Funding of Long-Term Care Mark Booth Center for

Funding of Long-Term Care Mark Booth Center for Gerontology and Health Care Research Brown University Harkness Fellows Final Reporting Seminar Orlando. June 2007

LTC NZ - Context residential homes struggle for survival Tuesday, 9 August 2005, 2: 15 pm Speech: ACT New Zealand pay increase will deepen crisis in elderly care Friday, 17 December 2004, 1: 34 pm Press Release: Residential Care New Zealand families appalled by bed shortage for lakes elderly The Southland Times | Saturday, 5 May 2007 largest-ever investment in elderly care - govt NZPA | Tuesday, 1 May 2007

LTC US - Context looming crisis of long-term care highlighted in new study Senior Journal March 1, 2006 long term care crisis builds Health Care News March 1, 2003 state on verge of 'very ugly' elder-care crisis Honolulu Advertiser Sunday, May 13, 2007 is it any wonder most people dread nursing homes? New York Times May 24 2007

LTC NZ - Context The Government has announced what it says is the largest-ever investment in care and support of the elderly. Health Minister Pete Hodgson made the announcement today, saying the Government recognised the need to raise the level of pay for workers who provided support to senior citizens. "We know that low pay and high staff turnover are a major workforce issue in aged care, " he said. "I expect district health boards to satisfy themselves that a sufficient proportion of the funding increase is reflected in improved wage rates, " Mr Hodgson said. "Providing quality residential care is a key focus of this budget. " NZPA 1 May 2007

Policy Context New Zealand • Funding provided by District Health Boards (21) • Nationally consistent contract defining services to be provided • Asset testing being removed • Income test remains • Over reliance upon residential care • Poor use of MDS USA • Self funded or funding through Medicaid • Medicaid funded federally / state but administered at state level • Asset and income test used • Over reliance upon residential care • Strong use of MDS

USA & NZ – LTC Issues • • • Ageing population Workforce Quality Rebalancing Funding HIT

Objectives • To determine how NZ may learn from approaches to the provision of long-term care in the US • To compare views and opinions of LTC experts in the US and NZ • To look at practical examples of rebalancing LTC

Methodology - Survey • • Initial Survey Design Expert Panels Cognitive Testing Web based survey – US base modified for New Zealand • Sample 3000 in US • Sample 300 in New Zealand

Methodology - Qualitative • Literature • Interviews with LTC experts • Interviews / visits to providers – e. g. : – PACE – Eden Alternative – Cash & Counselling – Pioneer Network – Green House Project

Survey • • Rebalancing Workforce Quality Funding Culture Change Regulation Health Information Technology

Recommendations • • Rebalancing Workforce Quality Funding

Rebalancing (1) Which of the following strategies would be MOST effective for rebalancing long-term care away from institutions and toward home based support services? Select your top THREE options. Limit the supply of rest home beds Increase the rates of reimbursement for home based support service providers Expand eligibility for home based support services Establish programmes that offer a comprehensive package of home based support services Provide a single point of entry through which individuals may access needed services at home or in the community

Rebalancing (2) • PACE (USA) – Capitated funding – Preventive focus – Transparency of service provision – Services provided in one location • PHOs (NZ) – Capitated Funding – Preventive focus – Population health approach – Transparency of service provision – ‘Virtual’ organisation

Workforce (1) Issues • • • Low pay Comparative low pay Low esteem Heavy Caseloads Lack of training

Workforce (2) Recommendations • • Training programmes Career pathways Improved salaries Improved image – building upon positive ageing initiatives

Quality (1) Issues • Loneliness, helplessness and boredom • Staff dissatisfaction • Poor physical layout • Carer stress

Quality (2) Recommendations • Culture Change – Client centered care – Physical change – Staff changes • Information Technology – Comparative information – Minimum dataset (Inter RAI) • Adult Day Care

Funding (1) How much do you oppose or favour each of the following approaches to paying for long-term care needs? An answer of 1 means that you strongly oppose the approach and an answer of 5 means that you strongly favour the approach. Strongly Oppose 1 Individuals should pay for most of their long-term care costs Adult children should contribute to their parents’ long-term care costs Employers should contribute in part to their employees/retirees long-term care costs Government programmes should cover most long -term care costs . . . Strongly Favour 5

Funding (2) • • Individualised vs. Government Role of family members Forward planning for LTC Linkage with other programmes

Next Steps • • Results by end June NZ analysis by end July US & comparative analysis in fall Policy recommendations to NZ Minister of Health and DG in August

Acknowledgements • • • Commonwealth Fund Prof. Vince Mor – Brown University Prof. Eddie Miller – Brown University Prof. Ngaire Kerse – Auckland University Dr Karen Poutasi – Ministry of Health Dr Gillian Durham – Ministry of Health