A Message from Center Deputy Director Renée Markus Hodin

As I sit at my home desk today, it’s nearly impossible to wrap my mind around all that has transpired over the past month as the country reels from the ever-growing coronavirus pandemic. We at the Center, along with all our Community Catalyst colleagues, are now in our fifth week of working remotely. While we, like many of you, are adjusting to these new realities, we are ever-mindful of the greater toll this pandemic is taking on frail older adults, people with disabilities, people of color, those with chronic conditions, and family caregivers and health care workers.

I’ve found myself comparing this pandemic to an onion with seemingly endless layers to peel. Each day, I am confronted by yet another effect that the virus and our necessary physical distancing create that I hadn’t thought about previously. All of us at the Center and Community Catalyst are finding new ways to adapt our work, whether by offering ideas and tools for organizing while being physically distant, or by weighing in with priority needs that should be addressed in the next COVID-19 response bill. By far, however, some of the most important work we’re doing is aimed at addressing racial and ethnic health inequities that, while they’ve always existed, have been laid bare in stark and disturbing ways by COVID-19. 

Amidst the tragic and heartbreaking stories of this virus’s cruel impact, I’m happy to share with you some purely joyful news: Center Director Ann Hwang gave birth to a beautiful and healthy baby girl, Silvia! I hope you’ll join me in congratulating Ann and her family on embarking on this wonderful new adventure!

In the meantime, I know I speak for everyone at the Center in hoping you, your families and your colleagues are safe and well. Don’t hesitate to reach out with feedback, questions or needs. And, as always, follow us on Twitter so we may stay up-to-date on each other’s work @CCEHI.

FROM THE CENTER & OUR PARTNERS

New Toolkit: Grassroots Organizing Strategies that Comply With Physical Distancing Protocols

Community Catalyst has created a new toolkit, At a Safe Distance: Grassroots Organizing Strategies that Comply With Physical Distancing Protocols, that provides an organizing framework for grassroots advocacy during this pandemic and shares practical ideas for continuing to reach impacted communities. In this toolkit, you will find a variety of organizing tactics that have been successfully used by organizations across the country. We provide a brief description of each tactic, information about who tried it and what results they got, and links to other relevant resources.

The toolkit will be a living document and we will add to it frequently as we identify promising new strategies, resources and examples. Feel free to bookmark the page and check back often as well as reach out if you have any questions, feedback or additional ideas/examples/resources to contribute.

Two Center Blog Posts Address Challenges of Isolation, Risks to Civil Liberties in Coronavirus Pandemic

Two recent Center blog posts address specific aspects of the many challenges presented by the coronavirus pandemic: We’re All in This Together: Protecting Individuals with Complex Health Needs During COVID-19 by Center Senior Policy Analyst Rachelle Brill and Tools to Help Advocates Reduce Social Isolation During the Coronavirus Pandemic by Center Program Coordinator Julia Watson. We encourage you to give them a read if you missed them over the past two weeks.

Upcoming Webinar: Supporting Family Caregivers of Older Adults through Times of Stress and Isolation

The next webinar in the Geriatric-Competent Care (GCC) series, presented by the Center in collaboration with the Medicare-Medicaid Coordination Office and the Lewin Group will be Supporting Family Caregivers of Older Adults through Times of Stress and Isolation. The webinar will offer strategies for supporting caregivers and their loved ones, up-to-date information on facilitating access to health and social supports from which caregivers might benefit, and practical tips for addressing the specific needs of caregivers experiencing social isolation and stress-related conditions.

The GCC webinar series helps providers in all settings and disciplines expand their knowledge and skills related to the unique aspects of caring for older adults and working with their caregivers. The webinar will take place Thursday April 30 from 12-1:30 p.m., EST. Click here for more information and to register.

Center Submits Comment Letter on Impact of Medicare Advantage and Part D Proposed Rule on D-SNP Look-Alikes

In February, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule relating to the Medicare Advantage (MA) and Part D programs. The provisions would have a broad impact on MA and Part D regulatory requirements, MA Organizations, Part D sponsors, health care providers, pharmacies and others. Center Project Manager/Senior Policy Analyst Leena Sharma submitted a comment letter to CMS focused on sections that impact Medicare-Medicaid enrollees, urging stronger provisions to curb the growth of Dual Eligible Special Needs Plan (D-SNP) look-alike plans.

Georgia Advocates Push Back on Rationing of COVID-19 Care for People with Intellectual and Developmental Disabilities

Stacey Ramirez, state director for Center Partner The Arc of Georgia is featured in a ProPublica article exploring the implications of COVID-19 for the more than 7 million Americans who have a cognitive disability. Concerning reports indicate that those who are most vulnerable to the coronavirus may also face inequities in access to treatment. For our partners at The Arc of Georgia, this fear hit close to home with the death of Emily Wallace, a 67-year-old woman with Down syndrome in a group home operated by The Albany Arc. Wallace died of the virus after becoming possibly one of the first persons in the nation with an intellectual disability to be diagnosed with COVID-19. An emerging threat now is how triage criteria (who receives treatment and who does not) is determined in disaster preparedness plans. Many states have provisions that include deprioritizing this group in the event rationing of lifesaving medical care should be instituted.

Maine and New York Advocates Shift Focus to Help Communities Respond to COVID-19

 

Maine volunteers take part in training to help others in need due to COVID-19

In the wake of COVID-19 disrupting their organizing campaigns, two Center partners, Maine People's Alliance (MPA) and Make the Road New York (MRNY), have completely retooled their operations in order to serve the people for (and with) whom they've been advocating. With incredible efficiency, MPA created Mainers Together, a webpage designed specifically in response to COVID-19 as a way to deliver services to those in need and for volunteers and local organizations to virtually collaborate to deliver them. MRNY created a page that lets people know about their rights, how to access them and contains other helpful resources. During this time of overwhelming need, it's inspiring and heartwarming to see communities come together to ensure the most vulnerable are not left behind.

Community Catalyst and Partners Awarded Contract to Conduct Family Caregiver Listening Sessions for Federal Advisory Council

The impact of the nation's aging population is felt most acutely by family caregivers. To understand and better serve their needs, the National Academy for State Health Policy (NASHP) has awarded a subcontract to Community Catalyst, in conjunction with LeadingAge LTSS Center @ UMass Boston and ET Consulting, LLC. The contract will fund these partners to analyze public input from a request for information on family caregiving needs and to conduct listening sessions for the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregiving Advisory Council. Recommendations from the Council will help inform Health and Human Services in its mandate to develop a national family caregiving strategy for how the federal government, states and communities can better address the needs of family caregivers. Progress on the Council's work can be found on NASHP's website.

Webinar Recording Available – Beyond Surveys: How Health Systems Engage Patients

In February, the Center partnered with the Health Care Transformation Task Force to release Organizational-Level Consumer Engagement: What It Takes, an in-depth look at the consumer engagement practices of three health care organizations – Children’s Mercy Kansas City, Hudson River Health Care and Trinity Health. The recording now available of our March 24 webinar, "Beyond Surveys: How Health Systems are Engaging Patients," offers the opportunity to hear directly from professionals working on engagement within each of the three case study health systems and from a panel of patients. This webinar offers the array of engagement structures each organization employs, what it takes (staff, dollars and time) for them to implement and sustain these structures, and, most importantly, the impact of engagement structures on the organizations and the people and communities they serve.

Idaho Governor, Supreme Court, and Legislature Unite to Improve Behavioral Health Care for Idahoans

On Feb. 19, Idaho Gov. Brad Little (R), all five Idaho Supreme Court Justices and Idaho legislators established the Idaho Behavioral Health Council, a new three-branch approach to improving care for Idahoans with mental health and substance use disorders. The Council will include 13 members, including representatives from all three branches of state government, educators and community partners to develop a statewide strategic plan with action-oriented, time-bound recommendations that improve access to care. Center partner The Idaho Behavioral Health Alliance, greatly influenced Gov. Little's Executive Order establishing the Council and has been tapped to identify a consumer to serve as a member, ensuring the voices of advocates will continue to shape the future of Idaho's behavioral health system.

ELDERCARE VOICES

Older Adults and Access to Health Care During COVID-19

Taneika Duhaney, MHAP

As the COVID-19 pandemic continues to spread, school closings are increasing, public gatherings are discouraged and public health officials continue to warn that, as testing increases, so will the number of positive cases. Older adults with chronic illnesses are urged to take precautions and contact their primary care provider if they become sick. However, many older adults lack Medicare or Medicaid coverage and don’t have a primary care provider to call. The absence of a primary care provider, especially during a public health crisis such as this pandemic, underscores the barriers many older adults experience in accessing routine care, resulting in delayed care and poorer health outcomes. Several key populations of older adults are at particular risk for experiencing barriers to care, especially during this current public health crisis: 

Older Adults Who Do Not Qualify for Medicare 

Many older adults, especially immigrants, do not qualify for Medicare because they or their spouses do not have the requisite ten years of Medicare-qualifying employment. These barriers are not equitably distributed: People of color, low-income communities and women are disproportionately impacted. Additionally, older adults who worked as farmworkers or domestic laborers may not be eligible for Medicare if their earned income was below the Social Security Administration coverage threshold. Workers in these occupational groups were excluded from the protections and benefits of the Social Security Act of 1935, which prioritized commerce and industry employment, sectors which excluded a significant percentage of African Americans and women. Income earned below the coverage threshold is non-taxable and does not count towards Social Security benefits. Without access to Medicare, many older adults do not have a primary care provider or access to other routine medical, dental or mental health care and may rely on emergency rooms (ER) for care. ERs are never the appropriate site for receiving routine care, but especially during the COVID-19 pandemic, seeking care in an ER is particularly dangerous. 

Dually Eligible Older Adults  

Even for individuals who do qualify for Medicare, and especially for the nine million low-income older adults who are dually covered by Medicare and Medicaid, barriers to accessing care are worsened by the Trump administration’s continued attacks on health care and public programs. Dually eligible older adults may not be able to access their doctor because they rely on public health insurance programs, which are often prioritized lower than private health insurance in part because private insurers reimburse at higher rates than Medicare and Medicaid. Also, many health systems and specialty providers prioritize private payers opt-out of Medicare/Medicaid enrollment or limit enrollment of these beneficiaries, putting dually-eligible older adults at increased risk of facing barriers to access care. 

Immigrant Older Adults 

Attacks on Medicaid and other public programs are especially harmful to immigrant older adults because of the new public charge rule, which would penalize immigrants if they use social programs such as Medicaid, the Supplemental Nutrition Assistance Program and public housing. Though the public charge rule makes several exceptions, many immigrants may not understand these nuances and, out of an abundance of caution, may elect to forgo Medicaid benefits or seek needed care. Making the difficult decision not to access health care, especially when ill, could worsen chronic health conditions and make older adults more susceptible to secondary illnesses and infections, including COVID-19. 

Older Adults Living in Rural Areas 

Older adults living in rural areas may be unable to access primary care because no doctors are available in their area. Currently, more than 77 million people live in health professional shortage areas and rural areas are more likely to experience provider shortages. The absence of primary care doctors and hospitals leaves many rural Medicare beneficiaries relying on urgent care centers for primary care. Urgent care centers provide timely care for aging adults; however, they are not a sufficient substitute for a primary care provider. Additionally, between 2013 and 2017, 64 rural hospitals closed. Without access to a hospital, rural older adults may struggle to access testing and treatment for COVID-19 or other acute or chronic illnesses. 

The public health experts’ recommendation to “call your doctor” if you suspect you’ve been exposed to COVID-19 leaves a significant portion of the older adult population without options. As the pandemic spreads across the country, older adults, adults with disabilities, older adults of color and LGBTQ+ older adults continue to be disproportionately marginalized by existing health care practices and policies that perpetuate existing inequities. Failure to address this issue could increase mortality and morbidity among those most at risk. These inequities can be addressed by opening a special insurance enrollment period across all states, relaxing Medicare and Medicaid eligibility requirements, and eliminating the public charge rule. These initial steps may improve access for many older adults to get tested and receive care for COVID-19, as well as other existing chronic health conditions, before it’s too late.  

Taneika Duhaney, MHAP, is a Health and Aging Policy Fellow working with the Community Catalyst Dental Access Project. Taneika is the Department Head of Patient Administration for Naval Health Clinic Patuxent River. In this capacity, she provides administrative support and services to military members, dependents and retirees. Having served over 18 years on active duty, Taneika’s interest in advocating for older adults stemmed from advocating for a family member. Taneika received her Master in Health Administration and Policy from Uniformed Services University of the Health Sciences and her Bachelor of Business Administration, specializing in Health Service Management from Saint Leo University. She is also a registered dental hygienist and has completed the Duke University Non-Profit Management Certificate.

NOTEWORTHY NEWS & FEATURES

States Can Use CARES Act Funding to Support Health-Related Social Needs Exacerbated by COVID-19 Pandemic

A recent National Academy for State Health Policy (NASHP) blog post identifies new options for states to address various social determinants of health, including housing, food, transportation, education and employment made worse by the pandemic. This post provides analysis of the CARES Act provisions and examples of states taking action. Some states have directed their National Guard units to aid in food delivery for vulnerable populations, issued moratoriums on evictions and invested in emergency housing, among other efforts.

Crisis Response Can Lead to Lasting Transformation

A new blog post from The SCAN Foundation highlights new flexibilities that have emerged for providers serving those with complex care needs as a result of the COVID-19 pandemic. Additional service availability through telehealth, expanded access to home and community-based services, and access to remote care coordination are all newly implemented changes that could positively impact service delivery and health outcomes for consumers. As health systems quickly adapt to beneficiary needs, the post offers considerations to keep care person-centered for the long term.

COVID-19 Resources for Older Adults, Family Caregivers and Health Care Providers

The John A. Hartford Foundation recently launched a resource page containing COVID-19 related resources  from their partners and grantees relevant to older adults, family caregivers and health care providers. The page is updated frequently and offers resources specific to consumers with complex care needs and the providers that serve them.

"You’re Doing It Wrong: What Changes In Medicaid and SNAP Reveal About the Trump Administration’s Moves on Social Determinants of Health"

A Health Affairs blog post outlines the Trump administration’s approaches to social determinants of health and describes their negative impact on vulnerable populations. While the administration has expressed support for promoting social determinants of health and made progress in a few specific programs, many of its reforms have been deeply inequitable, especially for low-income people, older adults and people with disabilities. Among other administrative rules, the article details the erosion of non-emergency medical transportation requirements and decreased SNAP benefits due to work requirements and other changes in eligibility.

Evidence from a Decade of Innovation: The Impact of the Payment and Delivery System Reforms of the Affordable Care Act

In recognition of the tenth anniversary of the Affordable Care Act, the Commonwealth Fund has released a summary of evidence from the ACA’s major innovations over the past decade. The summary overviews key programs implemented through the Center for Medicare and Medicaid Innovation (CMMI), including the Financial Alignment Initiative, State Innovation Models and primary care transformation programs. The resource provides a comprehensive evidence base for future health systems transformation.

STATE HIGHLIGHTS

Alaska

CMS has approved Alaska’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended to:

• Allowing providers to hire family caregivers as direct service workers for certain services, including in-home supports
• Allowing budgets in the Individual Supports Waiver to increase by $5,000 should an individual contract COVID-19 or a primary unpaid caregiver is quarantined
• Temporarily using an electronic method of delivery for case management and/or assessments instead of face-to-face requirements

Connecticut

CMS has approved Connecticut’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Allowing assessments to be conducted virtually and is extending the required frequency up to twelve months beyond the re-evaluation deadline
• Temporarily permitting an emergency increase in the individual cost limit for existing participants if needed to support them in the community safely during the emergency, and in order to avoid institutionalization
• Allowing assessments and reassessments to be conducted virtually and the requirements for frequency of reassessments will be temporarily waived, and will be extended to a maximum of three months beyond the initial re-evaluation deadline

Hawaii

CMS has approved Hawaii’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Allowing telehealth delivery of most day and employment services
• Modifying the prior authorization and/or exception review process
• Providing exceptions to the individual budget limits when needed to accommodate changes in service availability for a variety of circumstances that may arise from COVID-19

Iowa

CMS has approved Iowa’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Removing the annual cost limit for respite services during the COVID-19 emergency under the HCBS Intellectual Disabilities Waiver
• Allowing the homes of direct care providers to be authorized settings and allow direct care providers to move into the home of participants, subject to approval
• Adding home-delivered meals, companion and homemaker services to available self- directed services

Kentucky

CMS has approved Kentucky’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Allowing any enrolled Medicaid provider to offer home delivered meals
• Temporarily waiving requirements that out-of-state providers be licensed and located in Kentucky when they are actively licensed by another state Medicaid agency
• Ensuring the person-centered service plan is modified to allow for additional supports/and or services to respond to the COVID-19 pandemic

Massachusetts

MassHealth (Medicaid) approved a number of exceptions for managed care entities during the COVID-19 crisis which apply to One Care duals demonstration plans and to the Senior Care Options program. Some of the exceptions are:

• Relaxing referral and prior approval requirements and procedures so that members can get timely medically necessary testing or treatment
• Relaxing out-of-network requirements and procedures when access to urgent testing or treatment
• Covering testing, treatment and prevention of COVID-19; coverage must include a number items including home visits and drugs, including 90-day supplies and early refills of covered drugs

Michigan

A recent article in Modern Healthcare discusses Michigan’s proposal to create a five-employee office to transform how the state pays for health care through Medicaid. The ultimate goal of the Medicaid Transformation Office is to come up with a variety of new or enhanced "value-based" reimbursement systems for health plans, hospitals, physicians, nursing homes and home and community-based providers.

Minnesota

CMS has approved Minnesota’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver in order to allow initial assessments and annual re-assessments to be conducted by telephone or other remote methods.

New Mexico

CMS has approved New Mexico’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Doubling the assistive technology benefit from $250 to $500, including allowing the purchase of devices for remote video conferencing, training and monitoring by clinicians
• Ensuring the person-centered service plan is modified to allow for additional supports and/or services to respond to the COVID-19 pandemic
• Allowing the use of currently approved Level of Care (LOC) assessments on file to fulfill the annual LOC requirement for impacted waiver participants for the duration of the emergency

Pennsylvania

CMS has approved Pennsylvania’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Allowing residential habilitation services to be delivered by family members
• Extending respite in a licensed facility beyond 29 consecutive days without prior approval of the Community Health Choices-MCO in order to meet the immediate health and safety needs of program participants
• Allowing documentation of verbal approval or email approval of changes and additions to person-centered service plans be sufficient as authorization

Rhode Island

CMS has approved Rhode Island’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Modifying all person-centered service plan procedures to ensure that Medicaid members receive authorization for appropriate services, while preventing worker exposure to COVID-19
• Allowing initial level of care determinations to be conducted remotely and postponing annual level-of-care reevaluations for up to six months

In other Rhode Island news, a new report released by the Rhode Island Commission for Health Advocacy and Equity summarizes data collected through the state’s Health Equity Measures, a set of 15 measures that cover five domains: integrated health care, community resiliency, physical environment, socioeconomics and community trauma. The report is intended to educate the General Assembly, state agencies and partner organizations on health inequities in Rhode Island and includes examples of programs and policies in the state and across the country that are showing promise for reducing inequities.

Washington

CMS has approved Washington’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Expanding waiver transportation service to travel to non-waiver service such as transportation to another family member’s home, when that transportation is required to prevent illness or meet immediate health and safety needs
• Temporarily adding Wellness Education to the waiver to provide information regarding COVID-19 and health and safety
• Allowing beneficiaries to receive fewer than one service per month for a period of 90 days without being subject to discharge

West Virginia

CMS has approved West Virginia’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Allowing the service limit for Personal Attendant services to be exceeded if the beneficiary’s primary care provider become unable to provide services/supports
• Allowing legal representatives to pay Personal Attendants if the beneficiary’s primary caregiver become unable to provide services/supports.
• Allowing payment to Personal Attendants for the purposes of supporting a beneficiary during acute care hospital stays

Wyoming

CMS has approved Wyoming’s submission of an Appendix K to temporarily amend their Home and Community-Based Services (HCBS) 1915(c) waiver. A number of provisions have been amended such as:

• Providing Community Support Services in the participant's home
• Allowing participants who require hospitalization to receive the following services in a hospital setting for no more than 30 days: adult day services; community living services; companion services and personal care services

KEY DATES

Friday, April 17 (1-2 pm Eastern) - Webinar: Immediate Approaches for Collaboration During the COVID-19 Pandemic, presented by the National Coalition for Complex Health and Social Needs. Please register for the webinar.

Tuesday, April 21 (1-2 pm Eastern) - Webinar: 1135 Waivers in Action: Flexibilities, Limits and Next Steps for States and Providers, presented by Manatt Health. Please register for the webinar.

Thursday, April 23 (2:30-3:30 p.m. Eastern) – Webinar: ADA National Network Learning Session: COVID19, Health Care, and the ADA, presented by the Americans with Disabilities Act National Network. Registration closes at midnight, April 22. Please register for the webinar.

Thursday, April 23 (3-4 p.m. Eastern) - Webinar: Ensuring Continuity of HCBS During the COVID-19 Pandemic, presented by the Administration on Community Living and the Centers for Medicare and Medicaid Services. Please register for the webinar.

Thursday, April 30 (12-1:30 p.m. Eastern) - Webinar: Supporting Family Caregivers of Older Adults through Times of Stress and Isolation, presented by the Center for Consumer Engagement in Health Innovation in collaboration with the Medicare-Medicaid Coordination Office and the Lewin Group. Please register for the webinar.