Meeting the Health Care Needs of an Aging Population

0:04

Hello everyone and welcome to today's webinar, Meeting the Healthcare Needs of an Aging Population. Before we get started, I would like to go over a few items so you know how to participate in today's event. You've joined the presentation listening using your computer's speaker system by default. You will have the opportunity to submit text questions to today's presenters by typing your questions into the questions pane of the control panel. You may send in your questions at any time during the presentation. We will collect these and address them during the Q &A session at the end of today's presentation.

0:39

I would now like to introduce Kathryn Santoro.

0:43

Kathryn?

0:44

Thank you. Hello, I'm Kathryn Santoro, Senior Director of Programming at the National Institute for Healthcare Management Foundation. On behalf of NIHCM, thank you for joining us today for this discussion on meeting the care needs of an aging population. This webinar is part of NIHCM's Affordability Roadmap Webinar Series, where we're sharing research and expert perspectives on solutions to our nation's health care affordability crisis.

1:13

Previous webinars have covered the impact of health care consolidation on costs and quality, as well as the impact of escalating health care costs on the federal budget.

Today we'll hear from a prestigious panel of experts about how we can improve health outcomes for older adults while also ensuring equitable, affordable access to care. You can find biographical information for our speakers along with today's agenda and copies of their slides on our website. Copies of the slides are also in the handouts panel. We also invite you to join the conversation on social media using the hashtag #AgingandHealthcare.

1:55

I am now pleased to introduce our first speaker, Dr. David Grabowski, a professor of health care policy in the Department of Health care Policy at Harvard Medical School. His research examines the economics of aging with a particular interest in the areas of long-term care and post-acute care. We're so grateful to have him with us today to share his research and perspective.

2:20

David?

2:22

Great, thank you, Kathryn. It's really nice to be here with everyone and thanks to the NIHCM team for including me today. So I wanna speak directly, we have a broad topic today of meeting the healthcare needs of an aging population. I really wanna drill down and think about how we can meet their long-term care needs.

2:43

Let me start with just some data at a high level. We spend a lot of money in the U.S. on long-term care services. You can see there these are data from Kaiser. We spend over $400 billion annually on long-term care services. Most of that goes to where individuals want those services in the home and the community. And you can see they're in purple, most of those dollars are public dollars. They come from Medicaid. However, when you stack up the US against other countries, we don't look so great. We actually lag behind a lot of other countries in terms of public spending. Now, this is an overall spending.

3:25

But you can see, if you look down quite a ways on this list, usually the US, when it's health care spending, we're at the very top. Here, we're not an outlier. We're an inlier right there between Portugal and Israel. It is really countries in Northern Europe that are spending a lot of the dollars on long-term care. What we ultimately do is place a lot of this burden on families spending out of pocket, and we know these services are not cheap, and you can see here these are once again data from Kaiser. You can see the median income for a Medicare beneficiary. It doesn't take long, as many of us know, from our own families, whether it's assisted living, home health care, nursing home care, you very quickly spend out your savings and end up qualifying for Medicaid.

4:22

How do we make this work in the US if we largely have Medicaid and then we have some out-of-pocket? We do this on the backs of families. And these are some data from the Society of Actuaries where you can see up at the top there, we spend over $4 trillion in the U.S. on health care, over $2 trillion on food, according to the AARP. If you add up the cost of all that family caregiving, it's over $1 trillion, which is larger than our defense budget. The National Academies has a smaller estimate for just older adult caregiving by families, it's about 500 million, which is larger than what we spend on formal launch from care services, entertainment, apparel, consumer electronics. So we get launch from care in this country on the backs of families. And when individuals need formal launch from care services, it's Medicaid or largely paying privately. So our system was going along And really, COVID lifted the veil on our long-term care system. One of my colleagues called it a crisis on top of a crisis.

5:34

The short-term crisis was obviously the pandemic. It was COVID. We had a number of deaths of individuals in long-term care settings. We had long-term care recipients being isolated, high rates of loneliness. We did a piece showing nursing home caregiver, nursing home staff was the most dangerous job in America during the pandemic with death rates exceeding any other profession in the US. We had many, many staff leaving the profession. And obviously we had declining admissions and occupancy.

6:08

So that's the short-term crisis. The longer-term crisis is what's below and that's our system. We largely rely on Medicaid. Medicaid is not a very generous payer of long-term care services. We often have poor quality of care, inadequate staffing, low pay, Jasmine's gonna talk later in this session about disparities, all too often our nursing homes are these big institutional buildings that look like hospitals that don't really deliver person-centered care. We have a heavily regulated model that often isn't very effective in meeting the needs of our residents. And then we have a lack of quality and financial transparency. It's hard to tell what level of quality is being delivered in these settings and how the dollars are being spent. And finally, we have large shares of for-profit owners, some of whom are private equity groups and real estate investment trusts. It's really hard sometimes to follow the money. So how do we fix all of these kind of this longer standing crisis?

7:15

And I would argue, I wrote a piece in Nature Aging a couple of years ago where I said, we can't think about this as let's abolish nursing homes and get everybody out in the community. For older adults, we're probably always going to need nursing homes. Even those countries that were at the top of the spending list like the Netherlands and Sweden and Norway, they have nursing homes. They just have much better nursing homes than we do. They're much smaller, they're much more person-centered.

7:41

So I would argue we need to do four things. And these are just the beginning of a list, but I think these are four core issues. First, we need to invest in home and community-based services. Second, we need to shift to smaller home, resident-directed nursing homes. We need to do away with these large institutional facilities. We need to invest in workforce across the board in all settings in terms of better working conditions, pay and benefits. And then finally, we need to do a better job integrating clinical care in these settings. So let me work through each of these quickly in turn.

8:19

So first, investing in Medicaid home and community-based services. I want to tell this in three pictures. The first is in the upper left. Once again, data, great data from Kaiser, showing that in 1995, we spent 18 cents out of every Medicaid dollar that we spent on launch from care went towards home and community-based care. That's up to 59 cents today. So we've made incredible strides in rebalancing our launch from care system.

8:47

This rebalancing, however, has not been uniform. You can see that in the upper right in the map there. The darker shades are those states that have more heavily invested in home and community-based care. The lighter shaded states are those that are lagging behind. And then in the bottom, you can see, And we have a 700 ,000 individuals and there's probably a lot more individuals who aren't on waiting lists or on interest lists that need and would benefit from home and community-based services. So there's a lot of excess demand for these services. How do we fix this?

9:23

We need more funding. There was talk following the pandemic of $400 billion for home and community-based services. Those dollars never came to fruition. We definitely need to redouble our efforts in terms of additional funding. I would also argue we need more resources in helping older adults to navigate and access these services. I wrote a piece in The Hill with Ann Tumlinson and Bob Kramer about our system basically being a road to nowhere. We don't have enough dollars in home and community-based settings, and we don't really know how to navigate the car to the services that are there.

10:02

So a lot of work left to be done with HCBS. Transitioning to nursing homes, I put up some pictures here of the greenhouse model, which is one of the small home models that's out there. If you can believe it, all of these pictures are of greenhouse models around the country. In the upper left there, that's not just a neighborhood, that's a nursing home, if you can believe it. And we have greenhouses, these small home models where eight to 12 older adults are living in a community in rural, suburban and urban areas. And you can see in the middle panel there and the upper right, the table in the kitchen where older adults in a greenhouse model eat their meals together.

10:51

They have their own rooms where if you wanna enter their room, you knock on the door and it's their space and then in the bottom right, individuals navigating. Lots of data suggesting there's a higher quality of life. This is what residents really want. They want a more home-like setting, a smaller setting where it really feels like they're not living in an institution under someone else's rules. This is associated with a higher quality of life. We've done some work on greenhouse suggesting there's also a better quality of care and lower Medicare spending.

11:27

There are some savings there. Greenhouses is the largest small home model, but it's not the only one. There's certainly other models out there. We have very few of these homes. We have 15 ,000 nursing homes in the U.S. Very few, you know, a couple hundred might be considered these small home models. So a lot of work left to do to transform this. You can believe it, HUD, Housing and Urban Development, does back a lot of the loans, the capital that flows into nursing homes. We hear a lot about private equity.

11:58

HUD is actually the big backer of a lot of these loans. I won't get into the weeds here on our recommendations, but we wrote a piece earlier this summer suggesting HUD is falling short right now in terms of how it might encourage greater innovation in terms of these small home models, private rooms. There's all sorts of innovations that HUD could really encourage. However, they haven't, and there's work there to be done. Transitioning then to workforce. We need workers across the board. This was true before the pandemic. These are just nursing home staffing data. And we did a paper in 2019 showing that most nursing homes are below what CMS would expect based on their acuity-adjusted levels. You can see we need a lot more staff to encourage safe and high quality care. We lost a lot of staff during the pandemic, over 400,000 workers left. We've seen an uptick here, and so we're almost back. We're about 84,000 workers below what we were pre-pandemic.

13:10

So we need to continue to grow this workforce. How have nursing homes and other long-term care settings maintain their staffing? They've done it by foreign born staff. So we did a paper, Kate June and I showing that although we lost a lot of native born workers in nursing homes, foreign born workers actually largely stayed in the sector. And then this won't surprise anyone in another piece we did earlier this year. We had to turn to a lot of contracted agency staff. So we didn't have permanent staff, which would be associated with a higher quality of care. And so we had to, many nursing homes had to go out and get those contract workers.

13:53

How do we fix this? I wrote a piece in 2021 in Politico, nursing homes need fixing. Here's where to start. This is always to me, like, you know, two thirds of all spending is on labor. This is where you need to actually make this investment. It's better pay and benefits. We're going through a minimum staffing standard right now at the federal level that's been introduced and currently in place.

14:21

So the administration actually listened to that idea. We need higher reimbursement rates and accountability that those rates are gonna be directed towards staff. We need to provide career advancement for workers, a better place to work, a better working environment. And then obviously we need to increase immigration. And these aren't either or, we need to both increase pay and benefits and immigration to make sure this is a job worth having. Finally, this issue of investment in clinical care and long-term care settings. It's not just that we have an underinvestment in long-term care, it's that we have a fragmented reimbursement system where you can see there in the middle, most individuals in post-acute and long-term care settings, their care might be covered by Medicaid, but Medicare is covering all of their healthcare services, the physician services they're receiving, any time they go to the emergency department or the hospital.

15:16

And then potentially, you know, Medicaid and Medicare are bumping up against each other. And we see this a lot in terms of the quality of the clinical care that long-term care recipients are receiving. The canonical example of this issue is really clinical coverage in nursing homes, especially off hours. If you go in a nursing home in the evening or the weekend, there's not a lot of clinicians on site. This can result in trips to the emergency room, where if there's a call, a resident short of breath with a fever, call her physician.

15:56

This physician could come by and see them, could kind of work over the phone, but in In all instances, this physician is often transferring the resident to the emergency room and then they're getting admitted to the hospital. One solution here, and there's a lot of them, nurse practitioners, more clinicians on site, RNs, et cetera. One idea is the use of telemedicine. And telemedicine, obviously, rather than making that call to the individual's physician, now you're looking eye to eye with the physician.

16:34

There's an RN by the bedside there, helping facilitate a two-way video conference. The idea is this kind of intimacy through a video conferencing can prevent some costly transfers. And at least pre-pandemic, this wasn't covered. And so Medicare only covered this in rural areas. If you're an urban nursing home, you would have to pay for this yourself.

17:00

So we actually partnered with a nursing home chain here in Massachusetts, and they actually rolled out a randomized telemedicine intervention. We found amazing results by having that telemedicine intervention off hours rather than the traditional call to the covering physician. We prevented quite a few hospitalizations, which generated $100,000 per nursing home annually in Medicare savings, whereas the telemedicine service costs about 30,000. You don't need a degree in economics to figure out, hey, that's cost effective, that's really exciting.

17:43

So I was out trumpeting this result, presenting it at meetings. Meanwhile, the nursing home was sort of stewing on this. They said, wait a second, We're making the investment here, 30,000 a year, $100,000 savings to Medicare. They ended up discontinuing the program shortly after we generated our results. They didn't want to pay anymore to save Medicare money. That's really the disconnect that we're dealing with here in this area with this fragmented coverage.

18:15

The nursing home is receiving Medicaid dollars or private pay dollars, but Medicare is the one that's saving money when hospitals are prevented. And that's obviously any kind of investment here in clinical care, given that wrong pocket problem, if you will, is gonna be limited and unsustainable. How do we solve that? There are some models out there, and I'm gonna throw alphabet soup now at you, whether it's the PACE program, a lot of the different special needs plans or SNPs. There was also the financial alignment initiative for duals.

18:49

Lots of models out there. And these models actually account for a pretty small share overall of all individuals who are duly eligible in long-term care settings. They're still just a drop in the bucket. I wrote a piece in NIEJM last year where I argued that there's ways that we could actually fix this, whether we passively enroll individuals into these models, improve the alignment between Medicare and Medicaid, and convert some of the models that work very well like a traditional dual eligible special needs plan to one that's fully integrated.

19:25

We need to improve our data and measures that evaluate these programs and we need to move towards a more unified approach that is not that alphabet soup in terms of that that list. So to sum up here, there's a lot of work left to be done to meet the needs of aging Americans. I would argue four important areas are one, we need to grow home and community-based services. Two, we need to transform our nursing homes that are out there. Three, we need to invest in the workforce across all of these settings.

19:56

And finally, regardless of setting, we need to invest in clinical care. I'll stop there and say thank you and look forward to questions and comments. Thank you, Kathryn.

20:05

Thank you so much, David, for sharing these strategies. Next, we'll hear from Dr. Jasmine Travers, and assistant professor at NYU Rory Myers College of Nursing. She's one of a few researchers with expertise in health equity and health services research at the intersection of nursing home research, long-term services and supports and workforce issues. And we're so honored to have her with us today.

20:31

Jasmine. Rory, thank you so much, Kathryn.

20:34

I'm so honored to be here with this panel and follow David, who I work closely with as mentor and as a colleague. So today I'm excited to share with you some work that can help us understand how to dismantle structural inequities behind disparities in community living.

20:53

Next slide. I thought I'd start off with a story of how I came to this work. This right here is a piece that I wrote back in 2020 after a discussion that my brother and I had around planning for our mother's long-term care needs. My mother had just turned 70, and my brother wanted to talk about how we would navigate financing my mom's potential long-term care if she needed it in the future. He asked about Medicare, and I had to explain to him that Medicare doesn't cover long-term care needs.

21:24

And then he went to ask about long-term care insurance. But because of my mother's age, I told him how costly that would be with very limited benefit. Then we decided it was best to save. So we decided that we would have $100 per month saved across four siblings, which were total $400 on a monthly basis and equal to $4 ,800 per year, and we thought we were doing something.

21:48

But then when I looked at this in the whole grand scheme of things, it would have taken 10 years when my mom was 80 to be able to cover one year of a home health aid and to cover one year of nursing home care. We would have needed to start saving from when we were in my mother's womb. So to say that we, children who are educated, doing work in this space, and have the best intentions of planning for long-term care early, we're defeated after that conversation is an understatement.

22:16

And then I think about the rest of our country, those who are not studying this work and are facing a lot of structural barriers and how they are navigating staying in the communities that they want to stay in for as long as they should be able to stay in them for.

22:30

Next slide, please. 93% of older adults prefer to age in place in their own homes and communities, but despite this preference, many older adults end up in nursing homes unnecessarily due to unmet needs in the community setting.

22:57

Next slide. Particularly, a large proportion of users of nursing homes in recent years have been Black and Latino older adults, and unfortunately, these groups are most likely to experience disparities in these settings, such as increased pressure ulcers, increased antipsychotic medication issues, falls, and restraints, which leads us to the in-home study, which stands for identifying needs to help older adults maintain everyday community living through understanding unmet needs driving disproportionate and unnecessary nursing home placements.

23:38

In this study, we conducted 61 qualitative interviews with black, Latino, and white nursing home residents, family care partners, staff, and aging policy engaged partners to understand what black Latino older adults didn't have in the community, which drove their nursing home placement. What we found were seven categories of unmet needs. The first was assistance with activities of daily living and basic home maintenance, which includes challenges in getting assistance with meals, groceries, home health aid hours, homemakers, and social workers.

24:17

The second was challenges in resources or services, which included challenges in accessibility availability of resources, senior centers, for example, daycares and meal programs, and the complexity of insurance systems that David just talked about. The third is individual preferences, which was simply an individual's preference to not access some or all long-term services and supports because they just didn't want to have someone in their home, for example.

24:47

The fourth was equipped, available, and supported family, which included lack of knowledge on resources available to reduce burden for family care partners. Family care partners talked a lot about not even knowing what types of resources were available and how they might best care for their older adult loved one. The fifth was function of the home, which consisted of the accommodation of the home to meet the needs of the older adult, safety concerns, and the need for home modifications that would support the older adult to be able to live safely in that home.

25:19

The sixth was socialization, which included the need for companionship through means such as adult day centers, religious groups, and senior centers. And the last was treatment, which was specific to health treatment for the older adult and included lack of transportation to medical appointments, for example, scheduling difficulties for medical appointments and a shortage of skilled staff. As far as the root of these unmet needs leading to unnecessary nursing home placements, we found six policy-related structural drivers of these unmet needs, which included disproportionate access to services, disconnects between healthcare systems and communities, lack of age-friendly infrastructure, complex long-term care policy, financial burden, healthcare bias towards nursing home care.

26:10

Let's start with discussing disproportionate access to services. This was characterized by the lack of high quality services due to unequal distribution of services, workforce shortages, poor outreach, and lack of culturally tailored care. Here, a family care partner describes the lack of information provided to specific groups striving disproportionate access to supportive programs. This article further highlights disproportionate access in high quality home health agencies among Black, Latino, older adults because of structural and institutional barriers, such as residential segregation.

26:54

Next, driving a met needs is disconnect between healthcare systems and communities. This is in reference to lack of outreach of healthcare systems and other formal supports into communities to facilitate awareness and use of services and support. Also, lack of awareness on the health system side about what supports are already available in communities and how to direct people to them.

27:17

A policy expert stated, there's a challenge on our side, on the information and support provider side, that often we don't have the funds to do the kind of community outreach that we need. The adequate funding and funding cuts for agent services further creates challenges between healthcare systems and communities. Next is the lack of age-friendly infrastructure, which will be talked about in more detail next. But this is reflective of a desire to stay in the home and community setting, but the or community not being built to support the older adult in doing so or resources not being available.

27:54

This family care partner shared, we cannot make modifications. I mean, we rented and the landlord wasn't willing to make those changes. I don't know if the landlord would have approved it, even if the agency paid for it. I'm not sure that he would have wanted those modifications made. This table here additionally speaks to the specific housing challenges faced by older adults where 85% of AAAs reporting lack of affordable housing for older adults, 71% reporting unavailability of a long wait list for subsidized housing, 64% reporting increasing rents, which result in being priced out of long-term rental housing, and 63% report lack of accessible housing.

28:34

And next we have navigating complex long-term care systems. Our long-term care system, which David just talked about, is fragmented and disparate policies can lead to administrative burden, lack of coverage for services, and confusion as people try to obtain necessary care. A family care partner shared, there are always obstacles dealing with bureaucracy. You don't get direct answers and you have to have everything. There are very few communities or organizations that will put you at the right place. There's constant phone calls. It's very discouraging. You get different answers.

29:09

Next is financial burden of long-term care. The significant out-of-pocket costs of long-term care often make care in the community inaccessible. In regards to their older adult loved one, this family care partner shared, but she wasn't qualified to receive it for a discount or free, so it was so expensive. Here, we additionally see the burdens associated with financing long-term care, where four in 10 lack confidence they will be able to pay for necessary care as they age, including higher shares of Hispanic and low-income adults. And then right here, we see the realities of financial ruin, this idea of financial ruin being baked into the long-term care system.

29:57

And unfortunately, we lack an adequate long-term care policy and infrastructure because of challenges getting programs passed or the inadequacy of current programs. Finally, we have a health care bias towards nursing home care. Health care response during acute health exacerbations, for example, such as post falls, strokes, infections are often biased towards nursing home admission, this family care partner shared. Conversations with the social worker was basically kind of negatively received and pretty much advised that community living was not really an option.

30:35

So to get the care that he needed, he was pretty much confined to a nursing home. So where do we go from here? And David talked a lot about the policy interventions that we can think about, and I'll just go into some that he hasn't, but addressing both the long-term care financing and workforce issues, which David talked a lot about, strengthening financial assistant programs. So a lot of those who were in our study, they talked about not having access to different programs because they didn't have Medicaid, for example.

31:13

Allocating resources to community-based health and home-based care. So David talked also about different community-based care, such as PACE, a program of all-inclusive care for the elderly, but that is not readily available for people across the country and across the states. So how do we create more resources so more of those types of community-based care can be available to folks? Increased Medicaid covered hours of care, something that was significant among the groups that we spoke to is not having enough hours of home health aides, for example. So really providing more coverage for that. Prioritizing aging and place support, so creating neighborhoods that are conducive for older adults to live in and to experience life in. Implementing affordable housing initiatives.

32:05

There's a lot of housing burden among older adults that forces them into nursing homes because they cannot afford the houses that they are in. And providing home modification grants as well so that older adults can have the things that they need in their homes and be able to modify their homes in ways that will meet their needs. Providing diverse social engagement options. David also talked a lot about COVID and one thing that COVID did was, or during COVID, was a lot of shutdown of social programs such as adult day centers and senior centers. But this is very important for older adults where there are older adults who have just entered in nursing homes for socialization.

32:46

enhancing caregiver support and training. So making sure that we're really supporting our caregivers and providing them the knowledge and information that they need to provide the support that they do, but also respite support. David talks about telehealth services. Another big thing was transportation services that need to be readily available for older adults so that they can get to their appointments and get their medications and get their groceries, for example, and then measuring impact.

33:14

So as we're putting different things in place and measures and interventions, really understanding what's working and for whom so that we can make the necessary changes. I just wanna share with you, I bring to your attention, the ARP Long-Term Services and Support Scorecard, which this scorecard looks across five dimensions to measure state-level long-term services and support system performance from the viewpoint of users of services in the family. So you can look at this scorecard, whether you're in one of these states, whether you're a policymaker, a policy official, state official, whoever, clinician, researcher, and understand how a specific state is doing across five different measures, which I'll go into in a bit.

34:02

And you'll be able to see where you rank overall as far as your performance and long-term services and supports. And then you can identify what areas in which you're struggling in so that you can say, Okay, this is where we need to put our funding or put our time and resources to to improve and then also see what states are Doing well in other areas that you may not be doing well in and can use those states as a resource So I'll just go over the dimensions of This scorecard so it has five dimensions That really nicely kind of draw in some of the met needs that I talked about The first one is affordability and access, which measures affordable services that older adults have access to, ensuring that they have a strong safety net and equitable access.

34:54

It measures a dimension specific to choice of setting and provider. So do older adults have consumer choice? Is there a skilled workforce available to them measuring shortages? And then is community-based care equitable? And then it measures quality and safety. So are older adults getting respectful care? Are their preferences being honored? Are they having safe settings? And then are disparities reduced? And we talked about some of the disparities that specific groups are experiencing in different settings.

35:29

And then support for family caregivers. How well caregivers are supported? How well caregiver burden is being limited? and then also how culturally competent the support that is being provided is. And lastly, there's a dimension on community and integration which talks about the accessibility of services such as housing, if communities are age friendly and then if these communities are equitable. So this is something that I would urge you to consider looking at this scorecard and seeing how your state's fair in this and just kind of think about also some of the different policies and programs that are being introduced.

36:10

David talked about the minimum staffing standards that CMS recently introduced and the need to continue to advocate for those to support our workers. But then also there are some other programs that are being introduced, such as the state master plans on aging, which is looking to provide funding for many states to create a master's plan on aging where you can identify where your state might need to focus on when it comes to this long-term services support system, as well as other programs that focus on the workforce particularly. And then finally, this is just an image that I took early on in the pandemic when Mr. George Floyd was murdered, and this is a time when older adults was not supposed to be outside.

37:00

That was a death sentence if you've seen an older adult outside. And then I was riding my bike and I saw these older adults, they were protesting and I thought that this was one of the greatest acts of solidarity that I've seen, just seeing how these older adults were risking their lives for the lives of other people. So with that, I just end off saying older adults don't want to stop living even though they might need help with living. Thank you and pass it on over. Thanks so much, Jasmine.

37:32

And our final speaker today is Dr. Heidi Syropoulos, a physician leader with strong experience in complex chronic care management and working with clinicians and payers alike to maintain quality and cost measures. She is the medical director for Independence Blue Cross's Medicare Advantage plans.

37:53

And we're so grateful to have her with us today. We've heard a lot about caregiving and we're excited to hear more about their program. Great. Thanks, Kathryn. Next slide.

38:19

So what I'm going to be talking today really is the title is the lessons from our successful Medicare Advantage program. Really, I could talk for 30 to 40 minutes, but of course I've got 15, so I've consolidated and decreased the slides that I would normally present. So it's really a snapshot into our caregiver support initiative that we started about a year and a half ago through our Medicare Advantage plans. But before I even get into the caregiver initiative, I want to talk about what prompted us to start. What was the history behind our interest in providing and starting a caregiver pilot?

39:04

So, I really want to mention what an age-friendly health system is. In 20, you know, I came to the plan in 2016 after I had practiced geriatrics for 30 years. It was an interesting transition to going from taking care of individuals to now taking care of groups, trying to figure out how I could navigate within this system, and figuring out what was my clinical vision for the Medicare Advantage plans as the medical director for Medicare in our health plan.

39:36

And in 2018, there was really a groundbreaking article published in my trade journal, the Journal of American Geriatric Society, that talked about an age-friendly health system, new model of care called the 4Ms. This comes out of the necessity and the urgency of the United States where we see we're currently living in what many people call the silver tsunami. We're just a burgeoning elderly population that continues to grow in the United States, not just the U.S., all of the Western countries. And we really don't have a concise and simple model of care that can meet the challenges of caring for this growing population.

40:21

They set about and did a study and involved five premier health, very large health systems that looked at this model of care with the intent that following an essential set of evidence-based practices caused no harm and actually aligned with what matters to the older adult and their caregivers.

40:45

And then those four M's essentially are what matters, medications, mentation or your mind, which include screening and treatment for depression, delirium or dementia, and mobility. The three bottom M's, medication, meditation, and mobility, really are meant to be addressed and managed across all sites of care, but always in the context of what matters. So really the fourth M of what matters is really the most important.

41:19

Does the patient and has the patient had a conversation with their caregivers and their providers as to what's most important to them? Have they completed advanced care and planning documents? Had they talked about their goals of care? So this article really just was from the perspective of providers, doctors, practices, hospitals, nursing homes. But what about health plans? When I read that article, my first thought was, well, but the health plan and the payers really need to be invested in this age-friendly health system, in particular, Medicare Advantage Company, of course.

41:54

And the rationale, even more importantly, for independence, for focusing on the forums, is that 49% of our population is over the age of 75. It is true that Medicare, since its inception in the 60s, has improved in terms of chronic condition management for our older adults. We've gotten better at controlling blood pressure and decreasing stroke prevalence. We've gotten better at prevention in some ways, improving vaccinations, managing diabetes, and chronic illnesses. But almost half of HEDIS and CMS star ratings exclude people over the age of 75. And star ratings are essentially silent on the management of syndromes of aging.

42:39

So as a result of this, IBX takes this model of care very seriously. We've identified ways to enhance management of advanced illness. advanced care planning, focusing on ways to deprescribe, and caregiver support, along with other elements of geriatric medicine. We consider that defining that what those principles that define age-friendly health plans for independence members is that we feel that we should be accountable for the alignment, financing, and outcomes of a geriatric model of care.

43:16

It should be based on the forums of age-friendly care, should be economically viable under Medicare payment, focused on patient choice and quality measurement, and we recognize that for geriatric medicine, having a dedicated and loving caregiver is a key factor for good health. So how did our caregiver support start? It really started in a post-acute program that we started in, I wanna say 2021, my vice president for stars and risk adjustment contacted me and said you know we've been reviewing our mock cap survey results and we found that the members who rated us the worst in the health plan and in particular in the measure that asked patients when you needed care the most did you receive it those members who rated us the worst had all been either admitted to the hospital or in a sniff in the last six to 12 months and he said does that make sense to you and I said well Yes, definitely.

44:17

Coming out of the hospital or coming out of a nursing home is a tremendous pain point for a patient. So we internally designed our own post-acute care program. It included case managers outreaching to everybody who'd been in the hospital or the nursing home, having a handful of utilization management nurses at some of our high-volume SNFs, and also creating quality scorecards for our home health agencies and SNFs. but in part of that post-acute care program was born our initiative and a relationship with our vendor called Caralel, who we offered caregiver support to our members from.

45:00

So the pilot started in 2023, and that first pilot, as I mentioned, was really offering caregiver support only to those members who were in our post-acute care initiative. They'd been contacted by case managers or they received a flyer in the mail. Year two, which is now seven months old, we have expanded that target membership to include all members who are enrolled or engaged in case management and any member who has a diagnosis of dementia. Additionally, we introduced a pre and post assessment to measure impact on burden and resilience. The burden scale is the Zaret burden scale that goes from 0 to 16.

45:47

A high Zaret score would be 8. Our pre-score for our caregivers was 10.5. So highly burdened caregivers. Post-scores were down to 7.2. So we clearly had a measurable impact in burden. Resilience is measured by a Connor Davidson scale, which is on a scale of 0 to 10. It's really a scale that measures people's ability to cope under stress, a national average of anybody, even if you're not a caregiver, that score is about seven.

46:21

And the lower the score, the less resilient you are. Our pre-caregiver support scores were like 5.5. And post, they were up to 6.5, close to the national average. So what does Carallel do? Three broad and general things that they offer, solutions that they offer. One is what we call expert advocates. These are people that talk on the phone with members and assist them with a variety of different things. Then we have what we call intuitive digital support. This is a platform that people can contact and chat online if they prefer to text in that regard. And then they engage caregivers in a third way, having offering webinars, offering virtual support groups. They send content kits for social media and things like that.

47:23

This slide actually is a composite slide that looks at Carallel's overarching outcomes from many different Medicare Advantage plans. Much of this was found to be the same within Independence Blue Cross. The need, 62% of seriously ill members really rely on family caregivers. The average burden score for caregivers was 9.5 for Carallel. Of course, with IBX, we were actually 10.5, so our caregivers were far more burdened. A significant percentage of caregivers have never even heard of palliative care.

47:59

In terms of the experience, this really was the same for IBX as it was for any of the other Medicare Advantage plans that Carallel has contracted with. Noticed a significant increase in confidence amongst our caregivers, a decrease in feelings of isolation, and then that promoter score for their entire book of business is 87. For us, it's actually 91. When caregivers engaged with Carallel, they were highly engaged and really loved the support. In terms of impact, we don't have enough caregivers at this point in the initiative to be able to make a comment on costs, but it is fair to say certainly 75% of our end users also connected to benefits and resources. This gives you an idea of the growth. Who were these members?

48:53

Give you a sense when our case manager's calling members who've just come out of the hospital or anything.We're talking about an outreach of maybe 9 ,000 to 10 ,000 members in a year. A significant number of these people don't have caregivers or they don't perceive that they have a caregiver. Once they do have caregivers, it ranges and it varies from case manager to case manager. Some case managers report about 20% of their members want to be connected to Carallel and other case managers say about 80% of their burgers want to.

49:28

So there's some variability there. We have had about 370 total caregivers that have been involved in the initiative since the beginning, and we average about 84 users per month. Probably the nicest outcome we see here is that once you're engaged, there's at least 12 interactions per user. And this comment in the bottom right here about actions per case, what that's referring to is what are the actions that the advocate, either through texting or telephonic, is assisting the member's caregiver with.

50:05

Those are things like addressing complex emotional burdens, delivering education on disease and management, referring to a fitness program to address social isolation, connecting to virtual support groups, assisting with advanced care planning documents, things like that. We divide those action groups into three main categories. One is what you might call the emotional. That's, you know, talking about self-care, assisting with relationships within the family.

50:39

Another category would be called expense, which is really talking about home safety, home modifications, getting information on housing options, things like that. And another category, what I would be calling advocacy, which is essentially managing diseases and assisting with advanced care planning. So in the end, I would say we've learned a variety of things from the initiative. We've learned that engagement really comes either telephonically or it can come from mailers.

51:12

The majority of our members, caregivers, actually 66% of them do not have our health insurance. We've learned, and actually, 13% of the members who are caregivers for themselves, actually. They have no one at home and they have no children. We learned that we're able to decrease burden and increase resilience with a caregiver support program like this.

51:38

And we've also learned that the program really can impact and improve the number of personal representative request forms, those HIPAA forms that are so needed for the health plan to be able to communicate with a caregiver, and also it's really improved the completion of advanced care planning. We've learned that post-acute care participation caregivers really are engaged during very intense caregiving moments, and that dementia caregivers have skewed, at least initially, to early-stage engagement.

52:14

And, finally, I would say we've learned there and confirmed, and I think we all know this, but we've really confirmed that there are multiple barriers which create really stressful caregiving, and the top three really are lack of awareness of community resources, ignoring one's health, and, of course, the worst is being able to afford caregiving. Thank you.

52:43

Thank you, Heidi. We're going to go into our Q &A session. So I'm going to ask all of our speakers to come back on camera and off mute. And Heidi wanted to just start with a quick follow-up question for you. Someone asked if you could talk about the average age or the age range of the caregivers that you have found through your work. Oh, yeah, that's a good question.

53:12

They're, I don't have an average age, but the range is from someone who's actually a teenager all the way up to someone who's in their 90s. So we have people who are spouses who are taking care of their members. And we have young, very young adults who are assisting. Good question. We have another, this is a technology-related question. I know a few of you touched on telehealth. This person in the audience said, I haven't found telehealth to be senior-friendly, but is there anything being done to make this technology more senior-friendly?

53:58

You know, I think David, you had kind of mentioned maybe the having the help in the nursing home with using telehealth, Heidi, you might be able to talk too about, you know, people being able to use the digital tools that you have as well. But our experience is that it's, we can divide people into two groups who can use, those who can and those who are learning. And there are some people that are really reticent about it, using it, who actually know how to use it, but really just don't like using it.

54:35

Older adults, and I'll give my mother as an example, who passed away a couple of years ago, she wanted to do everything in person. This is really still in that generation of seniors who are over the age of 80, I would just say, they want to do things in person. She didn't want to use an ATM card. She wanted to go to the pharmacy and look the pharmacist in the eye. She didn't want to use mail order pharmacy, even though it was cheaper.

55:00

So there is this sense that there is a need for a connection. Part of it is because people were lonely at home, but part of it is just that was their world. They just didn't work. So there are many seniors that can use technology, but they're not accustomed to it. And they need assistance getting set up. So they turn to their grandchildren.

55:20

But my sense is that those systems that work the best, for example, Dr. Grabowski's commentary on telemedicine in the nursing home, where the nurse is there, I mean, then it works really, really well. Kathryn, if I could just jump in as well, we saw this play out exactly like Heidi described during the pandemic where CMS loosened the rules here in the US and allowed telehealth views broadly. And initially in 2020, we saw this massive spike.

55:52

And I think a lot of people thought, oh, the floodgates have opened. This is a brand new world, we're never going back. And then sure enough, to Heidi's point, People like being in person with their doctor, especially when you're 80 or 85. And so most return to the, we are above where we were pre-pandemic, but it's not nearly at those levels we were at 2020. Things really kind of came back to earth, if you will.

56:17

Jasmine, do you want to add anything based on your experience and kind of just, I know we face a lot of inequities and access to telehealth across all ages, but when thinking about creating, making telehealth more available or just digital platforms more accessible to older adults, also having different places available to older adults to be able to get support because it's not necessarily that the digital platform system needs to more age-friendly, but it's more trying to kind of support the older adult in understanding how to do something.

57:00

So those, and it was shared just before that, if you have family members, you kind of rely on them to do things, but those who don't have family members so readily available, you know, if they could just go to a library or a pharmacy or a grocery store and there's a person there that would just be able to help with navigating these digital platforms, and that would be just as supportive as well. Great. Thank you.

57:29

David, I have a follow-up question for you on the greenhouse model that you mentioned, and you mentioned the Medicare savings. Can you expand on that? And are there any kind of lessons from that that we could think about for other models of care? Sure. And we see this come up a lot. The reason we did that research was that there had never been a prior study saying if you have culture change in the building, if you're providing a higher quality of care, does that generate savings? And we found exactly that.

58:02

Is it enough to pay for the model? No. But is it an offset? Sure. And so how do we then think going forward? How do we kind of think more holistically? The problem is we're so siloed right now and fragmented that there's no way for the greenhouse model to capture any of those savings. And so I think as the federal government's thinking about new models, they need to keep those savings in mind.

58:26

I think that's really gonna be the next generation of programs, if we wanna kind of see more greenhouses, we need to incentivize that and realize there are savings in the system right now. We need to maybe direct some of those back to the greenhouse and other models like that that are generating those offsets. Great.

58:52

David, another question, and I know you had mentioned kind of the HUD influence maybe being a little bit more than private equity, but we did have a couple questions about the relationship between private equity and quality of care in nursing homes. Can you help our audience understand that a little bit?

59:13

Yeah, every sector in healthcare and outside of healthcare needs capital. Unfortunately, a lot of the capital of late in nursing homes has been these private equity groups. They come and they invest in nursing homes and other long-term care settings with a three to five year horizon. The first generation, we did some evaluations, didn't really lower quality. More recent evaluations, I think it's the second and third generation of private equity over the last kind of five or so years has been associated with lower quality. They do seem to be taking dollars out of direct care. Nursing homes are very complicated, oftentimes ownership structures. You can have these related parties that a management company and a real estate company and all these dollars aren't flowing back into staff and into resident care. So I do think we need greater scrutiny. And we did a piece earlier this year just suggesting CMS has begun to release more and more information on who owns these buildings.

1:00:13

We still, however, have a lot of trouble. We tried to match up their data with our own kind of data that had been generated through some of the financial company, Wall Street database on what's a private equity firm.

1:00:29

They didn't match very well.

1:00:30

CMS is currently falling way short in terms of identifying private equity. So we have a lot of work left to be done to sort of track who owns these buildings and how they're spending public dollars.

1:00:43

Great, thank you. We are out of time for today.

1:00:48

I did want to give our speakers just a quick second if you wanted to leave us with any kind of closing message before we close out, we can...

1:01:00

Heidi, do you want to get started?

1:01:04

Well, first of all, I wanted to thank NIHCM for inviting me. I actually thoroughly enjoyed David and Jasmine's talk. I would just point to the fact that Medicare Advantage plans have the advantage of actually being able to offer extra benefits to members. It's clear that this caregiver support is in many ways a drop in the bucket compared what many caregivers need. Many caregivers need actual assistance in the home. They need an aid in the home. But there are some efforts by CMS to actually, you know, with the guide model with dementia patients that are trying to tackle that problem. So thanks, Heidi.

1:01:56

David or Jasmine? Yeah, sure. Thanks once again to NIHCM and to Kathryn.

1:02:02

And I really, similarly, I really, Heidi really enjoyed your presentation and Jasmine's I'll just say very quickly long term care in many ways been a forgotten policy issue. I think we've ignored it for far too long.

1:02:13

Jasmine and I were part of a National Academies Commission where we tried to shed light on at least reforming nursing home care. I hope and one of my favorite quotes from that was that the pandemic really lifted the veil I think the veil is going back down again we're not sort of staying on this issue. I hope kind of over the next several years, especially with the aging baby boom generation, that launch from care gets increased attention because we have, I'll say it for maybe a 10th time today, but we had a lot of work to be done here.

1:02:43

So we need to roll up our sleeves and get going.

1:02:48

And I'll echo all of the sentiments that have been shared and I'll probably just leave one thing, going back to that ARP state scorecard that I shared. I just encourage and urge you all to go and look at that scorecard perspective of your states and see where your states fall along these dimensions and understand where you're doing and then where to actually prioritize your different efforts.

1:03:13

Great. Well, thank you all for joining us and sharing your work and perspectives. And thank you to our audience for joining. We'd love to get your feedback. There will be a brief survey that will open on your screen after this event and we will also share a recording next week.

1:03:31

So thank you all again for joining us today.

1:03:36

Thank you.

1:03:39

Thank you.