A new report from AARP ranking each state’s system for long-term care placed Indiana in the middle of the pack — the third of five tiers of rankings that considered support for family caregivers and diversity of in home- and community-based services.
Indiana came in 27th, an improvement from its 2020 ranking of 44th. The report covered a three-year period, 2020-2022.
“I think that when you really dive in and take a look at this scorecard, we did see some improvements across nine of the indicators,” Sarah Waddle, the state director for AARP Indiana, said. “We didn’t see any decline, but there are still some indicators where we are ranked very low or in the lower tiers.”
While the report found that nationally — for the first time — more than half (53%) of Medicaid spending on long-term supports and services went to home- and community-based services (HCBS), Indiana spent less than a quarter on such programs, at 23%.
Progress in Indiana has been ongoing, Waddle said, while the state switches to a managed care model. State leaders have said the change would allow the state to prioritize investments for HCBS, which the majority of elderly Hoosiers prefer.
“I think the message that we learned from the scorecard is that the majority of the country is now providing more than half of their resources toward home- and community-based services and Indiana is still hanging around 20%,” Waddle said. “And one thing we’ve got to do in order for that to happen is we’ve got to address workforce.”
Mixed reviews on workforce measurements
On average, just over half (54%) of the workforce left their facilities within one year’s time. In Indiana, the turnover rate is over 57% and understaffing means residents get less than the national average of care hours — 2.86 hours compared to 3.31 hours, according to the report.
“One of the most impactful investments states can make is improving the size, strength and stability of the paid direct care workforce,” read the report, noting that term including family caregivers.
“Few workers in any (Long Term Services and Supports) setting are earning a living wage or basic employee benefits that provide security for their families … These factors underscore the need for states to take continuing action to attract new workers and retain those currently in the field,” the report continued.
In particular, the report noted that pay for Long Term Services and Supports (LTSS) lagged behind comparable positions, with a $3.90 gap for Hoosier workers.
“We don’t see any decreases in those (workforce) areas, per se, but we know just from the conversation around managed care and throughout the pandemic that workforce really came to the forefront as an issue,” Waddle said.
But Indiana received recognition for its commitment to allowing nurse practitioners to delegate certain care tasks, including 15 of the 22 measured indicators analyzed by the report.
Ambre Marr, AARP Indiana’s state legislative director, credited that movement to a coordinated effort from several entities over the last three years, including legislation this year that removed prohibitions on certain types of feeding equipment for registered home health aides.
“(That limitation) really does cluster nurses in larger areas and leaves a lot of rural communities without any type of care. We have worked on that for many, many years,” Marr said. “This past year, I would say we probably got further than (ever).”
Strengths with presumptive eligibility, community integration
Marr said one of Indiana’s biggest strengths — which the report recognized — was its commitment to improving presumptive or expedited eligibility for HCBS under Medicaid.
“Indiana’s kind of at the forefront of this expedited eligibility,” Marr said. “It has been very successful in keeping people … going from the hospital straight into a nursing home when they could be discharged to the community. But because we don’t know if they’re eligible for Medicaid, we send them to the nursing home first until we figure it out.
“But a lot of times, they never leave. So if we can get them home first, they may never go to the nursing home.”
While Medicaid applications for LTSS must be processed within 45 days, that time is too long for many in need of services.
Better-resourced nursing homes have the flexibility to start right away and wait for approval, HCBS providers don’t have the same flexibility. Under presumptive eligibility, those HCBS providers will be paid even while an individual’s Medicaid application is processed and Medicaid will cover those costs.
“These policies can help people access HCBS almost as quickly as they can access nursing home services, thus helping people avoid short-term nursing home stays that can turn into much more expensive long-term stays,” the report said.
Many older Hoosiers prefer to age at home if given the choice, according to AARP. Especially considering that just 5.4% of nursing home residents live in a five-star facility — far lower than the national average of 16%.
A chart displaying where each state falls across the five tiers. (Chart from AARP’s 2023 Long Term Supports and Services Scorecard)
Presumptive eligibility, which started as a pilot program during the COVID-19 pandemic, won Indiana an innovation point from AARP along with its policies encouraging Green Houses, a form of smaller, more intimate care.
Indiana did not score innovation points for: restorative care, known as CAPABLE for short; enhanced hazard mitigation plans; state family caregiver tax credits nor Multisector Plans for Aging — though the latter is something the state’s Division of Aging is currently considering, Waddle said.
Indiana’s highest categorical ranking came in the Community Integration division, which Waddle said was a more “holistic” approach to aging that focused on supports outside of the traditional LTSS.
“I think a lot of times, we get focused on maybe one or two agencies within state government that are supposed to fix all of this and we know that it’s much broader than that,” Waddle said. “(It’s) about creating livable communities, places where people can age in place … not all roads lead to FSSA on this. We’ve got to be talking more broadly.”
Much of this action occurs within the private sector, Waddle said, specifically with age-friendly health systems, or care that addresses a person’s needs across their entire lifespan.
While every state has such health systems, Indiana has the largest presence nationwide when considering the size of the state’s elderly population with 306 programs per one million older adults.
Self-directed services, family caregiver supports identified as weaknesses
Indiana’s lack of support for family caregivers hurt its ranking, especially its lack of tax credits or flexible leave policies for caregivers. Family caregiver support was the only category where Indiana performed worse than average, coming in at the fourth tier.
While lawmakers have been resistant to implementing caregiver supports in the past, Waddle said Indiana policymakers could take its current process for self-direction it uses for disabled Hoosiers and replicate it for the elderly.
“I think doing some education around what self direction is, learning more about it and then helping people understand it …. This is an opportunity for you to pick a caregiver and pay that caregiver and really direct how you want your care to be,” Waddle said.
Under self-directed care, users have more control over who cares for them and how that care is delivered. In other states, the use of such services has skyrocketed from 740,000 people in 2009 to more than 1.5 million in 2021. Self-directed services also reduce family caregiver burdens and make long-term care easier for consumers.
Improvements ongoing
In a media call, Susan Reinhard, a senior vice president with AARP’s Public Policy Institute, recognized Indiana as one of the most improved states.
“You can’t really compare ranks from one year to another,” she said, recognizing differences in methodology and the inclusion of new parameters.
The 2023 scorecard utilizes tiers, rather than straight rankings, but the 2020 version placed Indiana in the bottom quartile of the country, in 44th.
“Much of that (progress) has to do with the efforts (Indiana has) been putting in over the last three years. They have been using the previous scorecard to help guide where they should make improvements and we’re very proud of the recognition that officials in the state have given us.”
However, Reinhard noted that the pressures on the long-term care system will only increase in the coming years. By 2035, it’s estimated that the number of adults ages 65 and older will outnumber the number of children under 18 — and minority population growth is expected to increase even faster, though non-white consumers had even poorer long-term care experiences.
“It’s really critical that we improve the aging experience for all Americans across the country,” she said. “Our ability to get this right largely depends on our ability to care for our loved ones as a society.”