It took a wheelchair ramp to get Floyd Hartley out of a nursing home.
And a stair glider. And a special mattress.
In all, the state's Medicaid program, which doesn't normally pay those kinds of expenses, shelled out about $6,200. The modifications allowed Hartley, now 52, to move in with his mother and sister in a neat East Baltimore rowhouse.
The state program also pays $22,500 a year for a personal care aide and the same amount to Hartley's sister to watch over him several hours a day - costs Medicaid doesn't usually bear.
That's still cheaper than keeping Harley in a nursing home, which in Maryland costs $60,000 a year and up.
Hartley is one of about 400 disabled people enrolled in a pilot program designed to get people out of nursing homes. A similar pilot program for the elderly is capped at 2,800.
Now Maryland is moving to broadly expand its efforts to move patients and dollars from nursing homes to home care, assisted living, adult day care, group homes and other home and community-based programs.
The reason is compelling: Maryland Medicaid already spends almost as much on 22,000 nursing home residents - more than $800 million a year - as it does to provide full health insurance to 400,000 adults and children.
With a growing older population and rising health costs, the state's nursing home tab - which has more than doubled in a decade - is bound to increase.
The initiative, called CommunityChoice, promises to reshape the way the state cares for tens of thousands of frail elderly and people with disabilities.
"We hope to create new kinds and levels of care we don't have now, to give more or better care in home or in home-like settings," said S. Anthony McCann, secretary of the state's Department of Health and Mental Hygiene (DHMH). "In general, it's the right thing to do, to give options to the patient," McCann said. And, he noted, "it's cost-effective."
The state's application is pending for a waiver of federal Medicaid rules, which generally don't allow community care. The new program likely wouldn't begin for at least a year.
"This is the treasure trove for the [health] department," said M. Gayle Hafner, a staff attorney for the Maryland Disabilities Law Center. "They have been paying maybe $80,000 a year for people to be in a facility where they don't want to be."
Most of the projected savings from CommunityChoice wouldn't come from moving people out of nursing homes - the state expects most who are there to stay. Rather, it expects to cut costs by keeping future Floyd Hartleys in the community longer or out of nursing homes altogether.
Advocates for the elderly and people with disabilities strongly support the movement to community care. Yet they are watching warily to see how the care will be managed.
McCann's plan calls for HMO-like private companies, called community care organizations, or CCOs, to be paid a flat fee per patient to make sure patients receive the appropriate care.
Concern of advocates
The advocates worry that the organizations could push patients to lower-cost programs to save money.
"We oppose [managed care] for people in nursing homes," said Kate Ricks, chairwoman of Voices for Quality Care, an organization of people with relatives in nursing homes that has been active in the planning of CommunityChoice.
"Our concern is that it's already very difficult getting care when you just have the nursing home and the Medicaid rules to deal with. Now, when someone has to go to the hospital, the nursing home has to call the insurance company."
McCann promises the state will monitor the community care organizations vigorously. "One of the places we want to go is to be far more sensitive to the issue of quality of care and of progress," he said. "We will be doing far more to measure, keep data in more detail."
It's even possible, the secretary said, that the state health department will modify its plans to create some form of "individual incentives" as an alternative to community care organizations. "I don't want to predict there will be," he said, "but I don't want to predict there won't be."
Besides the lingering issues over care management, experts say community care isn't a guarantee of cost effectiveness.
The cost of a nursing home in Maryland is running roughly $170 a day versus about $70 for medical adult day care.
The savings are clear for those for whom day care is sufficient. But for patients who need round-the-clock nursing attention, for example, the cost would be higher in the community than in a nursing home.
Experts also worry about the community care organizations introducing another layer of expense, and about what many call "the woodwork effect" - people now being cared for at home by families coming "out of the woodwork" to get state-paid community care.
Susan Tucker, executive director of the state health department's office of health services, said the pilot programs involving Hartley and 3,200 other elderly and disabled cost less per person than nursing home care.