OPINION: Decompressing Nursing Homes — California’s New Long-Term Care at Home Initiative

By Jason Bloome

As the number of COVID-19 related cases and deaths continue to rise in nursing homes, the California Department of Health Care Services (DHCS) and the Department of Aging have proposed a new initiative, called Long-Term Care at Home (LTCH), to provide a holistic, coordinated and bundled set of services to “decompress” skilled nursing facilities (SNFs) and allow eligible seniors to receive care at home instead of in nursing homes.  The benefit will support seniors transferring from a hospital or SNF to their home, or to prevent a nursing home stay.  DHCS is seeking approval for LTCH from the Centers for Medicare and Medicaid Services and the program is expected to begin in early 2021.

LTCH will be available to qualifying Medi-Cal recipients who would otherwise require skilled nursing or skilled nursing therapy to observe or manage a condition in a nursing home.  Participants would include those with full scope Medi-Cal, and individuals 21 years old or older who are enrolled with Medicare Part A or B, or both, and who are eligible for Medi-Cal services through the Medi-Cal state plan.

The benefit will be tailored to the needs of the individual and provide an alternative to congregate residential facilities (licensed residential assisted living, adult residential care homes or “room and board” settings are not eligible for LTCH).  The program will be monitored so that recipients do not receive duplicative services already provided by current Medi-Cal waiver programs, including MSSP and PACE.  DHCS will work with managed care plans participating with Cal MediConnect to integrate the Long-Term Care Program for eligible participants. 

Key goals of LTCH include:

1)     Provide qualifying Medi-Cal beneficiaries and their families with alternatives other than SNFs for long term care.

2)     Allow SNF transition to home for current SNF residents.

3)     Provide alternatives to SNFs for beneficiaries at home at risk of institutionalization.

4)     Allow beneficiaries to be discharged from hospitals to home, avoiding a SNF stay.

5)     Support efforts to decompress SNFs.

LTCH envisions three categories of care:

1)     Short-term skilled nursing resulting from hospital to home transfers. This category includes temporary therapy or clinical services for a person recovering from illness, injury or surgery which could include short-term help with activities of daily living, therapy, dressing wounds, dispensing medicine and physical, speech and occupational therapies.

2)     Long-term skilled nursing resulting from hospital to home, SNF to home, or as a means to prevent a nursing home stay. This category could include clinical personnel who would provide continuous nursing and medical services, and the equipment for diagnosis, prevention and treatment of injury or acute illness for chronically ill patients who need long-term skilled nursing care or therapies.

3)     Low acuity skilled nursing resulting from hospital to home, SNF to home, or as a means to prevent a nursing home stay.  This category includes less intensive, time-limited clinical personnel for patients who do not need continuous nursing and medical services, and the equipment for diagnosis, prevention and treatment of injury or acute illness for patients who need temporary nursing care and/or therapies.

In order to be approved by the federal government, LTCH must be cost neutral and not cost more than the cost of the equivalent Medicare and Medi-Cal services provided in a SNF.   In many cases, LTCH will be provided by licensed care organizations, including home health agencies, that will work in conjunction with the In Home Support and Services (IHSS) program.  Since many seniors end up as long-term SNF patients due to insufficient IHSS hours (the maximum allowable hours is 283 hours/month), LTCH would not be a viable option for seniors without family caregiving support who require long-term 24-hour custodial care.  

A far more effective tool than LTCH for decompressing nursing homes for seniors who require 24-hour custodial care—AARP/SCAN estimate at least 10,000 seniors on long-term care in SNFs have low level care needs that could be met in community-based care settings—would be implementing the California Advancing and Innovating Medi-Cal (CalAIM) initiative which would allow managed care organizations to use “in lieu of services” to pay for assisted living settings where 24-hour care is provided. Unfortunately, due to state resources being diverted due to COVID-19, the start date for CalAIM has been pushed back from early 2021, with no new start date yet announced. 

Jason Bloome is owner of Connections – Care Home Consultants, an information and referral agency to care homes in Southern California founded in 1990.  More information at carehomefinders.com.