Medicaid Managed Care - U.S. Senate Special Committee on Aging

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Because Mrs. M. does not present a need for skilled service, she
does not qualify for Medicare coverage. The ironic situation in Mrs.
M.'s case is that the minimal plan of care she is receiving is not
currently recognized as, or valued in, our Medicare system.
A higher level of care will need to be implemented if Mrs. M. deteriorates
and becomes Medicare-eligible. Should she need longterm
care in a nursing home it is likely she will need access to
<strong>Medicaid</strong> because she is "spending down" her private funds. Therefore,
there is no method of payment for the "low-tech, high-touch"
care that Mrs. M. currently requires.
In summary, the following represent "best practice" in the context
of managing a frail older adult in the community. It is crucial
that the providers of care have a working knowledge of geriatrics
and the care of those with Alzheimer's disease and related disorders.
These providers must be able to provide dementia-capable
services, which include substantial support and knowledge in the
area of caregiver stress; the plan of care is consumer-driven, and
the decision making process includes the individual and/or responsible
party, and the management be coordinated through an interdisciplinary
team of professionals, paraprofessionals, family members
and/or responsible parties.
The following represent obstacles in obtaining services; securing
payment for services in our current system for someone who needs
ongoing custodial care is almost impossible. The issue of needing
skilled care such as registered nurses, home health aides, physical
therapy, and occupational therapy versus custodial care, such as
companions, homemakers, or day care, is a significant problem for
people suffering from Alzheimer's disease. An individual with Alzheimer's
disease could be managed in a more cost-effective manner
if the system were designed as a combination medical-social
model of care.
Providers of care are not trained in providing the appropriate
level of care, especially in the area of dementia care.
The lack of a coordinated service delivery system fosters the current
expensive and complex system of long-term care.
My recommendations regarding managed care models for frail elders
include. First, managed care models must recognize that the
older adult and his or her informal support network of family and
friends are the central focus of the plan of care.
Second, managed care models must provide quality services
which respond specifically to the needs of frail elders. While the
high-tech interventions of the last decades respond to the needs of
some populations, services for elders must include "low-tech, hightouch"
services such as homemaker, companion, home-delivered
meals and day care.
Third, managed care organizations must utilize a comprehensive
care management model in order to identify the unique strengths
and deficits in each clinical situation, and to maximize all available
community resource options.
Fourth, managed care models must provide appropriate access to
specialty care when necessary. In view of the increasing prevalence
of Alzheimer's disease and related disorders, it is imperative that
the services of geriatricians, geriatric psychiatrists, neurologists,