Bridging the Gaps in CDPAP Accessibility through Higher Education Stewardship

Consumer Directed Personal Assistance Programs (CDPAP) provide chronically ill and physically disabled clients control over their Medicaid home care services, allowing them to personally select and direct aides. These supports promote independence and community living for groups that previously had limited alternatives besides nursing home placement. However in Missouri and within the St. Louis metropolitan area, outdated eligibility rules arbitrarily exclude large segments of at-risk populations from receiving services while capacity shortages deprive eligible recipients access from adequately meeting their needs. Higher education institutions have both the expertise and community obligation to pursue an agenda of advocacy, innovation and collaboration aimed at incrementally reforming an inadequate infrastructure.

The St. Louis Region’s Growing Vulnerable Populations

Demographic trends foresee escalating demands for Medicaid long term care supports as aging and disabled populations expand rapidly both statewide and within the St. Louis metro.

• Missouri’s over-65 population will grow by 43% from 2015 to 2025 — nearly twice as fast as the overall state population at 22%. By 2030 over 1 in 5 Missouri residents will be retirement age.

• Disability rates currently stand at 14% in Missouri versus 12.6% nationally. Over 800,000 disabled individuals reside in the state with over half between ages 21 to 64.

• In the St. Louis MSA, approximately 190,000 elderly and 270,000 disabled individuals rely on some form of governmental assistance to manage health, personal care needs and living expenses.

While many require limited supports to retain independence, a sizable portion progress to needing daily health aides or institutional services. However state budget allocations fail to reflect the imminent demographic surge about to overwhelm existing long term care systems. CDPAP provides a lower cost alternative to nursing homes, yet outdated eligibility rules exclude the majority of at-risk populations from qualifying for the program. Constant underfunding further erodes provider capacity to meet even current enrollees’ needs.

The True Costs of Unmet Needs

Constricted CDPAP accessibility ultimately damages community health outcomes and strains public resources further as preventable complications emerge:

• Est. 45% of likely beneficiaries in St. Louis cannot participate under present eligibility rules that exclude or discourage certain diagnoses regardless of level of impairment

• Qualifying enrollees face strict limits on reimbursable hours that cover less than 50% of disabled applicants’ total daily care needs

• At 4 of 7 surveyed area providers, average monthly wait times for CDPAP services exceeded 90 days with several cases over 1 year

These capacity shortfalls also negatively impact the economy through avoidable hospitalizations, forced family leave for informal caregiving, or caregivers reducing their own work commitments.

• A survey of St. Louis area hospitals revealed 47% of avoidable ER admissions for low-acuity conditions affecting elderly patients resulted from absence of early home interventions. Missouri Medicaid absorbs est. $24 million annually on potentially preventable hospital utilization in this category.

• Over 75% of informal caregivers are unable to maintain full employment due to intensifying demands; average family caregiver forfeits $750 monthly through leave and unrealized wages per AARP estimates.

Assessing Service Gaps and Access Failures

A variety of interlinked factors contribute to CDPAP services falling critically short of community needs. However, restrictive qualification standards arbitrarily exclude populations with genuine care dependencies regardless of diagnoses. Eligibility tied to skilled nursing approval fails to align with the personal assistance emphasis of CDPAP programs themselves. Key examples include:

• Younger Adults with Disabilities: Missouri imposes additional eligibility hurdles for applicants under age 65 beyond income and asset reviews. Only those deemed at risk of nursing home admission qualify, requiring evidence of specified diagnoses, cognitive / functional impairments and ADL deficits. Such narrow criteria bars access by lower impairment levels or disabling conditions like lupus, multiple sclerosis or spinal muscular atrophy.

• Individuals with Mental Illness (SMI): Those disabled by chronic mental disorders without co-occurring physical conditions remain outright ineligible for CDPAP participation. Despite assistance needs comparable to qualifying diagnoses, this exclusion exposes many economically disadvantaged SMI patients to exploitation or health declines from inadequate support systems.

Even clients awarded coverage must contend with overstretched providers challenged to offer adequate or timely solutions:

• Managed care regulations allow establishment of waiting lists once agencies reach pre-approved utilization thresholds. However given staffing volatility, most maintain persistent vacancy rates between 10-15%. This forces reduction of census levels despite client needs.

• Severe workforce pressures also undermine service quality where capacity exists. Average aide retention dips below 10 months across metro area providers per 2022 Home Care Pulse data. Such turnover risks consistent care relationships and staff familiarity with client needs or preferences.

Why Missouri Higher Education Cannot Stay Silent

Academia rightfully prides itself as an advocate for marginalized groups through scholarly enlightenment and preparing students aware of social justice needs. Yet in practice, disability and dependency issues receive relatively peripheral focus in terms of direct engagement aimed at community impacts. As higher education consumed over $1.3 billion in Missouri public funds in FY2021, taxpayer stewardship obligations accompany such investments to ensure public resources address urgent societal priorities.

While meaningful expansion of CDPAP accessibility requires sizable statutory and budgetary changes, higher education bears responsibility for raising visibility on consequences of status quo deficiencies:

• Quantifying Health Outcomes: Collaborative research categorizing avoidable injuries, excess hospital days and care inconsistencies resulting from inadequate or interrupted services counters arguments that restrictive eligibility serves public savings.

• Assessing Economic Costs: Academics enjoy greater credibility substating expenses from lost wages, forced institutionalization and increased medical spending tied to poor structured home-based care options.

• Spotlighting Service Inequities: Scholarly publications lend credibility confirming discriminatory resource allocations where 60% of long term funding covers 17% of beneficiaries (nursing home residents) but limited outside options for the majority aging or disabled populations.

State schools further possess extensive infrastructure to pioneer grassroots initiatives improving both caregiver quantity and quality:

• Staffing and Training: Healthcare academics can develop transitional credentialing or apprenticeships to expand entry-level hiring channels while applied learning capstones offer cost-effective experiential training.

• Technology Access: Information schools support affordable upgrades to remote patient monitoring, access to telehealth platforms and use of mobile documentation applications allowing smaller providers to increase census without added overhead.

• Specialized Resources: Joint programs through Schools of Social Work, Gerontology and Public Health furnish supplemental assessment capabilities, hands-on field experience and expert guidance missing from smaller agencies.

Unfortunately, disability / dependency support services remain largely outside higher education’s perceived domain – or institutional capacity – across much of the state. The University of Missouri system offers neither undergraduate or graduate majors specifically focused on health care administration leadership. Critical downstream positions like social workers, physical and occupational therapists, nurses and home health aides come predominantly from private programs.

Parallel Industry Transformations Show What is Possible

Skeptics reasonably question whether academia realistically can influence meaningful improvements absent political will for wider long term care reforms. However parallel scenarios in other spheres demonstrate potential when higher education leverages expertise and reputation towards resolving societal challenges:

Supporting Small Business Growth

• Problem: Missouri microenterprises historically struggled securing lending or niche expertise to sustain viability

• Response: Universities provided technical assistance with SBDC programs while scholarly publications quantified changing capital access patterns.

Aligning Training to Workforce Needs

• Problem: Widening skills gaps accompanied manufacturing growth yet hiring pools possessed mismatched competencies

• Response: Academia collaborated with industry associations expanding apprenticeship and career pathway programs.

Combating Public Health Crises

• Problem: Spiking substance abuse disorders overwhelmed local prevention resources across Missouri

• Response: New multidisciplinary research and practitioner certificates built specialized competencies.

If conveyed effectively, political leaders may come to recognize an engaged University community as partners towardsresponsible health infrastructure planning. Even modest initial collaborations can gradually close gaps in consumer directed care alternatives. But progress relies on academia recognizing their unique obligations – and opportunities – to champion inclusive living supports benefitting at-risk state residents.

Targeted Solutions Available Within Higher Education’s Reach

Common criticisms regarding the perceived insularity of University systems too often reflect accurate assessments of priorities and incentives guiding public academia today. Still numerous relatively modest initiatives with low resource requirements could meaningfully impacted through faculty and student efforts. Potential starting points include:

1. Sponsor Independent Assessments of Unmet Needs

CDPAP client tribunals and regional incidence studies bring empirical evidence to reform arguments. Schools of Public Health and Social Work represent ideal partners for grassroots agencies lacking time or evaluation capabilities.

2. Integrate Home Care Competencies Across Disciplines

Redesigning core curriculums in programs from nursing, psychology and even business fields reduces knowledge gaps undermining community care quality and Jobs appeal.

3. Host Online Portals Supporting Workforce Connectivity

Voluntary skills clearinghouses matching graduates / volunteers to aide vacancies eases applicant discovery burdens for understaffed providers.

4. Lead Multi-Stakeholder Quality Improvement Collaborations

Replicable consensus protocols measuring client satisfaction, avoidable hospitalizations and staff retention rates establish objective performance yardsticks for agencies struggling with inconsistent oversight requirements from multiple funders.

5. Align Public Scholarship to CDPAP Services Research

Student seed grants for Placements or capstone work at partnered providers offer inexpensive labor bandwidth allowing capacity for value-added initiatives and evaluation otherwise impossible for resource starved administrators.

Closing Thoughts

Many factors seemingly outside higher education’s control assuredly constrain the pace and scale of accessible long term care expansions. But complacency around status quo deficits reflects abdication of academia’s societal compact to contribute expertise towards resolving structural inequities. A Missouri campus unwilling to actively assess community living barriers or pilot apprenticeship programs improving caregiver quality tacitly endorses the exclusion and compromised care plaguing at-risk state residents under today’s broken infrastructure.

CDPAP services enhance thousands of recipients’ independence, health and engagement with Missouri communities. Yet the relative few benefitting represent merely a fraction of those whom expanded investments and eligibility could similarly empower both now and in the coming years. All academic disciplines possess opportunities to deploy teaching, research and outreach strengths benefiting these vital but historically overlooked healthcare supports. Start-up efforts at minimum provide pilot models while sparking wider conversations regarding the resources and reforms warranted to adequately serve coming waves of aging and disabled constituents. Even modest initial gains can inspire optimism and a vision that increased access lies within reach rather than a pipe dream. Higher education guided by conscience and compassion cannot in good faith abdicate from such causes.