What States Get Right And Wrong When It Comes To Home-Based Care Support

When it comes to long-term care services and home-based care, some states are much further ahead than others. But one thing most of those states agree on is that there’s still room to improve.

Last month, when AARP released its long-term services and supports state scorecard report, Minnesota came out on top, ranking number one on the list. That means the state scored high when it comes to factors such as affordability and access, choices of settings and providers, safety and quality, and more.

“Minnesota has long taken pride in doing very well in providing care for Minnesotans, whether it be the older adults or people with disabilities, so I think we have continued to work on that,” Kathy Messerli, executive director at the Minnesota Home Care Association, told Home Health Care News. “I would also say that while it’s hard to find a silver lining for the pandemic, one of them was certainly an increased awareness of the services that could be provided in the home, and the quality and the outcomes that come from that.”


This increased awareness has activated lawmakers and state regulators to move in a direction that is positive for providers, according to Messerli.

The Minnesota Home Care Association has also been active when it comes to increasing home-based care utilization. In order to achieve this, the organization has worked to educate physicians.

“We found early in the pandemic when we were presenting to [physicians], they said, ‘We’re really not recommending home care to our patients, because we’re just not sure whether or not they’re qualified,’” Messerli said. “One of my board members was able to say, ‘Let us figure out if they’re qualified, just get the referral done.’” We are really trying to elevate the awareness of home care, home health, and what all can be done in the home.”


The organization has also been able to advocate for higher reimbursement rates, which often leads to higher pay. In the 2022 session, the state received a 7% increase in Medicaid rates for home care.

Additionally, Minnesota’s Community First Services and Supports (CFSS) program will allow families, parents and spouses — or informal caregivers — to be paid to take care of their loved ones.

“They have really taken a broader scope to say, ‘What do we need to do to support providers who don’t have enough workforce?’” Messerli said. “Part of that answer is we need to get the families engaged.”

Despite Minnesota being a generally favorable environment for the delivery of home-based care, there is always more that can be done to further improve conditions.

For example, start of care evaluations conducted by providers are currently compensated as normal visits, which are presumed to be an hour.

“We all know it takes two, three to four, sometimes even six times as long, to do those evaluations and do all the follow up paperwork,” Messerli said.

Massachusetts — another state that scored a high ranking — also benefited from a shift in the mindset of policymakers regarding aging in place and at-home care services, Jake Krilovich, executive director of the Home Care Alliance of Massachusetts, told HHCN.

Krilovich pointed out that the state has always been somewhat at the forefront of access to care.

“We have the [Frail Elder Waiver] program that has been in place for many years, which is designed to find dual-eligible patients that would qualify for a nursing home, [but the waiver] allows them to stay at home with some support,” he said. “I think the program has been a model for the country, as other states have looked to adopt it.”

Like Messerli, Krilovich believes that there’s more that can be done to make things easier for home-based care providers to deliver services.

“We have Medicaid rates that are $40-$50 lower than commercial payers, or even Medicare,” he said. “As Medicare’s looking to cut reimbursement on their end, trying to make 2+2=4 gets harder.”

Krilovich also urged Massachusetts to look at ways to alleviate the burdens that providers face due to the state’s prior authorization requirements.

“Constantly going back and forth between the provider and the payer, about whether a patient needs six nursing visits, or if a patient needs seven nursing visits, all takes time, and ultimately, who pays for it at the end is the patient,” he said. “I’m not advocating against prior authorization, I just think it’s important to look at these provider burdens.”

In terms of performance, South Carolina is on the other end of the spectrum.

The state came in at 49 of 51 in AARP’s report, only ahead of Alabama and West Virginia. But this doesn’t tell the whole story, according to Tim Rogers, president and CEO of the South Carolina Home Care & Hospice Association.

“For home care costs, South Carolina ranks 14th,” he told HHCN. “The cost of private home care has not risen in South Carolina like it has in Georgia, Virginia, North Carolina, New York or California. South Carolina had a very good score when ranking access to home care agencies versus nursing homes.”

The AARP report ranked states overall, but it also detailed individual rankings for various performance indicators.

Even with this additional context, Rogers doesn’t deny that problems exist in South Carolina. He is quick to point out what is being done to make improvements in the state.

“Robert Kerr, the director of the South Carolina Department of Health and Human Services, has an open door to all health care services,” he said. “We have met with him multiple times, and he has been very forthright in what he can do to gain federal dollars, he’s working with the legislature on state dollars for Medicaid home care services, and listening to us on innovative approaches.”

Though change won’t happen overnight, South Carolina has already begun to see positive momentum.

“Rome was not built in a day, but we got rate increases last year, and this year for home care, aide services, as well as private-duty nursing,” Rogers said. “We also finally achieved, after a roughly four-year discussion, the policy that will eventually come into play called coexisting care. This means a Medicaid recipient doesn’t have to give up their hospice care or their in-home aid, they can have it at the same time. Up until now, they’ve had to choose, and I think that’s a travesty.”

Rogers expects coexisting care to be a reality by 2024. He credits Eunice Medina – chief of staff and deputy director of programs at the South Carolina Department of Health and Human Services – for working with the organization regarding this issue.

Ultimately, Rogers still thinks there’s still more to be done, especially when it comes to reimbursement rates.

“We’ve got to do a better job, and we’ve got to impress upon this to the legislature, in order to attract in-home aides, nurse aides, attendants, as well as nurses, registered nurses and LPNs,” he said. “We’ve got to be able to reimburse these agencies at a higher rate.”

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