Thousands of disabled Hoosiers need home health aides

INDIANAPOLIS — Thousands of disabled Hoosiers need home health aides. And with hundreds of thousands of Baby Boomers expected to hit retirement age in 2030, at which point more and more will start needing the same intensive care, Indiana doesn't have the infrastructure to handle it.

In 2019, Indiana spent 35% of its Medicaid long-term services and supports funding on home- and community-based services — which would cover home health aides — far below the nationwide average of 59% and the second-lowest in the nation.

According to the Alzheimer's Association 2022 report, Indiana had an estimated 43,460 home health and personal care aides in 2018, also known as the direct care workforce. By 2028, Indiana will need 59,990, a 37.5% increase.

During the COVID-19 pandemic, elderly Hoosiers looking to avoid nursing homes, which were uniquely vulnerable to the virus, realized they had few options to age at home due to the shortage of providers and employees. Additionally, advocates found that COVID-19 complications, or COVID-19 longhaulers, have increased the number of younger populations in need of home assistance.

"When the pandemic came, it really brought into focus the need to really reform the system," said Dr. Dan Rusyniak, the director of the Indiana Family and Social Services Administration. "If we (don't) have a workforce that (is) in the communities, then as this population of Medicaid recipients ages, it's going to be difficult to keep people at home if we're not able to provide services."

Recognizing this, the Family and Social Services Administration is urging the General Assembly to pay for a fundamental shift in how the state delivers services. Currently, Indiana operates under a fee-for-service model, which means states pay providers for each covered service. Starting in 2024, the agency would like to pivot into a managed care model, which they say would save the state money in the long term.

Under managed care, the state pays an insurance company to oversee the care of an individual — which Indiana already uses for government insurance programs like the Healthy Indiana Plan or Hoosier Healthwise. Opponents say the cost savings will be the result of fewer services approved for clients.

Stakeholders have known this change is coming but struggled to overcome the embedded challenges. Indiana has long relied on and invested in institutional care, such as nursing homes, even though the vast majority of Hoosiers prefer care at home.

Low wages, benefits stifle workforce

A 2017 brief from The Arc of Indiana, which advocates for Hoosiers with intellectual and developmental disabilities, analyzed Indiana's direct service workforce and reported that low wages in the industry prompted turnover as high as 45%. The average worker was 38 but had just three years of experience in the field.

"No one is satisfied with the current situation of multiple and frequent(ly) changing caregivers and compromised quality of care resulting from the inconsistency of the current (direct service provider) workforce," the brief said.

Rusyniak said the state's ombudsman system investigates and responds to reports of abuse or neglect by state healthcare providers. But to improve the system, Rusyniak pointed to the state's Direct Service Workforce Advisory Board and Direct Service Workforce Plan, which calls for investments to curate a workforce that is "well-trained, reliable and stable."

In particular, the $130 million in Workforce Investment Grants, launched in November, are rewarded to providers to combat the industry's low wages, which fall below the state's living wage, and inadequate benefits. At least 95% of the funding must go directly to workers. Going forward, FSSA will review its rate setting.

But Rusyniak noted that training for providers varied greatly from agency to agency and needed to be more comparable.

"If you're a direct service worker, training, It's provider specific, meaning that you go and you get hired by a specific provider and they provide the training," Rusyniak said. "So one of the strategies that we're looking at is how do we develop a more portable training and certification for individuals who are direct service workers so that everyone would get the same type of training."

Advanced training would allow these workers to specialize in caregiving types, such as dementia care or intellectual disabilities.

FSSA believes managed care would help Hoosiers navigate resources

Rusyniak urged Hoosiers to contact 211, which pivoted during the pandemic to respond to over 1.3 million calls about COVID-19 immunizations and testing resources. But the resource is designed to do much more, including housing or utility assistance.

"Healthcare in general — and it's not specific to Indiana, it's across the board — is complicated. And then when you blend in not just healthcare and health-related services but social services, etc. it gets even more complicated," Rusyniak said. "But (the resources are) all kind of disconnected."

Changes to increase the workforce — and the overall home- and community-based services — would benefit the thousands of Hoosiers who [think they] wouldn't need in-home assistance until [they were] much older.