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Program brings care to homes of elderly

A state project provides extra services seniors need so they can avoid going to nursing homes.

By STEPHEN NOHLGREN, Times Staff Writer
Published April 19, 2004

Three months ago, Clara Rodriguez figured she would have to leave Tampa's King's Arms apartment, her home for 15 years.

She was 82, overweight, arthritic and weak from a pacemaker operation. She could barely get out of bed to cook an egg. She seemed destined for a nursing home.

Then a social worker helped her sign up for a new program that helps frail elderly people stay at their homes. An aide bathes her three times a week. Someone else cleans her apartment, runs errands and washes her clothes. She gets her prescription drugs for free.

"I don't want to be bedridden. This has saved my life," she says. "I want to stay here as much as possible, and with their help I can."

Plug in soft background music, and Rodriguez could star in a touching commercial for the Nursing Home Diversion Project, Florida's latest venture into privatization and managed care.

The state pays private companies - some of them HMOs - a monthly fee to care for people who otherwise might land in nursing homes. The company decides what services it will offer, from simple help with medication, to adult day care, to permanent assisted living homes.

Companies can be quite creative. American Eldercare, which tends to Rodriguez, once escorted a client to the movies every Friday, because that's what kept her happy until she died.

Companies that spend wisely can make money. Companies that cut too many corners might lose their shirts if clients end up in hospitals or nursing homes, because the companies must foot those bills as well.

Two-thirds of Florida's 70,000 nursing home residents are on Medicaid. Often, they are middle-class people who exhaust their savings on $5,000-a-month care and rely on the state to pick up the slack. Though the federal government pays about 55 per cent of Medicaid's bill, the state's share tops $2.5-billion and is growing more than 10 percent a year.

Gov. Jeb Bush and some legislators view managed care as the solution. One sweeping proposal, rejected last week in the Senate, would have required all older people who need a Medicaid nursing home to enroll in a managed care company.

With that proposal now dead, the Nursing Home Diversion Project becomes Florida's best way to test managed long-term care - without making it mandatory.

Last year, Florida doubled its spending on the nursing diversion program. This year's House appropriations bill expands it another 50 percent while giving little or no new money to traditional in-home programs, like Community Care for the Elderly. If the Senate agrees, the diversion project will outstrip all fee-for-service programs designed to keep frail, elderly Floridians out of nursing homes.

"We have got to find some new models, whether these are the right ones or not," says Margaret Lynn Duggar, director of the Florida Council on Aging. "Maybe the only way to find out is by trying something bold."

But does managed care really save money?

A University of South Florida study last October found that a pilot diversion program cost Medicaid much more than two existing at-home programs. Over a three-year period, managed care clients cost the state an average of $55,820, a paltry sum compared to the $150,000 that a nursing home would have cost. On the other hand, the Medicaid Waiver and Assisted Living Waiver programs accomplished much the same goal for $30,000 to $40,000 per client.

Nevertheless, the governor and Legislature remain committed to creating a market for private, managed care.

Last fall, the diversion program expanded from a pilot project to a permanent program, available in urban areas all over the state. After the USF study, Florida reduced monthly payments to the managed care companies from roughly $2,300 per client to $2,000. Actuaries have recommended another $300 cut next January, though companies are lobbying heavily against that.

So far, about 3,000 Floridians have signed up for the diversion project, including 400 to 500 in Pinellas, Hillsborough and Pasco counties. Evercare, an affiliate of nationwide conglomerate UnitedHealth Group, commands about half the Tampa Bay diversion market.

Citrus Health Care is a small, Tampa-based HMO that opened for business in June. Its TangoPlan has 15 clients, including four who lived in nursing homes on Medicaid before signing up, said director JoAnne Dutcher.

Even Neighborly Care Network jumped into managed care last month, with two clients so far.

Known for years as Neighborly Senior Services, the company operates Meals on Wheels, adult day care, transportation and home health services in Pinellas County. The nursing home diversion concept puts all that together, said director Debra Shade.

"We saw that the HMOs were going to be enrolling our clients, the people we have been serving for 40 years," Shade said. "We were concerned they would not be able to receive the same level of care, so we got into it."

Existing at-home programs all have waiting lists, different eligibility rules and different ways to enroll.

"You have no idea of the jockeying that goes on" to match clients and services, Shade said. The diversion program lets the state make one payment, while forcing the managed care company to work things out. "It gives the client the ability to stay in their home and not worry about where the funding is coming from," Shade says.

HMOs make money by negotiating low rates to the hospitals, nursing homes and other services their clients need. But they also profit by pioneering creative approaches. They aren't hamstrung by ponderous bureaucracies when needs and medical techniques change.

Nursing home diversion companies, for instance, offer one-stop shopping. They truly "manage care." If Clara Rodriguez has a problem, she calls her American Eldercare case worker, who figures out a solution and sets it into motion. Evercare closely scrutinizes medications to make sure people really need them. On average, Evercare clients reduce their pill consumption by 20 percent after signing up, a spokesman said. Yes, pharmacists and doctors in traditional programs should be watching their patients' medications, but their money is not on the line, so they aren't as effective.

Florida's Elder Affairs Secretary, Terry White, supports the managed care experiment, but he also wants to apply one-stop shopping to the state's current network of programs.

Under a bill sponsored by Rep. Sandra Murman, R-Tampa, Florida would set up "aging resource centers" in every region. People who needed help could call the center to get information on an array of programs, from Meals on Wheels to nursing homes. People could find out whether or not they qualified for Medicaid. Functions now dispersed through a half-dozen offices would be centralized. It would help level the playing field between managed care and traditional programs.

Joan Lopata is not worried about public policy. All she knows is that an Evercare case manager helped her move back to her Largo mobile home two months ago. She had suffered a stroke a year ago and had been living in nursing homes.

Now Evercare gives her therapy at home for her paralyzed right side, a wheelchair ramp outside her front door, free drugs, help with bathing, frozen meals and laundry service.

"It's like getting out of prison," she said. "I have a chance to be myself again."

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