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AREA AGENCIES
ON AGING

THE COMMUNITY CARE CONNECTION

THE ESSENTIAL LINK IN CLIENT-CENTERED
COMMUNITY-BASED LONG TERM CARE SYSTEMS
July 1989

There is a pressing need for the development of a comprehensive long term care system in our nation. Regardless of the immediate fiscal constraints on the Federal budget, public consciousness about the issue has risen dramatically and the substantial growth in the numbers of persons of advanced age has given high visibility to an issue which cannot to be ignored.

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The Area Agencies on Aging, fulfilling their mandate to develop local comprehensive, coordinated systems of home support services, have fifteen years' experience in addressing the very problems policy makers are currently wresting with in attempting to devise a workable long term care program. Area Ageries on Aging have established care coordination units to prescribe and monitor services according to client need. These care coordination units enforce contracts for home health and support services to assure that standards for appropriate access, quality of care, and reasonable costs are met, and provide for the integration of those services on behalf of at-risk clients. Area Agencies on Aging in over half the states in the nation have solid care coordination systems and additional states are in the process of developing them.

These Area Agency on Aging coordinating units provide the local link that will allow the implementation of a Medicare or Medicaid comprehensive long term care program. The Area Agencies on Aging care coordination system is the oldest, most experienced, most extensive community-based long term care coordinating structure existing in the nation. With their solid individual care and community-wide coordination systems, Area Agencies on Aging are fully capable of meeting the principles upon which an effective long term care system must be based.

This paper is divided into three sections.. One section reviews the conceptual difficulties in utilizing the existing Medicare and Medicaid systems in providing community-based long term care to older persons. The second section discusses the role of the older Americans Act and Area Agencies on Aging in effectively providing community-based long term care. The final section presents several basic principles for long term care legislation.

Conceptual Problems for Kristing Medicare and Medicaid Systems in Providing Community-Based Long Term Care

It is becoming apparent that in the near future Federal policy makers will establish a national long term care policy and program, very likely as part of the Medicare or Medicaid program.

In response to increased public interest and demand, Congressional leaders have introduced a flurry of bills, almost all emphasizing community-based long tera home care, the overwhelming preference of disabled persons and their families. The bills reflect the fear of policy makers that, although the demand for home care is growing, the delivery of home care may not be satisfactorily managed and utilization and costs may spiral out of control. This fear is mirrored in the hesitancy of the private insurance industry to launch into long term care much beyond institutional care and the usual limited indemnity policies.

Public initiatives tend to build on federally-operated Medicare, an acute medical care system, or on Medicaid's state-operated extended care system, a primarily institutionally-based system. The massive reimbursement machinery in each of these systems makes available proven financial vehicles to facilitate the funding of a community-based long term care system. However, there are deep fundamental differences between long term home care and the care provided by the Medicare and Medicaid systems, and to extend their structures for service delivery to home care would leave unaddressed any effective measures to assure appropriate access to clients, reasonable cost to payers, and quality control

of services.

Long Term Care Differs From Acute Care

Long term care is concerned not with cures of disease, but with consequences of disease and disability. While a long term care client may have drug regimen and therapy for an illness, long term care focuses on providing support for those who are seriously disabled and unable to perform such activities of daily living (ADL) as getting in and out of a bed or chair, bathing, dressing, using the toilet, walking, or eating, and the instrumental activities of daily living (IADLS), such as preparing meals, grocery shopping, doing laundry, or performing housekeeping chores.

A medical episode encompasses a diagnosis of a disease or physical condition and a treatment designed to correct the problem and restore the patient. to health. It lends itself to a generalized predictability of the expenditure of resources, such as that embodied in Medicare's prospective reimbursement system, and to the documentation of patient condition.

Long term care, on the other hand, deals not with diagnoses reflected in measurable and observable symptoms which can be readily charted for review, but with the infinite combinations of physical strength and abilities, mental stability, motility, tolerance for pain, cognition, sensory acuity, and emotional strength, as well as the safety and security of the care setting, and the amily's willingness to help. These are factors which would confound the paper

utilization review efforts used in acute care.

Long Te Ecce Care Differs From Lone Te Institutional Care

The great majority of funds for all types of long term care is for room and board. Nursing homes, by providing shelter under one roof, consolidating meal preparation and laundry, and by standardizing the care regisen, can cut costs for tweaty-four hour care. But if a client does not need the continuous intensive care of the nursing home and if the private resources of the client and public funds are used judiciously, tone care can save public dollars. With home care, the client's own residence provides the shelter, the client may be helped or trained perform activities of daily living, and family caregiving may provide help to complement the client's own resources. This type of caregiving is often lost in the institutiocal setting. Community agencies may provide formal services when the client and family caregivers are unable to perform them, often at much less expense than institutional care would require.

The standardization of nursing home care, which provides some cost cutting, tends to override the dissimilar conditions and disabilities of residents, promoting their passivity and dependence. The isolation of institutional care can provide the potential for abuse and neglect which have plagued the reputations of mursing homes for years. Home care, on the other hand, affords greater individual tailoring of care, and by involving the family and informal supports in the caregiving responsibilities, can increase the opportunity for monitoring of client needs.

But home care can also be abused. acme health care agencies are funded primarily through third party payer systems, as are nursing homes. Eowever, home health care agencies are reimbursed on a fee-for-service basis rather than a per dien basis and can often times profit from a unilateral increase in the frequency and duration of services to a client. Further, unless care is monitored by a family and/or a case manager from an agency not vested in service delivery, neglect and/or abuse can occur. The types of surveys and evaluation systems currently used to monitor pursing boses would not be effective or appropriate for in-home care when living environments are enormously varied and widely dispersed.

The efficiency and effectiveness of home care can be assured through a system which can provide both client advocacy and the prudent expenditure of resources. It is in the national network of Area Agencies on Aging that such a system can be found.

The Kission of the Older Americans Act in Community-Based Long Term Care

Area Agencies on Aging were created by the 1973 amendments to the Older Americans Act and charged with the responsibility to strengthen or develop at the substate or area level a system of comprehensive, and coordinated services for older persons - services which will enable older persons to live in their homes or other places of residence as long as possible." Federal venture into community-based long term care.

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The Area Agencies on Aging, for the most part non-service-providing agencies, contract with local community agencies for the delivery of services to older persons. This contract process insures effectiveness and efficiency through competitive bidding and contract enforcement.

In the early 1980's, when health and human service systems were deregulated, service agencies proliferated and competition among them grew heated. It became apparent to Area Agencies that providers with conflicting purposes were becoming resistant to coordination, neither working together with clients nor sharing information about clients. The market system allowed providers to abandon their responsibility to unprofitable or difficult-to-serve elders, and appreciably raised the potential for abuse and neglect. Over time, the Area Agencies tightened their performance standards, targeted their services, and stepped up their monitoring, but it was obvious to Area Agencies on Aging that to fund the service system through performance-based contracts with select providers was not enough, that to serve the at-risk client required a coordination effort begizning with the individual client's needs and drawing in the appropriate services as those needs dictated. In response to the changes taking place in the service provider market system, Area Agencies moved into care coordination, (case/care management, as it is also called) not because it was mandated, but because it afforded them the opportunity to administer their funds and pool other resources in the best interests of vulnerable older persons, thus assuring appropriate access to quality services with maximum efficiency.

Care Coordination Assures Access To Appropriate Services

The Area Agency on Aging care coordinator can act as a gatekeeper, identifying at-risk clients who could avoid unnecessary institutional care by creating a home environment that the client can manage. The care coordinator, in consultation with the client and their family, designs a plan and manages the coordination of services from several agencies, and orchestrates the delivery of care. The care coordinator can also help with nursing home placement for those clients who require that level of care.

Care Coordination Assures Quality Caze

The care coordinator should be a client-criented monizer of the services prescribed in the care plans. With on-size visies, the care coordinator determines whether the tasks have been accomplished proficiently, what their impact has been, and whether there should be changes in care plans. On-site cbservations of the care plan implementation reveal first hand incidents of client neglect or abuse.

Care Coordination Contains Costs

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The care coordinator, as a funder or an authorizer of services, can prevent the upscaling and over-utilization of services. As observers of the acute care industry are aware, when providers may at their discretion treat illness without regard to cost on a fee-for-service basis, patients tend to receive an amount and a level of care far beyond what is necessary for quality treatment. can be an equally disturbing problem in community-based long term care. example, a provide: may try to justify home health care when less expensive homemaker service would be more appropriate, attend to the client four days a week when three.days would do as well, or continue the service weeks after it is no longer needed. The care coordinator, withous a vested interest in inflating services, but instead with a commitment to assure greatest impact of resources, can prevent imprudent service delivery by authorizing appropriate levels, frequencies, and durations of service based on observable client need. In addition, the care coordinator can work for the judicious use of other resources, including willing and able informal caregivers family members and friends whose efforts can reduce public costs.

The Area Agencies on Aging Are The Established Vehicles
For Implementation of Local Comprehensive Long Term Care Systems

An Area Agency on Aging is able to provide services far beyond the limited scope of those reimbursed by Medicare, including personal care, homemaker, chore services, home-delivered meals, minor home repair and alteration, electronic monitors, transportation, social support services, as well as health care — an

array of services which would completely confound the Medicare system as it is currently administered. This flexibility, as Area Agencies on Aging have learned, is absolutely essential to an effective community-based long term care system and requires a strong local care coordination structure to make it efficient and effective.

Some proposed long term care legislation has included care coordination (or case management) as an important access service to be added to facilitate in-home care and monitored through the established Medicare evaluation system as home care would be. Care coordination is, more accurately, an administrative function separate from in-home services, integral to local reimbursement and quality control procedures, and capable of ranging across a variety of settings (including institutional ones). Because of the fiscal and monitoring authority of care coordinators, there exists between them and providers an unavoidable and necessary tension essential to good service delivery. If incentives and roles of care coordinators and service providers are designed similarly used the existing paper review mechanism is legislation, and containment and quality control, the structure will invariably founder. coordination is different from services in the continuum of care. It is the local linchpin for community-based long term care systems.

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Area Agencies on Aging, in keeping with the intent of the Older Americans Acs have developed care coordination to give shape and direction to local long tes care in over half of the states. Increasingly, state Medicaid agencies have used the Area Agencies on aging's care coordination for Medicaid home care waiver programs, and Area Agencies on Aging have been able to integrate the Older Americans Act and Medicaid systems.

Regardless of the mechanism Federal policy makers will use to administer a national long term care service system, Medicare or Medicaid, any effective system will have a local care coordination component. Area Agency on Aging care coordination efforts on behalf of individual older persons parallel, complement, and enhance the area agency on aging's community-wide coordination efforts through planning, contracting, agency conferencing, and general advocacy. It ould seen altogether fisting that the Area Agencies on aging, with by far the lages: system experienced in coordinating home care, boch OF the individual and community levels, be the Federal vehicle through which a national comprehensive long te care system is operated.

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TO create another system to perform what the Aging Network is fully capable of doing, rather than adopt the existing Area Agency Network, would not only be wasteful, but would also isolate the programs of the Older Americans Act from the long term care system of which the Act instructs them to be a part and jeopardize the substantial state and local funding Area Agencies on Aging have drawn into their local systems of services.

Principles For Long Term Care Legislation

Whether the emerging long term care system is to be directed from the Pederal from the state level is beyond the scope of this paper, but, regardless, to assure that the system will be in line with our fundamental social values and will facilitate public understanding and utilization, it should rest on sound principles:

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1. The system should be client-centered, and managed by a non-biased care Coordinating agency.

All too often specific reimbursement systems limit service delivery systems to a narrow range of services, such as health services, or to a particular set of providers, such as licensed medical agencies, or to a specific setting, such as nursing homes. The net effect is to force at-risk persons with a wide variety of conditions and disabilities into a narrowly focused regimen which will frequently give inadequate support or will demand such restriction that a client's independence and dignity are sacrificed.

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A non-service-providing care coordinating agent with flexible fiscal authority can tap into the broad range of services available through diverse providers to tailor care to a client's demonstrated need. Health care, social support, and environmental support can be purchased as needed on the client's behalf. The care-coordinating agent should also manage the client's care in the hose, the nursing home, elder housing, the adult foster care home, and the adult day care center.

The System Should Provide Universal Eligibility

In eligibility, benefits, and costs long term care should be age-neutral. Although ninety percent of potential long term care clients are over sixty years, disability is no respecter of age. Many Area Agencies on Aging, operating under Medicaid waivers, routinely serve younger clients.

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