With a projected population of adults age 65+ to reach 80.8 million by 2040, the health and well-being of older adults — and the service systems that support them — will become even more imperative. State health policies help to shape these services through legislation, funding, and regulation.
To identify emerging state aging policy priorities, NASHP — with support from the West Health Policy Center — conducted a series of key informant interviews with a wide range of state officials, including health and human services secretaries/commissioners, Medicaid directors, aging and disability directors, and legislators. They come from nine geographically and politically diverse states: Arizona, Arkansas, Hawaii, Louisiana, Massachusetts, Michigan, Montana, New Mexico, and North Dakota. Although each state has its own unique challenges, key themes emerged from our conversations that included the following: the long-term services and supports workforce, promising practices in home and community-based services, the reconceptualization of nursing homes and assisted living facility service models, and the embedding of social determinants of health in service systems to address the well-being of older adults.
Addressing Long-Term Services and Supports Workforce Shortages
All of the nine states listed workforce challenges — particularly the recruitment, training, and retention of direct care workersas one of their top aging policy priorities. While this has been a long-standing issue for states, the COVID-19 pandemic further exasperated the gaps in workforce capacity. Some of the states are developing career ladders (AZ, MA, MT, NM) and increasing wages or rates (HI, LA, MA, MI). For example, Arizona‘s American Rescue Plan Act (ARPA) State Spending Plan includes an extensive workforce enhancement component with initiatives such as a caregiver pathway platform for individuals interested in a health care career as a direct support worker, career training & education, and an online database to track and monitor workforce development.
States are also looking to bolster provider network capacity, which includes serving the growing population of individuals with complex care needs, reaching individuals in rural areas, and developing adequate IT infrastructure (AZ, AR, HI, MT, NM, ND). For example, Arkansas’s ARPA State Spending Plan includes funding to improve placement options and accompanying services to support the transition process for clients with Intellectual or Developmental Disabilities (I/DD), significant Behavioral Health (BH) needs, and those who are aging and have physical disabilities. States are also prioritizing more natural supports such as providing information and services for family caregivers as a solution to workforce challenges and to embody person-centered care preferences (ND, NM). North Dakota, for example, noted how supporting family caregivers in the health care system is a beneficial policy toward addressing workforce shortages.
Promising Practices in Home and Community-Based Services
Another key aging policy priority among states is promoting promising practices in home and community-based services (HCBS). As states navigate current fiscal constraints, state policymakers are focusing on helping older adults remain in home-and community-based settings for as long as possible while also potentially reducing costly hospital and nursing home services. Michigan created a health equity project to increase the use of HCBS. One aspect of the project includes evaluating Medicaid data to analyze if the services offered to people differ based on race or ethnicity. Additionally, the project will work with local communities to learn what barriers contribute to service underutilization.
With person-centered care as a key focus of HCBS, Hawaii is working on a community-based palliative care benefit for beneficiaries with serious illnesses through Hawaii‘s QUEST Integration Medicaid 1115 waiver. Arkansas‘s ARPA State Spending Plan allocates funding for technology and training as technology-assisted support and digital health can benefit many Medicaid beneficiaries in the community. This includes creating the infrastructure for a statewide crisis continuum, as well as funding to support a review of the HCBS landscape to inform future client and workforce needs and services.
Reconceptualizing Nursing Home and Assisted Living Service Models
The COVID-19 pandemic shed light on the strengths — and gaps — in nursing home and assisted living service systems. Many states have experienced lower occupancies in nursing homes and are looking toward new and robust ways to utilize these places. Some states are exploring whether to repurpose sections of the homes while others are trying to identify how to sustain payments while improving quality of care.
Embedding Social Determinants of Health to Address the Needs of Older Adults
States are also incorporating social determinants of health (SDOH) into their service systems with the recognition that multiple socio-economic factors have a direct impact on the health and well-being of individuals. Housing and food security are two primary examples.
- Housing: To maintain continuity of care and support care transitions, several states are expanding technology and remote supports to allow individuals to choose and remain in the home and community (AZ, HI, LA, MA, MI, NM). Arizona currently has a pending Medicaid 1115 waiver that would provide 18 months of transitional housing for individuals leaving institutional Massachusettss housing initiatives include how communities can design spaces to be age-and dementia friendly, which culminated in the release of a toolkit by the Executive Office of Elder Affairs. Hawaii‘s Medicaid 1115 waiver includes community integration services, such as pre-tenancy supports and tenancy sustaining services, targeted at individuals who are homeless with complex health needs, including those leaving institutional (nursing facility) care.
- Food: With nearly 9.7 million older adults threatened by hunger even before the pandemic, food insecurity is another social determinant of health that is of concern for state policymakers (LA, MI, NM). In New Mexico, the new Food Farm and Hunger Act allows for a collaboration between the Department of Health and Department of Agriculture to evaluate “food desert” areas and connect local resources as a solution to combat senior hunger.
Conclusion
State officials continue to grapple with how to best support individuals as they age. The pandemic heightened reliance on family caregivers and the shortage of direct care workers who provide care. As the major public payer for long-term services and supports and regulator of providers, states policymakers are facing these challenges with increasingly aging populations. Although there are distinct differences between state aging priorities, there are also common themes which provide the opportunity for state-to-state learning across a multi-faceted policy framework.
NASHP is committed to assisting states in building systems of care to better address the needs of the country’s aging population. Working closely with state health policymakers, NASHP will focus on key state goals and investments related to workforce, aging in place, payment rates and value based purchasing, and social determinants of health. As we look to the future of our work, NASHP continues our commitment by elevating public policies to help states improve the health and well-being of older citizens.
Acknowledgment
NASHP would like to express our gratitude to the West Health Policy Center for its support and partnership, and to the state officials who shared their time and expertise.
