ManagedCareSupplement3

GENERATIONS – Journal of the American Society on Aging

to provide HCBS options that may help reduce spending on nursing homes. HCBS address many social determinants of health factors by providing resources for older adults and their caregivers, such as wellness and nutrition programs, supportive services (e.g., shopping, money management, house and yard work, meal preparation, toileting, dressing, bath- ing, and medication management), job training, senior centers, transportation, health promotion, and family caregiver support programs. HBCS also provide opportunities for community and civic engagement through various volunteer pro- ‘Social determinants can initiate the onset of pathology and serve as a direct cause for a host of chronic conditions.’ grams (National Association of Area Agencies on Aging, 2011). More than 20 percent of adults ages 60 and older receive HCBS (Greenlee, 2013). More than 90 percent of these service users have multiple chronic conditions (Kleinman and Foster, 2011) and related functional impairment (Barrett and Schimmel, 2010). With the rapid aging of the U.S. population, and the growing diversity of older adults (many of whom are Medicaid ben- eficiaries and have multiple chronic conditions), the number of individuals who could benefit from HCBS is expected to increase dramatically during the next two decades. Costs and con- sumer preference have led to a shift from skilled nursing facilities as the primary long-term-care option to HCBS. AARP research shows that 90 percent of people would like to age in their home and community (Farber et al., 2012), and they expect professional care to be provided in communities rather than only in institu- tional settings. Few studies examine the outcomes of HCBS. Those studies that do are focused on the cost- effectiveness of HCBS compared to nursing

homes (Doty, 2000). Findings from these stud- ies revealed that expanding access to HCBS increased aggregate long-term-care expen- ditures (that is, total long-term-care spend- ing, including spending for nursing homes and spending for HCBS combined). More specifically, these demonstration projects showed a substan- tial increase in HCBS use and a modest decrease in nursing home use. However, demonstration projects that targeted services to individuals who had both high levels of functional impair- ment and high risk of nursing home placement saw reductions in cost. If HCBS programs must be “budget neu- tral” to be deemed successful, they will fail the test. Budget neutrality is not the metric for suc- cess when it comes to Medicaid hospital pay- ments or expenditures for physician services. Rather, success should be defined by other mea- sures, including analysis of broader social crite- ria, to determine if the good HCBS programs do outweigh their cost by more than the good that could be obtained by spending the same amount of money in alternative ways. One study examined the effects of commu- nity-based services on the subjective well-being, probability of institutionalization, and mortal- ity of underserved community-dwelling older adults (Shapiro and Taylor, 2002). Findings indi- cated that early provision of in-home social ser- vices was positively associated with older adults’ subjective well-being and negatively associated with permanent nursing home placement and mortality. In addition, participants who received early provision of in-home social services were significantly less depressed, had a greater sense of satisfaction with their lives overall and with their social relationships, had a greater degree of mastery of over their environment, and were less likely to die or experience permanent nursing home placement than those who did not receive these services. My work demonstrates the importance of community-based programs for older African Americans. In the report, New Research High-

16 | Spring 2019

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