It was one of the happiest days 86-year-old Enid Beck has had in a long time. Her two-and-a-half-year-old great-granddaughter Jeanna Blank pushed her slowly down the long hallway of the Central Todd County Care Center nursing home in Clarissa.
Beck was on her way home.
Trips like this are increasingly common in Minnesota, as the state seeks to slow the rapid growth of long-term care spending.
But even as Minnesota saves money on nursing homes, it is seeing rapid increases in both assisted living and home based care spending. And as the number of elderly Minnesotans mushrooms, cost pressures will only intensify.
The nursing home helped Beck regain enough strength to return to Valley View Estates, an assisted living facility in Long Prairie, about an hour north of St. Cloud.
"It's very nice," Beck said. "It really is very elegant, and that is home now."
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Forty years ago, when you got too old to live in your house, you went to the nursing home and stayed there. Today, the goal is to get people in, get them well, and get them home.
"The length of stay in a nursing home is much less than it was 5, 10 years ago, where they'd come in for a year, a year plus," Long Prairie nursing home administrator Dan Swenson said. "Now it's 30, 60 days, 90 days tops."
It also saves the state money. Putting someone in the nursing home for a year costs nearly $60,000 dollars on average in Minnesota, twice the cost of assisted living.
But the state's persistent budget deficits have meant cuts for virtually every level of the long-term care system -- including assisted living facilities like the one Enid Beck calls home.
Those cuts may be just the beginning.
In 10 years, one in six Minnesotans will be over age 65. Like many rural parts of the state Todd County is already there. It also has the second highest rate of elderly poverty in central Minnesota, which makes recent state cuts more acute there.
"The people are not going to get as good of care, because [the state is] not reimbursing for the level of care that you're giving," said Sheila Towle, the nurse who runs Valley View. "I can't really see anything good coming of it."
The Legislature cut assisted living reimbursement rates by 2.6 percent last year. Valley View has seen a further reduction in payments this year because Minnesota recently changed the way it determines how much care a patient needs.
Towle says if cuts persist at this rate, she may have to turn away some patients who can't afford to pay for their own care.
Cuts hit home
Even home-based services -- which cost about a quarter of what assisted living does on average -- couldn't escape the budget axe last year.
Tammy Ford-Mullins holds up a wind chime from her 74-year-old mother's vast collection of hummingbird-themed knick-knacks. It tinkles, providing a brief distraction from her somber task. Then she places it in a carboard box.
Ford-Mullins is packing up her mother's apartment in Motley. Her mom had a stroke in February, and is too disabled now to keep living here.
"I've bawled washing the walls, because I feel like I'm washing away my mother's essence and independence," Ford-Mullins said.
Two years before the stroke, Ford-Mullins' mother had lost an eye to cancer. That's when Ford-Mullins, who lives on the northern edge of Todd County, quit her job so she could spend 36 hours a week caring for her mom.
"I'd cook. I'd do her laundry. I'd do her housekeeping. I'd help her with her bathing. Just about everything. Just so she could stay on her own," she said.
The state of Minnesota paid her to do those things as part of a program called personal care assistance. With an average wage of less than $11 dollars an hour, personal care assistants (or PCAs) present a significantly cheaper option than nursing home care or assisted living.
The money wasn't great, but for Ford-Mullins, that wasn't the point.
"I do truly believe that it is the last stand for the elderly to have their independence, because losing that independence, I've seen so many go down hill," she said.
Minnesota's personal care assistance program has proven to be an extremely popular alternative to the nursing home. State spending on PCAs doubled in just four years between 2003 and 2007.
But that explosive growth has made the personal care assistance program an attractive target for budget cuts. And it didn't help that Minnesota's Legislative Auditor found lax regulation made the program highly susceptible to fraud.
So last year the DFL-controlled Legislature tightened eligibility requirements for personal care assistance and increased oversight. Republican Gov. Tim Pawlenty made further cuts unilaterally as part of his package of unallotments last summer.
PCA advocates call the cuts short-sighted.
"As we go forward with the aging population in this country, the need for personal care workers and for people who care as much as they do is going to be phenomenal," said Long Prairie native Sally Knutson, who runs one of the largest home health care agencies in the state.
The number of Minnesotans over age 85 will double over the next 25 years.
Loren Colman, who oversees long-term care programs for the Department of Human Services, says that's exactly why the state needs to keep long term care costs under control.
"What we've tried to do is recognize that we don't have unlimited resources," Colman said. "And we need to target those resources to those people with the greatest needs."
As a public health nurse, Mary May helps connect resources with the people who need them in Todd County. And she's concerned about some of the recent cuts. But May says in spite of that, things are still far better for the elderly than they were when she started working here 24 years ago.
"I know we look at the changes and how it's impacted and how we're cutting," May said. "but when I think about what we have, I think we've tripled in terms of the amount of services and options that are out there."
The question for Todd County and the rest of Minnesota is: Will those services be able to continue as the aging population pushes their costs higher and higher?