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Why keep aging or disabled people in a nursing home if it's cheaper and better for them to be cared for at home? With that question in mind, states are testing programs to move people who don't need much care out of nursing homes. If that sounds easy, it's not. From member station WBUR in Boston, Martha Bebinger reports.

MARTHA BEBINGER, BYLINE: Dorothy Holmes was in the cozy pink bathroom of her mobile home in rural western Massachusetts two years ago getting ready to shower. Holmes, who was 75, reached for a bath mat, lost her balance and toppled forward.

DOROTHY HOLMES: And I got a big spot on my head. It almost conked me out.

BEBINGER: Holmes heard her husband come down the hall.

HOLMES: And when he turned the corner, all I heard was, oh, God, honey, what did you do now? After that, I don't know anything 'cause I passed out.

BEBINGER: Holmes spent almost three months in a hospital. She was transferred to a nursing home with ongoing heart, breathing and memory problems. She couldn't walk and a grapefruit-sized wound in her back wouldn't heal. Medicaid was paying Holmes' nursing home bill, but she knew the program didn't typically cover home care. Holmes grew anxious.

HOLMES: The only thing I worried about was not getting out. And I kept saying to him and one of my daughters, I says, you're not keeping me here are you?

BEBINGER: Holmes looks over at her husband, Larry.

HOLMES: Like maybe him and the kids saying, well, we don't know if we can handle this and that was before Martha came into it and told us all we could get for help.

BEBINGER: That's Martha Napierski, a case manager at WestMass ElderCare. She signed Holmes' up for a federal program that is letting states use Medicaid dollars to move patients out of nursing homes.

MARTHA NAPIERSKI: We made sure she had home-delivered meals, personal care, homemaking seven days a week, skilled nursing. And she also had physical therapy and occupational therapy.

BEBINGER: The federal program called Money Follows the Person, identifies patients, old and young, who have been in a nursing home for at least 90 days but who no longer need round-the-clock care. Holmes, despite all her medical problems, was an easier case because she had a home to return to and family members to help with her care. Finding housing for patients who have given up their homes, then buying appliances, basic furniture, a few plates and cups, may sound expensive.

But Priscilla Chalmers, who runs the agency where Holmes is a client says, think again.

PRISCILLA CHALMERS: Even with that expense, it's definitely a savings to the state and federal government to be spending their money on that as opposed to 7, 8, sometimes $9,000 a month for nursing home care. So it is a success from a humane point of view and also from a point of view of the cost savings to the state.

BEBINGER: Chalmers says Holmes is saving Medicaid $5,100 a month by returning home. But patients with more complicated needs won't save nearly as much. The Money Follows The Person program is off to a slower than expected start in Massachusetts and across the country.

Community agencies say it's hard to figure out how they'll get paid, what's covered and who qualifies. And then, resettling patients who are used to life in a nursing home can be difficult.

JULIAN HARRIS: It's a very complicated program for a variety of reasons. It's not a process that's sort of a one-size-fits-all.

BEBINGER: Dr. Julian Harris, the Medicaid director in Massachusetts, says putting together all the things each patient may need, bathroom renovations, the ride home care, rides to doctor's appointments is challenging, but...

HARRIS: This administration has really made a commitment to making access home- and community-based services possible.

BEBINGER: The commitment in Massachusetts and across the U.S. goes back to a 1999 Supreme Court decision that said state Medicaid programs have to pay for home care as long as it doesn't cost more than a nursing home or some other institution. It will be several years before supporters of this program will be able to say if it saves Medicaid money overall and whether patients are better off.

But Dorothy Holmes is sure. She's really glad to be back home.

HOLMES: It just means everything to me. My life is back, almost the way it always was.

BEBINGER: A new puppy, Jack, jumps onto Holmes' lap. A fourth great-grandchild has just arrived. Now, Holmes' main worry is when will she be strong enough to get up and chase after them. For NPR News, I'm Martha Bebinger in Washington.

SIEGEL: And that story is part of a collaboration of NPR, WBUR and Kaiser Health News.

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