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later. They have done a very good job for the States and really give us the information we need to play a strong role in long-term care. Thank you.

[The prepared statement of Mr. Reed appears in the appendix.] Senator ADAMS. Thank you, Mr. Reed. I will save my questions until all three of you have testified.

Mr. Dolsen, welcome to the committee. We are looking forward to hearing your testimony.

Mr. DOLSEN. Thank you, Senator Adams. It is a pleasure to be asked to speak today.

In the past few years, policymakers have been seriously addressing the issues of community-based long-term care. They have frequently expressed fear that to open Medicare or Medicaid, as it currently operates, to in-home long-term care would invite abuses and a raid on the Federal treasury. Their fears are not without some foundation. They have also expressed frustration in their search for a mechanism to manage the system, balancing client advocacy, and the prudent expenditure of public dollars.

The area agencies on aging recognized more than 10 years ago that the community-based long-term care system of older persons and their advocates' desire is embodied in the mission of Title III of the Older Americans Act, "to provide supporting services to assist older persons to remain independent in their own homes". And despite their modest funding and their being overshadowed by the two medical programs, they have been building that long-term care system. Today over 50 percent of all area agencies on aging provide, as a part of their advocacy efforts, client focused, service neutral case management.

Our National Association of Area Agencies on Aging has published two position papers on long-term care. Our biggest fear is that policymakers will not recognize that our network is the critical management system they have been seeking.

There are some remarkable similarities among the case management systems AAA's operate. A great majority of them follow the 10 commandments of case management posited by Dr. Rosalie Kane. The vast majority of AAA's are service neutral so their case management efforts can be effective individual advocacy and so their case managers can be flexible in service provision. And AAA's have authority over some services so that their advocacy may become manifest.

Much of what our AAA in southwestern Michigan does in case management is very similar to what most of the AAA's in the Nation do, but I would like to share with you today some of the key features of our operations, some of the less common features, and some of the conclusions we have drawn from our efforts.

We decided early on we would tightly target limiting our clientele to those with multiple and complex needs and requiring that each client be deemed eligible for nursing home admission by the Michigan Department of Public Health. We felt that this would give us a better handle to ascertain any impact on nursing home occupancy.

From both our Medicaid and Older Americans Act funds, we established direct purchase of service pools allowing case managers to buy necessary services on a client-by-client basis, including those

services for which we may not contract. Service standards, service charges, and service capacity are set out in purchase agreements with bona fide service agencies. The direct purchase pools also permit the purchase of nonrecurring items such as ramps, reach extenders, grab rails, the costs of housing adaptation, whatever it takes to get the job done.

We further insist from our Older Americans Act and Medicaid service providers that our case managers set frequency and duration of services we order from them.

We also make the client and family full partners in the management of care. We make certain that in every way possible client's preferences are respected. We not only make the family's help part of the care plan, but we take special pains to explain to client and family what the services are, what agency will provide each service, and what outcome they should expect from it. Then we monitor to see that the tasks were done in the professional manner expected, that the expected outcome was achieved, and that each service provider treated the client with respect and courtesy and understanding. We think that client and case manager working together are the best mechanism for quality assurance.

The impact of our case management project in the past 3 years has been in our opinion profound. Of our clientele, all of whom are appropriate for nursing home entry, 80 percent have been able to remain in their own homes. And the cost of their care in the home has consistently averaged 35 to 40 percent of the average nursing home for the region.

According to a study by Western Michigan University, our clients have needed to use medical facilities significantly less than a similar control group, and although we cannot prove absolute cause and effect, our area has the lowest nursing home occupancy of all the areas in Michigan relative to nursing home bed need.

In addition, we have been able to confirm what the Brandeis University study on cultural diversity has asserted, that it is not true that elders of color do not use formal services because they have their own substitutes. We have served minority elders at a rate three times their occupancy rate in nursing homes.

Our data on client services and expenditures confirm to our satisfaction that case management can assure appropriate access, high quality care, and reasonable cost in home-based long-term care. What we have done is not so extraordinary or difficult, merely carefully designed and purposefully implemented. What we have done can be easily replicated in almost every AAA in the Nation accommodating the full range of long-term care funding sources.

This is not to say that our project does not have some vulnerability. Our continued existence depends on a Medicaid waiver the State of Michigan is pursuing. The U.S. Health Care Financing Administration has some difficulty breaking out of the centralized paper review mode that has been the pattern of the acute care structure in the United States. We hope that HCFA could be encouraged to be more receptive to the kind of system we find works best in long-term care.

With regard to the role of the Older Americans Act in long-term care, we strongly recommend that the reauthorization make explicit a AAA's authority to provide directly without a waiver those


statutory services relating to an AAA's administration and advocacy, including individual assessment and case management. Those statutory services were once cited in the regulations as basic to an AAA's required functions.

We also recommend expanding the range of Title IIID and IIIB priority services to any services relating to home care, including minor home repair, home environment adaptation and environmental aids, as well as day care and respite care.

And we recommend that the act give explicit authority to AAA's to a portion of Title III funds to purchase directly through case management on a client-by-client basis in-home and community services necessary to assist at-risk older persons to live in their own homes. We feel that these relatively modest changes in the act can set State and area agencies on aging on the final stretch to completing the client focused management system that can make a national home-based long-term care system a reality.

Thank you.

[The prepared statement of Mr. Dolsen appears in the appendix.] Senator ADAMS. Thank you, Mr. Dolsen.

Mrs. Kennedy, welcome to the committee.

Ms. KENNEDY. Thank you, Mr. Chairman and members of the subcommittee. I appreciate being here. I recognize the importance of this committee and its link to the policy structure. And we commend this committee, if I may, for your diligent efforts in reexamining the network and its functions historically in looking at our common goal of achieving an independent life for all older people.

I think it is apparent that no one element of the aging network is more inspired or more committed or has greater vision, one above the other, in addressing these issues associative of quality of life for older persons. I am equally confident that the mission of area agencies on aging to serve as catalysts in the development and promotion of home and community-based long-term care services is both clearly reflected and responsibly demonstrated by area agencies across the Nation. And, that within the framework of the Older Americans Act, despite its complexity and perhaps more so because of its flexibility, the aging network continues to advance efforts to support and sustain quality of life for millions of older per


Each of us here acknowledges the issues associative with the growth of older persons, the unprecedented growth of the very old amongst them, and we recognize that heretofore government has assumed primary responsibility for public investment in response to those pressing needs. And we also recognize at this point that budgetary constraints at all levels of government dictate a careful examination of the services that are in the process of addressing long-term care to seek the most efficient, most cost effective systems for delivery.

I wanted to speak briefly on support for long-term care within the area agencies on aging nationwide, but also to recognize that in Mississippi, for purposes of this discussion I would speak, as long-term care system developers within our central focus or role as advocate coordinators and quality of service monitors, recognizing that not unlike other States, wide variances exist between

area agencies and the application of strategies intended to achieve our common goal.

It should be noted that in our State area agencies have adopted uniform service standards that have standardized prescreening mechanisms and access based on level of need, as Mr. Dolsen mentioned, the importance of being sure that there is some sort of equity in access based on uniformity. These procedures have helped us to link client needs with service options and have virtually eliminated duplicative kinds of assessments for Older Americans Act services with the exception perhaps of the Medicaid waiver for home and community-based care. Those assessments are confined in scope of authority in our State to Title III programs.

The extension of case management, linkages to other health and social systems, is limited although we are making inroads through specific kinds of contractual arrangements with in-home service agencies such as home health agencies. Direct involvement of the health care community in our State amongst area agencies is rather limited, and we are continuing to address collaborative kinds of efforts beyond the information and referral types of linkages that have been historical.

The dilemma of scarce resources in our rural State does not serve as reason for failure to be creative. The rural service agencies and organizations are usually small enough that they are not management layered in heavy kinds of ways. So, we are able to get a lot of networking and informal kind of progress together. This informality is not always conducive to the kinds of procedural barriers that emerge, though, and we have to continually address that.

I want to mention that Title III, part D funds of the act, even though they were limited, enabled us in our part of Mississippi to address the need for respite care that heretofore had not been available. We were amazed at the frugality of the use and demand for respite care on the part of families and caregivers. This holds true as well and the provision of respite care is one of the allowable services in the Medicaid waiver. While the utilization rates were low, we feel that it is because families contend that the very availability of respite allays their fear of crises situations, kind of holds it in reserve, if you will. But it is very important to them.

Coordination activities on the part of area agencies under our State under the guidance of our State Office on Aging have resulted in uniform standards of care, definitions of service, client satisfaction indicators, reporting procedures, all of the elements important to quality assurances. And most were developed through a long-range planning committee, a structure of State, area agency and provider coordination through staff. In fact, coordination of funding sources in the area agency experience and the management of limited resources is considered one of the strengths in our State in the development of long-term care.

We are very concerned in our State about the expansion of the Medicaid waiver for home and community-based care. It is gravely needed. Our State historically invests only the necessary matching funds, because of budget constraints and budget deficits, attract the Federal resources. We have a tremendous advocacy effort going on in our State to advance the support of community and local leadership to help us in that direction.

We welcome reauthorization of the act. We are not afraid of costsharing, although we caution against means testing. Any provisions in the act that assist us to direct attention to those elderly most in need, inclusive of low income minorities-historically services are provided in the higher percentile for minorities within the specific titles of the act ranging somewhere between 45 and 55 percent. We have a newer minority population of Vietnamese in my part of the State, and we are not touching services to those people at this point in time. So, we are concerned that we have more innovative, more explicit measures to address targeting and to help us reach those most in need. It is foremost as one of our goals.

I appreciate again the privilege of offering some of these recommendations to this committee today and again appreciate the opportunity.

[The prepared statement of Ms. Kennedy appears in the appendix]

Senator ADAMS. Thank you, Mrs. Kennedy, very much.

I have one question which I would like to address to all three members of the panel. I will start with Mr. Dolsen since he is on this end.

How much money is available to each of you under the act's part D in-home services program? What are you able to do with these funds, and how significant are they? I know what the total national amount is, but I need a breakdown of just what is actually reaching each of the States. Mr. Dolsen, can you give me some idea on that?

Mr. DOLSEN. Yes. In our area we serve a population over 60 of about 47,000, and Title IIID translates to about $16,000 for us.

Senator ADAMS. That is what I was afraid of.

Mr. Reed.

Mr. REED. I think, if I recall, the figure is around $85,000 for the entire State of Washington. That is distributed then amongst area agencies.

Senator ADAMS. Ms. Kennedy.

Ms. KENNEDY. Mr. Chairman, in our State in our planning and service area, there are about 87,000 persons 60 and older, and part D translates to about $9,000.

Senator ADAMS. Thank you.

Would any of you like to comment on what additional services you feel you would be able to provide if those funds were increased? We have a very small amount invested in this, and hearing your testimony just now indicates what a very small amount is available when it finally gets to the States. Mr. Reed, do you have a comment?

Mr. REED. Well, we would simply use it to expand the existing service system. There are many people who do not get into our service system because there simply is not enough money to care for all their needs. We are serving all those who meet the criteria that we have established by State regulation, but that does not mean we have met all the need in the State. There are many people who do not meet those criteria.

Senator ADAMS. I also want each of you to know that I was very interested in your comments on targeting and the system that you use for determining who should receive assistance. One of the key

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