Federal Incentives to Reform Long-Term Care Under the Affordable Care Act: State Adoption of the Balancing Incentive Program, 2011-2014.

OBJECTIVES: The Balancing Incentive Program (BIP) was an optional program for states within the Patient Protection and Affordable Care Act to promote Medicaid-funded home and community-based services (HCBS) for older adults and persons with disabilities. Twenty-one states opted to participate in BIP, including several states steadfastly opposed to the health insurance provisions of the Affordable Care Act. This study focused on identifying what factors were associated with states' participation in this program. METHODS: Event history analysis was used to model state adoption of BIP from 2011 to 2014. A range of potential factors was considered representing states' economic, political, and programmatic conditions. RESULTS: The results indicate that states with a higher percentage of Democrats in the state legislature, fewer state employees per capita, and more nursing facility beds were more likely to adopt BIP. In addition, states with fewer home health agencies per capita, that devoted smaller proportions of Medicaid long-term care spending to HCBS, and that had more Money Follows the Person transitions were also more likely to pursue BIP. DISCUSSION: The findings highlight the role of partisanship, administrative capacity, and program history in state BIP adoption decisions. The inclusion of BIP in the Affordable Care Act may have deterred some states from participating in the program due to partisan opposition to the legislation. To encourage the adoption of optional HCBS programs, federal policymakers should consider the role of financial incentives, especially for states with limited bureaucratic capacity and that have made less progress rebalancing Medicaid long-term services and supports.

[Difficulties and Policy Recommendations Related to the Deployment of Long-Term Care Resources in Taiwan`s Indigenous Areas].

Changes in the demographic structure in Taiwan have increased the need for long-term care (LTC). Person-centered and community-based care is being advocated. The need to address the specific LTC needs of Taiwan`s indigenous peoples has been a part of national LTC policy since National Long-term Care Plan 2.0 was adopted in 2015. The provision of LTC services and the deployment of related resources in indigenous areas generally lag behind Taiwan`s other areas. Potential reasons for this disparity include lack of in-charge, dedicated units; exclusive use of normative service models in indigenous areas; and conflict between talent cultivation and rooted development. Future policy should focus more on providing cultural care in indigenous areas and on offering more flexible and diversified development possibilities. The implementation of these policies may promote the development of LTC and the successful deployment of LTC resources in Taiwan`s indigenous regions.

[Health of Indigenous People and Cultural Sovereignty: Developing the Competence of Culture Safety Instructors Under the Long-Term Care 2.0 Program].

Taiwan`s various ethnic groups, including 16 indigenous groups, represent disparate distinct cultures and backgrounds. In long-term care, culturally safe services that reflect cultural expectations and practices must be provided to older-adult recipients of care. As frontline healthcare workers face practical challenges in providing these services appropriately, "cultural safety instructors" may be used to help facilitate indigenous cultural care. Therefore, it is vital to develop the role function and cultural competence of these instructors. In this article, related instructor qualifications, course contents, and expected results of an indigenous cultural safety instruction program are presented based on the theory of cultural competence and cultural safety. In addition, relevant perspectives on cultural safety instructors and their cross-cultural competence specific to indigenous peoples, including Dimitrov and Haque (2016) and Leininiger (1996), are integrated. It is hoped that this study promotes reflection and provides a reference on practice and policies related to long-term care for indigenous people.

Advance Directives State Requirements, Center Practices, and Participant Prevalence in Adult Day Services Centers: Findings From the 2016 National Study of Long-Term Care Providers.

OBJECTIVES: Adult day services centers (ADSCs) may serve as an entrée to advance care planning. This study examined state requirements for ADSCs to provide advance directives (ADs) information to ADSC participants, ADSCs' awareness of requirements, ADSCs' practice of providing AD information, and their associations with the percentage of participants with ADs. METHODS: Using the 2016 National Study of Long-Term Care Providers, analyses included 3,305 ADSCs that documented ADs in participants' files. Bivariate and linear regression analyses were conducted. RESULTS: Nine states had a requirement to provide AD information. About 80.8% of ADSCs provided AD information and 41.3% of participants had documented ADs. There were significant associations between state requirements, awareness, and providing information with AD prevalence. State requirement was mediated by awareness. DISCUSSION: This study found many ADSCs provided AD information, and ADSCs that thought their state had a requirement and provided information was associated with AD prevalence, regardless of state requirements.

Long-Term Care, Residential Facilities, and COVID-19: An Overview of Federal and State Policy Responses.

The COVID-19 pandemic has disproportionately affected residents and staff at long-term care (LTC) and other residential facilities in the United States. The high morbidity and mortality at these facilities has been attributed to a combination of a particularly vulnerable population and a lack of resources to mitigate the risk. During the first wave of the pandemic, the federal and state governments received urgent calls for help from LTC and residential care facilities; between March and early June of 2020, policymakers responded with dozens of regulatory and policy changes. In this article, we provide an overview of these responses by first summarizing federal regulatory changes and then reviewing state-level executive orders. The policy and regulatory changes implemented at the federal and state levels can be categorized into the following 4 classes: (1) preventing virus transmission, which includes policies relating to visitation restrictions, personal protective equipment guidance, and testing requirements; (2) expanding facilities' capacities, which includes both the expansion of physical space for isolation purposes and the expansion of workforce to combat COVID-19; (3) relaxing administrative requirements, which includes measures enacted to shift the attention of caretakers and administrators from administrative requirements to residents' care; and (4) reporting COVID-19 data, which includes the reporting of cases and deaths to residents, families, and administrative bodies (such as state health departments). These policies represent a snapshot of the initial efforts to mitigate damage inflicted by the pandemic. Looking ahead, empirical evaluation of the consequences of these policies-including potential unintended effects-is urgently needed. The recent availability of publicly reported COVID-19 LTC data can be used to inform the development of evidence-based regulations, though there are concerns of reporting inaccuracies. Importantly, these data should also be used to systematically identify hot spots and help direct resources to struggling facilities.

Stepping into the Breach of Federal Inaction: Reforming the Financing of Long-Term Services and Supports in the Post-CLASS Era.

The growing need for long-term services and supports (LTSS) poses significant challenges to both individuals and government. This article documents the continuing failure to tackle this problem at the national level-a failure that was most recently seen in the fallout from the Affordable Care Act (ACA), which included the single piece of national legislation ever enacted to comprehensively address LTSS costs: the Community Living Assistance Services and Supports (CLASS) Act. The CLASS Act was passed as part of the ACA (Title 8) but was repealed in 2013. Following its demise, policy experts and some Democrats have made additional proposals for addressing the LTSS financing crisis. Moreover, significant government action is taking place at the state level, both to relieve financial and emotional burdens on LTSS recipients and their families and to ease pressure on state Medicaid budgets. Lessons from these initiatives could serve as opportunities for learning how to overcome roadblocks to successful policy development, adoption, and implementation across states and for traversing the policy and political tradeoffs should a policy window once again open for addressing the problem of LTSS financing nationally.

COVID-19 in the Long-Term Care Setting: The CMS Perspective.

Safeguarding the health and promoting the well-being and quality of life of the most vulnerable and fragile citizens is a top priority for the Centers for Medicare & Medicaid Services (CMS). In response to the Coronavirus Disease 2019 (COVID-19) pandemic, numerous regulatory policies and 1,135 waivers of federal requirements have been implemented by CMS to give long-term care providers and professionals flexibility to meet the demands of resident and patient care needs during this public health emergency. Goals for these policies and waivers are increasing capacity, enhancing workforce and capability, improving oversight and transparency, preventing COVID-19 transmission, and reducing provider burden. J Am Geriatr Soc 68:1366-1369, 2020.

[Impact of the Dependency Act on regional spending on social services]. / Impacto de la Ley de Dependencia sobre el gasto autonómico en servicios sociales.

OBJECTIVE: In this paper we address whether the System for Personal Autonomy and Care of Dependent Persons contributes to increasing the volume of resources of the public social services system (displacement effect) or, on the contrary, whether this development has taken place at the expense of other social services (substitution effect). METHOD: Panel data analysis is used to explain how per capita expenditure on social services evolves in the Spanish Regions under the common regime in the period 2002-2016. RESULTS: The implementation of the Dependency Act is associated with a 14% increase in the level of per capita expenditure on social services. This effect raises 25% when the variable explained is expenditure on current transfers of a social nature. On the other hand, law changes introduced in 2012 and 2013 were associated with a reduction in per capita expenditure on current transfers of around 10%. CONCLUSIONS: This evidence would refute the hypothesis that the System for Personal Autonomy and Care of Dependent Persons had merely a "substitution" effect on autonomous spending on social services.

The Impact of the Long-term Care Homes Act and Public Reporting on Physical Restraint and Potentially Inappropriate Antipsychotic Use in Ontario's Long-term Care Homes.

BACKGROUND: We report on the impact of two system-level policy interventions (the Long-Term Care Homes Act [LTCHA] and Public Reporting) on publicly reported physical restraint use and non-publicly reported potentially inappropriate use of antipsychotics in Ontario, Canada. METHODS: We used interrupted time series analysis to model changes in the risk-adjusted use of restraints and antipsychotics before and after implementation of the interventions. Separate analyses were completed for early ([a] volunteered 2010/2011) and late ([b] volunteered March 2012; [c] mandated September 2012) adopting groups of Public Reporting. Outcomes were measured using Resident Assessment Instrument Minimum Data Set (RAI-MDS) data from January 1, 2008 to December 31, 2014. RESULTS: For early adopters, enactment of the LTCHA in 2010 was not associated with changes in physical restraint use, while Public Reporting was associated with an increase in the rate (slope) of decline in physical restraint use. By contrast, for the late-adopters of Public Reporting, the LTCHA was associated with significant decreases in physical restraint use over time, but there was no significant increase in the rate of decline associated with Public Reporting. As the LTCHA was enacted, potentially inappropriate use of antipsychotics underwent a rapid short-term increase in the early volunteer group, but, over the longer term, their use decreased for all three groups of homes. CONCLUSIONS: Public Reporting had the largest impact on voluntary early adopters while legislation and regulations had a more substantive positive effect upon homes that delayed public reporting.

The kids are alright - labour market effects of unexpected parental hospitalisations in the Netherlands.

Unexpected negative health shocks of a parent may reduce adult children's labour supply via informal caregiving and stress-induced mental health problems. We link administrative data on labour market outcomes, hospitalisations and family relations for the full Dutch working age population for the years 1999-2008 to evaluate the effect of an unexpected parental hospitalisation on the probability of employment and on conditional earnings. Using an event study difference-in-differences model combined with coarsened exact matching and individual fixed effects, we find no effect of an unexpected parental hospitalisation on either employment or earnings for Dutch men and women, and neither for the full population nor for the subpopulations most likely to become caregivers. These findings suggest that the extensive public coverage of formal long-term care in the Netherlands combined with widespread acceptance of part-time work provides sufficient opportunities to deal with adverse health events of family members without having to compromise one's labour supply.

Psychotherapy in Psychiatry: Fighting Alternative Facts.

In the Canadian province of Ontario, the Ministry of Health and Long-Term Care is proposing to impose arbitrary limits on access to psychotherapy provided by physicians. This column presents and debunks 3 myths associated with this ill-conceived proposal: (1) that long-term psychotherapy costs the health care system too much money, making it necessary for the government to curb this spending; (2) that long-term psychotherapy is a non-evidence-based treatment being needlessly spent on the worried well; and (3) that we need to focus on quick treatments, not long ones.

LTC 2.0: The 2017 reform of home- and community-based long-term care in Taiwan.

Taiwan planned to establish a social insurance-based long-term care system in 2016. However, due to the change in political parties that year, it was decided that Taiwan's long-term care policy would remain a tax-based financing scheme. The new policy focuses on providing home- and community-based service (HCBS); a three-layer HCBS service network within towns and districts was set to provide the 17 types of services in the HCBS spectrum, including preventive care. The reform was criticized as being too restrictive and lacking flexibility. However, the HCBS service spectrum has been widened, the target group has been enlarged, and thus HCBS utilization has increased. A rolling amendment has continued into 2018: the HCBS system requirement has been eased, and a new capitalized fee-for-service payment system has been launched. This paper discusses the analysis of the policy reform.

From fragmentation toward integration: a preliminary study of a new long-term care policy in a fast-aging country.

BACKGROUND: Taiwan, one of the fastest-aging countries in the world, started implementing version 1.0 of its long-term care (LTC) plan in 2008. In 2017, LTC Plan 2.0 began a new era with its goal to integrate Taiwan's fragmented LTC service system. LTC Plan 2.0 also aims to establish an integrated community-based LTC system incorporating both health care and disability prevention. This three-tier model consists of the following: two LTC services with a day-care center as their base and case management (Tier A), a day-care center and a single LTC service (Tier B), and LTC stations that provide primary prevention services and respite services for frail community-dwelling older adults to prevent further disabilities (Tier C). A defined cluster of agencies in a local area works together as a Tier ABC team. LTC Plan 2.0 is a new policy for Taiwan, and hence it is important to understand the agencies' initial difficulties with implementation and identify future challenges to help further policy development. METHODS: This preliminary study explored the challenges to implementing LTC 2.0 through in-depth interviews based on Evashwick's integration mechanisms with representatives from three service teams. We interviewed three chief executive officers and three case managers. RESULTS: We found that the LTC Plan 2.0 mechanisms for service integration have been insufficiently implemented. Recommendations include (1) Build up the trust between agencies and government, avoid duplication of LTC services within Tier ABC team, and encourage agencies within a team to create a shared administrative system with the same mission and vision. (2) Clarify the roles and responsibilities of government care managers and agency case managers. (3) Provide an integrated information system and create an official platform for sharing client records across different agencies and caregivers. (4) Establish a tool and platform to track the budget and payment across different levels of service as soon as possible. CONCLUSION: There is an increased demand for LTC services in Taiwan because of its rapidly aging population. Our findings shed some light on the challenges to developing integrated LTC services and thus may help both policymakers and service providers find ways to overcome these challenges.

Catastrophic risk associated with out-of-pocket payments for long term care in Spain.

OBJECTIVES: This study analyses the financial burden associated with the introduction of copayment for long-term care (LTC) in Spain in 2012 for dependent individuals. MATERIAL AND METHODS: We analyse and identify households for which the dependency-related out-of-pocket payment exceeds the defined catastrophic threshold (incidence), and the gap between the copayment and the threshold for the catastrophic copayment (intensity), for the full population sample and for subsamples based on the level of long-term care dependency and on regional characteristics (regional income and political ideology of party ruling the region). RESULTS: The results obtained show there is a higher risk of impoverishment due to copayment among relatively well-off dependents, although the financial burden falls more heavily on less well-off households. Our findings also reveal interesting regional patterns of inequity in financing and access to long-term care services, which appear to be explained by an uneven development of LTC services (monetary transfers versus formal services) and varying levels of copayment across regions. CONCLUSIONS: The new copayment for long-term care dependency in Spain is an important factor of catastrophic risk, and more attention should be addressed to policies aimed at improving the progressivity of out-of-pocket payments for LTC services within and between regions. In addition, formal services should be prioritised in all regions in order to guarantee equal access for equal need.

A value-critical policy analysis of the nursing home reform act: a focus on care of African American and Latino residents.

Improving nursing home care has been a central legislative focus since the 1980s; The major response effort to address these reports of poor-quality care was first met with a federal rule in 1987, the Nursing Home Reform Act (NHRA). Since enactment of the NHRA in 1987, and despite an increasing utilization of nursing home care by aging minorities, the standardization of care practice, or quality indicators (e.g., structural, process, and outcome measures), within long-term nursing home care have remained relatively unchanged. This paper reports a value-critical policy analysis of the most recent final action rule, effective on November 28 of 2016 by the Centers for Medicare and Medicaid Services (CMS) with a particular focus on its impact on African-American and Latino older adults. This paper presents results of two policy analyses. Taken together, this merged analysis focuses on an overview of the problem, the groups most affected by the problem, current program goals and objectives, forms of benefits and services, and a current state of the social problem. Following the analysis, we present changes and improvements to be made, as well as proposals for reform and recommendations for policy changes.

Ontario's Retirement Homes and Long-Term Care Homes: A Comparison of Care Services and Funding Regimes.

ABSTRACTGrowing demand for beds in government-subsidized long-term care (LTC) homes in Ontario is causing long waitlists, which must be absorbed by other residential alternatives, including unsubsidized retirement homes. This study compares Ontario's LTC homes and retirement homes for care services provided, funding regimes, and implications of differential funding for seniors. Descriptive data for both types of homes were collected from public and proprietary sources regarding service offerings, availability, costs, and funding. Overlaps exist in the services of both LTC and retirement homes, particularly at higher levels of care. Although both sectors charge residents for accommodation, most care costs in LTC homes are publicly funded, whereas residents in retirement homes generally cover these expenses personally. Given waitlists in Ontario's LTC homes, many seniors must find residential care elsewhere, including in retirement homes. Several policy alternatives exist that may serve to improve equity of access to seniors' residential care.

The impact of Dependency Act benefits on employment.

OBJECTIVE: To assess the amount of employment generated from the effective development of the Dependency Act in 2012, by evaluating the number of jobs depending on whether in-kind services or cash benefits were applied. METHODS: The level and total costs of dependency were obtained by using the Survey on Disability, Personal Autonomy and Dependency Situations of 2008. The consumption of dependent households was collected from the Household Budget Survey of 2012 carried out by the Spanish Statistics Institute. The impact on employment was estimated using an extended Input-Output model based on Symmetric Input-Output Tables and labour data from the Spanish National Accounts Base. RESULTS: The total estimated costs of dependency in 2012 were 4,545 million Euros for in-kind services and 2,662 for cash benefits. One hundred and ninety-five thousand, six hundred and sixty-eight jobs were generated in 2012 from dependency costs, and132,997 were linked to in-kind services and 62,671 to cash benefits. Every million Euros allocated for dependency by the Government returned 53.33 jobs linked to in-kind services and 46.21 to cash benefits. Furthermore, 341,505 jobs would have been created if dependency benefits had been exclusively offered via in-kind services. CONCLUSIONS: Dependency benefits were equally distributed between in-kind services and cash benefits in 2012. Given that two out of three job positions generated from dependency benefits are linked to in-kind services, while the remaining third is generated by cash benefits, we conclude that around 146 thousand more jobs would have been generated if benefits had been offered as in-kind services instead of overusing cash benefits.

Homeowner Behavior, Health Status, and Medicaid Payment Eligibility: Evidence from the Deficit Reduction Act of 2005.

This paper analyzes the effect of a change in the status of housing equity as a protected asset for Medicaid long-term care payment eligibility. A difference-in-difference-in-differences strategy is employed to estimate the effect of the policy on the housing equity holdings of potentially treated individuals. Using a panel of unmarried homeowners, the policy induced treated individuals who were likely to require long-term care to hold less housing equity by values of $82,000 to $193,000 relative to control individuals. This equates to relative reductions of 12 to 29 percent for treated individuals after the policy change. Similar effects are not observed when considering health measures less predictive of long-term care services and for a sample of married households who were unlikely affected by the policy. These estimates confirm the importance of the housing asset as a shelter for Medicaid eligibility.