Long-Term Care in Texas: Shifting Focus to At-Home

A fall three years ago changed Pat Smith’s life. She had been active and self-sufficient, doing the laundry, cleaning the house and cooking for herself and her husband.

But her injury reduced her mobility and independence, and the couple decided to move last year to an assisted living facility in Abilene. Soon after, her husband of 64 years, J.W. “Snuffy” Smith, died.

Smith, 84, lives in a one-bedroom apartment with a kitchenette. Since the coronavirus pandemic began, her family leaves groceries and supplies at the front door of her building.

She can move herself from her wheelchair to her bed and bath. If that changes and she needs to be lifted, she will have to move into a nursing home.

Smith “always wanted to be as independent as possible, and I can see that,” said Patty Smith, 62, her daughter-in-law. “I’d rather have less restrictions, too.”

Smith’s changing levels of care highlight an issue Texas lawmakers are facing: How much funding do they direct to institutional care and how much to home- and community-based services?

When AARP surveys its members, the vast majority indicate that they want to age in place at home as long as possible, just like Pat Smith.

To that end, AARP Texas wants state legislators, through their control of Medicaid funding, to adopt policies that do more to support living at home or in less restrictive settings, such as assisted living facilities.

The Legislature begins meeting on Tuesday, Jan. 12.

“We’re going to be pushing for the state to adopt policies that ensure that nursing homes are the placement of last resort,” said Amanda Fredriksen, associate state director for AARP Texas.

‘Perverse incentive’ on care

The state’s managed care program for older adults and people with disabilities, STAR+PLUS, contracts with private health plans to provide long-term services and support. But the plans “are paid more to place someone in a nursing home than to care for a person at home,” Fredriksen said.

“It creates a perverse incentive” to put people in institutional care, she added.

AARP backs changes that would boost funding for home care. In addition to medical services, support might include hiring an attendant to help with meals, medications, bathing and dressing. It could also mean placement in assisted living facilities, which provide these types of services.

The state is likely to realize some cost savings by the rebalancing of long-term placements away from nursing homes, Fredriksen said. “It’s a real win-win when the most cost-effective options support consumers’ preferences, too,” she said.

The prevalence of COVID-19 in Texas nursing homes underscores the risks inherent in care delivered in communal settings.

By mid-December, more than 98 percent of the state’s 1,220 nursing homes had at least one case among residents and staff. There were more than 52,000 cases —affecting more than 58 percent of the state's nursing home population —and more than 5,900 deaths.

In contrast, there were only about 5,596 cases among residents of the 2,000 assisted living facilities in Texas—roughly 12 percent of that population—and fewer than 900 deaths.

Tom Korosec is a writer living in Dallas.