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Home & Community Based Services

Life at the Intersection: Older Adults Need a Response to COVID-19 Grounded in Equity

By | BLOG, Health Equity, Home & Community Based Services

Dorothy is in good spirits, but tired and growing increasingly impatient. In January – well before life for most Americans had been dramatically disrupted by COVID-19 with stay at home orders and the shut down of non-essential businesses – the 72-year-old Chinese American living in Seattle, Washington’s Chinatown began to see signs that her community’s life was slowing down. She’d been reading the daily headlines in the Chinese newspaper about the virus in Wuhan and other parts of China. But when the dim sum parlor across the street was only about a quarter full on a normally busy Saturday afternoon, and her building’s annual Lunar New Year celebration was cancelled, it all became real.

Dorothy’s story, and the stories of her community, highlight the importance of intersectionality in our response to the coronavirus. An intersectional framework considers the ways that various forms of inequity operate together, exacerbate each other, and sometimes create unique challenges. It can lead to better policies that recognize the different ways the older adults in our communities are experiencing the crisis.

During the period described above, Dorothy was heart-broken to learn that her neighbor, Mr. Zhang, had been attacked while riding a local bus. Mr. Zhang was riding the bus home after doing some errands, while wearing a face mask, not because he was sick but because he was aware of the asymptomatic nature of the virus; he wanted to protect himself and others. Several passengers on the bus began harassing him and threatening him. They told him to go back where he came from and threw garbage at him. Others in the Asian American Pacific Islander (AAPI) community have reported a surge in verbal and physical assaults in the wake of what President Trump has repeatedly labelled the “Chinese virus.”

Considering all the circumstances, Dorothy – like many of her neighbors – decided to self-quarantine beginning in early February. She stopped going to the nearby temple, and her local bakery in Chinatown has suspended business operations through the end of April. In the wake of the pandemic, AAPI seniors are experiencing unprecedented levels of loneliness and isolation. But the implications for older adults like Dorothy extend far beyond social – even the home and community-based services (HCBS) that keep her healthy and living in the community are affected. She has asked her caregiver to stop coming and avoids her local adult day health center.

Adding to her fears, getting local and accurate information about the pandemic has been difficult. Aside from her Chinese newspaper, information about the coronavirus in Dorothy’s native language has been limited, particularly local news with Washington-based resources and guidance. Many AAPI older adults across the country are language-isolated, which further debilitates their ability to fight the virus. Like many older adults, Dorothy is not on social media and does not regularly use mobile technology, so information is even more limited.

Supporting older adults who may be isolated, experiencing discrimination (or even hate crimes), who may be limited English proficient (LEP), in addition to being low-income, and whose cultural background is not reflected in the mainstream requires a comprehensive and intersectional COVID-19 response strategy. For Dorothy and other older adults in her community, such a strategy begins with acknowledging that her experiences and needs during the pandemic may look different from other older adults or other AAPI individuals, and is informed by her life at the intersection of multiple identities.

At a minimum, an intersectional response should:

  • Denounce Racism. Importantly, intersectionality-informed policies identify the racism and xenophobia spurred by the coronavirus and require local, state, and federal leaders to denounce it and couple their statements with providing ample support to hate crime prevention resources. For a community that lives with the trauma from the experiences of Vincent Chin, Joseph Illeto, Navrose Mody, and others, efforts to curb hate crimes and xenophobia are crucial. In response to a problematic rise of hate crimes in the wake of the virus, the New York Attorney General created a hotline to report coronavirus hate crimes and xenophobia.
  • Acknowledge Heightened Needs. COVID-19 policies must recognize Dorothy and others like her may have already started self-quarantining well in advance of any state or federal directive, and that accordingly, their needs for socialization, food security, and home and community-based services are perhaps heightened relative to those who began staying at home much later.
  • Be Culturally Competent. Policies have to be created with all communities in mind. For example, even calls from our nation’s health experts to not buy and wear masks fails to recognize the ways in which such a message may be received in AAPI communities, informed by their experiences with Severe Respiratory Syndrome (SARS) less than 20 years ago. Another example of cultural competency is around food. During this outbreak, while the need for home-delivered meals to older adults has skyrocketed, it is just as important that those meals are prepared using culturally familiar ingredients and cooking methods.
  • Include Outreach Strategies for Various Language and Cultures. At a minimum, intersectionality requires in-language resources to reach LEP older adults like Dorothy. In 2020, government agencies cannot rely solely on Google translate, tweets via social media, or employ a one-size-fits-all approach. Outreach to AAPI older adults and other communities must include partnerships with local community-based organizations and ethnic media who have the expertise to communicate with these populations.

For those older immigrants, language-isolated older adults or older adults of color, the harms of the coronavirus will undoubtedly be compounded. Dorothy, Mr. Zhang, and so many others like them are not adequately served by policies that only partially address their lived experiences. If they are going to survive this pandemic and in order for them and their communities to thrive, our response to the coronavirus must be intersectional.

*Dorothy and Mr. Zhang are not real people but their stories are based on real accounts from on-the-ground advocates, the media, and loved ones.

FAQ: Low-Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services

By | FACT SHEET, Health Care, Health Care Defense, Home & Community Based Services, Medicaid, Medicare, REPORTS

The Affordable Care Act (ACA) enables full-benefit dual eligibles who receive certain Medicaid home and community-based services (HCBS) to receive Medicare Part D covered drugs at no cost. This requirement is called institutional cost-sharing, and was designed to put people who receive HCBS at home on an equal footing with those who are in institutions (who are also not charged any co-pays). Unfortunately, despite the institutional cost-sharing requirement, pharmacies still ask dual eligibles to pay co-pays for covered drugs.

Justice in Aging created an FAQ, Low-Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services, to give advocates working with dual eligibles the tools they need to prevent these co-pays. The FAQ discusses whom the cost-sharing rule applies to, the length of the cost-sharing protection, and what to do if a dual eligible HCBS-enrolled individual is prompted for a co-pay at the pharmacy or is entitled to a refund. Advocates should review the FAQ and make sure to their HCBS-enrolled dual eligibles are not paying any co-pays for their Part D drugs.

Fact Sheet: Make the Expanded Spousal Impoverishment Protection Permanent

By | FACT SHEET, Health Care, Home & Community Based Services, Medicaid, REPORTS

Married seniors and adults with disabilities overwhelming want to live at home and age in place. Increasingly, federal and state Medicaid rules have prioritized home and community-based services (HCBS) which allow people to stay in their homes and in their communities. Congress recently helped these efforts by expanding a Medicaid eligibility rule, known as the spousal impoverishment protection, to individuals eligible for HCBS. The protection makes it possible for an individual who needs a nursing home level of care to qualify for Medicaid while allowing their spouse to retain a modest amount of income and resources. However, the expansion of the spousal impoverishment protection is set to expire on March 31, 2019 unless Congress acts. This means that individuals who qualified under the expanded protection may lose access to Medicaid and to their HCBS and may be left with no choice but to move into institutional long-term care, away from their spouses.

Letting the spousal impoverishment protection expire will hurt families and force more people out of their homes and their communities. We urge Congress to make the expanded spousal impoverishment protection permanent so seniors and people with disabilities can age in place and with dignity.

Justice in Aging has created a fact sheet on the importance of the expanded HCBS spousal impoverishment protection and calling on Congress to make it permanent so seniors and people with disabilities can age in place and with dignity.

More older residents on Medicaid wait list in Florida than any other state, attorney says

By | Health Care, Home & Community Based Services, IN THE NEWS, In-Home Supportive Services, LITIGATION, Long Term Care, Medicaid

Florida Record: More older residents on Medicaid wait list in Florida than any other state, attorney says (January 7, 2019)

A lawsuit has been filed against the state of Florida over extremely long wait time in accessing in-home Medicaid care. Justice in Aging, along with Disability Rights Florida and the Southern Legal Counsel, is representing the six plaintiffs currently suing the state.

“According to national statistics, there are more older adults and adults with disabilities on the wait list for community-based services in Florida than any other state,” Regan Bailey, litigation director for Justice in Aging. “The failure to provide long-term care places people at risk of unnecessarily entering a nursing facility just to get the care they need which should be provided at home.” Read the full article.

How States Can Prevent Evictions When Implementing Federal HCBS Regulations

By | Health Care, Home & Community Based Services, ISSUE BRIEF, REPORTS
This new issue brief discusses how states should implement the new federal Home and Community-Based Services (HCBS) regulations in order to prevent improper evictions.

In 2014, the Centers for Medicare and Medicaid Services (CMS) released regulations that set standards for the settings in which HCBS are provided. To implement these regulations, each state must have a transition plan approved by CMS by March 2019, with full compliance required by March 2022.
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Senate ACA-Repeal Knocks Down House, Builds Shack

By | Affordable Care Act, BLOG, Health Care, Health Care Defense, Home & Community Based Services, HOMEPAGE
Over 90% of older adults say that they want to remain in their homes as they age, rather than going into a nursing home. A successful and popular program, Community First Choice (CFC), lets people do just that.

The revised Senate health care bill brings an idea that should be a hard sell for the over 3 million older adults and people with disabilities who rely on Medicaid for in-home care. On top of a massive almost $800 billion cut to Medicaid that guarantees shrunken programs and eliminated services, the Senate bill kills CFC and replaces it with an inferior version that provides fewer services for a limited time only.

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As Demand for At-Home Care Grows, States Debate How to Pay for It

By | Home & Community Based Services, IN THE NEWS, Long Term Care, Medicaid, Nursing Homes

Governing.com: As Demand for At-Home Care Grows, States Debate How to Pay for It (7/2017) Justice in Aging’s Kevin Prindiville discusses the increasing funding need for at home and in-community-based programs as older Americans opt to stay home. “The trend is shifting at every level to care at home and in community-based settings. People are increasingly asking for and expecting this.”

New Regulations Create Opportunity for Better Long Term Services and Supports: Medicaid Managed Care Regulation Preview

By | BLOG, Health Care, Home & Community Based Services, HOMEPAGE, In-Home Supportive Services, Person-Centered Care Planning
States and the federal government spend over $14 billion a year on Medicaid managed long-term services and supports—yet, there has never been an clear federal regulation defining state and managed care plan responsibilities in this massive enterprise. Until now. Last week, the federal Centers for Medicare & Medicaid Services (CMS) released a final regulation on Medicaid Managed Care. This new regulation details, among other things, the federal government’s expectations for states and managed care organizations (MCOs) that contract to deliver managed long-term services and supports (LTSS) for older adults and people with disabilities. Read More

WEBINAR: California’s New Health Homes Program: The Basics

By | Health Care, Home & Community Based Services, WEBINAR
When: Wednesday, March 30, 2016 11 a.m.- 12 p.m. PDT

The state of California is moving forward with implementation of the Health Homes for Patients with Complex Needs also known as the Health Homes Program (HHP). The HHP is aimed at providing extensive care coordination for the highest risk Medi-Cal beneficiaries to improve their health outcomes. Implementation is scheduled to begin in certain counties starting January 1, 2017.

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Just Like Home: The Impact of the Federal HCBS Regulations on Older Adults

By | Home & Community Based Services, ISSUE BRIEF, Medicaid, REPORTS

New federal regulations have established first-time standards for when settings qualify as “community-based” for the purposes of Medicaid-funded Home and Community-Based Services (HCBS). Each state is charged with developing a transition plan to meet these standards. These plans will have a huge impact on older adults receiving Medicaid-funded HCBS in assisted living, adult day services, and other settings.

Consumers and their advocates must be heard in the states’ transition planning processes. Justice in Aging’s new issue brief provides policy recommendations for consideration by states and stakeholders. The transition plans must confront and answer many important questions.

  • What service models are eligible for payment?
  • Should services in assisted living facilities be covered?
  • What about adult day care programs?
  • Does the size of these programs matter?
  • And should programs be allowed to be “secure”, i.e., locked, if they care for persons with dementia?

The recommendations address (among other things) how to assess settings for compliance, judging whether a setting is integrated with the community, protecting consumers from eviction, and applying the regulations when consumers have dementia.