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The Dichotomy of Expanding Home Care while Reducing Private-Duty Nursing at Home

When it comes to providing home- and community-based services to TennCare's elderly and disabled, the state is walking a tightrope … working to expand such services when clinically appropriate and cost-effective while simultaneously reducing at-home, private-duty nursing benefits for some patients. While these two efforts may appear contradictory, both are aimed at the same target — more people appropriately cared for at home and in their community.

"Our goal is to look at the population we serve to understand the preferences that people have and to try to figure out a way to spend the state's limited resources — and right now they are very limited resources — to serve the broadest number of people," explained Assistant Commissioner Patti Killingsworth, TennCare's chief of long term care services. "That means creating a rational benefit structure that allows care in the community to be provided cost effectively so that more people will have the choice to receive care at home."

That's not an easy mission, as was evidenced on Sept. 30, when the legislative TennCare Oversight Committee heard testimony from TennCare officials and heartrending scenarios from patients and families losing round-the-clock, every day skilled-nursing care at home. "It is very difficult to hear what are very compelling and very difficult situations when people relay individual stories. None of these decisions are made lightly …," Killingsworth said. "At the end of the day, we absolutely believe that the vast majority of these individuals will continue to be able to receive care at home with a different array and combination of benefits."

The New Law

In March, Gov. Phil Bredesen outlined details of the "Long Term Care Community Choices Act of 2008," which the General Assembly approved. Effective July 1, the law expanded alternatives to nursing homes by encouraging so-called "consumer-directed care options." Those options could include hiring non-nursing caregivers, improving access to assisted-living facilities and advancing companion care. The act also streamlined the eligibility process and designated one entity to coordinate all of a TennCare member's health services.

One champion of the legislation has been the Tennessee Health Care Association, which represents nearly 300 nursing homes and other long term care facilities. Wouldn't that organization's support be counterintuitive? Not according to Executive Director Ron Taylor, who said the act's provisions must be viewed "in context" and as an opportunity for nursing homes to break with tradition.

"We fully understood that there are individuals who can be served at home and don't need to be in the nursing home. Secondly, we understood that there were … and there are … provisions in that bill that encourage nursing homes to diversify to provide those services. Thirdly, we think that nursing homes are appropriately situated in the community to provide those services," he said. "We have been long term care providers for decades, and we, in many cases, have the capacity and capabilities to provide those services and are the logical ones to do that and help build that infrastructure."

The Community Choices Act received a welcomed boost in September when the federal government expanded the number of TennCare enrollees eligible for home- and community-based services. TennCare has a federal waiver allowing Medicaid members who qualify for nursing home care to instead get help at home, as long as the cost is the same or less than a nonskilled nursing home. More than 4,300 TennCare members were already receiving care that way, and the September expansion allows 2,300 more people into the program.

Putting a Lid on Costs

On the flip side, TennCare officials included in the bureau's fiscal year 2009 budget its intention to rein in skyrocketing spending for private-duty nursing and realign benefits to spread those dollars across a larger number of elderly and disabled members. That implementation has begun, affecting approximately 900 beneficiaries who receive 24/7 private-duty nursing services. Some of those people will need to move to nursing homes to ensure they continue to receive the skilled-nursing care they need all the time.

According to TennCare budget figures, home health and private-duty nursing spending rose from $861,000 in fiscal year 2003 to more than $81 million in 2007. "We had a benefit that was growing beyond the state's ability to sustain (it) … growing at significantly more than double-digits every year. We were going to need millions and millions of new dollars that the state didn't have to be able to sustain that benefit," Killingsworth said.

Round-the-clock, private-duty nursing runs about $300,000 annually, while a patient can be cared for in a nursing home for about $50,000. "So it's not cost-effective care at all, and that means that if I serve one person with that 24-hour benefit, I have to say 'no' to 24 others who could be supported in a home- and community-based waiver program for the same amount of money."

When speaking to reporters in August, Bredesen said, "Part of the idea of what we're doing with home- and community-based services is to say, 'Let's not zero in on one kind of care. Let's look at what is the most suitable care.' In the case of nursing-home care, there is a lot of suitable care that is less expensive and better in some ways. … I think the underlying theme here is to say, let's pick a level of care which is appropriate and reasonable and common sense for these people."

Advocates for the elderly and disabled aren't buying it. "The legislators and the Bureau of TennCare, in our estimation, do not have a good understanding of the impact these cuts would have on families. These are really draconian, terrible cuts," said Tony Garr, executive director of the nonprofit Tennessee Health Care Campaign. He contended that changes in the payment structure to managed care organizations resulted in the dramatic spike in private-duty nursing costs. Killingsworth refutes that.

Garr also charged that mismanagement is an issue. "Gov. Bredesen would like to characterize it as people abusing the system, but I guarantee you that I would characterize it as a program that has been mismanaged by this governor. … Rather than manage the program, they've chosen just to cut the hell out of the program," he said.

Another advocate, Randy Alexander with the Memphis Center for Independent Living, accused TennCare decision-makers of being "unwilling to meet and compromise and find a way to listen to the community that has the real experience. … If we had a needs-based system with a lot of different service-delivery models, we could have a system that saves money." Alexander acknowledged that some beneficiaries of 24-hour nursing care could safely receive some services delivered not by a nurse. If that were changed, he added, it would free up funds to allow the direst patients to continue full-time nursing care.

Garr suggested grandfathering in the patients who currently receive 24/7 private-duty nursing, but Killingsworth said that won't work. "The federal government doesn't allow you to say, 'We're going to protect this group of people and give them more than everyone else.' You don't get to do that kind of targeting," she said, adding, "We would need $50 million to grandfather this current population."

The new private-duty nursing limit, which went into effect on Sept. 8, is 27 hours of nursing care, plus another eight hours of unskilled care. A combination of five additional hours is allowed for beneficiaries who qualify for a skilled-nursing facility. Killingsworth said the 900 beneficiaries affected by the change aren't under a strict deadline. "It's an individualized process for those people," she said.

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