The Office of Research and Demonstrations within SRS has created a separate identifiable unit in the Health Services Division to focus on long-term care. Analysis of long-term care financing, developing alternatives to institutionalization, and studying the impact upon health delivery systems of a series of alternatives, including nonmedical services, is being emphasized.

Although the long-term care R. & D. program is primarily concerned with the delivery of health care and other appropriate services to the chronically ill and disabled of all age groups, the elderly comprise the highest proportion of the population in need of these services. Promoting community care alternatives to institutionalization for the chronically ill and disabled who want and are able to function outside of institutions can have an important effect upon the lives of the elderly.

During fiscal 1975, two demonstrations and analyses of community-wide coordinated health and social services delivery programs were initiated. The major thrust of this effort is to determine whether integrating services on a community-wide basis can improve the quality of care and reduce costs for delivering longterm care to the chronically ill and disabled. The projects are in early planning stages. One, in the State of New York, entitled "Demonstration of CommunityWide Alternative Long-Term Care Models," is testing the feasibility of developing community-wide, populations-based models for the organization, delivery, and financing of care within Monroe County, N.Y. The second project, in the State of Washington, "Community-Based Care Systems for the Functionally Disabled-A Project in Independent Living," is an effort to examine the effects of focusing State social services on coordinating health and social services delivery in order to prevent unnecessary institutionalization and improve the quality of care for high-risk populations. Each of these projects is an attempt to provide care plans for the population-at-risk which contribute to the maintenance of integrity and self-sufficiency through appropriate services and placements fitting the functional capacity of the long-term care population. Each will attempt to develop a link to the continuum of care important for this population as well as links with service providers for care delivery. In each of the projects, costs will be tracked and evaluation of effectiveness undertaken through comparison with a control community. In fiscal 1976 two additional projects were approved, one in Georgia, "Cost Effective Alternatives to Nursing Home Institutionalization," and Vermont, "Long-Term Care Proposal."

A research project primarily concerned with exploring the visibility and costeffectiveness of delivering services to the chronically ill and disabled in settings other than day care centers, nursing homes, and long-term care hospitals is expected to have several additional products. The project, "The Feasibility and Cost-Effectiveness of Alternative Long-Term Care Settings," is being undertaken by the Standford Research Institute. Its products, when completed, should provide a number of case studies on long-term care programs outside of nursing homes and long-term care hospitals. (A companion investigation of day care centers has been undertaken by the Health Resources Administration.) A comparision of costs for participants of like functional capacity in nursing homes and the studies settings within the same geographic area will provide insights into the relative costs for different service packages for such groups. These case studies may provide guidelines on initiating similar programs useful to innovators developing community care projects. In addition, a bibliography on studies of long-term care providing systematic information on developments in this field and a report on the effects of legislative, regulatory and/or administrative programs on the feasibility of establishing alternative long-term care programs are being prepared.

The Utah Long-Term Care Payment System project is a statewide experiment designed to link reasonable cost reimbursement with the quality of care within skilled nursing facilities. It is not only designed to respond to the requirements of section 249 of Public Law 92-603 but to add to the system a structure which will increase nursing home accountability for appropriate services to the patients as well as provide an opportunity for the type and level of care extended to individual patients to be a component in the cost-reimbursement system.

The demonstration projects program in public assistance under section 1115 of the Social Security Act has provided grants to State public welfare agencies for several additional projects during fiscal 1975 which are totally or partially concerned with providing a variety of services to elderly recipients in public welfare.

A project in Pennsylvania on health services is demonstrating how such services should be administered to persons 65 years or older who were victims of a flood disaster.

In California, Texas, and Wisconsin, projects are demonstrating the effect of social services including day care and homemaker services in keeping the elderly in their own homes instead of in intermediate care facilities and nursing homes. A project in New York City, "Project Monitor in Day Hospital in Rehabilitation Medicine," is testing the effect of day hospital care in lieu of 24-hour hospitalization.

Housing allowances are being made to the elderly in eight experiments which are being carried out by the Department of Housing and Urban Development. Waiver of plan requirements has been granted by the Secretary to enable SSI recipients to participate in the experiments without having their grant entitlement reduced.

A project in Alaska permitted the exclusion from income for the purpose of determining supplemental security income (SSI) eligibility of monthly benefits which are paid by the State of Alaska to elderly people who have lived there more than 25 years.

Current plans for research and evaluation projects for fiscal 1977 include a project to develop a method for comparing long-term care costs and services, a demonstration of incentive reimbursement system for long-term care, and a project in effectiveness of SNF/ICF standards.

2. SOCIAL SERVICES PROGRAM

During the first quarter of fiscal year 1976, social services programs for the aging were funded under provisions of title VI of the Social Security Act for the 50 States and the District of Columbia, and under provisions of titles I, X, XIV and XVI for Puerto Rico, the Virgin Islands, and Guam. During the remaining three quarters of the fiscal year, service programs were funded under title XX. Public Law 93-647, which established title XX grants to States for social services under the Social Security Act, became effective on October 1, 1975, replacing the social services provisions of titles IV-A and VI for the 50 States and the District of Columbia. Title XX may serve not only persons who receive aid to families with dependent children and supplemental security income payments but also, at State option, intact families and individuals with gross monthly income not exceeding a level set by the State which must be within limitations established by the Federal legislation. Under Federal legislation, funding in the fiscal year of the social services for aging under both titles VI and XX was included in the $2.5 billion ceiling on Federal financial participation for public assistance social services.

Approximately 287,000 SSI aged recipients from the 50 States and the District of Columbia received services during the first half of fiscal year 1976. Data regarding expenditures for this group of eligibles in fiscal year 1976 is incomplete at this time.' It has also been estimated that the most frequently provided service was related to the health needs of these persons and that the next most frequently provided was that of homemaker and home health aide service. Other major services provided were information and referral, family counseling, chore services, and protective services.

Continued efforts to upgrade services to the elderly at the Federal level included working with the following: the Domestic Council Task Force on Drug Abuse; the Interagency Task Force on Home Health Services (a national effort to increase the use of home health services as an alternative to inappropriate institutional care); the President's Committee on Mental Retardation; and the National Council on Homemaker-Home Health Aide Services, Inc. This latter includes a project funded by the Edna McConnell Clark Foundation to extend homemaker-home health aide services by utilizing older persons for provision of these services.

A joint agreement was developed between Administration on Aging, Office of Human Development and Community Services Administration (presently Public Services Administration), Social and Rehabilitation Service to promote joint efforts at the Federal, State, and local levels to develop comprehensive, coordinated social service systems for elderly native Americans served by these two administrations of HEW.

1 The new social services reporting system introduced by SRS requires States to provide data on a quarterly basis. The data for all of fiscal year 1976, including the transitional quarter. is incomplete and requires additional refinements which preclude our providing accurate estimates for the full year.

The Office of Research and Demonstrations within SRS has created a separate identifiable unit in the Health Services Division to focus on long-term care. Analysis of long-term care financing, developing alternatives to institutionalization, and studying the impact upon health delivery systems of a series of alternatives, including nonmedical services, is being emphasized.

Although the long-term care R. & D. program is primarily concerned with the delivery of health care and other appropriate services to the chronically ill and disabled of all age groups, the elderly comprise the highest proportion of the population in need of these services. Promoting community care alternatives to institutionalization for the chronically ill and disabled who want and are able to function outside of institutions can have an important effect upon the lives of the elderly.

During fiscal 1975, two demonstrations and analyses of community-wide coordinated health and social services delivery programs were initiated. The major thrust of this effort is to determine whether integrating services on a community-wide basis can improve the quality of care and reduce costs for delivering longterm care to the chronically ill and disabled. The projects are in early planning stages. One, in the State of New York, entitled "Demonstration of CommunityWide Alternative Long-Term Care Models," is testing the feasibility of developing community-wide, populations-based models for the organization, delivery, and financing of care within Monroe County, N.Y. The second project, in the State of Washington, "Community-Based Care Systems for the Functionally Disabled-A Project in Independent Living," is an effort to examine the effects of focusing State social services on coordinating health and social services delivery in order to prevent unnecessary institutionalization and improve the quality of care for high-risk populations. Each of these projects is an attempt to provide care plans for the population-at-risk which contribute to the maintenance of integrity and self-sufficiency through appropriate services and placements fitting the functional capacity of the long-term care population. Each will attempt to develop a link to the continuum of care important for this population as well as links with service providers for care delivery. In each of the projects, costs will be tracked and evaluation of effectiveness undertaken through comparison with a control community. In fiscal 1976 two additional projects were approved, one in Georgia, "Cost Effective Alternatives to Nursing Home Institutionalization," and Vermont, "Long-Term Care Proposal."

A research project primarily concerned with exploring the visibility and costeffectiveness of delivering services to the chronically ill and disabled in settings other than day care centers, nursing homes, and long-term care hospitals is expected to have several additional products. The project, "The Feasibility and Cost-Effectiveness of Alternative Long-Term Care Settings," is being undertaken by the Standford Research Institute. Its products, when completed, should provide a number of case studies on long-term care programs outside of nursing homes and long-term care hospitals. (A companion investigation of day care centers has been undertaken by the Health Resources Administration.) A comparision of costs for participants of like functional capacity in nursing homes and the studies settings within the same geographic area will provide insights into the relative costs for different service packages for such groups. These case studies may provide guidelines on initiating similar programs useful to innovators developing community care projects. In addition, a bibliography on studies of long-term care providing systematic information on developments in this field and a report on the effects of legislative, regulatory and/or administrative programs on the feasibility of establishing alternative long-term care programs are being prepared.

The Utah Long-Term Care Payment System project is a statewide experiment designed to link reasonable cost reimbursement with the quality of care within skilled nursing facilities. It is not only designed to respond to the requirements of section 249 of Public Law 92-603 but to add to the system a structure which will increase nursing home accountability for appropriate services to the patients as well as provide an opportunity for the type and level of care extended to individual patients to be a component in the cost-reimbursement system.

The demonstration projects program in public assistance under section 1115 of the Social Security Act has provided grants to State public welfare agencies for several additional projects during fiscal 1975 which are totally or partially concerned with providing a variety of services to elderly recipients in public welfare.

A project in Pennsylvania on health services is demonstrating how such services should be administered to persons 65 years or older who were victims of a flood disaster.

In California, Texas, and Wisconsin, projects are demonstrating the effect of social services including day care and homemaker services in keeping the elderly in their own homes instead of in intermediate care facilities and nursing homes. A project in New York City, "Project Monitor in Day Hospital in Rehabilitation Medicine," is testing the effect of day hospital care in lieu of 24-hour hospitalization.

Housing allowances are being made to the elderly in eight experiments which are being carried out by the Department of Housing and Urban Development. Waiver of plan requirements has been granted by the Secretary to enable SSI recipients to participate in the experiments without having their grant entitlement reduced.

A project in Alaska permitted the exclusion from income for the purpose of determining supplemental security income (SSI) eligibility of monthly benefits which are paid by the State of Alaska to elderly people who have lived there more than 25 years.

Current plans for research and evaluation projects for fiscal 1977 include a project to develop a method for comparing long-term care costs and services, a demonstration of incentive reimbursement system for long-term care, and a project in effectiveness of SNF/ICF standards.

2. SOCIAL SERVICES PROGRAM

During the first quarter of fiscal year 1976, social services programs for the aging were funded under provisions of title VI of the Social Security Act for the 50 States and the District of Columbia, and under provisions of titles I, X, XIV and XVI for Puerto Rico, the Virgin Islands, and Guam. During the remaining three quarters of the fiscal year, service programs were funded under title XX. Public Law 93-647, which established title XX grants to States for social services under the Social Security Act, became effective on October 1, 1975, replacing the social services provisions of titles IV-A and VI for the 50 States and the District of Columbia. Title XX may serve not only persons who receive aid to families with dependent children and supplemental security income payments but also, at State option, intact families and individuals with gross monthly income not exceeding a level set by the State which must be within limitations established by the Federal legislation. Under Federal legislation, funding in the fiscal year of the social services for aging under both titles VI and XX was included in the $2.5 billion ceiling on Federal financial participation for public assistance social services.

Approximately 287,000 SSI aged recipients from the 50 States and the District of Columbia received services during the first half of fiscal year 1976. Data regarding expenditures for this group of eligibles in fiscal year 1976 is incomplete at this time.1 It has also been estimated that the most frequently provided service was related to the health needs of these persons and that the next most frequently provided was that of homemaker and home health aide service. Other major services provided were information and referral, family counseling, chore services, and protective services.

Continued efforts to upgrade services to the elderly at the Federal level included working with the following: the Domestic Council Task Force on Drug Abuse; the Interagency Task Force on Home Health Services (a national effort to increase the use of home health services as an alternative to inappropriate institutional care); the President's Committee on Mental Retardation; and the National Council on Homemaker-Home Health Aide Services, Inc. This latter includes a project funded by the Edna McConnell Clark Foundation to extend homemaker-home health aide services by utilizing older persons for provision of these services.

A joint agreement was developed between Administration on Aging, Office of Human Development and Community Services Administration (presently Public Services Administration), Social and Rehabilitation Service to promote joint efforts at the Federal, State, and local levels to develop comprehensive, coordinated social service systems for elderly native Americans served by these two administrations of HEW.

1 The new social services reporting system introduced by SRS requires States to provide data on a quarterly basis. The data for all of fiscal year 1976, including the transitional quarter. is incomplete and requires additional refinements which preclude our providing accurate estimates for the full year.

Negotiations are under way between the Administration on Aging, Office of Human Development and the Public Services Administration, Social and Rehabilitation Service, to enter an interagency agreement to address special needs of older persons arising out of the energy crisis.

A similar interagency agreement between the Rehabilitation Services Administration, Office of Human Development, and the Public Services Administration, Social and Rehabilitation Service is being developed which will promote cooperative arrangements between State and local vocational rehabilitation agencies and social service agencies serving disabled older persons.

In September 1976, an interdepartmental agreement was signed between HUD and HEW to coordinate the provisions of Public Law 93-383, the Housing and Community Development Act of 1974, with Public Law 93-647, title XX of the Social Security Act. The two departments are cooperating to establish and expand key efforts to create more effective environments, services and opportunities for persons residing in federally assisted housing.

FISCAL YEAR 1977

Objectives of the Public Services Administration for fiscal year 1977 include, through cooperative Federal and State efforts, the following:

1. Assure that the title XX statutory and regulatory provisions are met for the second program year, including the initiation of corrective action programs where necessary;

2. Develop the designated State agencies' capacity for effective services delivery, either directly or through agreements with providers;

3. Initiate any regulatory changes for the second program year found necessary or desirable out of the first program year experience, or for the third program year out of the second program year experience;

4. Strengthen each State's social service public planning process for the second title XX program year, which in some States began on either July 1, 1976, or October 1, 1976; and for the third program year, which in most States will begin July 1, 1977, or October 1, 1977; and

5. Provide for continuing evaluation of States' services program. Below are charts of the services from a sampling of States. The services, the number of clients, and estimated total expenditures were taken from the final comprehensive annual service program plan for each State in the sample.

It should be noted that in most cases States have not separated the aging from other clientele who are also expected to receive the services listed. Therefore, dollar amounts include expenditures for eligible persons in addition to the aging, unless specified.

For these reasons and for the reason that one person could be eligible for and receive more than one service, no totals have been shown on these charts since to do so could be misleading.

COMPREHENSIVE ANNUAL SERVICES PLAN FOR THE PERIOD OCT. 1 1976, TO JUNE 30, 1977