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believe that it is the only way to guarantee that clients of a long-term care system have an advocate in the program. The approach would be likely to be duplicative and therefore expensive.

A third possible approach is to have the original determination of eligibility, the initial assessment, and the initial care plan done by one agency or unit of an agency and then to have ongoing case management provided by another agency or unit of an agency. This approach does not effectively separate the "gatekeeper" and clinical case management tasks, because the ongoing case management would still include both "gatekeeper" tasks (i.e., reassessments and redeterminations of the amount and kind of services to be authorized for a client) and clinical case management tasks.

The fourth possible approach, and the one that is in effect in most existing programs that allocate longterm care services and/or funding for services, is to assign responsibility for both ongoing administrative case management tasks and clinical case management tasks to the same agency and case manager. This is the approach that raises concerns about the incompatibility of administrative "gatekeeping" tasks and clinical tasks. If this approach were adopted for a national long-term care program, safeguards would have to be built into the program to try to ensure that case managers' determinations of the amount and kind of services to be authorized for clients would be fair and that case managers would perform clinical tasks for their clients to the greatest extent possible. Such safeguards could include training for case managers about how to balance the conflicting demands of the "gatekeeper" and clinical/advocacy roles, the provision of forums for consultation and supervision for case managers who confront difficult decisions about the amount and kind of services to be authorized for a client, and an effective appeals process. Some people would argue that these safeguards are not adequate to ensure that people have an advocate in the program.

Each of the 4 approaches discussed above has drawbacks. The important point is that there is no imple way to separate the "gatekeeping" and clinical case management tasks and that placing the responsiility for these tasks in different agencies or different inits of the same agency may create more problems han it solves with respect to balancing the adminisrative "gatekeeping" tasks and the clinical tasks of ase management. 5

A different reason for placing various case management functions in ore than one agency is to create an oversight mechanism by which one gency would review decisions about services made by the other agency. olicy makers might decide that such an oversight mechanism is necessary if, example, the Federal government were paying for long-term care services at were being authorized by State-administered agencies, and the Federal

Who Should Receive Case Management in a Long-Term Care Program?

As discussed in the previous section, decisions about the amount and kind of services people receive through a long-term care program probably must be made by case managers. Thus everyone who receives services through the program must receive case management in the sense of the administrative tasks that are essential to allocate services and funding for services in accordance with program regulations.

Whether everyone who receives services through the program should receive case management beyond those essential administrative tasks is another question. As discussed earlier, at least some people who need long-term care services also require assistance with defining their service needs, locating and arranging services, and coordinating the services of multiple providers. Anecdotal evidence suggests that many people who need long-term care require these kinds of assistance.

The findings of an exploratory study conducted for OTA in Pennsylvania and of market surveys conducted for the Robert Wood Johnson Foundation's Supportive Services Program for Older Persons indicate, however, that some people do not want case management. The study conducted for OTA involved interviews with 46 family caregivers of people with dementia (73). Some of the caregivers did not want and did not think they needed case management. Onefourth of the caregivers said they would rather arrange services themselves than have a case manager act as an intermediary. The caregivers' major concern about case management was control: they wanted to retain control over the kinds of services to be provided for their relative with dementia and over who would provide the services.

The findings of market surveys conducted for the Robert Wood Johnson Foundation's Supportive Services Program for Older Persons also suggest that many older people and their families do not want case management and that they do not understand why they might need it (33). Older people and their families who responded to the market surveys indicated that they did not see themselves as "cases" to be managed and that they did not understand why they would need a special person or a special set of functions in order to obtain services. Many of them expressed confidence in their ability to define their own

government wanted to review the service allocation decisions made by the State-administered agencies. Creating such an oversight mechanism would not necessarily resolve concerns about the incompatibility of "gatekeeping" and advocacy-related tasks in case management, however. In fact, these concerns would be relevant to decisions made by both agencies.

sites had contracts with homemaker/home health aide agencies, and at those sites, procedures for monitoring quality and responding to inadequate services were detailed in the contracts. At sites that did not have contracts with service providers, procedures for monitoring quality and responding to problems were less structured and less formal. Sites that had funds to purchase services used the threat of withholding payment to pressure providers into improving their services. That option was not available to sites that did not have funds to purchase services.

These findings from the Channeling Demonstration and the findings of some State programs that allocate long-term care services or funding for services (e.g., Ohio's PASSPORT program and Pennsylvania's LAMP program) suggest that it is not case managers per se that monitor and control the quality of longterm care services but rather case managers in an agency or program that has explicit procedures for this purpose. Policy makers should not assume that simply involving case managers in a long-term care program will guarantee that the program will monitor and control the quality of services.

Finally, OTA's analysis of the potential role of case managers and case management agencies with respect to the quality of services for people with dementia suggests that case managers may be legally constrained from referring clients to services based on the case managers' judgments about the quality of the services. A 1987 Oregon case Bionic Health Care, Inc. v. State of Oregon Department of Human Resources, et al. (19) concerned a situation in which case managers who worked for a public agency had stopped referring clients to one nursing home that they believed was providing poor care and that was under review by the State licensing and certification agency. The nursing home sued, arguing that it had a valid State license and was certified by Medicare and Medicaid and that the case managers could not refuse to refer clients there. The nursing home won, and the case managers have been instructed not to make recommendations to clients about service providers.

OTA has no information about how often case managers in programs that allocate long-term care services or funding for services recommend certain service providers on the basis of quality. One member of the advisory panel for the OTA study interviewed case managers who refer people to nursing homes found that the case managers generally believed that they were legally constrained from making referrals on the basis of quality (38). An analysis is needed of any legal constraints or legal risks that may be incurred by a long-term care program and the agencies and case managers that implement it when the case managers authorize services on the basis of their quality.

CONCLUSION

This paper has discussed several different aspects of case management and has suggested ideas and options that policy makers could consider in designing the case management component of a national long-term care program. Because of the widespread uncertainty, confusion, and disagreement about what case management is, it would be easy for policy makers to leave difficult policy issues unresolved, to be worked out in the case management process. Some of the policy issues that could be left unresolved are: what kinds of people are eligible for what kinds of services; whether the relative emphasis in the program is on cost containment or providing more services for people; what the role of clients and their families should be in decisions about the services they will receive; and whether the long-term care program will be responsible in any way for the quality of services to which it connects people and if so, how. People who need long-term care are extremely diverse, so the application of policy decisions in each of these areas to an individual client's situation must be left to the case manager's judgment. The basic policy decisions-that create the program structure within which case managers will make judgments about individual client's situations—should be made, however, by those who design the system.

References

1. Abrahams, R., Capitman, J., Leutz, W., et al., "Variations in Care Planning Practice in the Social/HMO: An Exploratory Study," Gerontologist 29(6):725-736, 1989.

2. Abrahams. R., and Lamb, S., "Developing Reliable Assessment in CaseManaged Geriatric Long Term Care Programs," QRB 14(6):179–186, 1988. 3. Abrahams, R., Nonnenkamp, L., Dunn, S., et al., “Case Management in the Social/Health Maintenance Organization," Generations 12(5):39–43, 1988. 4. American Bar Association, Commission on Legal Problems of the Elderly, "Report to the House of Delegates," approved by the House of Delegates of the American Bar Association, San Francisco, CA, August 1987.

5. American Hospital Association, Office of the General Counsel, Legal Memorandum: Discharging Hospital Patients: Legal Implications for Institutional Providers and Health Care Professionals: Report of the Task Force on Legal Issues in Discharge Planning (Chicago, IL: 1987).

6. American Nurses' Association, "Nursing Case Management," Kansas City, MO, 1988.

7. Amerman, E., "The Nurse/Social Worker Dyad in Community-Based Long-Term Care," presented at the annual meeting of the Gerontological Association of America, San Francisco, CA, November 1983.

8. Applebaum, R.A., "Lessons From the National Channeling Demonstration," Generations 12(5):58–61, 1988.

9. Applebaum, R.A., "What's All This About Quality?" Generations 13(1):5–7, 1989.

10. Applebaum, R.A., Atchley, S.J., McGinnis, R., et al., A Guide to Ensuring the Quality of In-Home Care: Final Report of Ohio's Quality Assurance Project (Oxford, OH: Miami University, April 1988).

11. Applebaum, R.A., and Christianson, J., “Using Case Management To Monitor Community-Based Long-Term Care," Quality Review Bulletin 14(7):227-231, 1988.

12. Applebaum, R.A., and Wilson, N.L., “Training Needs for Providing Case Management for the Long-Term Care Client: Lessons From the National Channeling Demonstration," Gerontologist 28(2):172-176, 1988.

13. Austin, C.D., “Case Management: Options and Opportunities," Health and Social Work 8(1):16-30, 1983.

14. Austin, C.D., “History and Politics of Care Management," Generations 12(5):7-10, 1988.

15. Austin, C.D., Borgatta, E.F., and Roberts, E.A., Improving Access for Elders: The Role of Case Management-Final Report (Seattle, WA: University of Washington, Institute on Aging, January 1987).

16. Austin, C.D., Law, J., Roberts, E.A., et al., Case Management: A Critical Review (Seattle, WA: University of Washington, Pacific Northwest LongTerm Care Gerontology Center, 1985).

17. Balmer, D.L., Manager, Division of Administrative Compliance, Illinois Department on Aging, "The Illinois Department of Aging Quality Assurance Program," presented to "The National Conference on Home Care Quality," conference sponsored by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, DC, June 2, 1988.

18. Beatrice, D.F., “Case Management: A Policy Option for Long-Term Care," Reforming the Long-Term Care System: Financial and Organizational Options, J.J. Callahan and S.S. Wallack (eds.) (Lexington, MA: Lexington Books, D.C. Heath & Co., 1981).

19. Bionic Health Care, Inc. v. State of Oregon Department of Human Resources et al, Civil No. 87-0816-PA, Nov. 2, 1987.

20. Brody, E.M., "The Family at Risk," Alzheimer's Disease Treatment and Family Stress: Directions for Research E. Light and B.D. Lebowitz (eds.) (Rockville, MD: U.S. Department of Health and Human Services, National Institute of Mental Health, 1989).

21. Brown, T.E., Jr., Director, Office of Program Management, South Carolina Department of Health and Environmental Control, remarks to the National Council on the Aging symposium "Case Management: Fad or Fact?" Washington, DC, Apr. 14, 1988.

22. Brubaker, T.H., "The Long-Term Care Triad: The Elderly, Their Families, and Bureaucracies," Aging, Health, and the Family, T.H. Brubaker (ed.) (Newbury Park, CA: Sage Publications, 1987).

23. Callahan, J.J., "Paying for Case Management," Generations 12(5):75,76, 1988.

24. Cantor, M., Rehr, H., and Trotz, V., "Workshop II: Case Management and Family Involvement," Mount Sinai Journal of Medicine 48:566-568, 1981. 25. Capitman, J.A., Haskins, B., and Bernstein, J., “Case Management Approaches in Coordinated Community-Oriented Long-Term Care Demonstrations," Gerontologist 26(4):398-404, 1986.

26. Dolan, K.R., and Holtz, J., "The Commission on Accreditation for Home Care in New Jersey," Caring 5(4):49-50, April, 1986.

27. Downing, R., "The Elderly and Their Families," Case Management in Human Service Practice, M. Weil and J.M. Karls (eds.) (San Francisco, CA: Jossey-Bass Publishers, 1985).

28. Fessler, S.R., and Adams, C.G., "Nurse/Social Worker Role Conflict in Home Health Care," Journal of Gerontological Social Work 9(1):113–123, 1985.

29. Freeman, I.C., “Consumer Advocacy Issues in Case Management," Improving Access for Elders: The Role of Case Management-Conference Proceedings (Seattle, WA: University of Washington, Institute on Aging, 1986).

30. Grau, L., "Case Management and the Nurse," Geriatric Nursing 5(8):372-375, November/December 1984.

31. Greene, R.R., Social Work with the Aged and Their Families (New York, NY: Aldine de Gruyter, 1986).

32. Harrington, C.H., Grant, L.A., Ingman, S.R., et al., "The Study of Regulation of Home Health Care Agencies in Two States: California and Missouri," Institute for Health and Aging, University of California, San Francisco, CA, December 1988.

33. Hereford, R.W., "New Community Services for Older People," presented at the 34th annual meeting of the American Society on Aging, San Diego, CA, March 1988.

34. Intergovernmental Health Policy Project, State Financing of Long-Term Care Services for the Elderly, Vol. I: Executive Report, D.J. Lipson and E. Donohoe (Washington, DC: May 1988).

35. Justice, D., State Long-Term Care Reform: Development of Community Care Systems in Six States (Washington, DC: National Governors' Association, April 1988).

36. Kane, R.A., "Case Management in Health Care Settings," Case Management in the Human Service Practice, M. Weil and J.M. Karls and Associates (eds.) (San Francisco, CA: Jossey-Bass, 1985).

37. Kane, R.A., "Case Management: Ethical Pitfalls on the Road to HighQuality Managed Care," Quality Review Bulletin 14(5):161–166, 1988.

38. Kane, R.A., Professor, School of Public Health and School of Social Work, University of Minnesota, Minneapolis, MN, statement to the Office of Technology Assessment Advisory Panel on Methods of Locating and Arranging Health and Long-Term Care Services for Persons With Dementia, Washington, DC, June 23, 1988.

39. Kane, R.A., Penrod, J., Davidson, G., et al., Case Management Costs: Conceptual Models and Program Descriptions (Minneapolis, MN: University of Minnesota, 1989).

40. Kemper, P., Applebaum, R., and Harrigan, M., A Systematic Comparison of Community Care Demonstrations (Madison, WI: University of Wisconsin Institute for Research on Poverty, 1987).

41. Kerr, M.H., and Birk, J.M., “A Client-Centered Case Management Model," 14(9):279–283, 1988.

42. Leutz, W., Abrahams, R., Greenlick, M., et al., "Targeting Expanded Care to the Aged: Early SHMO Experience," Gerontologist 28(1):4–17, 1988. 43. Levine, I.S., and Fleming, M., Human Resources Development: Issues in Case Management (Rockville, MD: National Institute of Mental Health, 1986).

44. Litwak, E., Helping the Elderly: The Complementary Roles of Informal Networks and Formal Systems (New York, NY: Guilford Press, 1985).

45. Lowy, L., Social Work With the Aging (New York, NY: Longman, 1985).

46. Mathematica Policy Research, Inc., Princeton, NJ, The Evaluation of the National Long-Term Care Demonstration: Final Report, National LongTerm Care Channeling Demonstration, prepared by P. Kemper, R.S. Brown, G.J. Carcagno, et al. for the U.S. Department of Health and Human Services, Contract No. HHS-100-80-8157, Washington, DC, May 1986.

47. Mathematica Policy Research, Inc., Princeton, NJ, The Planning and Operational Experience of the Channeling Projects, Vol. 1 and Vol. 2, National Long-Term Care Channeling Demonstration, prepared by G.J. Carcagno, R. Applebaum, J. Christianson, et al. for the U.S. Department of Health and Human Services, Contract No. HHS-100-80-8157, Washington, DC, July 1986.

48. Mumma, N.L., “Quality and Cost Control of Home Care Services Through Coordinated Funding," Quality Review Bulletin 13(8):271-278, 1987. 49. Mundinger, M.O., "Community-Based Care: Who Will Be the Case Managers?" Nursing Outlook 32(6):294–295, 1984.

50. National Academy of Sciences, Institute of Medicine, Improving the Quality of Care in Nursing Homes (Washington, DC: National Academy of Sciences, 1986).

51. National Association of Social Workers, "NASW Standards and Guidelines for Social Work Case Management for the Functionally Impaired," Silver Spring, MD, 1984.

52. National Council on the Aging, National Institute of Community-Based Long-Term Care, "Care Management Standards: Guidelines for Practice," Washington, DC, 1988.

53. Parker, M., and Secord, L.J., "Private Practice of Case Management," Generations 12(5):54-57, 1988.

54. Pennsylvania Department of Aging, "LAMP Demonstration Site Program Requirements, Planning Allocations and LAMP Contract Format for FY 1987-88," LAMP Bulletin No. 87-1, Harrisburg, PA, June 1, 1987.

55. Phillips, B.R., Kemper, P., and Applebaum, R.A., “Case Management Under Channeling," Health Services Research 23(1):67–81, 1988.

56. Phillips, B.R., and Schneider, B., "The Appropriateness and Consistency of Assessments in the Pennsylvania Long-Term Care Assessment and Case Management Program: Final Report," Mathematica Policy Research Inc., Princeton, NJ, june 30, 1988.

57. Sabatino, C.P., "Homecare Quality," Generations 13(1):12–16, 1989. 58. Schneider, B., "Care Planning: The Core of Case Management," Generations 12(5):16-18, 1988.

59. Seltzer. M.M., Ivry, J., and Litchfield., J., "Family Members as Case Managers: Partnership Between the Formal and Informal Support Networks," Gerontologist 27(6):722-728, 1987.

60. Seltzer, M.S., Simmons, K., Ivry, J., et al., "Agency-Family Partnerships: Case Management of Services for the Elderly," Journal of Gerontological Social Work 7:57-71, 1984.

61. Silverstone, B., and Burack-Weiss, A., Social Work Practice With the Frail Elderly and Their Families: The Auxiliary Function Model (Springfield, IL: Charles C. Thomas, 1983).

62. Simmons, K.H., Ivry, J., and Seltzer, M.M., "Agency-Family Collaboration," Gerontologist 25:343–346, 1985.

63. Steinberg, R.M., and Carter, G., Case Management and the Elderly (Lexington, MA: Lexington Books, D.C. Heath & Co., 1983).

64. Sussman, M.B., "Family, Bureaucracy, and the Elderly Individual: An Organizational-Linkage Perspective, “ Family, Bureaucracy, and the Edlerly, E. Shanas and M.B. Sussman (eds.) (Durham, NC: Duke University Press, 1977).

65. Torres, M.S., "Quality Assurance of Brokered Services," Quality Review Bulletin 14(6):187–192, 1988.

66. U.S. Congress, House of Representatives, Select Committee on Aging, The "Black Box" of Home Care Quality, prepared by the American Bar Association, Comm. Pub. No. 99-573 (Washington, DC: U.S. Government Printing Office, August 1986).

67. U.S. Congress, Office of Technology Assessment, Confused Minds, Burdened Families: Finding Help for People With Alzheimer's and Other Dementias in press, 1990.

68. U.S. Congress, Senate, Special Committee on Aging, Nursing Home Care: The Unfinished Agenda, Serial No. 99-J (Washington, DC: U.S. Government Printing Office, May 1986).

69. U.S. Department of Health and Human Services, Office of the Inspector General, "Home Health Aide Services for Medicare Patients," draft, Washington, DC, April 1987.

70. Vladeck, B., "Quality Assurance Through External Controls," Inquiry 25:100-107, 1988.

71. Weil, M., "Key Components in Providing Efficient and Effective Services," Case Management in Human Service Practice, M. Weil and J.M. Karls (eds.) (San Francisco: CA: Jossey-Bass, 1985).

72. White, M., "Case Management," Encyclopedia of Aging, G.L. Maddox, R.C. Atchley, L.W. Poon, et al. (eds.) (New York, NY: Springer Publishing Co., 1987).

73. Zarit, S.H., Malone Beach, E., and Spore, D.L., “Case Management as an Approach to Dementia: An Exploratory Study," contract report prepared for the Office of Technology Assessment, U.S. Congress, Washington, DC, July 1988.

ROLE

OF FEDERAL AND STATE GOVERNMENTS AND VOLUNTARY ORGANIZATIONS ORGANIZATIONS IN ASSURING QUALITY OF CARE IN IN SELECTED LONGTERM CARE SERVICES

Carol O'Shaughnessy and Richard Price

This is in response to your request for information on the role of Federal and State Governments and voluntary organizations in assuring quality of care for selected long-term care services. For purposes of our review, we have defined long-term care services as being provided in four distinct settings: (1) nursing homes, (2) the home, and (3) adult day care, and (4) board and care homes. Home care includes both home health care and nonmedical supportive services, such as personal care, homemaker, and chore services. This memorandum discusses Federal and State requirements and the activities of voluntary organizations aimed at assuring quality of care in each of these settings.

INTRODUCTION

Assessment of quality care in long-term care services generally includes three components: establishment of standards of care; monitoring the degree to which standards are met; and enforcement of standards. Assessing quality of care for long-term care services is difficult, due partially to the wide range of settings in which long-term care services are provided and the complex needs of chronically impaired populations. Settings range from skilled nursing homes where patients receive intensive nursing services to home and community-based services which respond to a variety of supportive service needs. Federal efforts to assure quality has generally been devoted to the review of the structure and process by which long-term care providers deliver services, for exam

• Prepared for the U.S. Bipartisan Commission on Comprehensive Health Care (The Pepper Commission), by Carol O'Shaughnessy and Richard Price, Specialists in Social Legislation, Education and Public Welfare Division, Congressional Research Service, August 25, 1989.

ple, by focusing on the organization of the provider, and staff qualifications and training. Recently some Federal attention has been directed at client-centered assessment procedures in nursing homes and home health services.

Although a number of Federal programs support long-term care services-primarily Medicaid, Medi

the Social Services Block Grant Program (SSBG), the Older Americans Act, and the Supplemental Security Income (SSI) Program-Federal requirements for assuring quality of care through the establishment, monitoring, and enforcement of standards vary significantly across these programs. In part because of the large commitment of Federal dollars to nursing home care under the Medicaid and Medicare programs, concern with quality of long-term care services has focused on this particular setting during the past two decades. However, in the past few years, quality of home care has also become an important issue for policymakers. This relatively new interest has come with awareness of a rapidly growing home health care industry and increasing expenditures under the Medicare program. The number of home health agencies participating in Medicare has more than doubled in less than a decade-from 2,858 in 1979 to 5,769 in 1988. Program payments for home health care increased from $542 million in 1979 to $2.6 billion in 1988. Quality issues in home care have also arisen as the nature of services delivered in the home has changed and as more technologically intensive services requiring greater expertise from home care personnel have come on the market. In addition, quality of home care has become more prominent as Congress considers a variety of proposals to increase Federal support for home and community-based care.

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