One of the most important public health findings over the last several decades has been that there are a number of factors, beyond medical care, which influence health status and contribute to premature mortality. Of these factors, social circumstances and the physical environment (particularly the home) especially impact an individual’s health.
Housing takes on even greater importance for older Americans since they spend a significant portion of their day in this setting. Ensuring a safe, age-friendly home and utilizing the home as a potential site of care for seniors should be seen as important policy objectives to support care management.
By 2030, 74 million Americans, representing more than 20 percent of the overall population, will be 65 years of age or more. Absent a comprehensive and sustained national response, the well-being and safety of millions of older Americans will be jeopardized by the following realities: increased demand for expensive long-term services and supports (LTSS), a high prevalence of chronic disease, grossly inadequate retirement savings, and a severe undersupply of affordable and suitable senior housing.
Healthy Aging Begins At Home
One set of possible solutions to these challenges requires greater integration of America’s health care and housing systems. A growing body of evidence is showing that more tightly linking health care with the home setting can reduce the costs borne by the health care system.
As an example, Vermont’s Support And Services at Home program, run by housing provider Cathedral Square, is demonstrating how housing—when combined with supportive services for seniors—can slow the rate of growth of Medicare spending. In addition, a recent study by the Center for Outcomes Research and Education in partnership with Enterprise Community Partners, Inc., found that Medicaid-covered residents who moved into affordable housing properties used more primary care, had fewer emergency department (ED) visits, and accumulated lower medical expenditures. Cost savings were highest for seniors and individuals living with disabilities.
Following are a set of opportunities to accelerate the integration between health care and housing for our nation’s seniors. These opportunities go beyond traditional Medicare’s home health care coverage and Medicaid’s coverage of nursing home care. Each involves key actors in the nation’s health care system: public and private insurers, health care professionals, and hospitals. (More detail on each of these recommendations can be found in a report released today from the Bipartisan Policy Center’s Senior Health and Housing Task Force.)
Publicly Assisted Housing
The Medicare program should increase its focus on vulnerable seniors for whom services at a home setting could yield improved outcomes and reduced health care costs. One population of focus should be the approximately 1.3 million older adult renters living in publicly assisted housing, the vast majority of whom are dually eligible for the Medicaid and Medicare programs.
More specifically, the Centers for Medicare and Medicaid Services (CMS) should solicit proposals from health care entities (e.g., accountable care organizations, managed care plans, and provider groups) willing to be accountable for quality, health outcomes, and total costs of care for Medicare beneficiaries in publicly assisted housing. Applicants would have to partner with a large housing property or a network of housing organizations within a particular service, or “catchment,” area to achieve the volume of participants necessary to conduct and evaluate the demonstration.
Eligible applicants would ensure the delivery and coordination of health care, LTSS, and preventive services and wellness programs within a congregate housing setting, using housing-based service coordinators and evidence-based models or programs that have a track record of helping beneficiaries remain in their homes and reducing health care utilization.
Eligible applicants would receive advanced payments (e.g., an amount per beneficiary on a monthly basis), which they could use to make important investments in their care-coordination infrastructure—including financially supporting housing-based service coordinators—and to provide the models and programs described above. The demonstration would look at health outcomes and costs over a five-year period and match participants with comparable control groups. Any realized savings would be shared among participating entities and partners, including Medicare and Medicaid.
Approximately one in three older adults fall annually, resulting in approximately 2.5 million ED visits, 700,000 hospitalizations, and approximately $34 billion in health care costs. Falls are the leading cause of injury-related death in older adults, and most falls occur in the home setting.
The nation, should strive to reach the Healthy People 2020 goal of a 10 percent reduction in the rate of emergency-department visits due to falls among older adults. There are several ways to further orient federal programs toward falls prevention and make this a top priority:
- CMS should clarify with providers that falls risk assessments are a mandatory element of the Annual Wellness Visit, as are referrals to falls-prevention programs for those found to be at risk for falls. CMS should also ensure that measures related to falls prevention are embedded in all of its quality-measurement programs. Quality measures should go beyond screening for falls, as is currently required of accountable care organizations, and also include quality measures that reduce the actual incidence of falls. In addition, CMS should ensure that falls prevention becomes a key part of the next scope of work of its Quality Improvement Organizations.
- States, through state plan amendments to their Medicaid programs, could ensure that evidence-based falls-prevention programs in the community are provided and reimbursed. If the programs reduce falls-related health care expenditures by senior dual-eligible beneficiaries, consideration should be given to sharing any Medicare savings with state Medicaid programs.
- Congress should authorize a new Modification Assistance Initiative (MAI), administered by the Administration for Community Living, that would work on an interagency basis to coordinate federal resources available for home modifications central to falls prevention.
- The Centers for Disease Control and Prevention (CDC) should help states collect improved epidemiological data to target provider training to regions with high fall rates and ensure that community-based falls-prevention programs are available in localities where there is the highest need.
Health Risk Assessments
Beyond preventing falls, the Medicare program has an opportunity to identify additional health risk factors that may exist in the home through health risk assessments (HRA). CMS requires Medicare providers to administer HRAs as part of the annual wellness visit. HRAs are also commonly used by Medicare Advantage plans and are occasionally administered in the home.
With respect to Medicare Advantage plans, CMS does not require utilization of a specific HRA but, in its 2016 Medicare Advantage Final Rate Notice & Call Letter, strongly encouraged plans to adopt recommended best practices for in-home assessments, including components of a model HRA developed by CDC. Though CDC’s sample HRA included important questions on health behaviors, activities of daily living, and self-reported biometric measures, it did not include questions related to housing and/or LTSS. CMS should encourage all providers, but specifically Medicare Advantage plans, through questionnaires or in-home visits, to include assessments of the home in HRAs to enhance optimal aging in place.
Money Follows the Person
For the first time in 2013, the majority of Medicaid LTSS spending ($146 billion) was devoted to care in home- and community-based settings instead of institutional care. Congress has supported rebalancing Medicaid LTSS in several ways over the last decade, most recently, through the Affordable Care Act, by extending the Money Follows the Person (MFP) initiative.
As of December 2014, the MFP has helped states safely transition nearly 52,000 institutionalized Medicaid beneficiaries to community settings in over 45 states. While the majority of those transitioned are younger individuals with disabilities, approximately 37 percent have been older adults. The last year states can request MFP funding is 2016, though they will have until 2018 to transition beneficiaries from long-term institutional care and until 2020 to use these funds to support participants in home- and community-based settings. It is estimated that a significant number of senior nursing home residents could still be transitioned into communities if the MFP continues beyond its current funding cycle ending on September 30, 2016.
The program should be extended and funds appropriated at a level similar to previous years until a decision is made whether it should become a permanent part of the Medicaid program. This will ensure that states continue to build the necessary infrastructure to allow an older adult to transition from an institutional setting to a quality and stable community-based arrangement. To determine the appropriate funding level, analyses should be conducted to demonstrate whether transitioning beneficiaries from institutionalized settings to community settings results in cost savings to the Medicaid program.
Medicaid Coverage of Housing-related Services
The federal Medicaid program currently pays for housing in the form of nursing homes, but it does not otherwise allow capital funding for supportive housing and it does not pay for room or board. In a recent Medicaid Informational Bulletin, the agency laid out a number of opportunities through which states could be reimbursed for providing housing-related activities and services.
Medicaid should gain comprehensive knowledge of how each state is currently using these various opportunities and to what extent older beneficiaries—specifically beneficiaries dually eligible for Medicare and Medicaid who are at risk for institutionalization—are eligible to utilize these services. Not only should Medicaid track this information, where possible, it should also seek to quantify the impact of these services on beneficiary outcomes and health costs.
In addition, states such as New York are using their own Medicaid dollars (nonfederal) to pay for newly constructed supportive housing units and subsidies for use in existing units. Medicaid should ask states that pay for housing using their own dollars to evaluate their respective interventions and share data on beneficiary health outcomes and potential cost savings. This information could help inform policies of other state Medicaid programs as well as future federal Medicaid policy with regards to the coverage of housing-related services.
Preventing Hospital Readmissions
Medicare pays for more than 14 million hospital stays annually. Each hospital discharge offers an opportunity for health care personnel to inquire about aspects of housing that may impact a senior individual’s recovery at home. Hospitals should begin to more explicitly incorporate questions into their discharge process regarding both housing stability and falls risks. These issues are all the more important given that Medicare reimbursements to hospitals are now impacted by 30-day readmission rates.
Community Health Needs Assessment
In addition, the nearly 3,000 nonprofit hospitals across the country could take a larger role in assessing the housing of seniors as part of their community-benefit obligations. Specifically, the Affordable Care Act requires hospitals to file community health needs assessments to maintain their tax-exempt status with the Internal Revenue Service (IRS). Hospitals that uncover a lack of senior housing options in a community should consider working with partners such as city housing and planning commissions to address this issue as part of their community implementation plans.
The Path Forward
The ideas above serve as strong examples of how the health care sector could better take into account the home setting to optimize health outcomes and reduce health care costs for our nation’s seniors. These are not the only opportunities.
For example, CMS and state Medicaid programs should encourage greater reimbursement of telehealth and other technologies in the home that have the potential to improve health outcomes and reduce costs. In 2014, reimbursements for telehealth accounted for less than $14 million out of the more than $600 billion spent through the Medicare program. The shift away from fee-for-service payment toward value-based delivery and payment models represents a key opportunity for broader integration of telehealth.
Another opportunity involves the nationwide scaling of the Independence at Home demonstration to support home-based primary care for frail Medicare beneficiaries. Finally, greater use of bundled payments for care of asthmatics could support funding of home remediation services that remove triggers for asthma.
Many health care entities around the country realize the importance of factoring the home setting into a patient’s care management plan and seizing opportunities to utilize the home as a site of care. Taking this knowledge and using it to reshape health and housing services could have an enormous, positive impact in the lives of millions of Americans through reduced costs and better outcomes.