Caregiver support has been a consistent priority of The Biden Administration. Today's announcements included many actions to support childcare as well as long term services & supports (LTSS) for adults. Below are some direct quotes from the White House Fact Sheet focused on LTSS, along with our commentary.
VA Self-Direction Expansion
"Executive Order directs the Department of Veterans Affairs (VA) to improve access to home-based care for veterans who require support with activities of daily living, like bathing and getting dressed, by giving them more decision-making power over who delivers that care and when. VA is directed to consider expanding its Veteran Directed Care program to all 172 VA Medical Centers by the end of Fiscal Year 2024. This program provides veterans with a budget to hire personal care assistance including from family members."
The VA started self-direction programs in 2009. These programs have consistently shown high caregiver and care recipient satisfaction, with the same or better outcomes. Today less than half of VA Medical Centers offer self-direction. After more than a decade of slow rollout, this announcement means that many medical centers within the VA will need to quickly adopt these programs to meet the 2024 deadline.
New Dementia Care Model
"Executive Order directs HHS to consider testing a new dementia care model that will include support for respite care (short-term help to give a primary family caregiver a break) and make it easier for family caregivers to access Medicare beneficiary information and provide more support to family caregivers during the hospital discharge planning process."
Traditional healthcare has struggled with managing dementia care, so the recommendation to test a new care model is welcomed. The hospital discharge part seems to be a dementia-focused extension of the The Caregiver Advise, Record, Enable (CARE) Act, first adopted by Oklahoma in 2014 and now in 45 states. The Act requires that hospitals ask patients if they have a family caregiver, record that person's information in the EHR, and then provide information & training on medical or nursing tasks to that family caregiver. While the Act is well-designed, there is mixed awareness and compliance to it from hospitals. Identifying a family caregiver is much more commonly done than training the caregiver.
Only other note is that this section includes 1 of 2 times that Medicare is mentioned (the other is around nursing homes). Since Medicaid and the VA tend to have accountability for long-term care, they are the focus of most of these actions. We think there is a lot of opportunity to influence caregiver experience through Medicare, especially in post-acute care and dementia. This may be a future area of focus.
Addressing Care Workforce Shortages
"Executive Order directs HHS to consider issuing several regulations and guidance documents to improve the quality of home care jobs, including by leveraging Medicaid funding to ensure there are enough home care workers to provide care to seniors and people with disabilities enrolled in Medicaid"
This directive is reliant on the Department of Health & Human Services (HHS) to "consider" issuing regulations. It makes sense to use Medicaid funding because that's the benefit that absorbs the most LTSS cost today. But the use of those funds will need to be strategic. Turnover of home care workers is 60% and the aging population is quickly growing. Having enough care workers will require either a big raise in pay to compete with other jobs, or building large new pipelines for caregivers. As supporters of self-direction and pay to family caregivers, we'd like to note that the average tenure of a family caregiver is 4 years - far longer than that of a home care worker.
$150B Budget Request for Addressing Workforce Shortages & Increasing Community Living
"The President’s Budget also includes $150 billion over the next decade to improve and expand Medicaid home care services—making it easier for seniors and people with disabilities to live, work, and participate in their communities. This funding would improve the quality of jobs for home care workers and support family caregivers. The Administration is also promoting the use of apprenticeship programs and partnering with employers, unions, and others to recruit, train, and keep long-term care workers on the job"
This refers to a proposed budget, so will require congressional approval. Great to see the proposed investment in home care services. This can expand professional workers and also open up investment for increased self-direction, where family members and friends can be identified and paid as caregivers.
An example of a state initiative to recruit, train, and keep care workers on the job is the CalGrows initiative in California. This work has invested $89M in 2023 to provide better training & career support for direct care workers and family caregivers. Funding may lead to additional state initiatives like CalGrows.
Overall, we are excited for continued action in this space!