A national AARP scorecard places Indiana in the middle tier when it comes to its long term supports and services system. Photo by Getty Images.

By Whitney Downard
Indiana Capital Chronicle

INDIANA — A new report from AARP ranking each state’s system for long-term care placed Indiana in the middle of the pack — the third of five tiers of rankings that considered support for family caregivers and diversity of in home- and community-based services.

Indiana came in 27th, an improvement from its 2020 ranking of 44th. The report covered a three-year period, 2020-2022.

“I think that when you really dive in and take a look at this scorecard, we did see some improvements across nine of the indicators,” Sarah Waddle, the state director for AARP Indiana, said. “We didn’t see any decline, but there are still some indicators where we are ranked very low or in the lower tiers.”

While the report found that nationally — for the first time — more than half, 53%, of Medicaid spending on long-term supports and services went to home- and community-based services, Indiana spent less than a quarter on such programs, at 23%.

Progress in Indiana has been ongoing, Waddle said, while the state switches to a managed care model. State leaders have said the change would allow the state to prioritize investments for HCBS, which the majority of elderly Hoosiers prefer.

Mixed reviews on workforce measurements

On average, just over half, 54%, of the workforce left their facilities within one year’s time. In Indiana, the turnover rate is over 57% and understaffing means residents get less than the national average of care hours — 2.86 hours compared to 3.31 hours, according to the report.

In particular, the report noted that pay for Long Term Services and Supports lagged behind comparable positions, with a $3.90 gap for Hoosier workers.

But Indiana received recognition for its commitment to allowing nurse practitioners to delegate certain care tasks, including 15 of the 22 measured indicators analyzed by the report.

Ambre Marr, AARP Indiana’s state legislative director, credited that movement to a coordinated effort from several entities over the last three years, including legislation this year that removed prohibitions on certain types of feeding equipment for registered home health aides.

Strengths with presumptive eligibility, community integration

Marr said one of Indiana’s biggest strengths — which the report recognized — was its commitment to improving presumptive or expedited eligibility for HCBS under Medicaid.

While Medicaid applications for LTSS must be processed within 45 days, that time is too long for many in need of services.

Better-resourced nursing homes have the flexibility to start right away and wait for approval, HCBS providers don’t have the same flexibility. Under presumptive eligibility, those HCBS providers will be paid even while an individual’s Medicaid application is processed and Medicaid will cover those costs.

Many older Hoosiers prefer to age at home if given the choice, according to AARP. Especially considering that just 5.4% of nursing home residents live in a five-star facility — far lower than the national average of 16%.

Presumptive eligibility, which started as a pilot program during the COVID-19 pandemic, won Indiana an innovation point from AARP along with its policies encouraging Green Houses, a form of smaller, more intimate care.

Indiana did not score innovation points for: restorative care, known as CAPABLE for short; enhanced hazard mitigation plans; state family caregiver tax credits nor Multisector Plans for Aging — though the latter is something the state’s Division of Aging is currently considering, Waddle said.

Indiana’s highest categorical ranking came in the Community Integration division, which Waddle said was a more “holistic” approach to aging that focused on supports outside of the traditional LTSS.

Much of this action occurs within the private sector, Waddle said, specifically with age-friendly health systems, or care that addresses a person’s needs across their entire lifespan.

While every state has such health systems, Indiana has the largest presence nationwide when considering the size of the state’s elderly population with 306 programs per one million older adults.

Self-directed services, family caregiver supports identified as weaknesses

Indiana’s lack of support for family caregivers hurt its ranking, especially its lack of tax credits or flexible leave policies for caregivers. Family caregiver support was the only category where Indiana performed worse than average, coming in at the fourth tier.

While lawmakers have been resistant to implementing caregiver supports in the past, Waddle said Indiana policymakers could take its current process for self-direction it uses for disabled Hoosiers and replicate it for the elderly.

Under self-directed care, users have more control over who cares for them and how that care is delivered. In other states, the use of such services has skyrocketed from 740,000 people in 2009 to more than 1.5 million in 2021. Self-directed services also reduce family caregiver burdens and make long-term care easier for consumers.

Improvements ongoing

In a media call, Susan Reinhard, a senior vice president with AARP’s Public Policy Institute, recognized Indiana as one of the most improved states.

The 2023 scorecard utilizes tiers, rather than straight rankings, but the 2020 version placed Indiana in the bottom quartile of the country, in 44th.

However, Reinhard noted that the pressures on the long-term care system will only increase in the coming years. By 2035, it’s estimated that the number of adults ages 65 and older will outnumber the number of children under 18 — and minority population growth is expected to increase even faster, though non-white consumers had even poorer long-term care experiences.