Elder abuse is a serious and growing problem we know too little about and, worse, too often ignore. It comes in many forms—physical, financial, and emotional. Yet, even as society focuses on addressing child abuse, it has fallen far behind when it comes to responding to elder abuse. Here are a couple of examples of the right way, and the wrong way, to confront this problem:

First, the wrong way.  A true story with a few details changed: An 85-year-old man with life-threatening cancer lives at home with his wife (who is unable to care for him) and his adult son. The son, who serves as his father’s primary caregiver, is under tremendous stress, has serious behavioral issues, drinks heavily, and takes drugs. One day he brings home a handgun. When a paid caregiver learns about the weapon, she contacts her home care agency that, in turn, calls the community’s Adult Protective Services staff.

APS does nothing itself to investigate the matter. Instead, it calls the local police. An officer goes to the home, asks each of the residents if there is a gun in the house. They all deny it, and the officer leaves. There is nothing to be done, APS tells the home care agency, until “something happens.” That is to say, until the son shoots someone.

Here is a different way to address elder abuse: New York City responds aggressively to allegations of abuse, using teams of law enforcement officers, social workers, lawyers, and others. But a key challenge is helping abused elders find a safe place to live.  A Bronx nursing home has helped find a solution.

In 2004, the Hebrew Home at Riverdale and the Pace Women’s Justice Center created what became the Harry & Jeanette Weinberg Center for Elder Abuse Prevention. The project partners with more than a dozen government and non-profit organizations to provide a range of legal assistance, medical care, and social services to victims of abuse. It also trains law enforcement personnel and other service providers.

Much of the direct assistance is available to those who can still live in the community. But a key element is a shelter for abused seniors located at the Hebrew Home (and available to all regardless of religion). These elders, many of whom may have nowhere else to go, can stay for as long as a few months, though some may stay for just a few days.

The Hebrew Home solution is a classic win-win. Like many large, older nursing homes, the facility is plagued with empty beds. Rather than letting the space go to waste, the Hebrew Home created a shelter and opened up some otherwise-unused rooms to abused seniors.

The most interesting part of this story is that the Weinberg Center is now replicating the Riverdale experience at seven additional sites, including Fairfield, CT, Albany and Rochester NY, Minneapolis, Atlanta, and Providence, RI.  There are plenty of other facilities that should follow suit.

At a time when senior services budgets are being squeezed, local governments, communities, and senior service providers need to work even more closely to find solutions. Dan Sewell of the AP wrote a nice piece on Sunday describing a couple of programs, including the Hebrew Home project.

But I can imagine even more ambitious efforts to reach out to communities. Senior villages, those grassroots non-profits that have sprung up in hundreds of neighborhoods around the country, seem like an ideal partner for a Weinberg-like program. So do churches, temples, synagogues, and mosques.  

As the population ages, more and more seniors will be victimized by abuse. But there are solutions that can be built on existing resources. We just need to look for them.

Broad-based, integrated, community-wide initiatives can help keep seniors out of the hospital, says an important new study from the Journal of the American Medical Association.

The study, done by a team led by Dr. Joanne Lynn of the Altarum Institute’s Center on Elder Care and Advanced Illness is new evidence that by working together, hospitals, physicians, social workers, nursing homes, home health agencies, and community organizations can help seniors reduce both initial hospitalizations and readmissions. This suggests that such teamwork can improve the quality of care for elders with chronic disease.

The researchers looked at 14 initiatives across the country, all involving Medicare Quality Improvement Organizations (QIOs). These are private, Medicare-funded groups that work with medical providers and seniors in each state to improve the quality and efficiency of health care. The study looked at networks in a broad range of communities throughout the country from Miami, FL to Whatcom County, WA. The sites were rich and poor, urban and rural, and those with relatively high hospital usage and those with lower utilization.

Participants used a wage range of methods to reduce hospitalizations. Nearly all used care transition nurses who are specially trained to coach high-risk patients in ways to care for themselves. Most used Project RED (Re-Engineered  Discharge) that standardizes hospital discharges. Nursing homes used software called INTERACT which helps nurses identify and manage residents’ changing health status. What’s striking is these are all readily available off-the-shelf tools that any facility can use.

Some of the programs also used community relationships to help seniors stay out of the hospital. The program in Tuscaloosa, AL, for instance, built on ties with local churches. I have written in the past about a similar model in Memphis TN that aims to accomplish the same goal.  

In other communities, hospitals and nursing homes did a better job sharing data. In others, nursing facilities changed the way they cared for new admissions. My friend Joanne Kenen wrote a nice piece for Politico describing how some of these local projects operate.

The bottom line is that both initial hospitalizations and rehospitalizations were lower in the 14 communities than in 50 similar communities that did not use these interventions.

There are several important caveats to this study. The first is that fewer hospitalizations are not necessarily the same as better care.  It was also hard to find perfect matches between those communities that used the initiatives and those that did not. It also turned out that hospitalizations and readmissions declined in both sets of communities, though they fell more in those that implemented quality programs. Finally, while admissions and readmissions fell, rehospitalizations as a percentage of discharges (a commonly used measure) did not.

Still, this study builds on a growing body of evidence that when doctors, hospitals, nursing homes, community organizations, and patients themselves work together, seniors are more likely to do a better job caring for themselves. And that can keep them out of the hospital, which is usually  a very good thing.

On New Year’s Day, as part of the law that kept the nation from toppling over the fiscal cliff for two months, Congress quietly repealed the Community Living Assistance Services & Support (CLASS) Act, and created a new commission to recommend broad long-term care reforms that could affect financing, delivery and care workers.

I was, and continue to be, very skeptical about the commission’s ability to accomplish much. But after spending this week talking to Washington insiders, I heard several express the hope that the panel could at least achieve two important goals: Defining the problem and broadly framing future solutions.

Just getting a bipartisan commission of Congress to acknowledge the importance of the challenges facing those receiving long-term supports and services and their caregivers would be a huge step forward. Acknowleging that our current system of financing and delivering  this care is terribly inadequate would be another big step. And defining the roles of government programs such as Medicaid as well as private insurance would be yet another significant achievement.

Still, that would be a long way from proposing specific reforms–an accomplishment that seems far out of reach for this group. Members of the panel, as I noted last week, must be appointed by the end of this month and the commission has only six months after that to make proposals to Congress. The panel has no budget and will have to rely on staffers from Congress and the executive branch. Its make-up–nine Democratic appointments and only six GOP selections–almost guarantees partisan squabbling.

 Worst of all, even if the group could reach a consensus, there is no requirement that Congress ever vote on its plan.

Yet, several veterans of past long-term care battles in Washington are hopeful that this group can at least frame a future debate. I agree that it would be very valuable. And I hope they are right and I am wrong. But I’m not holding my breath.

The New Year’s budget agreement to avoid the fiscal cliff includes two key measures that could be critical to people receiving long-term supports and services and their caregivers. The first repeals the Community Living Assistance Services and Supports (CLASS) Act. The second creates a new national commission to develop a plan for better financing and delivery of long-term care services.

Unfortunately, there may be less than meets the eye to both of these long-term care provisions. The CLASS Act had already been abandoned by the Obama Administration. And the commission, sadly, seems like a classic congressional study, destined to gather dust on a bookshelf somewhere. 

The repeal of CLASS was hardly a surprise. The measure, a piece of the 2010 health reform law, was supposed to create a new national, voluntary long-term care insurance system. But it was roundly criticised by Republicans and had little support among Democrats.

Most important, actuaries found that, without substantial changes, the program’s premiums would be far too expensive for most buyers and projected it would be financially unsustainable. As a result,more than a year ago, the Obama Administration refused to implement the program. Its repeal was widely expected. The only real question was when and how would it be killed.

At first glance, the budget agreement includes an important trade-off–the creation of a national long term care commission. The idea of such a panel has been pushed for a couple of years now by Senator Jay Rockefeller (D-WV). 

The 15-member panel would include members appointed by the  White House as well as Democratic and Republican leaders of the House and Senate. Its ambitious goal: To “develop a plan for the establishment, implementation,and financing of a comprehensive, coordinated, and high-quality system that ensures the availability of long-term services and supports for individuals in need of such services and supports… and individuals desiring to plan for future long-term care needs.”

Panel members are to reflect the interests of recipients of care, their caregivers, providers, care workers, long-term care insurance companies, and state Medicaid officials.

It all sounds great–and long overdue. The country has not taken a comprehensive look at the long-term care needs of  frail seniors and younger people with disabilities since the Pepper Commission more than two decades ago. Yet, there are elements in the measure creating this panel that are very troublesome.

The first is that is it on very tight time frame. Members must be picked within a month and the panel must submit a proposal to Congress and the White House within six months after that. It is hard to imagine any group solving issues this complex in just six months.

Second, the commission would live in the bureacratic ether. It has no connection to the Department of Health and Human Services or any other federal agency. This can be good, in that it may avoid long-standing bureaucratic turf wars. But is more often bad, because it means the commission has no natural supporters inside an Administration.  

Finally, and most important, the law  includes no requirement that Congress ever actually vote on the panel’s recommendations. This is an old Washington trick, and one that usually consigns commissions such as this and their proposals to the policy dustheap.

I hope I’m wrong and this commission does tackle these critical issues. We’ll know a lot more when we see who is appointed to the panel. But I don’t have high hopes.

In 2012, about 13 million seniors participated in Medicare Advantage (MA) managed care plans—about 27 percent of the Medicare population and twice as many as were enrolled just seven years ago.

This rapid shift to managed care by seniors may be just a first step towards a fundamental change in the way Medicare is delivered and financed. And it has the potential to transform the way long-term supports and services are provided as well.

Medicare managed care comes in many forms. Almost two-thirds of MA enrollees participate in HMO-type plans, such as Kaiser Permanente, where treatment is delivered by employed staff. A rapidly growing alternative is offered by preferred provider organizations (PPOs) where community physicians and nurses are under contract with insurers. Among other versions are Special Needs Plans (SNPs) that provide care for people with complex medical requirements, including those who are  very poor and very ill and who are eligible for both Medicare and Medicaid (dual eligibles).    

Typically, Medicare pays these plans a fixed monthly fee per patient. In return, managed care companies provide their patients with all necessary care, including all-important care coordination. These firms are at risk for costs, so if they can manage expenses, they may keep the extra payment as profit but if  their costs of care exceed the Medicare payment, they will lose money.  

Managed care is especially important for seniors with chronic diseases. It holds the potential for far better care than traditional fee-for-service Medicare, which is often chaotic, disorganized, and duplicative. Yet, MA plans carry their own risks for patients. Unless financial incentives are correctly designed, the firms that operate these plans can be rewarded for discriminating against the sickest patients or denying care to high-cost participants.

Do MA patients use less health care than traditional Medicare enrollees? And is that a good thing, or a potential problem?

So far, the experience is mixed. A December, 2012 study  for the journal Health Affairs found that MA patients were one-quarter to one-third less likely to visit hospital emergency departments, likely to spend less time in the hospital, and less likely to receive outpatient surgery. On the other hand, rates of doctor visits were about the same as in fee-for-service Medicare.

MA patients were less likely to have elective knee and hip replacements but more likely to have heart bypass surgery. A separate insurance industry study found MA patients were less likely to be readmitted to the hospital within 30 days of discharge.  

Medicare also measures quality and safety for both MA plans and fee for service providers. By these standards, MA quality is improving. For several key outcome measures, such as controlling high blood pressure and managing diabetes, HMOs scored significantly higher than PPOs. Starting in 2012, Medicare began paying high quality MA plans a bonus.  

Medicare uses a star rating for MA plans (1 is the lowest, 5 is the highest). In October, it reported 127 plans had 4 or 5 star ratings.

For now, MA plans do not necessarily save Medicare money. In fact, for several years MA plans have been getting higher Medicare subsidies than fee for service providers. The 2010 health law will gradually reduce the level of these subsidies and plans will have to find ways to provide high quality care for less money—the challenge that fee for service Medicare providers already face.

MA plan have enormous potential to better coordinate care for seniors and others with chronic disease. Someday, they may also become the basis for a system that integrates medical care with long-term supports and services. For now, MA plans in all their forms remain a work in process. They have some real benefits, including premiums that are substantially lower than for fee-for-service. But consumers need to consider these plans very carefully. And so do policymakers.

A new insurance company survey of financial advisers reports that four-in-ten have clients who ask about giving away their assets so they can become eligible for Medicaid long-term care.  Oddly, though not surprisingly, the same advisers report their clients say that a key goal of their long-term care planning is “maintaining control.”

The online survey, by Nationwide Financial, questioned a small, self-selected sample of advisers, so the results may not be representative. And remember, this survey did not report that 40 percent of clients want to spend-down, only that 40 percent of advisers had clients who asked about it.

Most research suggests that few ever follow through with this strategy. Still, if control and independence are really your goals, the last thing you want to do is rely on Medicaid for your long-term supports and services. Here are some reasons why:

Medicaid benefits vary widely from state to state. And while a handful of programs provide beneficiaries some flexibility, Medicaid is loaded with rules about what is, and what is not, covered. While home care is becoming more common, assistance is still often available only in nursing homes. And even where Medicaid home care is offered, the level of assistance is often low and many enrollees face long waiting lists before such care is available to them.  

Medicaid pays only limited benefits for residents of assisted living facilities. It may pay for some assistance with daily activities, such as bathing or eating, but does not pay for room and board, which represents the bulk of costs. Medicaid normally won’t pay for independent senior living either.

While Medicaid does pay for nursing home care, getting into a high-quality facility is not easy. And once you get in, you may have very different accommodations than private pay residents.  

Nursing homes normally are not required to accept Medicaid residents. Indeed, because facilities say they lose money on Medicaid stays —a new industry-funded study reports that nursing homes lose an average of about $22-per-Medicaid patient per day—the best nursing homes limit the number of Medicaid residents they will accept at any one time.

The trick is to get into a high-quality facility while you are still paying out of pocket. Once you are there, the facility is not allowed to evict you if you run out of money and go on to Medicaid.  Nursing facilities, of course, know this. So they’ll often want to be sure you can pay for a year or more before accepting you. That may mean you have to enter a nursing facility long before you need to, just so you can get into your facility of choice.  

Also, keep in mind that while a facility may not reduce its care if you shift from private pay to Medicaid, it can make some changes. For instance, in nearly all facilities Medicaid residents must share a room.

Finally, Medicaid makes it tough to artificially give away assets in order to benefit from the program. One rule penalizes you if you give away your money within five years of being admitted to a nursing home.

At first glance, giving away money to relatives may seem attractive. But Medicaid is a program aimed at the poor and it faces severe budget issues.  Besides the ethical issues of gaming the system (which I think are significant), you might want to think twice about turning your care over to a government program that is chronically short of money.

Slowly but surely, more people who receive Medicaid benefits for long-term supports and services are getting their care at home rather than in nursing facilities. Still, only about 3.3 million seniors and younger people with disabilities who require long-term care get such help at home—about 1 million more than in 2000.

Overall, the program now spends about $50 billion or 45 percent of its long-term care budget on home and community care, according to a new study by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured. A decade ago, it spent about $20 billion.  

Yet the number of people receiving home and community care, and the amount of money individual states put into that care, varies widely. For instance, in 2009 Medicaid spent an average of $15,371 per person on home and community care. But Illinois spent only about $5,200 while Tennessee spent more than $35,000.  

These big state-to-state differences are important, especially since both federal Medicaid spending and state flexibility may be key issues in budget talks over the next year. If lawmakers give the program less money but more flexibility, these state variations could widen considerably.   

Medicaid is the largest single payer of long-term supports and services, funding almost half of all paid long-term care. It dwarfs the benefits provided by private long-term care insurance or what people pay out of pocket. But the Medicaid program, run by the states but jointly funded by states and the federal government, is required to provide care only in nursing facilities.

States may also offer long-term services and supports to people living in the community but must first get federal permission. The feds also give them leeway in deciding how much care they fund and who gets it.    

Nearly all states have home and community programs, but many reduce costs by restricting eligibility or limiting benefits. For instance, some states limit participation (and save money) by setting more restrictive rules for those applying for home care than for those getting care in a nursing facility.

Another way states save money is to allow only a limited number of participants in home care programs at any one time. Others are placed on a waiting list. Overall, more than a half-million Medicaid beneficiaries were waiting for home and community care in 2011, 75,000 more than in 2010. The average wait was more than two years, which is especially problematic for the frail elderly, many of who are likely to die before reaching the top of the list.

These wait lists vary widely for different populations and among states. For instance, in California only about 1,300 people who were aged and disabled were waiting for home and community care in 2011. In Louisiana, a much smaller state, 27,000 were waiting, and in Texas almost 44,000 were on the list for home care benefits.

Most people who need supports and services want to get that care at home. And states say they want to deliver such care in the community. But, as the Kaiser study shows, many states are still reluctant to provide that assistance through Medicaid. Their home and community-based programs exist on paper, but often are often insufficient for the needs of the frail elderly and those younger people with disabilities who are trying to stay at home.

Too often, we stash our elders away in institutional residential care facilities. And, sadly, even many active seniors choose to separate themselves from the broader world, opting for what they see as the safety and security of gated communities.  

This week, I spent a couple of days in Rochester, N.Y., where the St John’s Living Community has developed two alternatives to this world of hidden elders. One is a new independent living community that is explicitly opening itself up to the surrounding neighborhood. The second: Two 10-bed nursing homes that have been built in the midst of a middle-class subdivision, as fully integrated into the neighborhood as the private homes that surround it.

At first glance, the independent living community, called Brickstone, is not unlike hundreds of other upscale senior residences. Still under construction, it will include 102 townhouses, apartments, and bungalows, with a community center, walking trails, shops, and restaurants. It is a short walk from another St John’s facility called the Meadows, which provides both independent and assisted living.

What’s different is St. John’s aim to reach outward rather than turn inward. It invited local colleges to teach undergraduate courses at the Meadows. Shops and restaurants at Brickstone’s village square will be open to the broader community, not just limited to its residents. A lecture series is also open to the neighbors and includes programs that include children’s literature and story “slams.” Duane Girdner, St. John’s marketing vp, calls Brickstone an “ungated community.”   

St. John’s other initiative is even more interesting. It has built two “Green House” nursing facilities right in the middle of a new suburban development called Arbor Ridge in Penfield, N.Y.  Green Houses are themselves an important innovation, replacing big institutional nursing facilities with small homes for 8-10 residents.

Green Houses provide residents with broad autonomy, allowing them to choose, for instance, when to get up and when to eat. And they have profoundly changed the role of the nurses and nurse’s aides  who provide direct care. The concept has been around for several years, but until now most Green Houses have shared a campus with sister care facilities, often large, more traditional nursing homes.

St John’s Arbor Ridge project is very different. There, two single-story nursing homes sit in the midst of an otherwise ordinary subdivision.  From the outside, the facilities look much like the ranch houses that share the development. The goal: To integrate the nursing homes –and their residents– as much as possible into the community.

Soon after the facilities opened last spring, St. John’s threw a well-attended community party. Since then, staffers report no complaints or concerns from the neighbors, but neither has there yet been much bonding. 

I’ve visited some similar-sized assisted living facilities that have also located in residential neighborhoods. And the concept works. After a few years, local kids come by for Halloween trick-or-treating, neighbors get to know residents–and  something like a community is created. That’s what St John’s has in mind.   

Of course, the idea of seniors living in community settings is entirely unremarkable. Yet, even elders who live in their own homes are increasingly disconnected from their neighbors.  Old friends move away. Younger couples are busy with their kids. If an elder can no longer walk or has trouble hearing, she is less likely to meet new people. She can be living in a community but entirely isolated from it.

St. John’s is trying repair those broken links, both for active seniors and those with significant cognitive and physical limitations. If it succeeds, it can blur the line between institutional living and community living. And that would be a very good thing.

Medicaid is in the budget bull’s eye. But many lawmakers aiming to cut the program have no idea what it does, and how important it is to frail seniors who need help with daily living. The popular image of Medicaid: health care for a poor mother and her children. The all-too-common reality: long-term supports and services for an 85-year old widow with dementia.

With Congress and President Obama looking for both a short-term way to avoid the dreaded fiscal cliff and a long-term deficit reduction deal, Medicaid and Medicare are at the top of the hit list—in large part because they are so costly.

Let’s leave the debate over Medicare for another time. But Medicaid, frequently lumped in with Medicare and Social Security as one of those vaguely threatening “entitlements,” is another matter.

Medicaid, jointly funded by the federal government and the states, does two jobs. It provides health care for those poor mothers and their kids—who represent about three-quarters of enrollees. But two-thirds of the Medicaid budget is spent on the frail elderly and younger people with disabilities. And one-third of all Medicaid spending—about $120 billion– is for their long-term care alone.

In recent months, conservatives have taken up the cry that the U.S. has become a “Nation of Takers,” to borrow the title of a recent book by American Enterprise Institute scholar Nick Eberstadt. It became a common campaign theme of GOP presidential candidate Mitt Romney. A recent column by Washington Post columnist Bob Samuelson nicely summarizes this view. And too often Medicaid is casually tossed into the conversation.

So who are the Medicaid takers? Among the elderly, they are among the nation’s most vulnerable. They are frail, often suffer from multiple chronic diseases (such as heart failure, dementia, or diabetes), and are impoverished.  Many were once middle class but, due to illness, are without financial resources in old age.

Look at the roughly 9 million people who are sick enough and poor enough to be eligible for both Medicare and Medicaid (often called the dual eligibles, or just the “duals”). Some are poor, but relatively healthy. Many others are not.

Two-thirds of the duals are aged 65 or older. According to MedPAC, the independent commission that advises Congress on Medicare, 38 percent have cognitive or mental impairments, 22 percent have multiple physical impairments, and 23 percent live in nursing homes or other institutions.

Sixty percent of those duals who live in nursing homes or other institutions have dementia or some other cognitive impairment. According to the Kaiser Family Foundation, one-quarter of elderly who are eligible for both programs need assistance with at least three activities of daily living (such as bathing, going to the bathroom, eating, or dressing). Many are, in other words, helpless.

Among the 1 million dual eligibles who are the most costly Medicaid patients,  nearly half are aged 80 or older, three-quarters need help with 3 or more activities of daily living, three-quarters live in institutions, and one out of every six has Alzheimer’s.  

Ninety percent are poor or near-poor. More than half have incomes of less than $10,000. And 90 percent have no other insurance. According to Kaiser, 70 percent are women and only about 20 percent are married. Some have adult children to care for them. Many others do not.

There is no doubt the U.S. has a long-run budget problem, and that we need to do a better job caring for the frail elderly who are chronically ill and need both medical care and long-term services. Maybe we can find a way to  provide these people with better care and save money. Maybe we can find an alternative to Medicaid, at least for people who were once middle-class. But taking a meat axe to Medicaid in a frantic attempt to hit a politically-motivated budget target is not the way to do it.    

With the election behind him, Barack Obama’s first item of business will be dealing with the fiscal cliff–that toxic combination of tax increases and automatic spending cuts that are due to kick in on Jan 2, unless Congress acts to delay or replace them with a long-term deficit reduction plan. 

Going over the cliff would mean deep cuts in a wide range of government programs. And even though Medicaid and Social Security are exempt from the spending reductions, dozens of other important senior services programs are on the block.

Overall, more than $54 billion would be slashed from non-defense programs for 2013. And many provide critical supports for people with long-term care needs who are trying to live at home. While Medicaid is exempt from the spending reductions, the rest of the infrastructure people need to stay in the community, such as transportation, personal assistance, subsidized housing, and adult day would all face deep cuts.

Many would hit programs operated under the Older Americans Act. According to the Leadership Council of Aging Organizations,  if Congress goes over the cliff and the cuts last through 2013, the consequences would be severe. Among them: A reduction in nearly2 million rides for seniors, a cut in case management services for 290,000 seniors, and a cut of 750,000 adult day slots. Caregiver supports would be cut by $12.6 million, social service block grants (which fund programs such as meals, transportation, and adult foster care), would be cut for 345,000 people aged 60 and over. More than 1 million seniors would lose homemaker services and 1.5 million would lose in-home personal care services.

Keep in mind that the  idea of the fiscal cliff was to make the tax hikes and spending cuts so draconian that Congress and the president would agree to a long-term budget deal to avoid them. So far, that strategy has failed miserably. The question now is whether Obama will find the key to unlock Washington’s frozen politics and avoid the automatic cuts.

Make no mistake, programs such as Medicaid and Medicare will be the focus of any long-range fiscal solution. But changes will come only after months of serious debate. They may themselves be very difficult for seniors and providers. But going over the fiscal cliff won’t prevent them. It might even make them more likely.

In the long run, an era of fiscal constraint may require communities to pick up some of these government programs, such as transportation. But that can’t happen overnight.  

It helps no-one if  by partisan inaction, Congress and the president hammer senior services with mindless, needless, across-the-board cuts that will come from toppling over the cliff.