Family caregivers need support: Medicare should cover in-home care aides 

November is “National Family Caregivers Month,” and the Caregiver Action Network, the nation’s leading family caregiver organization, presented the 2019 Hands-on Help Award to former U.S. Senator Chris Dodd (D-Conn.) at their annual celebration on Nov. 14. Dodd is a caregiver for his siblings and has been a vocal advocate for the nation’s caregivers. 

While family caregivers truly do selflessly give of themselves in the care of others, they need more than our recognition of their work. They need the Medicare system to provide appropriate resources for the care of their family members.

As a geriatrician, every week I see patients who are fortunate to have family who are able to provide medical care and support.

However, I also see more patients who do not have family available to provide full care, are in desperate need of more home care support, but cannot afford the price tag, which can be around $3000 each month.

I have an 81-year-old patient (I’ll call her “Jane”) who lives alone and has a loving family. Her children call frequently to check on her. She has a 55-year-old daughter who lives locally but works 12-hour days to support her own children. Jane’s daughter would love to be able to stay with her mother, but can’t afford not to work.

At home alone one day, Jane fell. She laid on the floor for six hours before she was able to get to the phone to call 911. EMS transported her to the hospital. She was diagnosed with a hip fracture and required surgery. As her geriatrician and primary care physician, I had one question: How did you fall?

For me, the worse part of Jane’s fall wasn’t that she broke her hip, it was how she fell: Jane had walked to the bathroom. However, when she tried to get up from sitting down, she realized she had forgotten her walker on the other side of the room.

She tried to pull herself up on the counter, but slipped and fell to the ground. Her fall could have been prevented. If there had been someone to assist her to the bathroom, they could have ensured she had her walker to support her. Jane fell because she was alone.

Jane is not just one of my patients, she is one of the hundreds of patients I see in my outpatient clinic each year, and among the tens of thousands of patients around the country who fall at home alone.

The National Council on Aging reports that “one in four Americans aged 65+ falls each year. Every 11 seconds, an older adult is treated in the emergency room for a fall; every 19 minutes, an older adult dies from a fall.”

My patients want to age in their home, but as their care needs increase, they have difficulty getting reliable, affordable in-home care aides. Many spend their final years in a cycle of recurrent hospitalizations and stays in skilled nursing facilities, unable to afford in-home care aides, which can cost about $3000 each month or $40,000 annually.  

Both the U.S. House and Senate have put forth bills to increase the geriatric workforce: H.R. 2781, Educating Medical Professionals and Optimizing Workforce Efficiency and Readiness (EMPOWER) for Health Act of 2019 in the House, and H.R. 4397, Direct Creation, Advancement, and Retention of Employment (CARE) Opportunity Act in the Senate.

The CARE Act in the Senate, specifically, is a big step forward for in-home care aides and proposes funding for “training, providing career pathways, mentoring, and allowing for local and regional innovation to address workforce shortages in a high-demand field.”

While this is a great step toward highlighting the shortage of qualified workers and proposing training and support, we need to take the reforms further and support their services through Medicare so that all beneficiaries truly benefit. 

With our aging population in the U.S., the need for in-home care assistance is growing, but long-term in-home care is not a Medicare benefit.

Having in-home care is only an option for people who can afford it. This issue is at the core of care for our aging population. The Medicare system is not providing the most effective preventive care.

Medicare covers hospitalizations, surgeries, pacemakers, many types of medicines, and even 90 days of skilled nursing care each year, but once those acute issues are resolved, you’re on your own. Once patients are discharged home, there is often confusion on medication changes or new diagnoses.

Without close transition of care, patients are especially vulnerable to getting sick again and having to return to the hospital. A properly trained in-home care aide could assist in the transition and continue therapies started in the hospital. 

To be sure, these proposed increases in benefits could lead to increased health care costs. However, the average cost for one day in the intensive care unit is $3000 — the same amount to provide one month of in-home care aid.

As it now stands, Medicare won’t pay for the care aide to prevent re-hospitalization, but it will pay for the hospital stay. Similarly, Medicare covered the costs of Jane’s surgery and hospitalization, but does not cover the cost of an in-home care aide that could have prevented her fall in the first place. 

Family caregivers are a great resource when available, but if not available there should be an option for appropriate in-home care for all Medicare recipients. In-home care can prevent falls and other traumatic events.

Without in-home care, we’re leaving our family members alone and at risk. That’s no way to treat our grandparents, aunts, uncles, friends and neighbors. We may not be available to stay home with them, but Medicare should support trained care aides who can be.

Laurie Archbald-Pannone, M.D., MPH is an associate professor at the University of Virginia in Geriatric Medicine. She is the medical director of the UVA Geriatrics outpatient Clinic at JABA. She is a fellow of the American Geriatrics Society and American College of physicians, as well as a 2019-2020 UVA Public Voices fellow.