Ohio faces a demographic reckoning. With 55 million Americans now over 65, including 2.2 million Ohioans, Ohio’s older adult population is expected to grow faster than the national average, while its population under 65 is projected to shrink. Nationally, by 2050, the number of individuals aged 85 and older is expected to double, creating an unprecedented demand for services as this population becomes more diverse and economically vulnerable. Innovation and collaboration will be especially critical in supporting those who won’t qualify for existing programs and in simplifying access to a complex system of providers and resources.

Fortunately, Ohio also boasts remarkable aging service innovators, from National Church Residences’ expertise in institutional transitions back to the community, to United Church Homes’ expanded service coordination beyond its affordable housing communities, to the Area Agencies on Aging serving as key partners to managed care organizations for the MyCare Ohio program. Success in Ohio’s aging future will hinge on building on these kinds of examples, mastering collaboration, and creating integrated systems that serve vulnerable populations effectively, irrespective of federal funding levels.

To that end, the following questions represent critical challenges reflecting conversations happening in boardrooms, county commissioner meetings, and strategic planning sessions across Ohio and the country.

Building Age-Ready Communities: Key Questions for Local Stakeholders

1. How can state and counties align their aging-in-place investments with those of payers, providers, and purchasers to increase the value of existing programs and resources?

As the aging population grows rapidly, states and counties can maximize aging-in-place investments by establishing unified visions that bring together public agencies, healthcare systems, and private sector partners under shared, evidence-based strategies. This requires deliberate alignment with state and local priorities while engaging private insurers, employers, and community organizations as strategic co-investors. Ohio exemplifies this approach through its remarkable growth in age-friendly communities—36 communities have now achieved age-friendly designation, including 10 new communities since early 2023, demonstrating accelerating momentum toward the development of systematic aging-in-place infrastructure.

Ensuring accountability and tracking progress are essential in demonstrating the effectiveness of public-private investments. Tools like data dashboards help maintain initiative momentum and adapt to needs. Additionally, strategically coordinating funding from various sources, such as Medicaid, Medicare, and private insurance, can enhance resource integration. The Westchester Public/Private Partnership for Aging Services exemplifies how shared resources can improve aging-in-place outcomes while serving as a replicable blueprint for creating age-friendly communities.

2. How can support for older adults in rural communities be increased? 

While urban areas grapple with capacity, rural Ohio faces a different challenge: doing more with less. Nearly one in three rural Ohioans is now 60 or older—a concentration that’s both a testament to community strength and a preview of coming pressures. These challenges include limited access to healthcare specialists, transportation systems designed for different needs, and the risk of social isolation as neighbors and family members become more dispersed. Ohioans in rural and Appalachian regions are designated as priority populations in eight of the nineteen outcomes outlined in Ohio’s 2023-2026 State Plan on Aging.

Additionally, local leaders across health plans, hospitals, aging services organizations, and government are uniquely positioned to expand telehealth networks that bring care directly into homes, invest in the broadband and housing infrastructure that makes aging in place possible, and build homegrown training programs that keep caregivers rooted in their communities. Partnerships between Area Agencies on Aging, rural hospitals, and community organizations can create integrated care models that align multiple funding streams, including Medicare and Medicaid, as well as Older Americans Act and county resources. What is needed now is coordination to replicate or scale approaches that will be key to ensuring sustainable aging support for Ohio’s rural older adults and ensure the access required for the changes underway.

3. How can stakeholders reduce social isolation and increase access to age-friendly behavioral health services?

The National Academies of Sciences, Engineering, and Medicine report, “Addressing the Impact of COVID-19 on Social Isolation and Loneliness”  documents the impact of COVID-19 on social isolation and loneliness among older adults. The report recommends five strategies to promote social connectedness and reduce social isolation, including:

• Community-based support: Using existing community infrastructure to leverage the resources of community service networks.
• Community leadership: Partnering with communities to design and deliver services, forcing inclusive, action-oriented alliances to enhance social connection and solutions tailored to each unique community.
• Digital environments: Utilizing online support groups to address loneliness and social isolation, being cognizant of cultural or generational preferences for electronic communication platforms.
• Social infrastructure: Designing inclusive and multifaceted public infrastructure and mixed-use planning, incorporating libraries, gardens, shops, cafes to promote social connectedness.
• Comprehensive policy initiatives: Proactive policymaking to aid in the enhancement of social connectedness through supportive programs that address older adults’ unique challenges.

In addition to trends in social isolation, depression and anxiety are frequently unreported and untreated in people age 65 and older; and people over the age of 65 are among those at the highest risk for suicide. Community and state agencies need to come together to expand access to age-friendly mental health and substance use disorder services and to engage older adults in preventive and supportive strategies. Healthy lifestyle programs like Healthy U are offered in communities statewide through the Ohio Department of Aging and local Area Agencies on Aging. These programs offer depression screenings and approaches to managing depression, anxiety, and chronic disease.

4. What are new and innovative approaches to expand affordable housing to prevent homelessness, unsafe living situations, and preventable healthcare costs?

According to the 2024 Ohio Housing Needs Assessment Executive Summary, the number of older Ohioans who live alone is increasing. One in eight Ohio households – or more than 613,000 – houses a single adult aged 65 or over. Aging householders living alone face unique challenges when it comes to maintaining the cost and upkeep of homes, especially among those who wish to age in place. Furthermore, one in eight mortgage holders aged 55 and over (13%) is severely housing cost burdened. Nineteen percent of mortgage holders aged 65 and over and 25% of those aged 75 and over are severely mortgage burdened.

Members of the Ohio General Assembly proposed a comprehensive solution to the housing crisis, including:

• Increase access to affordable housing for all Ohioans regardless of income by increasing the number of new units being built and helping local governments and for-profits and non-profits rehabilitate existing housing stock.
• Provide property tax relief that promotes tax fairness for all Ohioans with targeted assistance for veterans, seniors, first-time homebuyers, and low-income and middle-income renters.
• Update zoning laws and building inspection laws to reduce regulatory obstacles and allow for new housing developments; modernize real estate agency agreements; increase property conveyance transparency; and make changes to the eviction process.

Even for older adults who have affordable housing, most will need support at some point to age in place. The Age-Friendly Health Systems resources from the Institute for Healthcare Improvement provide a great framework for supporting older adults to age in place – the 4Ms of age-friendly organizations. These include (1) understanding what matters to older adults, (2) helping with medication issues, (3) preventing, identifying, and managing mental health conditions and dementia, and (4) ensuring mobility needs are met. 

5. How can the state increase older adults, caregivers and communities access to   information that is easy to understand about resources to support aging in place?

Currently, Ohio has a 29-year life expectancy gap by zip code, partly driven by unequal access to aging resources. With 99,484 older Ohioans speaking languages other than English, simply having services is not enough; information must be accessible and culturally relevant.

Older adults struggle to navigate complex systems to find housing assistance, healthcare options, transportation, and caregiver supports. Many give up before getting help. Research shows that nationally, 21% of Area Agencies on Aging employ Community Health Workers (CHWs), with 20% more seeking to add them. These trusted community members serve as cultural bridges, providing linguistically appropriate connections to care, accompanying older adults to appointments, and offering emotional support and companionship.

Gaps exist, but there are solutions where partnerships can accelerate progress.

• Community-Based Organizations: Expand CHW programs, host resource fairs in culturally familiar venues like faith centers and community halls, develop peer-to-peer information networks.
• Health Plans: Fund CHW positions, create simplified resource materials, and integrate aging services information into member communications.
• Local Government: Support broadband access in underserved areas, fund transportation to resource centers, and coordinate age-friendly community planning.
• Private Sector: Provide workplace caregiver supports and partner on innovative outreach methods.

Better access to information requires a coordinated effort. Communities are finding that reaching older adults requires innovative partnerships that meet them where they are, whether that’s at their church, community center, doctor’s office, or through a trusted neighbor who understands their language and culture.

Programs for All-Inclusive Care for the Elderly (PACE) plans are programs aimed at keeping low-income older adults living in the community and out of nursing homes, providing home care, prescriptions, meals, and transportation to participants. The Centers for Medicare & Medicaid Services (CMS) recently proposed changes to the risk score model used for PACE (which determines the calculation for how many Medicare dollars PACE gets) that will create funding vulnerabilities in the Medicare rate. If approved, this would likely mean PACE programs get significantly lower funding amounts from Medicare than under the current model. The final notice is expected to be released in April 2025. If approved, this change would be fully phased in by 2029.

PACE enrollees, as compared to enrollees in Medicare Advantage plans, disproportionally have conditions that will no longer be risk-adjustable, such as depression, leading to an across-the-board drop in risk scores. Along with the reduced funding for PACE programs, this risk model change will create data submission issues for PACE organizations and their vendors. When health plans, who are much more risk-score focused in general than PACE plans, underwent this same change, risk scores dropped by between 5%-20%. If PACE programs don’t fix their data submissions in 2025, they’ll lose money in 2026 and beyond.

To sustain and grow, PACE leaders must understand and plan for the change to v28 risk scores. HMA’s team of consultants and our actuaries from Wakely, an HMA Company, have put together an analysis to help PACE plans understand and prepare for the transition:

• HMA will create reports showing the current (v22) risk score, the proposed (v28) risk score, and the impact by diagnosis category to help with potential recapture efforts.

• Identify data submission problems and suggest strategies for fixing them.
• Outline potential financial and operational adjustments uncovered during the analysis.

HMA has found that this the change in the process of diagnosis submission is a blind spot for many PACE plans and may be more critical to mitigate than the impacts from the risk adjustment model change.  

HMA & Wakely will be hosting a booth at the National PACE Association Spring Policy Forum in Washington, DC on March 17 and 18. If you are attending, we hope you will visit us there. If you would like help understanding the potential impact to your PACE organization, contact us about developing an analysis to help you respond to these changes.

This week, our In Focus section reviews the request for responses (RFR) for the Massachusetts One Care and Senior Care Options (SCO) programs, released by the Massachusetts Executive Office of Health and Human Services (EOHHS) on November 30, 2023. The programs provide physical, behavioral, long-term services and supports (LTSS), and other community services to Medicare and Medicaid dual-eligible beneficiaries. Implementation is set to begin January 1, 2026.

One Care

One Care launched in 2013 as a Section 1115 Medicare-Medicaid Plan (MMP) program dual demonstration waiver. It operates under a financial alignment initiative (FAI) capitated model. The program provides integrated care to dual eligible adults ages 21 to 64. Individuals may remain enrolled in One Care when they turn 65 years old as long as they continue to meet all other requirements. Members can also access an independent LTSS coordinator.

As the Centers for Medicare & Medicaid Services (CMS) sunsets the FAI dual demonstrations, One Care will shift to a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) beginning in 2026, pending federal approval of the Section 1115 amendment request. Members will have exclusively aligned enrollment with the same plan for both Medicare and Medicaid coverage.

SCO

SCO launched in 2004 and is currently a FIDE SNP with exclusively aligned enrollment. Medicaid enrollees ages 65 and older with or without Medicare are eligible. Enrollment in this managed care program is voluntary. Individuals on the Frail Elder Waiver can only join SCO.

RFR

Massachusetts will award separate contracts for One Care and SCO but may prefer bids from plans seeking to operate both; however, plans may submit bids to operate one type of plan. The state seeks to offer both One Care and SCO coverage for eligible individuals in as many counties as possible, and ideally statewide. Plans must propose to cover people in at least six counties for each type of plan.

To be selected, plans will need to have a contract with CMS to operate a FIDE SNP in Massachusetts in 2026. Applications must be submitted to CMS by February 2025.

Timeline

Letters of intent are due February 15, 2024, and the deadline for responses is March 22, 2024. Plans will be selected by November 1, 2024. Implementation is set to begin January 1, 2026. Contracts will run an initial five-year term through December 31, 2030. Contracts may be renewed for up to five years in any increment.

Current Market

Commonwealth Care Alliance, Tufts, and UnitedHealthcare serve 43,000 One Care members.

SCO incumbents WellSense Senior Care Options (formerly BMC Healthnet), Commonwealth Care Alliance, Fallon Health, Molina/Senior Whole Health, Tufts, and UnitedHealthcare serve 77,000 members.

Link to RFP

This week, our In Focus section reviews the new Guiding an Improved Dementia Experience (GUIDE) Model, announced by the Centers for Medicare & Medicaid Services (CMS) Center for Medicaid and Medicare Innovation (the Innovation Center) on July 31, 2023.

In addition to announcing the Innovation Center’s GUIDE Model, CMS released five final fiscal year (FY) 2024 payment rules this past week. Of note, these regulations set higher than anticipated reimbursement rates for many providers:

• Medicare Hospital Inpatient Prospective Payment System
• Medicare Skilled Nursing Facility Prospective Payment System
• Medicare Hospice Payment Rate Update
• Medicare Inpatient Psychiatric Facility Prospective Payment System
• Medicare Inpatient Rehabilitative Prospective Payment System

CMS also released the 2024 projected Medicare Part D premium and bid information, which may provide early indications on the effects of the Inflation Reduction Act’s drug pricing policies.

GUIDE Model: Parameters and Opportunities

President Biden signed an Executive Order in April 2023 on Increasing Access to High-Quality Care and Supporting Caregivers. The order directed the Innovation Center to develop a payment and delivery system model for dementia care. The program is intended to improve the quality of life for people living with dementia, reduce strain on unpaid caregivers, and help people remain in their homes and communities through improved care coordination and management, caregiver education and support, and respite services.

The announcement this week outlines the basic parameters of the model, which track with CMS’s focus on reducing health disparities, supporting innovation, and addressing affordability. CMS expects that the model’s additional support for caregivers will reduce federal spending on hospitalizations and post-acute care. Notably, CMS projects savings will come from reduced long-term nursing facility placement through a decrease in Medicaid spending on the federal medical assistance percentage (FMAP). Helping Medicare enrollees stay in their homes may also lower state spending on long-term care.

Additional information, including the application to participate, will be available this fall. In the meantime, CMS is accepting letters of interest through September 15, 2023. The model will begin on July 1, 2024, and run for eight years.

HMA’s experts identified the below list of policies that will be important for provider organizations, caregivers, and other stakeholders considering participation in the model:

• GUIDE Model participants will be Medicare Part B enrolled providers/suppliers, excluding durable medical equipment (DME) and laboratory suppliers, that are eligible to bill for Medicare physician fee schedule services and agree to meet the care delivery requirements.
• The GUIDE Model comprises two tracks for participation—one for established programs and another for new programs.
  • Established programs must have an interdisciplinary care team, including a care navigator, use an electronic health record (EHR) platform that meets the standards for certified EHR technology, and meet other care delivery requirements as outlined in the request for applications.
• If a participant cannot meet the GUIDE healthcare delivery requirements alone, CMS will allow the provider or supplier to partner with other Medicare organizations, to meet the mandates.
• The model also includes policies designed to reduce disparities in dementia care. For example, CMS plans to conduct outreach with organizations that do not yet offer comprehensive dementia care or lack prior experience with alternative payment models such as safety net providers. Participants also will need to develop health equity plans, and a “health equity adjustment” will be made to payments for providers that serve disadvantaged beneficiaries.
  • CMS will support model participation for these organizations by providing technical assistance and learning support as well as a pre-implementation year to prepare for participation.
• CMS will test an alternative payment methodology for participants that deliver key care management and coordination services to people with dementia and their family caregivers, including comprehensive, person-centered assessments and care plans; 24/7 access to a helpline; and caregiver support and education, such as training on how to best care for a relative with dementia. CMS clarifies that GUIDE is not a shared savings or total cost of care model and does not address coverage of novel Alzheimer’s drugs.
• Participants will assign Medicare fee-for-service beneficiaries, including people who are dually eligible for Medicare and Medicaid, living with dementia and their caregivers to a care navigator. This individual will help people access services and supports, including clinical services and non-clinical services such as meals and transportation through community-based organizations. Model participants will also help caregivers access respite services, which enable them to take temporary breaks from their caregiving responsibilities. Evidence demonstrates that respite enables caregivers to care for individuals with dementia at home for a longer period, thereby forestalling institutional placement.

CMS will host a webinar with more details about the model on Thursday, August 10, from 2:00−3:00 pm.

The HMA team will continue to evaluate the GUIDE model and other Innovation Center opportunities. If you have any questions about the model or any of the new regulations, contact our experts below.

We also would like to remind our readers that the HMA team hosted a webinar last week on the Medicare Behavioral Health proposed changes titled “New tools for Medicare policy changes impacting behavioral health services”. We previously discussed those changes in the July 19, 2023 In Focus.