It sounds like a great idea: Move people out of long-stay nursing facilities and back into their communities, and give them flexibility to spend government dollars on the care they need. Such a change could make care more person-centered and reduce costs. But a federal/state demonstration aimed at achieving that goal has moved very few people.
For six years, the federal government and state Medicaid officials have been giving people the opportunity to return to their communities through a $4 billion demonstration program called Money Follows the Person. Although 41 states are participating, less than one percent of nursing home residents have successfully made the transition, and most of them were younger people with disabilities.
Many people live in nursing homes because Medicaid often pays for care only in those facilities. Many could benefit from an opportunity to return to their communities. But the MFP program shows just how hard it is to get them there.
Over its life, according to a new report by Mathematica Policy Research, the program has moved a total of only about 35,000 people back into their communities. Only about 37 percent–12,924–were aged 65 or older. Four in ten lived in just three states—Ohio, Texas, and Washington.
Over time, many people leave the program. Some die. Others are readmitted to nursing facilities. As a result, in June, 2013 about 9,400 were participating in MFP. In the first half of 2013, 4,812 new participants enrolled– about 1,800 of them older adults. To put that in context, The Kaiser Family Foundation estimates that in 2011, about 1.3 million people lived in nursing facilities.
Some who leave facilities come back. In June, 2013, about 6 percent of all participants, and about 8 percent of seniors, returned to facility care—the highest rate in four years. While some states reported no reinstitutionalizations, six (Kansas, Kentucky, Nevada, Oklahoma, Rhode Island, and Tennessee) said more than one-quarter of their older enrollees had to go back to facilities. In Rhode Island, half of participants over 65 made the round-trip.
Why has the program struggled so much? The main reason may be the lack of accessible, affordable housing. It seems obvious, but you can’t expect people to return to their communities if they have nowhere to live. This is a particular problem with seniors, who may have sold their homes to pay to get into a nursing home in the first place, or may have moved because they could no longer safely live in their old house.
Since MFP is a Medicaid-based program, participants have few assets and very limited income. Thus, most need subsidized housing unless they move in with relatives. According to Mathematica, 27 states reported a lack of accessible affordable housing, and 22 reported a shortage of rental vouchers.
The MFP program is yet another example of how hard it is for the frail elderly to live in the community without the necessary infrastructure of housing, transportation, nutrition, and other social supports. Medicaid-funded home health aides alone are not enough.
It may be that some nursing home residents would like to move but simply cannot, perhaps because their physical or cognitive limitations are too severe or because they do not have the family supports they need.
Interestingly, from January to June 2013, nearly one-quarter of those who left a nursing facility under MFP moved into a group home or assisted living facility.
MFP’s attempt to give people more independence and flexibility by letting them manage their own budgets and supervise their own aides has also been a disappointment. Nationwide, in the first half of 2013, just 1,420 people were managing their own budgets and 921 had hired their own personal assistants.
Congress has funded MFP through 2019. The concept is terrific. But, so far at least, it has failed to unlock the nursing home door for many frail seniors.