Funding of Long-Term Care

Mark BoothCenter for Gerontology and Health Care Research

Brown University

Harkness Fellows Final Reporting SeminarOrlando. June 2007

LTC NZ - Context

Families appalled by bed shortage for Lakes elderly

The Southland Times | Saturday, 5 May 2007

Largest-ever investment in elderly care - Govt NZPA | Tuesday, 1 May 2007

Pay Increase Will Deepen Crisis in Elderly CareFriday, 17 December 2004, 1:34 pm

Press Release: Residential Care New Zealand

Residential homes struggle for survival Tuesday, 9 August 2005, 2:15 pm

Speech: ACT New Zealand

LTC US - Context

Looming Crisis of Long-Term Care Highlighted in New

Study Senior Journal March 1, 2006 Long Term Care Crisis Builds Health Care News

March 1, 2003

State on verge of 'very ugly' elder-care crisis Honolulu Advertiser

Sunday, May 13, 2007 Is it any wonder most people dread nursing homes? New

York Times May 24 2007

LTC NZ - Context

The Government has announced what it says is the largest-ever investment in care and support of the elderly.

Health Minister Pete Hodgson made the announcement today, saying the Government recognised the need to raise the level of pay for workers who provided support to senior citizens.

"We know that low pay and high staff turnover are a major workforce issue in aged care," he said.

"I expect district health boards to satisfy themselves that a sufficient proportion of the funding increase is reflected in improved wage rates," Mr Hodgson said.

"Providing quality residential care is a key focus of this budget."

NZPA 1 May 2007

Policy Context

New Zealand• Funding provided by

District Health Boards (21)

• Nationally consistent contract defining services to be provided

• Asset testing being removed

• Income test remains• Over reliance upon

residential care• Poor use of MDS

USA• Self funded or funding

through Medicaid• Medicaid funded

federally / state but administered at state level

• Asset and income test used

• Over reliance upon residential care

• Strong use of MDS

USA & NZ – LTC Issues

• Ageing population

• Workforce

• Quality

• Rebalancing

• Funding

• HIT

Objectives

• To determine how NZ may learn from approaches to the provision of long-term care in the US

• To compare views and opinions of LTC experts in the US and NZ

• To look at practical examples of rebalancing LTC

Methodology - Survey

• Initial Survey Design

• Expert Panels

• Cognitive Testing

• Web based survey – US base modified for New Zealand

• Sample 3000 in US

• Sample 300 in New Zealand

Methodology - Qualitative

• Literature• Interviews with LTC experts• Interviews / visits to providers –

e.g.:– PACE– Eden Alternative– Cash & Counselling– Pioneer Network– Green House Project

Survey

• Rebalancing

• Workforce

• Quality

• Funding

• Culture Change

• Regulation

• Health Information Technology

Recommendations

• Rebalancing

• Workforce

• Quality

• Funding

Rebalancing (1)

Which of the following strategies would be MOST effective for rebalancing long-term care away from institutions and toward home based support services? 

Select your top THREE options.

Limit the supply of rest home beds

Increase the rates of reimbursement for home based support service providers

Expand eligibility for home based support services

Establish programmes that offer a comprehensive package of home based support services

Provide a single point of entry through which individuals may access needed services at home or in the community

Rebalancing (2)

• PACE (USA)– Capitated funding– Preventive focus– Transparency of

service provision– Services provided in

one location

• PHOs (NZ)– Capitated Funding– Preventive focus– Population health

approach– Transparency of

service provision– ‘Virtual’ organisation

Workforce (1) Issues

• Low pay

• Comparative low pay

• Low esteem

• Heavy Caseloads

• Lack of training

Workforce (2)Recommendations

• Training programmes

• Career pathways

• Improved salaries

• Improved image – building upon positive ageing initiatives

Quality (1) Issues

• Loneliness, helplessness and boredom

• Staff dissatisfaction

• Poor physical layout

• Carer stress

Quality (2)Recommendations

• Culture Change– Client centered care– Physical change– Staff changes

• Information Technology– Comparative information– Minimum dataset (Inter RAI)

• Adult Day Care

Funding (1)

How much do you oppose or favour each of the following approaches to paying for long-term care needs?  An answer of 1 means that you strongly oppose the approach and an answer of 5 means that you strongly favour the approach.

Strongly Oppose 1

. . .Strongly  Favour 5

Individuals should pay for most of their long-term care costs 

Adult children should contribute to their parents’ long-term care costs

Employers should contribute in part to their employees/retirees long-term care costs

Government programmes should cover most long-term care costs

Funding (2)

• Individualised vs. Government

• Role of family members

• Forward planning for LTC

• Linkage with other programmes

Next Steps

• Results by end June

• NZ analysis by end July

• US & comparative analysis in fall

• Policy recommendations to NZ Minister of Health and DG in August

Acknowledgements

• Commonwealth Fund• Prof. Vince Mor – Brown University• Prof. Eddie Miller – Brown University• Prof. Ngaire Kerse – Auckland

University• Dr Karen Poutasi – Ministry of Health• Dr Gillian Durham – Ministry of Health