Gaps in Health Care for Elderly

1. Thanks for speaking out, Clyde.

   Home care is a great investment — often keeps people out of nursing homes. I’ve been a strong supporter of this. Your point about the assets is well taken. Let me get some info on where we are this conversation — we’ll post it here.

   /w.

2. Is there somewhere I can sign up to follow subsequent posts on this topic?

   One service that seniors could really use would be a “problem-solving”
   phone number that they can call when they are faced with a problem that
   baffles them. A mysterious letter arrives in the mail promising great rewards for a small investment, or containing a government form that is asking questions that the senior cannot understand for purposes that are opaque, or a bill demanding payment for services that the senior has no recollection of receiving. Or the plumbing stops working. Or the lock on the front door breaks. Or their computer suddenly stops working. Lots of people have friends or relatives living nearby but lots don’t. This would not necessarily be a public service — it might even work as a business, marketed to sons and daughters. But it is not a simple problem.

3. Thanks, Fred. We’ll post resources here for you shortly.

   You can subscribe to my newsletter at this link.

4. Dear Will,
   I enclose the eloquent testimony of geriatric social worker Cassie Cramer, made last year regarding IN-HOME mental health supports for elders.
   John

   March 28, 2013

   Liz Mahlia, Chair
   Joint Subcommittee on Mental
   Health and Substance Abuse

   Dear Representative Mahlia and Honorable Subcommittee Members:

   Thank you for inviting me to speak today. I am here as a social worker working in Protective Services, which I have done since 2009, and as a peer advocate. As a person with a mental health condition myself, I advocate for policy that supports mental health recovery. As a person closely attuned to mental health, I know that we are not funding geriatric mental health and home based peer, mental health and wellness supports anywhere near enough to meet the needs. These supports will produce cost saving outcomes including decreased Medicaid-funded hospitalization and nursing home admission, and increased client autonomy.

   There are many exciting developments and budding in-home supports for older people. I have seen how beautifully these programs can work to transform lives – like Maria, a Spanish speaking woman who was so depressed she had stopped eating and getting out of bed. She responded remarkably well to an in-home psychiatrist, began taking ESL, and looking for childcare work opportunities. Or John, a musician in his sixties, who had MS and depression. When we first met he missed his appointments, did not take his MS medications, and would crawl down the stairs to let me in. His doctor believed that he was “headed for a nursing home.” John and I worked together to come up with a way to manage his care needs. He enrolled in a managed care program and moved into a handicapped accessible apartment; he now receives treatment for depression and takes his MS medication which has slowed down the progression of his disease.

   Unfortunately, these stories reflect what could be possible, as opposed to a reality, for the majority of older adults with mental health conditions. Often, people are unable to get mental health care because they are unwilling to switch their trusted primary care doctor who they have seen for years to one of the very few networks providing the service. The few programs that do offer in-home mental health care are stretched thin and often have long waitlists. In home visits are not fully reimbursed, resulting in cuts to the numbers that can be served at home. Other times, a client who is fortunate to receive in-home therapy or an in-home nurse case manager may not hit it off with the person who is assigned. I hear it all the time from program coordinators, “I’m sorry, we really can’t re-assign a new provider,” and that person is left without care. They end up in the ER, and the costly, ineffective cycle begins again. As a person who has been on the receiving end of services, I know that a good match with someone you connect with is key to successful mental health care.

   Perhaps most significantly, we need to move away from policy and practice that inadvertently looks at older adults, and particularly older adults with mental health conditions, as objects or children. I frequently get calls from providers or community members who tell me that a person “needs to be placed in a nursing home.” Placement. Would you want to be placed somewhere else?

   Many of these calls are from medical providers who are frustrated about a patient’s “medical self-neglect.” At a loss for a way to communicate effectively with their patient, and unaware of available community solutions such as in home mental health and wellness supports, they believe the only recourse is a nursing home. They describe their patient as “stubborn” and “difficult.” As a peer advocate, I have a different view. Here is someone who may automatically veto mental health supports because they have been confined to a psychiatric hospital prior to commitment laws, or had bad experiences with early medications. Or someone who has experienced many losses, may not be able to drive or work; when they are told what they have to do by a provider, they dig in their heels. It is their dignity and autonomy at stake. Peer-led trainings and supports would go a long way to ensure more effective communication and continuity of care.

   A number of these callers saying that “an Elder needs to go somewhere else” because they “don’t belong” are property managers, who undoubtedly face pressures from other residents who are calling with complaints, or are facing upcoming inspections. There is a lot of talk about housing search assistance, but there also needs to be a focus on housing maintenance; not just because stable housing is integral to maintaining recovery, but also because the process of eviction and housing search and advocacy – particularly for someone with an eviction record – are a tremendous drain on financial and human resources. Prevention in the form of available legal services, like Cambridge Somerville Legal Services or Community Action Agency of Somerville,and training for public housing property managers in de-escalation and sensitivity to mental health conditions, is essential to support people with invisible disabilities in the community. I would argue that there is such a need that it would be wise to develop a task force to address eviction prevention for individuals with mental health conditions.

   We appreciate your commitment to obtaining quality and accessible mental health supports, and ask that you support Restoration of Funding for the EOEA line item Geriatric Mental Health to increase mental health supports for older adults. We ask that you support the Special Commission on Recovery and include representation within this commission for the needs of older adults. We also ask that you support the development of programs which offer choice of clinician, and include a full array of services for wellness, integration in community, and recovery, including holistic and peer support services. As our parents and we ourselves grow older we must ensure that people are treated with dignity as they go into the final chapter of their lives. We look forward to working together with you to secure home-based supports that foster mental health recovery for the most experienced, oldest among us.

   Sincerely,
   Cassie Cramer, LICSW

5. Clyde,

   Current Legislation in Massachusetts that may affect Home Care for elders is limited. As of right now the FY2015 budget is unlikely to cut any state funding for home care, decrease services, or alter eligibility requirements. The budget may actually increase funding for home services, but it is hard to tell how that will influence eligibility requirements or provided services down the road. There are currently two Bills in the House, H.2573 and H.2574 which are proposing up to a $1500 tax credit or deduction to taxpayers for are directly paying for home care services either for themselves or for elder family members.

   Currently state support for Home Care comes primarily through the Mass Home Care Program, overseen by the Executive Office of Elder Affairs. This program can provide varying levels of Home Care support to elders as determined by nurses who do a personal evaluative analysis on how much care an elder needs provided. However, there are financial eligibility requirements for this program. Individual elders must be at least 60 years of age and need to have an annual income less than $24,838, and couples must have an income under $35,145, and anyone using MassHealth is also eligible. Monthly copayments for these home services vary based on income level between $9-130 for individuals and $17-140 for couples. For more information about the basics of program you can look at either http://www.mass.gov/elders/homecare/ , or http://www.massresources.org/home-care-program.html .

   Another program that provides home care service for more “frail” elders is the Enhanced Community Options Program (ECOP). This program is for seniors who require more service and help completing activities of daily living. If you would like to find out more about this program or how to apply to either this or the normal Mass Home Care program you can visit http://www.massresources.org/home-care-program.html#ECOP.

   Federal Medicare may also provide some home care services, but the services they provide or subsidize are required to be “intermittent” and are usually less substantial and more temporary than those provided through Mass Home Care. For example, Medicare will only pay for home care that is needed less than 7 days a week and less than 8 hours a day over a 21 day period. Depending on personal needs, Mass Home Care and other state programs can help fund more permanent care.

   If you have any more questions or concerns about home care you can also contact the phone number 1-800-AGE-INFO, or visit the website (https://www.800ageinfo.com/learncenter.asp?id=178412) run by the executive office of elder affairs and Mass Home Care that answers questions about Home Care Service programs and health care coverage. You can also contact SHINE (Serving the Health Information needs of Elders) or the private agency Mass Home Care for questions about Healthcare coverage that pertains to Home Care or Elderly Healthcare in general.

   James Stadler, Intern for Senator Brownsberger

6. James, nice job. I hope this information is helpful to our readers.

   John, thank you for sharing this eloquent testimony.

   Home care is one of those things that seems like a luxury for the public sector to provide. But on the contrary, it is a great investment in public health which returns huge dollars in avoided institutionalization — not to mention the huge human benefit of giving people their dignity in the community.

   I am a strong supporter of home care spending for seniors and the disabled.

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