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Gov. Phil Bredesen at a recent Long-Term Healthcare Roundtable.

In a tight budget year, Gov. Phil Bredesen has declared the need to set priorities. For Tennessee’s chief executive, his 2008 streamlined agenda places heavy emphasis on continuing education initiatives and implementing fundamental change to the state’s long-term care system.

Although the changes outlined in the “Long-Term Care Community Choices Act of 2008” are directly tied to TennCare, the governor has expressed his belief that reworking the system could ultimately benefit a much larger population. The focus on transforming long-term care traces its roots back to a campaign promise Gov. Bredesen made while running for office. That promise stemmed, in part, from his own personal experiences with the limited options available to his mother.

“I’ve seen how much she wants to stay in her own home,” he said of his mother, “and I’ve seen how there have been times it would have been difficult for her to do that without the family support she has.”

With a growing elderly population, the governor’s family story is one that is being played out in homes across the state and the nation. However, Bredesen has said that Tennessee lags 10-20 years behind many states in care options for the elderly and disabled.

Addressing the Tennessee Nurses Association (TNA) at the organization’s recent Legislative Summit (see related story on page 13), he said, “As everyone in this room well knows, healthcare is hard enough to manage when you’re young and healthy. If you’re old and sick, you should not be forced to navigate a system as complex as ours today. The bottom line is that there needs to be a simple process that leads to a richer set of choices.”

He added that the bipartisan legislation, which resulted from working with elected officials and the Long-Term Care Joint Study Committee, is not “tinkering around the edges” of the current system but taking a “wholesale approach” to reforming the way the state handles such care within the Medicaid system.

The governor said that, in today’s model, access is fragmented without coordination among the multiple points of entry into the system. Another problem, he pointed out, is the systemic bias toward the most costly option of residential care even when lower-cost alternatives might better suit the needs and desires of those requiring services. Currently, 98 percent of the state’s $1.1 billion spent on long-term care is allocated to skilled nursing facilities.

The Long-Term Care Community Choices Act is structured to create a faster process for determining eligibility, a single point of entry into the system, a menu of care options ranging from in-home providers to adult day care facilities to residential care, support services for family caregivers and a “one stop shop” for information about resources for the elderly and disabled within the community.

Darin Gordon, deputy commissioner of TennCare, said, “We often times have people wind up in nursing homes who could be better served in another setting.”

One alternative, he continued, is to look at self-directed care whereby a family member, neighbor or other appropriate person could help with in-home care at a much lower rate of reimbursement. Although Bredesen and Gordon initially were skeptical about such an option, both believe it is workable when proper controls are put in place. Gordon pointed out that more than 40 other states currently rely on self-directed care programs to some degree.

In his public comments, the governor has repeatedly stressed that this act is not about pulling people out of nursing homes today but rather about rethinking the options for those coming into the system in the future. However, it is certainly possible some current residents might be able to relocate to another setting if additional service options were to become available.

To increase the service spectrum, the governor has called on skilled nursing facilities to broaden their concept of service lines and diversify how they deliver care, much like hospitals have done over the past few decades with the addition of outpatient services and on-site medical offices.

In her role as executive director of the Tennessee Association of Homes and Services for the Aging (TNAHSA), Carrie Ermshar has had the opportunity to voice both support for and concerns over the ultimate implementation of the plan.

“We have been at the table for many weeks now on this,” she said of TNAHSA, which represents the full spectrum of service providers for the aging.

“We applaud the efforts, and we’re very supportive of this bill,” she continued. “Of course, the devil is in the details.”

First and foremost, Ermshar said, it is important that consumers have choices and viable options to stay in their homes — whether that be a family home or assisted living facility — as long as possible. However, she continued, it is also important that resources be made available to providers who are being asked to change their service lines.

“The traditional nursing home model will change completely. It won’t be able to continue as is,” she pointed out. “We don’t want quality nursing homes to be put out of business because of this.”

Although there are still many details to hammer out, she said of the major stakeholders, “We are all very committed to working together to find those answers.”

Ermshar added that under the new plan, nursing homes would continue to play a vital role in the aging service spectrum by caring for the most frail and medically complex cases. With the proper assistance and resources, she said, providers in the continuum of care have the opportunity to expand services.

“Everyone will have to come out of their comfort zones and evolve into different models,” Ermshar stated.

Gov. Bredesen recognizes that such a major shift won’t happen overnight or without some trepidation from the key players. Still, he is hopeful.

“I want nursing homes to take a much broader approach to how they provide care to the elderly and disabled,” he said. “In the end, they’ll wind up much the better for having done that.”



Key Components of the Long-Term Care Act

• Create consumer-directed care options including the ability to hire non-traditional caregivers such as family members, neighbors or friends but with accountability measures in place for the use of taxpayer funds.
• Use existing Medicaid funds to serve more people in cost-effective home and community settings.
• Broaden residential care choices in the community beyond skilled nursing facilities with new options such as companion care, family care homes and improved access to assisted living facilities.
• Streamline the eligibility process for faster service delivery.
• Streamline the enrollment process for new providers.
• Establish a single point of entry for people who are not on TennCare today and need access to long-term care services through Medicaid or other available programs.
• Designate one entity to coordinate all of the care a TennCare member needs, including medical, behavioral and long-term care.
• Install an electronic visit verificaton system to monitor home care

May 2008

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