Kathy Bessette has lived in the same modest home her husband remodeled 34 years ago, building memories as she watched nine children grow.
So when the widow began to require long-term care, she was determined not to let Medicaid push her into a nursing home. With the help of home care providers, an adult day program, and an emergency-response device fastened around her wrist, she stayed put.
"To know that I can make choices in my own home - that's the best part of my day," says Ms. Bessette, watching birds peck at a feeder and admiring her miniature pig collection from her chair. The second best part? Slipping into her favorite flannel sheets each night.
Now, all of Vermont's eligible seniors are entitled to the same decision, with a first-in-the-nation waiver under Medicaid that gives them greater flexibility in choosing nursing homes, residential care facilities, or their own homes.
Before, even though nursing homes are often more expensive, Medicaid guaranteed seniors space there, while only allotting a limited number, like Bessette, the option to receive home care.
The program comes as states struggle to rein in costs of Medicaid, the nation's medical assistance program for the poor and handicapped, especially as aging baby boomers put tremendous strain on entitlement programs. According to the National Conference of State Legislatures, Medicaid costs have soared in the past 10 years, comprising 17 percent of state budgets in 2005.
A large part of the cost is long-term care: Medicaid payments for nursing homes in 2003 amounted to $40.6 billion, according to the Centers for Medicare & Medicaid Services.
Many states are looking to Vermont for an example, as their budget constraints converge with a sense of personal independence that today's seniors increasingly desire.
"This is really taking us back a century, to when seniors always aged in the home," says Churchill Hindes, president of the Visiting Nurse Association of Chittenden and Grand Isle Counties. "We had gotten away from that for most of the 20th century, but we are going back to the idea of growing old at home."
Some say home care would cost Vermont just half of what institutional care does.The state's goal is to use savings accrued as seniors shift to home-based care to serve more people, including those who don't qualify for Medicaid's long-term services.
Called Choice for Care, the new waiver program, which went into effect Oct. 1, sends 12 nurses across the state to assess the needs of Vermont's elders. Those who prefer care at home or in residential care facilities receive support for their daily maintenance, such as help with bathing or grooming. They can also enroll in adult day care and emergency-response programs.
Vermont previously allowed only 1,200 seniors the option to receive community-based care.
"Before, many would go to nursing homes, because otherwise they would have nothing," says Susan Reinhard, co-director of the Rutgers Center for State Health Policy in New Jersey. Some seniors may need little more than a wheelchair ramp or help coordinating doctor's visits. "What Vermont got away from is yes or no, all or nothing."
Joan Senecal, deputy commissioner for the Vermont Department on Disabilities, Aging, and Independent Living, says the state has always had an ethos of personal choice. "Vermont is such a small state," she says. "We can do it statewide and be a laboratory without it being too overwhelming."
Many across the state hailed the program, and are watching it as it unfolds. Dolly Fleming, of the Community of Vermont Elders in Montpelier, says her organization is working with long-term care providers to make sure that adequate support is provided to those choosing the waiver.
Kirby Dunn, of HomeShare Vermont, which pairs seniors with those looking for affordable housing, says that home care could actually cost more for some patients.
Under the new program, Vermont will spend the same amount of money for five years that it did under the former rules. Ms. Dunn, who supports the program, questions whether there will be sufficient caregivers to serve all seniors or if logistics, like travel time between seniors' homes, will create hidden costs.
"The scary part for the state is that they are only going to get a set amount of money, and a lot more people could come in the door and need care," says Dunn.
The waiver program is often paired with other services, such as long-term medical homecare, often paid for by Medicare. Some might hire a family member to facilitate care, while others might have a rotating staff.
Bessette, for example, works with a variety of caregivers, and also attends adult day care five times a week, but she spends the night by herself. "I wouldn't want to be any place but here," she says.
Despite the varied options that seniors might choose, one thing is steady: a familiar setting.
"The constant for me is your own bed," says Dr. Hindes. "Throughout all of this, you eat supper at your own kitchen table, surrounded by the things that are important to you.... For seniors, that's very important."