Washington a model for seniors’ long-term care
As the nation prepares for a growing older population, states that want to improve their long-term care systems often look to Washington state.
That’s because, for the past few decades, Washington has been reforming its long-term care services for seniors. In Washington, older adults can choose from a wide variety of options for long-term care — whether it’s in a nursing home, in a licensed adult-family home or in their own home, with the help of a professional or family caregiver.
“Our program is truly unique in America. … We continue to successfully establish laws and policies that support choice, self-direction, and quality services and oversight for our state,” said Bea Rector, the acting assistant secretary for the Department of Social and Health Services’ Aging and Long Term Support Administration. “We spend a lot of time in technical assistance with other states calling us and saying, ‘How do you do that?’”
Washington’s long-term care system consistently earns high marks in a ranking commissioned by the AARP Foundation, The Commonwealth Fund and The SCAN Foundation.
That ranking, the 2017 Long-Term Services and Supports Scorecard, shows Washington leading among all 50 states. In rankings conducted in 2011 and 2014, Washington came in second.
“Washington’s #1 rating on the scorecard is a proud moment for our state,” said Cathy MacCaul, advocacy director for AARP in Washington. “We have worked hard to serve our older residents, those with disabilities and family caregivers.”
In Washington, about 77,000 residents a year receive assistance through ALTSA for long-term care. About 10,000 of them reside in nursing homes, while others live in adult family homes or assisted living facilities. The vast majority remain in their home with the help of a caregiver.
Even though most of these adults don’t require nursing-home care, nursing-home coverage is the only federally required long-term care service for Medicaid recipients, Rector said. So Washington state has passed laws to fill the void, creating its own entitlement program and Medicaid waivers to offer more options.
These changes have saved taxpayer money by keeping aging adults from paying for care they don’t need. Rector’s administration estimates that since 1999, the state has saved $4.4 billion through reforms to its long-term health care system. Those savings have been reinvested in programs that help adults who are elderly or disabled.
Supporting family caregivers
Sally Brewer of La Conner wanted to receive care in her home following a diagnosis of Alzheimer’s disease in her mid-70s.
“After raising three sons and taking care of me for 60 years, she began to slow down, and gradually it turned into a couple of trips to the emergency ward,” said her husband, 85-year-old Bob Brewer. “That’s when I knew she was going to need care.”
Bob approached the state’s Department of Social and Health Services, not knowing what to expect. DSHS helped the couple, who were on a fixed income, apply for a Medicaid waiver called Community Options Program Entry System. They were assigned a caseworker and found an in-home caregiver to provide nursing and housekeeping duties. Bob said the help he received from the agency went above and beyond.
Eventually, because of Sally’s disease, she had difficulty getting along with her in-home caregivers, so Bob decided to become her caregiver. He entered the state’s Family Caregiver Support Program, which provides services to unpaid family caregivers, including information, screenings, respite care, support groups and training.
Bob attended caregiver workshops, through which he met other family caregivers. “I was able to share ideas sitting with other people in similar situations. (It) was a wonderful experience for me,” he said.
Despite what was happening in her brain, Sally’s overall physical health didn’t decline too badly, Bob said. He could get her out of the house most days, often driving to a restaurant for a burger.
In February, Sally died in her sleep in the couple’s home. Bob said he was grateful that his wife spent her final years there.
“I was able to have Sally stay with me in familiar surroundings. She could actually see her grandchildren more often because they lived nearby, and she could have her little dog. Part of every day was happy,” he said. “I want this program to get whatever kind of credit it can. It restored my faith in bureaucracy.”
Their story is not unique. Today, there are more than 820,000 unpaid family caregivers in Washington, who provide 80 percent of the long-term care administered in the state.
Later this year, Washington will offer more services to unpaid family caregivers of Medicaid-eligible residents who are 55 or older through a new waiver. The waiver also will provide assistance to people who need long-term care services or supports but who are not financially eligible for Medicaid.
Preparing for an older population
Despite the state’s success in improving its long-term care system, more will need to be done for a growing aging population.
By 2030, one in five Washingtonians is expected to be 65 or older; 2016 census estimates place the current number at about one in seven. People can now expect to live two to three decades beyond the traditional retirement age of 65.
Some working adults find themselves with parents — and even grandparents — who need long-term care. People also are having fewer children, meaning there won’t be as many family members available to care for aging relatives.
This population shift is sometimes referred to as the “silver tsunami,” but Rector said the tsunami metaphor doesn’t fit because tsunamis recede. There is not a time in the foreseeable future when the size of the 65-and-older population is expected to return to the way it was.
Whatever you call it, the rising need will put a greater demand on working families and government resources.
“We are well positioned in that we have a great community-based system that’s cost effective and available,” Rector said. At this point, however, “I don’t think anyone is totally prepared.”
Rector said solutions could include using new technologies to keep in touch with long-term care recipients, helping family caregivers remain healthy for as long as possible and creating communities better suited for the aging population — those with good sidewalks and transportation systems and that are close to grocery stores and medical offices.
Other advocates have called for private insurance plans specifically for long-term care.
The federal health care debate complicates matters. The push in Congress to repeal the federal Affordable Care Act appears stalled for now, but if it were revived, AARP’s MacCaul said it could unravel the state’s successes in long-term care.
The number of seniors and adults with disabilities in Washington who depend on Medicaid-funded long-term services and supports is expected to grow to 90,000 by 2028.
For long-term care recipients, Medicaid cuts recently proposed in federal legislation could cause more reliance on family members; less independence in their daily lives; fewer care options; a lower level of personal care; cuts to meals, transportation and supplies; and less frequent monitoring of health and chronic conditions.
Summit on Aging
In October 2013, Gov. Jay Inslee convened the state’s first Summit on Aging to build a strategic plan to prepare for a swelling older population.
The summit jump-started a legislative committee on the subject. Some of its suggestions have been enacted:
- Developing an Alzheimer’s and Dementia State Plan.
- Creating the Community First Choice Option program through the Affordable Care Act to provide more community and home-based services for long-term care.
- Making new investments in caregiver support services, including ensuring a livable wage for professional caregivers.
- Supporting more end-of-life planning and palliative care.
- Creating the Small Business Retirement Marketplace to improve seniors’ financial security by giving employers and employees more affordable and high-quality retirement options.
- Investing in more Adult Protective Services resources to prevent financial exploitation.
- Providing more transit and safer pedestrian infrastructure to connect retail, health and other community services.
- Increasing awareness about falls through Stay Active & Independent for Life, a strength, balance and physical fitness program for people ages 65 and up.
“We can be proud that we provide aging adults choice and dignity when it comes to the services we offer, and we are going to make sure that the long-term care system in our state not only endures but gets even better,” Inslee said.