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Prepared Statement of Rosalie A. Kane, DSW

Senator Adams, Members of the Subcommittee on Aging, I am Rosalie Kane, a professor in the Division of Health Services Research at the School of Public Health and in the School of Social Work, both at the University of Minnesota. I also direct the Long-Term Care Decisions Resource Center, one of the 6 National Resource Centers on Long-Term Care funded by the Administration on Aging. Since October 1988, our Center has provided training, technical assistance, research and development and information dissemination to State Units on Aging (SUAS) and Area Agencies on Aging (AAAs) to assist them in developing or refining community long-term care programs. Our Center's particular topics of expertise include case management and assessment, links between acute care and long-term care, and ethical issues in long-term care.


In the last 2 1/2 years, the University of Minnesota's Resource Center has worked with more than half the states, and in many has provided intensive targeted assistance. We, therefore, are positioned to be familiar with the Aging Network roles in long-term

I would emphasize several points about the aging network and long-term care. First, the Aging Network is already heavily involved in long-term care, often providing the ongoing leadership to evolve a system of community-based care despite multiple, confusing funding sources, and often providing the entry point and care coordination (or case management) to link services to the client. Second, the Aging Network is heavily involved in developing and refining the technology necessary for community long-term care, including development of assessment tools, criteria for prioritizing need and planning services according to need, management information systems, and even quality assurance systems. Third, the Aging Network is well suited because of its mission and its structure to take this leadership and perform these roles, including case management.

Fourth, the challenges to the Aging Network differ in the 1990s from those of the 1970s when the Network was young, with long-term care at the center of those challenges. And, fifth, there is substantial interstate variation in the extent and nature of community long-term care financing and delivery, as well as the in role of the Aging Network. Finally, as requested by the Subcommittee, I will comment on some of the ethical issues confronting the OAA with regard to long-term care.


It is too late to ask whether the Aging Network should become involved in longterm care: the Aging Network is involved in long-term care. In many states--Washington, Pennsylvania, Massachusetts, Florida, Oregon, Maine, Arkansas, Illinois, Georgia, Michigan, Arkansas, Kansas, Indiana, and North Dakota among them, the SUAS and at the local level the AAAs have been designated lead agencies for all or a substantial part of the long-term care effort. In some instances, the Aging Network is responsible for coordinating almost all the community long-term care programs. In such states, the Network manages not only Title III OAA dollars but special state revenues (often a big part of the service dollar), Title XX moneys, and Medicaid waiver dollars. Oregon, where substantial administrative consolidation has occurred, is the most striking example of this leadership for the Network, but other states have similar arrangements. In some states (for example, Pennsylvania) the Network conducts Nursing Home Preadmission Screening, which forms the basis of eligibility for Medicaid waiver programs. In some states (for example, Florida) the Aging Network functions parallel to and in coordination with a Medicaid waiver program run by social service authorities, but the Aging Network itself manages statewide programs that vastly swell the service potential of Title III of the OAA

In some states, particularly those with strong traditions of county social service (for example, Wisconsin, Minnesota, South Carolina), the Aging Network is not the

officially designated lead organization, but the SUAS provide strong leadership through planning and training, and have developed ways that Title III services play an important role in a coordinated approach to long-term care. Wisconsin is an excellent example of this pattern. The SUA staff has provided intellectual leadership for the wide range of Medicaid waiver and other state programs and has been instrumental in developing and promulgating what has become known as the Wisconsin philosophy of long-term care. This is a client-centered philosophy with a commitment to client choice, autonomy and social participation and to flexibility in service delivery. In some states (notably California) where different lead agencies are competitively selected for the Medicaid waiver program and for another statewide program of case management with fewer services (called Linkages), the state SUA is the lead for both programs and AAAs have often been selected as the lead agencies.

In yet other states, where community long-term care systems are less developed and coordinated, the governor has appointed the SUA to develop a statewide long-term care planning effort. For example, the Hawaii SUA has recently undertaken such an effort and the SUAS in Idaho, New Mexico, and West Virginia are currently engaged in statewide planning. AOA discretionary grants such as the long-term care systems planning grants available in FY 1990 and quality assurance development grants available earlier have been helpful in encouraging this kind of development.

It is also noteworthy that Aging Network agencies were highly visible as lead sites during the era of long-term care demonstrations in the 1970s and 1980s. For example, in the Long-Term Care Channeling Demonstration co-funded by HCFA and AOA, which was the culminating community long-term care demonstration, 6 of the 10 lead sites were




Many of the programs that I have described are mature programs that have been giving leadership and allocating long-term care resources since the 1970s. As might be expected, such programs are well along the road to developing the structure and technologies necessary for an optimal community long-term care system. In many states, new assessment tools are being developed. In this fiscal year, our Resource Center is working intensively with 3 states that are currently developing or consolidating assessment tools, and has provided comment to 6 others on their ongoing work with assessment tools. Some states are currently involved in designing screening tools and an appropriate feeder and referral system for community-based long-term care. Many states are examining the way case management is delivered in the state and are creating new manuals and guidelines to bring consistency and quality control to this pivotal function. Some states have been particularly interested in designing information systems (for example, Colorado and South Carolina), and quality assurance systems for personal care services, Title III services, and case management itself (for example Ohio, Wisconsin, and South Carolina). In various parts of the Aging Network, consideration is being given to new ways to merge services with housing. States are developing plans for adult foster care, assisted living, and other such programs that combine shelter and services and, in some states (notably Oregon and Washington) have incorporated such housing programs into the Medicaid waiver programs administered by the SUA.


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The Aging Network's historical mission is coordination and advocacy on behalf of older citizens. On all levels-federal, state, and local-both coordination and advocacy are pivotal in long-term care. Indeed, case management is a function that requires both advocacy and coordination.

given its structure and evolution in the last two decades:

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All things being equal, the Aging Network is well-suited for major roles in LTC


The Network has access to a grass roots constituency of seniors through its meal sites and Senior Centers, which provide an efficient mechanism for education and for casefinding. It also provides a mechanism to discover the ongoing and changing needs of older people.

The Network has developed a capacity for Information and Referral, which also is a mechanism for casefinding and channeling, as appropriate, to community case managers.

The AAAS tend to be well respected organizations in the community without the stigma associated with "welfare” in the minds of many seniors.

Because AAAs serve all people regardless of income (though targeting recently to those in greatest need), they are well suited to manage a range of services, each with differing eligibilities.

When Network agencies provide case management in long-term care, they may be particularly well-positioned-because of Title III-to offer a continuum of services. They may also be well positioned to involve volunteers in the programs.



Since the enactment of the OAA, the needs of Seniors have changed. Although poverty among the elderly is still present (especially among very old women and disadvantaged minority persons), financial security for older people has on the whole dramatically improved. The last 30 years have brought life-prolonging technologies, leading to a larger group of disabled elderly people in the community. New pressures for early discharge from hospitals has exacerbated the need for community based long-term care. The persons who gravitated to meal sites and Senior Centers in the early days of the OAA are no longer 60 and 65, but 80, 85, and 90. Persons now 60 or 65 and even 70 and 75 rarely identify themselves as old. While their health is good, they typically have their own sources of stimulation and nutrition. Some clients of congregate meal sites and senior centers are themselves the family caregivers for very old parents and other relatives. The subgroups among the old who now are most in need of advocacy and coordination are those with functional impairments. Without abandoning its traditional and important role of general advocacy for older persons in the spirit of Title I of the

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