SeniorLink™

Caregiver Homes, Inc. of Massachusetts Boston, MA

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Background

Edmund Dern and Florence Whelan live on the South Shore. Although they need 24-hour care, they are still able to live at home with the support of their full-time caregivers and Caregiver Homes™ of Massachusetts.

Caregiver Homes’ Adult Foster Care Program pays caregivers up to $18,000 each year and trains and educates them to provide care at home for a senior or disabled adult. Professional support is provided by Registered Nurse and Care Manager teams that develop individual Plans of Care and monitor client health with regular visits and by checking daily caregiver online notes. Care Managers also coordinate with other services such as Adult Day or Home Health, Hospice and Private-Duty Nursing. Caregivers appreciate the reimbursement (it’s not taxed and non-reportable to the IRS) and support that allow them to care for a family member, and clients are comfortable at home and in their communities.

A Hull resident, Dern is an accomplished musician and singer who performed with his band on the South Shore almost nightly for many years. He casually mentions that he was once the opening act for Sammy Davis, Jr. and Liza Minnelli at the old Diplomat Hotel in South Florida. He just as casually talks about the stroke and two amputations he had to undergo, and that he now requires the use of a wheelchair and fulltime caregiver. “It could be worse,” says the ever-optimistic Dern.

After his stroke, Edmund was told by hospital doctors and staff that he would need to arrange around-theclock care before he could go home. Seeking information about Adult Foster Care, the Dern family spoke to Denise Baxter-Powell, the Regional Director of Caregiver Homes. Denise “stepped us right through the process and got us into their program within six weeks,” says Donna Dern, Edmund’s daughter. “Caregiver Homes just took such a weight off my shoulders.”

Under Adult Foster Care and MassHealth regulations, spouses and legal guardians are not allowed to become paid caregivers. The person who stepped in to become Edmund’s full-time caregiver was Janet White, long-time friend of both Edmund’s and Donna’s. Donna says, “Before Janet came, we had a lot of difficulty arranging care. We had to have daily meetings about who could be here to cover.” Now, with Janet’s full-time care, and the ongoing support and payment she receives from Caregiver Homes, life is much calmer. “I’m just glad he’s alive. I couldn’t have done it without this program,” says Donna.

Marshfield resident Florence Whelan had been living with her daughter, Carol, and son-in-law, Richard, for twenty years when her son-in-law passed away. Carol was concerned that she would lose her house and the ability to care for her 97-year-old mother, until she saw an ad and contacted Caregiver Homes.

Again, it was Denise Baxter-Powell who responded to her call. Florence was able to qualify for Medicaid and Caregiver Homes under the Frail Elder Waiver, and Denise walked them through the application process. “Who would ever know a program like this existed? It sounded too good to be true,” Carol comments.

In addition to the twice-monthly payments that have allowed Carol to keep her home, she appreciates the support of her mother’s Care Manager, Miriam MacKenzie, and Registered Nurse, Karin Sullivan. She comments, “That’s why it’s so nice to be in this program, there are people you can talk to. It’s always nice seeing these two!”

When asked how her days are spent as her mom’s caregiver, Carol smiles and says, “I’m so lucky, my mother is always so pleasant, and she’s such a good mother. It’s wonderful that I’m able to do this.”

Medicaid is a joint federal-state program (known as “MassHealth” in Massachusetts) that provides health insurance coverage to certain categories of low-income individuals. It was created on July 30, 1965, through Title XIX of the Social Security Act and is responsible, among many things, for providing eldercare services to the indigent disabled adult population. Each state administers its own Medicaid program. The Federal Center for Medicare & Medicaid Services (CMS) monitors the state-run programs and establishes requirements for service delivery, quality, funding, and eligibility standards. Federal contributions to each state program’s costs are made on a specific ratio. The ratio for Massachusetts is 50/50. Medicaid programs are the primary payer for 64% of nursing facility residents in the USA. Nationally there are over 15 thousand nursing homes that generate a total inventory of approximately 1.7 million beds with costs growing at a rate of 3% annually. In 2007, Medicaid spent nearly $48 billion providing nursing home care.¹

Massachusetts spent $2.59 billion on nursing home care in 2007 through MassHealth.² The Commonwealth’s population of elders 65+ years of age was near 860,000.³ Of that group, over 26% had disabilities⁴ and 20% of the adults with a disability were poor⁵ – living at or below the official definition of poverty by the federal government – a subtotal of approximately 45,000. Accordingly, because the over 65 population is increasing rapidly (Figure 1), the number of older persons with disabilities is escalating. The Commonwealth’s population of those aged 65 and older is projected to grow by 35+% from a level of 850,000 in the year 2000 to a total of 1.16 million by the year 2020; a potential for an additional 62,000 poverty-stricken disabled elders.⁶

Problem

The growing demographic of elderly and disabled individuals compounds the State’s problem of an expensive long-term care delivery system that is skewed toward nursing facilities. According to national figures compiled in 2005 by CMS combined with the 2000 US census data, Massachusetts has the 17th highest number of nursing home beds in the nation and more than twice as many beds per capita as Florida, which has the highest percentage population of elders in the nation. Consequently, elders represent 12% of MassHealth recipients, yet account for 37% of its expenditures.⁷ Given the projected increase in Massachusetts’ elderly population in the coming years, both the Office of Health and Human Services and the Office of Elder Affairs have been lobbying for solutions to the eldercare problem:

“Supporting an increased number of people with disabilities in the community is key to creating a fiscally sustainable long-term system while better meeting the needs and preferences of the Commonwealth’s citizens.”⁷

The Commonwealth’s current administration of the has further reinforced the need to find more effective approaches to providing long-term supports for aging adults, particularly those with disabilities. Officials are continuing the initiatives of the Romney administration to find solutions that allow older adults to remain in the community and that carry lower costs than nursing home care:

“The Patrick Administration’s long-term care policy is community first, an approach that emphasizes maximizing independence in home and community settings while assuring access to needed institutional care.”³

There are other governmental initiatives supporting community based solutions. CMS approves waivers that allow states the flexibility to manage their long term care programs. MassHealth implemented a waiver that allows community based eldercare programs to operate through the State’s Adult Foster Care program (AFC). Additionally, the Caring Homes Pilot was introduced in the 2006 budget that allows family members to be paid in return for providing housing and care for frail elderly family members. Finally, the State’s 2005 Legislative Session voted on “Acts concerning nursing home relocation, preadmission and choice of long term settings”.

Solution

SeniorLink™ (SRL) is a Boston-based elder care company that has created a unique, cost effective, community-based program for elders with disabilities. The program is administered by Caregiver Homes of Massachusetts, Inc. (CGH), a wholly owned subsidiary of SRL. The CGH program was developed primarily for elders who meet MassHealth/Medicaid criteria for nursing home care. It began with the tenet that many elders with disabilities can prosper and live life to their maximum functional capability with independence and dignity in a community setting.

CGH couples a stable family home environment with the specialized medical, mental health, nutritional and social interventions needed by each disabled adult. This is accomplished by enlisting a caregiver, often a family member or local acquaintance, to provide food, board and care for the disabled adult. CGH pays the primary caregiver a stipend that represents the majority of the daily AFC rate of $83.09 and provides them with the support and oversight to manage their duties. MassHealth is billed for days the client is in service. The program combines the benefits of safe, residential care, in a community setting at less than 50% of the $170 daily rate of nursing homes. In essence, CGH saves the Commonwealth an amount equal to its revenue. Further, as the payment made to the caregiver is a stipend, it is consequently considered tax free income.

The CGH program brings together all of the medical and social services needed by adults with levels of disability that qualify them for nursing home care. The concept wraps intensive assessments of the total health and social strengths and weaknesses of each elder, the suitability of the intended home setting and appropriate consideration of the potential caregiver. From these assessments, a Geriatric Care Manager (GCM) and Nurse form a multidisciplinary team to develop an individualized treatment plan. The team continuously assesses the implementation of the plan and measures its success. It is important to note that CGH is responsible for the oversight of care and not for the direct administration of medicine or therapy.

A vital tool of the program is SeniorTouch™, a proprietary web based application used to oversee and manage the care of the elders. SeniorTouch™ is used daily by the caregiver and clinical team. It is a HIPAA compliant, electronic medical record of care and a database of all program histories available to the GCM, physicians, administrators and others who may view relevant information on a “permissions” basis. Each day, a caregiver must log in and complete a daily note that answers questions relative to the physical and mental condition of the elder and include comments on life at home. SRL compiles this information into a database that has grown in less than three years to over 200,000 daily notes that contain over 10 million answers and comments concerning geriatric care. This is a first of its kind gerontological database and veritable gold mine of expert knowledge for medical research.

SeniorTouch™ is also a valuable tool for the caregiver as it includes a messaging system, document downloads, links to research on particular topics, training tutorials, policies and procedures and answers to frequently asked questions. CGH staff train the caregiver on the use of this system and offer caregivers computers when needed.

Genesis

SRL was established in 1999. SRL is a for- profit business that derives revenues through two subsidiary businesses, Seniorlink Care and CGH. Initially the business was based on Seniorlink Care, a national network of GCM’s working as private contractors for seniors in need of eldercare supervision. It is a private pay business model that serves families where the elders typically live a great distance away from the children or guardians. In 2004, the CGH concept began. CGH is based on the nationally recognized care model of “Mentor Homes”. In 2006 the “Caring Homes” pilot began, but it was not until 2008 that CGH would have its first full year of business.

The largest cost associated with the start up of CGH has been the continued development of SeniorTouch™. By the end of 2009, development costs for that software system will have exceeded $2.5 million. The cost of funding CGH to breakeven, beyond the Seniortouch expense, has been approximately $2 million of equity and $1 million of debt. As the business grows, the cash flow requirements have increased, owing to the lag between payments to caregivers and receipts from MassHealth.

Expanding the CGH program into other states will require additional use of a line of credit to cover related start up costs. The estimated start up costs for establishing an individual state subsidiary range between $300,000 and $1 million depending on the regulations and the velocity of the business growth. These costs assume a cash flow breakeven in 12 to 24 months. Alternatively, larger amounts of investment can be made to rapidly expand a subsidiary with a correlated change of time to break even.

Recently the Commonwealth of Pennsylvania accepted a proposal from SRL for “development and training support for domiciliary care enhanced models.” Essentially, that consulting assignment leverages the procedures of the current CGH business in Massachusetts and combines them with best practices of other community-based elder programs around the country. SRL engaged in this assignment to help establish a CGH program in Pennsylvania. The proposal’s work will be completed by September of this year and the operation could begin in PA later this fall. Currently, there are also discussions with three other states interested in starting CGH programs.

Procedure

Today, CGH is a proven alternative to nursing home placement. The ability to be paid a tax free stipend for their services has allowed many individuals the opportunity to provide care for an elder. Most often the caregiver is not financially able to stay at home and provide care without the CGH compensation. That monetary situation often leads to the difficult family decision of placing an elder in a nursing home, likely the most undesired setting the elder would choose. CGH is an important option for poor, disabled elders to remain in the community.

SRL was able to demonstrate to MassHealth that allowing family members to be caregivers is a positive step toward creating and scaling a community-based eldercare program. Historically, the notion of a relative’s being paid for care was prohibited in the public health arena. In reality, this ban had no logical basis and primarily existed due to a misconstrued view that there was an underlying conflict of interest in paying family caregivers. However, as Adult Foster Care has taken hold in several states with diverse populations, it has become apparent that relatives actually provide the best care to the elder, are the most immediate caregiver candidates and that few conflicts of interest exist. Nevertheless, it took a considerable effort to change the Commonwealth’s policies regarding family caregivers, with the exception of spouses and guardians. Now that Caregiver Homes has progressed within the State, the same forces that first resisted family caregivers have come forward to propose that spouses and guardians should also be eligible caregivers. Unfortunately that proposal has not yet succeeded. (As a matter of note, Seniorlink is experiencing the same initial questioning of family caregiving as it prepares to do business in Pennsylvania.) Over 90 percent of the CGH caregivers in MA are related to their clients. Through SeniorTouch™ data, CGH is demonstrating that the quality of care provided by a family member is typically superior to that provided by a stranger.

Comparing the cost of an AFC placement ($83 per day) to the cost of a nursing home placement ($170 per day), the resulting savings to the Commonwealth are approximately $32,000 per year per CGH placement. In 2008, on an annualized basis, CGH saved MassHealth/Medicaid over $11 million by placing 357 disabled adults in a community setting. The Company is on track to more than double its number of placements in 2009.

Conclusion

CGH intends to expand nationally. The problems MassHealth faces are prevalent in most states. Overall, Medicaid spends over $60 billion for institutional Long Term Care.¹⁰ The level of savings that the Commonwealth enjoys through CGH can also be achieved by other states. Potentially, the CGH program could save Medicaid billions of dollars per year.

The first CGH expansion is in Pennsylvania. The Company recently signed a contract with that state and fully expects to have an operating business there by the end of Q4, 2009. Further, CGH intends to expand its services beyond the elderly disabled to all adult disabled (16 years old and above), contracting business with other healthcare departments.

Massachusetts is steadily adopting AFC as an alternative as an option to nursing homes. While the State understands the financial and other benefits of community based care, it has not pressed the option within the MassHealth system. Most of the Commonwealth’s Medicaid elderly dollars go to institutions, despite the fact that elders prefer care in a community setting. The State has one of the highest levels of 65+ nursing home utilization in the country. Over the past two decades, states such as Oregon, Vermont and Washington have grown their community based care for the elderly to a level where the minority of Medicaid clients are being served in nursing homes. Over that same period of time, the home care population in Massachusetts had fallen–the exact opposite trend. Clearly, in order for home care numbers to grow to the point of being on par with those of nursing homes, the State needs to emphasize community-based options. The current process for choosing a long term care setting needs to be reevaluated to allow for a longer decision making period in the pre-admission process and a relocation option for elders already placed in nursing homes needs to be encouraged.

Contact the Authors:

Endnotes

1. The Henry J. Kaiser Foundation. State Health Facts.org Retrieved from http://www.statehealthfacts.org/profileind.jsp
2. MassHealth Office of Long-Term Care. Boston
3. U.S. Census Bureau (2008). Table 16. Resident Population by Age and State: 2007. Washington, DC: Author. Retrieved from http://www.census.gov/ popest/states/asrh/SC-EST2007-02.html
4. Commonwealth Corp, The Links between Poverty and Disability, Vol. 4 – Is. 6, 2006
5. U.S. Census Bureau, Population Division, Interim State Population Projections, 2005
6. Center for Disease Control, State-Specific Prevalence of Disability Among Adults — 11 States and DC, 1998
7. ARP, A Balancing Act: State Long-Term Care Reform (#2008-10)
8. Executive Office of Health and Human Services, Executive Office of Elder Affairs, “Transforming Long-Term Supports in Massachusetts” (December 1, 2003)
9. Executive Office of Health & Human Services and Exec. Office of Elder Affairs. (2008) Long-Term Care in Massachusetts: Facts at a Glance
10. The Henry J. Kaiser Foundation. State Health Facts.org Retrieved from http://www.statehealthfacts.org/profileind.jsp