cash and Counseling in 2001 and expanded it again in 2004. Currently, the Choices Home Care waiver program serves 390 clients in Columbus, Toledo, Marietta and Rio Grande. Judy Patterson, who oversees the program for the Ohio Department of Aging, says it has been a success, especially in rural areas where home health agencies are harder to find and for clients who require split shifts or odd hours for their care.

Whether the program is expanded to the rest of the state depends on what happens to the next biennium budget, which legislators will vote on in June, department of aging officials said.

For the past decade, Ohio has been struggling to shift more of its frail elderly and disabled away from nursing homes and into lower cost alternatives such as assisted living and home care. In 1995, 90 percent of Ohio's long-term care recipients were living in nursing homes. By 2005, that percentage had dropped to 65 percent. The Ohio Department of Aging estimates the shift has saved Ohio taxpayers $1 billion.

But Ohio lags behind other states that are moving much faster toward giving people choices in home and community-based care. According to a study by the AARP, Ohio spent 30 percent of its Medicaid dollars on alternatives to nursing home care in 2007, ranking 39th among states in providing home- and community-based care.

States like Oregon and Washington that have long advocated a variety of care choices for the elderly spend more than 60 percent of their Medicaid dollars on nursing home alternatives, including adult foster homes and group facilities as well as home care.

Gov. Ted Strickland and Department of Aging Director Barbara E. Riley recently put Ohio's legislators on notice that they want to accelerate the state's shift from institutional care. In an address Thursday, March 5, before a subcommittee of the Ohio House Finance and Appropriations Committee, Riley said her agency is dedicated to "real long-term care system reform that will achieve a better balance between home- and community-based services and institutional services."

The administration is pushing for a unified long-term care budget that would eliminate the spending caps for assisted living and in-home care while unlimited funding is available for nursing home care. Instead, Riley said, "the premise of (the unified budget) is that services are available to the consumer based on their need and their choice, not the funding stream."

If approved by state legislators, a unified budget would end the waiting lists for in-home care and assisted living for both the frail elderly and disabled citizens of all ages, she said. Putting the full range of long-term care services on an equal footing could save the state up to $900 million in Medicaid spending, she said Friday, March 6.

In the current economy, Riley said the state has no plans to increase Medicaid payment to home health aides. "But if we're able to reduce long-term care spending up to $900 million, then the money becomes available to do things like raise the amounts of payments" to caregivers.

Riley laid out the challenge in her testimony to the finance subcommittee. "With very limited resources, we must continue to serve frail and vulnerable Ohioans while retooling to address the changing needs and expectations of the burgeoning baby boom generations."

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