The modern-day nursing home had its awakening in the 1960s, but when the '70s arrived, society began recognizing the poor living conditions of institutionalized care. Labeled as park-and-die facilities, the '80s brought a paradigm shift toward assisted living, which promised a bright future and revolutionized senior care.
Now, Montana and the U.S., is taking another jarring step in geriatric health care — aging in place.
As a string of 11 nursing home closures rippled through the state’s rural communities in 2022 — more closures than occurred in the four years leading up to the pandemic — Gov. Greg Gianforte responded by encouraging the aged to grow old at home with the help of in-home care services or with their families.
While the data does reflect a growing desire to age at home, the state lacks the infrastructure to keep up with the swell in demand for in-home care services. Between the shortage of in-home services and the massive reduction in institutionalized care, most citizens with aging or disabled family members are left with no choice but to become the full-time caregiver.
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Family caregivers in Montana are providing about $1.76 billion annually in unpaid care to their loved ones. That’s a $350 million increase from 2019, according to recent research by AARP.
In the years since the pandemic began, thousands more Montanans have started caring for ailing loved ones, which even for the most capable of families, is exhausting and trying work.
“I can tell you first hand it’s very challenging,” said Mike Batista, director of government affairs with AARP. “It strains family relations, sometimes you feel like you lost your private time. Usually if you’re a fulltime caregiver, it’s not surprising to see them drop out of the workforce.”
More often than not, it’s women who leave their jobs and devote their lives to being the caregiver, according to previous reporting by The Gazette.
Mentally and physically demanding, it’s work that requires people to have a break.
Countless Montanans testified before legislators during the first half of the session that accessing basic in-home services is almost impossible. Respite care is inconsistent and expensive, but provides short-term relief for the caregiver to run errands or take care of their mental health.
In-home certified nurse assistants (CNA) or other clinical providers is even more difficult to access and is often expensive for the consumer.
These types of services help support caregivers and make it possible for vulnerable citizen to age in place.
No clear plan
The in-home care industry needs significant investment from the State of Montana in order to stabilize and then expand, but so far Gianforte has not voiced any specific plans for the future.
“At what level will the department fund (in-home care) services?” Batista asked. “I don’t think they know that yet.”
When asked if health department has plan to expand or further invest in in-home care services beyond the provider rate budget, Jon Ebelt, communications director for the state health department, did not respond to or acknowledge the Billings Gazette's questions. Instead, Ebelt sent a list of the current services offered by the state.
Ebelt was also asked what the state will do to expand family caregiver support and if this was a priority for the administration. He disregarded the questions and did not provide an answer beyond what is being discussed at the legislature.
The state health department did not offer any structured plan for building up in-home services going forward. Gianforte deferred questions from The Gazette to the health department, which is operated under his direction.
Constituents have noticed the lack of solid footing, saying only that they hope they can convince Gianforte and lawmakers during the interim that investing in health care for the elderly and disabled is worthwhile.
Demand for in-home care services exploded during the pandemic and continues to climb, said Dawna Brinkel, CEO of HomeCare Montana. But like nearly every other sector in human services, the unprecedented workforce shortages has prevented her from meeting the needs of the state.
Strengthening the workforce depends on higher wages. But being able to offer those wages is directly linked to the amount of funding legislators direct to Medicaid provider rates — the amount of money the state reimburses providers for services administered to a Montana Medicaid recipient.
“Our reimbursement needs to be addressed,” Brinkel said. “Money is the essential base. We shouldn’t be competing against coffee shops (for workers).”
A recent provider rate study commissioned by the state to assess shortfalls in Medicaid reimbursement revealed that nearly every wage under the senior and long-term care division is severely underfunded.
Oftent, the direct care workers are seen as domestic house cleaners, said Jim Morton, board chair for HomeCare Montana. He explained that these providers bring a wide array of services to rural parts of the state including wound care, toileting, mobility, exercise, urinary and bowel systems management along with hygiene and cleanliness support.
“They need professional recognition,” Morton said.
In-home care representatives from across the state asked lawmakers to fully fund to the recommended rates published in the provider rate study and to consider building in inflationary adjustments that would help stabilize the industry into the future.
But so far efforts to build up reimbursement have fallen flat. This week, House Appropriations voted against an amendment that would have increased rates and provided inflationary adjustments.
Earlier in the session, the Human Services Subcommittee voted to increase rates from the governor’s proposal but chose not to meet the benchmark. Over the two years of the biennium, it would cost the state an additional $25 million out of a $7 billion budget to meet the benchmark rates.
Brinkle is pleased with the work done in the Human Services Subcommittee that increased rates from the governor’s proposed budget. It’s a historic investment in Medicaid provider rates and will help to stabilize the industry.
“Home- and community-based services is finally getting the recognition it deserves,” Brinkle said, but in order to meet the demand, more investment is needed.
No legislation in sight
In-home care providers are now relying on a timely and meaningful discussion with lawmakers during the interim to secure additional funding. There they will make their case again that direct care workers not only need completive pay, but also need training in their field.
Traditionally, direct care work lacks employee support and opportunity for advancement, making it a hotspot for high turnover, according to previous reporting by The Gazette.
But so far, Gianforte has not said there will be additional monetary commitment from the state going forward. But, even so, at HomeCare Montana they’re full of proactive ideas.
For one, Morton sees a future where licensed clinicians have the ability to delegate tasks to non-licensed employees. The non-licensed employees would need additional training in order to carry out the care plans for the supervising nurse, but the model would increase efficiency.
But in order to expand the scope of services in this way, in-home care would need investment from the state that goes beyond the provider rate increases, Morton said.
This session, nursing home reimbursements have been front and center. As the second half the session kicks off, no other legislation specific to in-home care has bubbled to the surface.
When asked if providers were disappointed in this, all said they are hopeful for the interim period.
“In order to see success it has to originate in the (state health) department,” said Batista with AARP. “Any expansion for in-home care wasn’t ready for prime time.”