Title: G. Lawrence Atkins LTSS Policy & Research Fellowship: Reflections from Grace Hong

Publication date: March 2024

As I hugged her goodbye, my grandmother discreetly slipped a folded $20 bill into my hands. My maternal grandmother was a woman who always gave more than she had, without hesitation or expectations. During the times she stayed with our family, I would often find her around various corners of the house, scrubbing the floors, organizing the pantry, and tending to the plants. It’s not that our home was particularly untidy or neglected – this was simply her way of showing care and love.

My grandmother was diagnosed with Alzheimer’s disease in her 70s. Since she was dually eligible for both Medicare and Medicaid, thankfully, her Medicaid coverage allowed her to receive care in a nursing facility when she could no longer live on her own. Her Medicare coverage allowed her to recover in a hospital when she contracted Covid-19 during the early days of the pandemic. Yet, I often think about how the coordination of her care could have been enhanced, how support for her adult children caregivers could have been strengthened, how her time living in her home and her community could have been elongated – and if any of these changes would have slowed the progression of her disease or improved her health outcomes.

I am grateful to have had the opportunity to work with the Long-Term Quality Alliance (LTQA) and the National MLTSS Health Plan Association (MLTSS Association) this past summer to learn about and work on LTSS policy issues related to these questions. Although I had personal experiences, my academic and professional exposure to long-term services and supports (LTSS) issues was limited due to the lack of focus on the aging and disability population in my graduate program. Thus, I pursued this fellowship to gain a deeper understanding of policy solutions in this field. Over the summer, I was able to collaborate with a diverse set of stakeholders – including research centers, managed care organizations (MCOs), LTSS providers, policymakers, interest groups, and foundations – and hone the skills necessary to engage effectively in policy research, advocacy, and communications.

Throughout my fellowship, I worked on various projects spanning a wide range of topics. In particular, I worked on several projects pertaining to direct care workers – professionals who provide a range of services (e.g., personal care, medication assistance, support with activities of daily living) to individuals unable to care for themselves independently due to age, disability, or other factors. Shortages in this workforce have become a pressing issue in the field given the increasing demand for LTSS driven by the rapid growth of older adults and people with disabilities in recent years.

With LTQA, I learned about the challenges in measuring the impacts of direct care workforce shortages on care gaps among individuals receiving LTSS – largely driven by limited data collection infrastructure and standardization of metrics on the workforce. I participated in interviews and focus groups with key stakeholders, conducted desktop research and qualitative analyses of our findings, and drafted key sections of a research paper on what data are currently being collected on access to and adequacy of the direct care workforce. With the MLTSS Association, I supported the Direct Care Workforce Workgroup’s development and dissemination of a report that identifies promising practices that MLTSS managed care organizations (MCOs) are using to bolster the direct care workforce and advocates for federal and state policy changes that could further support the adoption of these practices among other MCOs and LTSS providers.

While I was new to the LTSS policy space, my fellowship introduced me to many interesting, pressing LTSS policy issues relating to workforce adequacy, quality of care, affordability, data gaps, equity, use of technology, integrated care, and more. Urgent action is needed to collectively develop and implement solutions that better support the rapidly growing population of individuals with LTSS needs and their caregivers. I have outlined some of my key takeaways on the LTSS policy field below:

1. There is growing interest in advancing integrated care for dually-eligible individuals at the federal and state levels, but barriers to implementation remain. Some of these barriers include states’ beliefs that benefits will primarily accrue to Medicare, limited Medicare expertise within state governments, wide variability in states’ current levels of integration, and a mixed evidence base on integrated care models that requires further development of research studies.
2. A majority of LTSS is funded by Medicaid, and Medicaid is operated by states. While this structure gives states the power and flexibility to innovate and tailor solutions to their population, states differ in the degree to which they invest in their Medicaid programs due to varying levels of resources, expertise, and political will. Consequently, there are variations in LTSS across states with regards to access, affordability, data availability, equity, and quality. Collaborative efforts among a diverse set of stakeholders are needed to establish national standards that hold states accountable without imposing excessive burdens or restrictions.
3. There are many opportunities for MCOs to partner with states, LTSS providers, and other MCOs to coordinate on network-wide efforts and investments to improve care for individuals with LTSS needs. Though progress has been slow, we have observed powerful examples of MCOs collaborating to invest in workforce development in states like Tennessee and Arizona.

 I am grateful for the insights and skills I gained during my time with LTQA and the MLTSS Association, not only through my participation in projects but also through the mentorship I received from Larry Atkins, Carrie Blakeway Amero, Wendy Fox-Grage, and various team members. After completing my Master in Public Health program at the Harvard T.H. Chan School of Public Health in December 2023, I am excited to bring my learnings to The Menges Group where I will be supporting MCOs developing proposals to improve care for the Medicaid and LTSS population.

While the images of my grandmother’s selfless, sunny demeanor are now limited to my memories, she has inspired my commitment to serving others and leveraging health policy to improve care for individuals with LTSS needs, and the impact she has had on my life will last far into the future.