A number of psychosocial interventions for persons with Alzheimer’s disease (PWAD) have demonstrated success in improving quality of life for both PWAD and their caregivers in home and community-based settings, which is where more than 70 percent of this population reside. These interventions have been tested and replicated in randomized controlled trials financed by the federal government, and yet they are not included in the Medicare home health benefit – the government’s largest home-based benefit for the elderly population and the one which dominates the PWAD population.
These interventions include counseling for patients and their spouses (individually and as a couple), telephone access to counselors, and a variety of home-based skill-building services. The bulk of them have been tested by Dr. Mary Mittelman at NYU and Dr. Laura Gitlin, formerly at Jefferson in Philadelphia and now at Johns Hopkins. Dr. Mittelman’s work began at NYU Langone Medical Center in New York City and has been further tested and translated into settings including Washington Heights (NYC), New Zealand, and Minneapolis. She has demonstrated that her interventions delay nursing home admissions, thus decreasing costs and improving quality of life.
Through the Philadelphia Corporation on Aging and other healthcare providers, Dr. Gitlin has tested multiple interventions including home-based environmental skills building using occupational therapists to assess home environments, train caregivers, and bring in outside contractors to make home modifications. She also has tested multiple tailored interventions for this population using a multidisciplinary assessment tool that guides treatment plans to achieve positive results. Evidence shows that these and similar interventions are effective, and they can only be used outside the home health benefit. The rationale for the exclusion, then, may just be a remnant of its original intent.
The Medicare home health benefit is acute-care oriented; it is not geared toward patients with degenerative diseases. Further, to receive the benefit a patient must be homebound and in need of only intermittent skilled nursing or physical therapy; it does not provide mental health services (and restrictive social work coverage means that just 1 percent of all Medicare home health benefits are social work visits). Importantly for psychosocial interventions, the benefit prohibits services to caregivers and does not pay for any services other than nursing, physical therapy, speech therapy, home health aide, and social work. Integrated healthcare is not covered.
What can be done? Congress needs to focus on such realities and, at a minimum, create a process to screen evidence-based interventions for use in Medicare home health (no such process currently exists); fund demonstration projects to test interventions such as Gitlin’s and Mittelman’s either as part of the Medicare home health benefit or as an adjunct, specialized Alzheimer’s home care benefit; and immediately expand the scope of services which social workers can provide under the existing Medicare home health benefit.
Dr. Bill Cabin is an assistant professor of instruction in the School of Social Work. He researches the disconnection between evidence-based research on effective psychosocial interventions for Persons with Alzheimer’s disease (PWAD) and their caregivers and the limits of the Medicare home health benefit. Dr. Cabin’s work is inspired and informed by his 30 years of experience in the field of home care management.
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