The State of State Long-Term Care Policies

How can state policymakers meet the increased demand for long-term services and supports and ensure quality care for often-vulnerable populations, while staying within tight budgets?

It’s not an easy task. For one thing, state policies aren’t the only factor shaping long-term care. There are federal policies, regulations, funding and initiatives; market, financial and workforce pressures; professional and educational trends; changing demographics, especially with regards to age, health and whether there are family members who can help; and healthcare system realities.

To further complicate the picture, the priorities for quality long-term care depend on who you ask.

“Someone in the industry would probably say that long-term care providers need more resources,” explains University of Wisconsin-Madison School of Nursing Associate Dean Barb Bowers, PhD, RN, FAAN.

“Frontline staff want better training, pay and benefits, with accountability for poor performers. Nurses want more staff and greater flexibility in scheduling. Families are most concerned that staff are familiar with and engage their loved one. The residents themselves want meaningful relationships with other residents and staff.”

Still, state policies account for wide variations in the quality of long-term services and supports. “Where you live really matters,” summarizes “Raising Expectations,” a comprehensive report released last year by AARP, the Commonwealth Fund and SCAN Foundation.

Wisconsin’s long-term care system compares favorably to that of most other states. “Raising Expectations” ranks Wisconsin eighth nationally, based on composite measures of affordability and access, choice of setting and provider, quality of life and quality of care, support for family caregivers, and effective transitions.

The report identifies two factors directly impacted by state policies that are major drivers of long-term care quality overall: the percentage of long-term care funding that goes towards home and community-based services (HCBS), and how many low- to moderate-income adults with disabilities access long-term care services through Medicaid. States “establish both functional and financial eligibility standards for Medicaid coverage” and “directly affect access to HCBS and choice of services and providers,” notes the report.

In Wisconsin, just over 46 percent of Medicaid and state long-term care funds go towards HCBS for older adults and adults with physical disabilities. That’s the tenth highest percentage nationally. New Mexico, which ranks first on this measure, directs 65 percent of its long-term care funds to HCBS. Wisconsin data on the reach of the Medicaid long-term care safety net for adults with disabilities was not available, according to the report.

Of the report’s composite measures of long-term care quality, Wisconsin ranks in the top ten nationally for choice of setting and provider, and for quality of life and quality of care. However, Wisconsin barely ranks in the top quarter of states for effective transitions, and falls to the second quarter on support for family caregivers and affordability and access.

Why does Wisconsin not compare as well on these dimensions of long-term care quality?

The report defines effective transitions to capture information about disruptive transitions between care settings and the ability of people to transition from nursing homes back to the community. Particular issues for Wisconsin include the number of home health patients with a hospital admission (25 percent), nursing home residents with low care needs (26 percent), and new nursing home stays that last 100 days or more (20 percent).

On support for family caregivers, Wisconsin’s score suffers because it does not require employers to offer paid family leave and sick days, protect caregivers from employment discrimination, or conduct assessments of family caregivers when their loved one begins using long-term services and supports. Wisconsin caregivers are more likely to report worry, stress, and a lack of time and rest than are caregivers in 19 other states.

Wisconsin’s affordability and access score is hurt by the median private pay costs for nursing home and home care services here. A year’s stay in a nursing home costs nearly three times an older adult’s median household income in the state. Thirty hours a week of home care services over a year eats up 95 percent of household income.

In just over ten years, the baby boomers will start entering their 80s. By strengthening state long-term care policies now, we can help ensure their and their families’ well-being.

–Diane Farsetta
Map from the Wisconsin Department of Health Services