The Generation Project













Seniors deserve options regarding long-term care

Originally published in the Fort Wayne Journal Gazette

Editorial: By E. Mitchell Roob Jr. and Steve Smith
August 14, 2006

Your 92-year-old widowed grandmother falls down and breaks her hip. She stays at the hospital for a few days after surgery and then transfers to a rehabilitation facility. After another week, she transitions to a nursing home, the first several months paid for by Medicare. Your family questions: “More than three months after Grandma first fell, is the nursing facility the most appropriate setting for her?” She wants to be independent, active and healthy.

Should your family consider an assisted-living facility, moving back home with the assistance of a personal attendant or adult day care? Regardless of the choice, you, your parents and your grandmother have just become customers of long-term-care services in the State of Indiana.

Although a comprehensive care facility, such as a nursing home, is often the best option, many seniors would prefer and are able to live more independently. The Indiana Family and Social Services Administration supports 25,000 people in nursing facilities across the state, but only a fraction of this number is in alternative care settings. For example, fewer than 200 are supported in assisted-living facilities.

Last year, FSSA directed 75 percent of its $1.65 billion long-term care dollars to institutional care, while only 25 percent of those dollars were spent on long-term care alternatives such as home health care, assisted living and adult day services. Since the financial criteria for nursing-home coverage by Medicaid are less restrictive than the criteria for alternative care, the choice of a long-term care option often becomes a financial decision, not a quality-of-life decision. We do not want to force this unfortunate decision on our seniors.

Our goal is simple: Modify the long-term care business model through direct intervention into both the supply of and demand for long-term care services. To accomplish this, FSSA is working closely with health care providers, professional associations and advocacy groups to create a new image of long-term care as a spectrum of options, from community-based services, such as assisted living and adult day care, to nursing homes.

This business model modification is imperative to control our long-term care expenditures and provide our aging baby boomers with the long-term care options they will demand.

FSSA must make significant policy changes. Once enrolled in Medicaid, a qualified senior is entitled to care in a nursing home but not entitled to care in an alternative setting. Therefore, we must establish uniform financial eligibility for institutional and community-based care models to truly give seniors choice.

Adjusting reimbursement rates will make home- and community-based options financially feasible. For example, on July 1 rates for assisted living services increased 25 percent. This adjustment will close the gap between reimbursement for assisted living and nursing home care. Rates for all other options to nursing homes will also increase substantially.

Modified, less restrictive policies and appropriate financial incentives for long-term care providers will also encourage the needed development of physical infrastructure for alternative care models. FSSA’s proactive efforts will prompt entrepreneurs to consider entering the long-term care marketplace. Most importantly, customers will have a level playing field in order to make the best choice for their particular situation.

While the supply is being developed, the demand for home- and community-based options must also grow. FSSA will also embark on an educational campaign to present long-term care as a single service offering that contains multiple options, not simply nursing homes or nothing. Fewer than 2 percent of referrals to nursing homes in Indiana are made by the family or individual who needs the care. Ninety-eight percent are made by another person or entity. Therefore, FSSA must actively market to a wide array of customers and stakeholders to ensure that all long-term care options are considered.

The development of alternative care models for seniors is a vital step toward creating an integrated long-term care solution. Moving forward, FSSA, partner organizations, families and seniors must also work together to address other important issues surrounding care for our seniors.

We should discuss who finances their care and promote personal responsibility options, such as purchasing long-term care insurance. We must define quality care and hold providers accountable to high standards. After all, Indiana has an obligation to our aging Hoosiers to allow them to age with dignity in the setting of their choice.


E. Mitchell Roob Jr. is secretary of the Indiana Family and Social Services Administration. Steve Smith is director of FSSA’s Division of Aging. They wrote this for Indiana newspapers.