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Clearly, the particular criteria for adequacy used here could be debated. I believe that such discussion is needed in almost every state, and that the aging network should have an explicit focus on creating opportunities to reach state and local consensus on what constitutes adequate home and community care options for elders. Through the focus on advocacy, the Older Americans Act and the aging network are the logical vehicles for fostering such consensus building. The experiences of states do not indicate that these advocacy roles preclude participation in pre-admission screening, care management, and quality assurance. Most aging network leaders seem convinced, however, that system coordination functions and advocacy cannot be performed adequately by agencies that are direct providers of care. Further, recent experience in states facing severe fiscal crises or unexpected growth in demand for long-term care report that it is difficult to both advocate for the needs of elders and develop acceptable approaches to budget reductions or further rationing of

care.

Our research does indicate that there is a continued vital need for aging network participation in development, implementation, and maintenance of home and community long-term care systems. The Older Americans Act can strengthen this role by:

Insisting on the development of comprehensive approaches to community long-term care capacity building and service provision; and

Viewing the network as both a vehicle for planning and as an active participant in assisting potential users of public and privately financed services to gain access to care, as well as in ensuring affordable, efficient, coordinated and high quality care for users.

Finally, two other challenges are directly related to the capacity of state and local governments to create and sustain adequate community long-term care infrastructure. I believe that these two issues should be highlighted as the role of the Older Americans Act and the aging network are reviewed:

(1) Cultural diversity. There is continuing evidence that elders from racial and ethnic minority groups, elders in less affluent neighborhoods, and elders in rural areas have inadequate access

:

(2)

to community long-term care services. Recent studies indicate that these differences are at least partially caused by the orientations of providers to diversity and their level of understanding for the unique issues in serving these populations. The Administration on Aging and the network should continue to have a special advocacy and service delivery focus on those who are least well served in current systems.

Long-term care labor force: Care for the chronically ill and disabled aged requires special interpersonal and technical skills, and yet nursing home, home care, and day care workers receive lower wages and less adequate benefits than any other job category. The Administration on Aging and the aging network should be directed to continue their attention to the quality of life and work of those who care the aged as a major quality of care issue.

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Pre-admission screening (PAS) for determination of the appropriate level and setting for care.

State-level management structure and standards for local administration of PAS to determine level and setting for client care.
PAS conducted for current Medicaid enrollees and those expected to be eligible for Medicaid after admission to nursing home or
community care.

In person assessment conducted prior to physical placement within the nursing home, prior to Initiation of community services, or.
prior to spend down to Medicald in nursing home, except for emergency placements with protocol for assessment within a few days.
Assessment process is standardized, measures functional, medical and social factors, and there is multidisciplinary review.
Assessment is conducted in hospitals, homes, community facilities, and nursing homes.

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Comprehensive assgasmens, planning and management (CAPH) for home and community oriented serviceL.

State-level management structure and standards for local administration of comprehensive assessment, care planning, periodic
reassessment, and on-going service arrangement and monitoring.

CAPM for community-oriented services controls multiple funding sources for Medicald enrolled and other individuals.
Assessment process is standardized, measures functional, medical and social factors for Medicaid enrolled and other individuals.

CAPM services performed by Individual or team with on-going responsibility as client needs and eligibility changes and/or established
procedures for transfer of responsibility.

Identifiable state and local agency with primary responsibility for both PAS and CAPH.

single state agency or coordinating council formally designated as spordinater and manager of local delivery system including PAS and CAPM, even if multiple agencies participate in financing, reimbursement, and quality and efficiency regulation. That is, agrvice. management may by delegated to a single state agency, perhaps through an inter-agency memorandum of understanding, to manage services statewide.

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FIGURE 1

STATE INFRASTRUCTURE FOR LONG-TERM CARE: ASSESSMENT CRITERIA DEFINITIONS

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Either single entry point for PAS and CAPM at local level or explicit procedures for client entry to standardized PAS and CAPM services.

Identifiable local agency for accessing appropriate services supported by multiple funding streams. That is, at the local level, there is one agency that can access and provide case managed services. These services may be funded by more than one funding source.

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FIGURE 1 (continued)

Explicit formal lake between health care providare chosolsels, shyalslana, home health assosieer and local level CAPH BRODGY

Explicit contracts or memori of understanding to share client status and service use Information between local agencies
responsible for PAB and CAPM and the following health care providers: acute care hospitals, home health agencies, and physicians.
There are established procedures In the PAS and CAPM agencies and the local health care providers to ensure timely sharing of
Information by all providers in the local system.

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Geotrasts or mooranda of understanding between state-level agency and QAPM providers, and between CARN providare and diress agrvice proxidar

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Formal procedures for licensure or certification of agencies that provide home health, personal care/homemaker, and adult day care
services that include employee training and supervision requirements, quality assurance mechanisms, and clinical and financial record
keeping requirements. that is, are provider ancian licensed/certified? If yes, then agency personnel need not be individually
licensed to meet criterion.

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Formal procedures for licensure or certification of home health aides, personal care aides, homemakers, and other paraprofessional
home care workers who are hired directly by ellents or CAPM agencies on behalf of clients rather then through licensed or certified
agency that reference training requirements. That fe, if individual workers are hired directly, outside of the auspices of a
provider agency, the Individual provider must be licensed/certified to satisfy the criterion.

Explicit contraste or memoranda of understanding between the state-level agency responsible for PAS and CAPH and the local CAPM provider(s).

Expllelt contracts or memoranda of understanding between local CAPM provider(s) and direct long-term care providers.

Contracts or memoranda are written and standardized, and are negotiated, monitored and enforced at the local level by the CAPM agency.

Contracts or memoranda provisions includes staffing requirements, staff training and supervision requirements, professional standards and service guidelines, procedures for client monitoring, client grievance procedures, quality assurance program guidelines, and clinical and financial reporting requirements, and payment rates and procedures.

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Source: Pendelton, Capitman, Leutz, Omata, "State Infrastructure for Long-Term Care: National Aging Resource Center, Brandeis Univeralty, June, 1990.

A National Study of State Systeme, 1989",

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Source: Pendelton, Capitman, Leutz, Omata, "State Infrastructure for Long-Term Care
National Aging Resource Center, Brandela University, June 1990.

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A National Study of State Systems, 1989",

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