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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 simple way to separate the "gatekeeping" and clinical case management tasks and that placing the responsibility for these tasks in different agencies or different units of the same agency may create more problems than it solves with respect to balancing the administrative "gatekeeping" tasks and the clinical tasks of case management.5

A different reason for placing various case management functions in nore than one agency is to create an oversight mechanism by which one agency would review decisions about services made by the other agency. Policy makers might decide that such an oversight mechanism is necessary if, for example, the Federal government were paying for long-term care services hat 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.

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Most commentators agree that case management in long-term care includes these five functions (6,13,18,24,25,31,36,39,43,51,52,61,63,71,72), but there are still many unresolved definitional issues with respect to case management. First, some commentators include other functions-notably, case finding, screening, client education, and counseling-in their definitions of case management. Second, the implementation of each of the case management functions varies, depending on factors such as the type of the agency that provides it, the objectives and other functions of that agency, whether the agency provides services in addition to case management, the goals, educational background, experience, and training of the case manager, and the number of clients the case manager has. The same factors also influence the relative amount of emphasis the case manager and the agency place on each of the case management functions.1

Many conceptual distinctions have been proposed to categorize the differences in the role and practice of case management in different agencies and settings (see, for example, Austin, et al., 1985 (16); Capitman, et al., 1986 (25); Kane, et al, 1989 (39); and Weil, 1985 (71). Two conceptual distinctions are particularly important in thinking about the case management component of a national long-term care program. The first of these is a conceptual distinction between case management as an administrative process and case management as a clinical or helping process. In many agencies that allocate long-term care services or funding for long-term care services, case managers perform certain tasks that are essential for the administration of those benefits in accordance with agency or program regulations. These administrative tasks include determining people's eligibility for the benefits, authorizing the benefits, and monitoring and accounting for their use. When case managers are responsible for these administrative tasks, the case management functions mentioned earlier are modified to include the tasks. For example, the function of arranging and coordinating services is modified to include administrative procedures for authorizing services and funding for services. The functions of monitoring the services and of reevaluating the client's needs are modified to include procedures to account for the services and

1 In this paper, the term "case manager" is used to refer to an individual who performs the case management functions listed above. As is true of case management, however, the term "case manager" means different things to different people, and in reality, some individuals who perform these case management functions are not called "case managers" and other individuals who are called "case managers" do not perform the functions.

funds that are used and to recertify the client's eligi bility for services.

In some agencies that allocate long-term care serv ices and funding for services, case management is primarily a series of administrative tasks intended to allocate benefits in accordance with agency or program regulations. In other agencies, case management is primarily a clinical or helping process in which the case manager functions more as a professional helper, counselor, and client advocate than as an administra tor of benefits. Clinical case management responds to a variety of difficult problems that confront people who need long-term care. One of those problems is that the long-term care service environment is ex tremely complex and fragmented in many communities, so that some people who need long-term care require assistance to locate and arrange services. A second problem is that some people who need longterm care have multiple service needs, so that they may require assistance in coordinating the services of several different providers. Lastly, some people who need long-term care require assistance in defining the problems they are facing, determining what kind of services might be helpful, and mobilizing informal (unpaid) sources of help (relatives, neighbors, friends, church groups, etc.). As professional helpers, counselors, and client advocates, case managers provide all these kinds of assistance.

If it were possible to make a clear distinction in reality between case management as an administrative process and case management as a clinical or helping process and call one case management and the other something else, it would be easier for everyone to understand and communicate clearly about case management and its role and operation in a national longterm care program. That distinction cannot be applied precisely in reality, however. As practiced in many agencies, case management includes both administrative and clinical tasks, and many case managers administer long-term care benefits for their agencies perceive themselves as professional helpers, cour selors, and advocates. 2 Moreover, OTA is not aware of any research that shows that as a group these case managers perform the clinical case management tasks differently than case managers who do not administer benefits.

2 In a study by the University of Washington, 127 case managers in ager cies that allocate services and funding for services in Oregon and Washingt State were asked to rate the importance of 11 possible goals of case manage ment (15). All these case managers' jobs involved administrative tasks related to allocating services and funding for services, but the goals they identified most important had to do with helping and advocacy. In the view of these case managers, at least, the administrative and clinical aspects of case mas agement are intertwined.

Even though the conceptual distinction between case management as an administrative process and case management as a clinical or helping process cannot be applied precisely in reality, it is useful in thinking about the role and operation of case management in a long-term care program because it underlies one of the primary areas of disagreement about case management in such program. It is in the context of performing administrative tasks related to the allocation of program benefits that case managers become the "gatekeepers" in a long-term care program, and it is in that context that they are likely to be perceived as restricting clients' access to needed services. Some people argue that case management as an administrative "gatekeeping" process is not compatible with case management as a clinical or helping process and that the "gatekeeping" and clinical case management tasks should be performed by different agencies or different units of the same agency. Other people argue that the two types of tasks can be effectively performed by the same agency or unit. This issue is discussed further in a later section of this paper. OTA's perception is that both the administrative and clinical tasks are performed by the same case manager in most long-term care programs that allocate services or funding for services-at least after an initial determination has been made that an individual is eligible for the program.

The second important conceptual distinction in thinking about the case management component of a national long-term care program is the distinction between a case management process that is "service-centered" vs. one that is "comprehensive." Service-centered case management is case management that is provided in conjunction with the provision of a particular service (e.g., homemaker or home health aide services). Comprehensive case management takes place independent of the provision of any particular service (46).

The distinction between service-centered and comprehensive case management is important because it underlies two other areas of disagreement about case management in a long-term care program. Many agencies and individuals that provide services also "case manage" their clients. One area of disagreement is whether a long-term care program should provide case management for people who are receiving case management from a service provider in conjunction with a particular service (i.e. service-centered case management). The more widely debated issue is whether service providers should be the case managers for a long-term care program. Both issues are discussed later in this paper.

Some commentators make a distinction between case management and "care management," "care co

ordination," "service coordination," or similar terms. Although these distinctions may be meaningful within the conceptual framework developed by a given commentator, the terms are not used in a consistent way by different commentators. Thus, the use of these terms does not facilitate clear communication about case management, and OTA does not consider the terms helpful in thinking about the case management component of a long-term care program.

Should Case Managers Determine the
Amount and Kind of Services
People Receive Through a National
Long-Term Care Program?

3

Case managers determine the amount and kind of services people receive in virtually all existing longterm care programs that allocate services or funding for services. In many of these programs, there are at least two steps that take place before the amount and kind of services a person will receive are determined. First, the person's eligibility for the program is determined. Eligibility is usually determined on the basis of only a few factors and may or may not be determined by a case manager. Once the person is found to be eligible for the program, he or she usually receives an assessment by a case manager. Based on the results of the assessment, the case manager then develops a plan of care which includes a determination of the amount and type of services that will be authorized for the person. The assessment usually addresses many more factors than are considered in the eligibility determination. Factors such as the person's mental, and emotional status, the person's living arrangements and physical and social environment, and the availability of help from informal (unpaid) caregivers are frequently included in the assessment. All of these factors are relevant to determining the amount and kind of services a person needs but not necessarily relevant to determining eligibility for the program.

In many long-term care programs, the assessment is based on a formal assessment instrument-i.e. an interview schedule that addresses all or many of the factors just noted. If there were an assessment instrument that could accurately determine the amount and kind of services a person needs without requiring the judgment of a case manager, that instrument could be used to determine what services the long-term care program should provide for the person. Sometimes descriptions of client assessment and care planning in

3 Existing long-term care programs generally base eligibility for program benefits on categorical criteria (age, disability, etc.), medical and functional status, financial need, and/or the person's need for nursing home care, as defined by the State's Medicaid program regulations.

long-term care programs sound as if there are such instruments and as if the determination of the amount and kinds of services authorized for clients of the program comes directly from the assessment instrument. At present, however, there is no assessment instrument that has been shown to identify the amount or kind of services that people need. In fact, research indicates that even in long-term care programs in which there are standardized assessment procedures that include the use of an assessment instrument and the case managers are trained to follow the procedures precisely, clients who are the same in terms of the factors addressed by the assessment are perceived by different case managers as having different needs, and the amount and kind of services authorized for them by different case managers vary (1,25,58).

Some efforts are underway to standardize care planning, so that the same amount and kind of services will be authorized by case managers for people whose assessments are the same (1,58). These efforts are not complete, however, and it is not clear how soon such a "case-mix" approach to long-term care planning might be ready for use in a national longterm care program. Nor is it clear that determinations of the amount and kinds of services to be authorized for clients of a long-term care program should rely solely on an assessment instrument without requiring the judgment of a case manager. It is clear, as mentioned earlier, that there is currently no assessment instrument that has been shown to identify the amount or kind of long-term care services that people need.

Aside from having a case manager determine the amount and kind of services to be authorized for clients of a long-term care program, the only other alternative would be to allow people who are eligible for the program to decide what services they need (with or without the advice of a physician, other health care or social service professional, or anyone else) and then to set up a procedure by which the program would review and authorize or decline to authorize reimbursement for the services retrospectively. If this approach were implemented, people who were eligible for the program would use longterm care services and then they or the service provider would submit a claim for reimbursement, in much the same way that claims are submitted for Medicare reimbursement for home health care services. OTA is not aware of any long-term care program that operates in this way.

The main points here are: 1) that the determination of the amount and kind of services to be authorized for a person through a long-term care program is different from the determination that the person meets the eligibility requirements for the program, and 2)

4

that there appears to be no viable alternative to having a case manager determine the amount and kind of services to be authorized for people through a national long-term care program. These points raise certain problems for such a program. The first prob lem is the predictably negative response of people who are found to be eligible for the program and then discover that, in fact, a case manager will determine the amount and type of services they will be authorized to receive through the program. This problem is likely to be particularly acute if the long-term care program is an entitlement program.

Another problem is that the administrative "gatekeeping" tasks in case management clearly arise in the context of assessment and care planning, not just eligibility determination. Therefore, if policy makers want to separate the administrative "gatekeeping" tasks from the clinical tasks in the case management component of the long-term care program in order to address the alleged incompatibility of the two types of tasks, it will be necessary to place the responsibility for assessment and care planning in one agency or unit of an agency and the responsibility for the clinical case management tasks in another agency or another unit of the same agency.

Some recent proposals for a national long-term care program place the responsibility for determining eligi bility in one agency or one unit of an agency and the responsibility for assessment, care planning, and other case management functions in another agency or an other unit of the same agency. The rationale that is sometimes given for this approach is to separate "gatekeeping" and clinical case management tasks. Clearly, this rationale is based on a misunderstanding of the process by which decisions are made about the amount and kind of services that will be authorized through the program.

the

Another possible approach is to place the responsi bility for eligibility determination, assessment, and care planning in one agency or one unit of an agency and the responsibility for clinical case management tasks in another agency or unit. Since people's service needs change over time, assessment and care planning must be ongoing. If this second approach were imple mented, each client would have to have two case benefits and managers, one to administer the program one to perform clinical case management tasks. Although this approach might create an adversarial relitionship between the two case managers, some people

Although there appears to be no viable alternative to having a case me

ager determine the amount and kind of services to be authorized for people

through a long-term care program, many structural and operational aspec of the program will affect how the case manager performs this function Some of these structural and operational aspects are discussed later in the

paper.

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 དྲ། 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 nits 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, or 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.

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