Gov. Phil Bredesen with senior at Long Term Care bill signing (gov's office)After lagging behind the rest of the country for years, Tennessee is catching up fast when it comes to improvements in its health care system aimed at elderly and disabled residents. More of them are getting the assistance they need in their homes — at a much lower cost than at a nursing home. A lot of this change is the direct result of efforts by Governor Phil Bredesen.

Nearing the end of his eight years in office (he is required to leave due to term limits this year), Bredesen decided to focus on getting Tennessee off the bottom rung in rankings of states that offer consumers choices in long-term care. Just a few years earlier, only a few hundred Tennesseans were able to get Medicaid funding for anything but a nursing home. Now, it is one of a handful of bellwether states that offer a broad range of alternatives to nursing home care.

Like every other state, Tennessee is bracing for an avalanche in demand for long-term care as the biggest generation in American history — 77 million so-called Baby Boomers born between 1946 and 1964 — begins to hit retirement age next year. And, long-term care costs are growing faster than any other state expense. That’s partly because Americans are living longer.

It is well known that the vast majority of people with long-term care needs want to remain in their homes. And research shows that the cost of providing care in the community can be as little as one-third the amount of a comparable nursing home stay.

When seniors qualify financially and are deemed to need care, Medicaid funding for a nursing home bed is guaranteed. For those who want to remain at home, funding is often only a possibility and a national shortage of home health providers can mean long delays.

Bredesen, a Democrat, knows all this inside and out — he was once in the health insurance business himself — and he had no illusions about the difficulties of reforming the system.

He needed an ally in the Legislature to make wide-ranging statutory changes in the way Medicaid finances long-term care. Democratic Sen. Lowe Finney became the champion Bredesen was looking for. Together they criss-crossed the state in 2007, talking to the elderly and disabled and their advocates. They negotiated with the state’s powerful nursing home industry to ensure major private players would support the plan.

Betting on Managed Care

In 2008, the Legislature unanimously approved a bill that would make Tennessee one of just a few states to contract out its long-term care program to managed health care organizations.  The federal government took a full year to approve it.

Tennessee CHOICES logoTwo months ago, TennCare CHOICES, opened its doors statewide with the goal of helping 11,000 people remain at home or return to their homes in the first year — all for the same amount the state paid in 2009.

“The change is like night and day,” says Wilo Clarke, a caseworker for a managed care company in central Tennessee where the program started as a pilot earlier this year. “More and more, people in the nursing facilities are hearing about this program. They want to do whatever it takes to go home.”

Under the plan, low-income frail elders and adults with disabilities who are medically eligible for nursing home care may opt to receive the services they need in their homes, as long as the total cost is equal to or lower than the cost of a nursing home stay.

It’s too early to tell whether CHOICES will accomplish its goals. But so far, more than 40 percent of some 3,300 new enrollees are opting either to move out of a nursing home or avoid going to one in the first place.

Many Success Stories

There are many success stories. A 56-year-old Nashville resident named Larry is a good example. He suffered a stroke two years ago and had an amputation. Because his wife could not care for him at home, he reluctantly entered a nursing facility. When the new program began providing training and support services for his wife, Larry was able to go home and spend time with his children and grandchildren.

Critics have argued that the managed care companies’ financial incentives to keep people out of nursing homes could result in unsafe home care for people who really need round-the-clock nursing. But others say the companies have just as much incentive to avoid dangerous situations that could lead to expensive emergency care.

Still, the big fear in offering more home-based services is that people who never would consider entering a nursing home “will come out of the woodwork” and apply for Medicaid. Surveys have shown that for each patient in a nursing facility, two more with the same level of disability are making do at home.

Bredesen acknowledges the state’s new program will result in Medicaid serving more people. But he says it’s a good thing, as long as overall costs do not climb.

Although the social and fiscal benefits of public funding for home- and community-based services are clear, states have been slow to take the steps required to bring about change. But, Alaska, California, Minnesota, New Mexico, Oregon and Washington State now spend more than half of their long-term care dollars on alternatives to nursing facilities. Colorado, Idaho, North Carolina, Texas and Vermont are moving in the same direction. Tennessee and 23 other states have made less progress, spending less than one-quarter of their long-term care budget on non-institutional care.

The new federal health care law — the Patient Protection and Affordable Care Act — has a chance of changing that. It includes financial incentives for states to spend at least 50 percent of their long-term care dollars on non-institutional services and offers a grant for every person who leaves a nursing home to receive services in the community.

In Tennessee, both supporters and critics of the CHOICES program say only time will tell whether the managed care organizations will be able to keep a lid on costs. But for those directly affected, Tennessee’s experiment is already offering hope.

(Source: – Lauren Lambert, former Pew Center on the States researcher, contributed to this article)

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