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

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The medical assistance program under title XIX of the Social Security Act is a Federal-State partnership through which Federal matching grants help States provide medical services to aged, blind, and disabled individuals and to families with dependent children who meet stringent financial standards. The program is administered by the Medical Services Administration in HEW's Social and Rehabilitation Service. Total expenditures for the program in fiscal year 1975 were $12.6 billion of which the Federal share was approximately 55 percent.

Forty-nine States (Arizona plans to initiate a program in July 1976) and the District of Columbia, Guam, Puerto Rico, and the Virgin Islands operate medicaid programs. In each State, a single State agency is responsible for administering the medical assistance program in accordance with a State plan that has

been approved by the Social and Rehabilitation Service. The State plan enumerates the services to be covered by the program and must conform to the statute (title XIX of the Social Security Act as amended) and the regulations issued by the Department of HEW.

Required services commonly used by the elderly include the following: -physician services;

-inpatient hospital services (except in institutions for tuberculosis or mental diseases);

-outpatient hospital services;

-other laboratory and X-ray services;

-care in a skilled nursing facility;

-home health services; and

-family planning services.

The statute gives States the option of providing some or all of a list of optional services. In that list, the following are of interest to the elderly: -clinic services;

-prescribed drugs;

-dental services;

-prosthetic devices;

-eyeglasses;

-private duty nursing;

-physical therapy and related services;

―other diagnostic, screening and preventive and rehabilitative services; -emergency hospital services;

-podiatrists' services;

-optometrists' services;

-chiropractic services;

-care in institutions for mental diseases;

-care in institutions for tuberculosis; and

-care in an intermediate care facility.

About 19 percent of medicaid's nearly 23 million patients are 65 or older. About 40 percent of medicaid's funds are spent on this group. Individuals over 65 are the principal users of skilled nursing and intermediate care facility services and services in institutions for mental diseases.

Eligibility for medicaid is related to eligibility for the supplemental security income (SSI) program, a Federal income maintenance program for the aged, blind, and disabled (title XVI of the Social Security Act) that became effective January 1, 1974. Title XIX gives each State the choice of using the SSI definition of "aged, blind, and disabled" in determining medicaid eligibility or of establishing a more restrictive definition of its own. States also have options in regard to determining financial eligibility for medicaid. A State may use the Federal SSI payment as the income level, the SSI payment plus its own supplement (if any), the income level of the "medically needy" (if it offers medicaid to the medically needy), or an income level more stringent than any of these.

It is thus important for aged persons to realize that eligibility for a cash SSI payment does not automatically make them eligible for medicaid.

Because States do not follow the same procedures, aged individuals who want to find out whether they are eligible for medicaid should first call their local welfare or social services offices to find out what rules the State is following and which office is making medicaid eligibility determinations. The local welfare/ social services office will be the right place to apply in some States and the local social security office in others.

Aged persons who are covered by medicaid usually have to find their own physicians and other health care providers, and should make sure that the health care providers they want to use will accept medicaid patients. Medicaid patients should not accept bills for services covered by the medicaid program. The providers should send bills to the State medicaid agency or its designated fiscal agent. If a patient finds it difficult to find a provider willing to accept a medicaid patient, his local welfare or social services office will often be able to help him find one. Medicaid is also required to assure that eligible individuals have transportation to and from providers of medical service.

SPECIAL PROGRAM ACTIVITIES SERVING THE ELDERLY

Recognizing the heavy emphasis on institutional care which has developed in the medicaid program and in keeping with the Department's objective of en

couraging alternatives to institutionalization, MSA has developed and funded (in some instances in cooperation with the Administration on Aging) several projects designed to provide a complex of services to the aging. The following are programs underway at the present time:

On Lock Center

This center was established in 1972 to provide much needed geriatric services to elderly Chinese, Italian, and Filipino persons living in the Chinatown-North Beach section of San Francisco. It was funded as an R. & D. project by SRS. There is a strong health component, with an occupational therapist in charge of the program. Other primary staff includes a full-time Public Health nurse, a part-time physician (internist), a physical therapist, nutritionist, speech therapist, and reality-recreation therapist. The program emphasizes rehabilitation but also provides much needed maintenance services. Eighty percent of the participants are over 70 years old. Most of the participants have medical problems that require supervision on a sustained basis.

Mosholu-Montefiore Day Care for Elderly

This program is located in Bronx, N.Y., on the grounds of the Montefiore Hospital and Medical Center. This program was funded by SRS in 1972 as an R. & D. project. The staff is composed of one director (MSW), three aides, one social worker, one counseling specialist, one R.N., one L.P.N., one OT, and one secretary, all full time. The physician is part time. The program uses the facilities of an existing institution (the Monetfiore Center) for the meals and social programs. The daily health care of the participants is supervised by the R.N. and L.P.N. Procedures for special care, such as physical therapy or emergency treatment, are provided by staff of the Montefiore Hospital or Community Center. Recreational activities based on a participant's medical needs and interests are provided as a part of the daily schedule.

St. Camillus

This facility, located in Syracuse, N.Y., is a 130-bed skilled nursing facility which also offers a wide range of outpatient services such as occupational therapy, physical therapy, pulmonary care, diabetic care, and arthritic care. The day care program is operated as an independent program; however, patients admitted to the day care program receive most of their services from the St. Camillus Outpatient Department. The primary staff is composed of a registered nurse, social worker, and administrative and clerical personnel. Other staff are sharesd by St. Camillus SNF and the day treatment program.

Patients must have their own physicians. Day center personnel work cooperatively with each patient's physician to develop a care plan and obtain written orders. Care plans and physicians' orders are reviewed by day center staff with the private physician at least every 30 days. The medicaid rate is $12.50 per day, excluding transportation. Transportation costs vary with arrangements. Currently, taxi rates are about $5 per patient per day. There are approximately 45 persons in this program.

Burke Day Hospital

This program operates like a subsidiary of the Burke Rehabilitation Hospital of White Plains, N.Y. Although the day hospital is an independent program, the administrative staff has contracted with the Burke Hospital to utilize many of its services.

The day hospital is distinguished from the programs described above in two ways: (a) The patients served generally have more chronic medical problems, and (b) diagnostic and treatment services are more sophisticated.

Convenient access to the Burke Hospital treatment facilities permits employment of these sophisticated diagnostic and treatment services such as radiological therapy, hydrotherapy, or electroencephalography for the day hospital patients.

The physician for the day hospital is a member of the Burke Hospital medical staff and is part time for the day hospital. Other primary staff includes a primary nurse practitioner, registered, nurse, licensed practical nurse, physical therapist, occupational therapist, speech therapist, and recreation therapist. The

program emphasizes rehabilitation and is vitally concerned with patients who have chronic medical conditions and require an intensive maintenance program to keep them from being hospitalized for long periods of time.

Wisconsin Community Care Organization

This program's overall objective is to demonstrate that a substantial segment of the elderly and functionally disabled population may be maintained in their own homes at a cost lower than that of the present pattern of institutionalization through the provision of a packaged continuum of health and health related social services, such as meals-on-wheels. An inherent premise of this objective is the belief that this population would prefer to continue to live at home if possible. This premise as well as the overall objective will be tested as a part of the project evauation.

The CCO seeks to demonstrate that quality of care can be improved over that which is the experience in the current medical assistance program by introduction of interventionary health related social services and limited health services as offered by the CCO. This objective is based in part on data cited on accelerated rates of debilitation following institutionalization, studies on debilitation as a result of inappropriate placement and the experience of health maintenance organizations in reducing the demand for acute care services by early provision of lower level health services. Again, this premise will be tested as part of the evaluation design. Specific indices will be examined in the CCO population in contrast to a control population in the current system to test achievement of this objective.

FISCAL 1976

To implement the mandate of Public Law 92-603, section 222, titles XVIII and XIX awarded the following contracts:

Prospective Reimbursement

During a 3-year period 16 hospitals in South Carolina will participate in a prospective rate reimbursement experiment through a contract awarded to the University of South Carolina. There are three major aspects of the experiment: (1) budget review guidelines, (2) cost savings measures and measurements, (3) rating criteria for new ventures capital expenditure programs. In general, the evaluation will examine and analyze the strengths and weaknesses of this approach to cost containment. It will also examine the efficiency and effectiveness of the total program as well as the three program components mentioned above. The program components will be studied in terms of their effects on hospital budget preparation processes, hospital budgets, hospital decisionmakers motivational changes, and changes in new ventures projects funded.

Homemaker and Day Care Experiments

Section 222 authorizes experimentation to establish an experimental program to provide day care services under title XIX and part B of title XVIII; and to determine whether coverage of homemaker services would provide suitable alterations to posthospital benefits presently provided under title XVIII. In June 1975, contracts were awarded to the following agencies:

Combined Homemaker and Day Care Services.-Lexington-Fayette County Health Department, Lexington, Ky.; San Francisco Home Health Agency, San Francisco, Calif.

Day Care Services.-Burke Rehabilitation Center, White Plains, N.Y.; St. Camillus Nursing Home, Syracuse, N.Y.

Homemaker Services.-Homemaker-Home Health Aid Services, Providence, R.I.; Los Angeles Intercity Home Health Agency, Los Angeles, Calif.

Day Hospital and Rehabilitation Medicine

A proposal has been developed with the Albert Einstein College of Medicine (Bronx, N.Y.) because of concern over the high cost of inpatient rehabilitation

care.

2 Housekeeping aid and transportation.

The Einstein experiment will test the assumption that day hospital services can result in a substantial reduction in medical care costs for the seriously disabled, compared to conventional inpatient hospital treatment, without reducing the quality of care. If the experiment is clinically successful, it must be determined if the reduction in cost is sufficient to warrant medicare and medicaid covering the cost of transportation for day hospital services under the program. The program will evaluate the effectiveness of a day hospital service as a substitute for the conventional inpatient hospital for the treatment of the seriously disabled. The project would also include an intensive family training program as a part of effective day hospital care.

OFFICE OF EDUCATION

On December 10, 1976, the Commissioner of Education and the Commissioner on Aging met to discuss a joint working agreement, the purpose of which is "to promote the more exective and efficient use of the resources available to the Office of Education and the Administration on Aging in order to maximize the educational opportunities for older persons." The draft agreement sets out a series of 23 goals and objectives which the two agencies hope to pursue together. Among the joint strategies currently under discussion which will be utilized to implement these objectives are:

-Establishment of an interagency committee to continue providing leadership and coordination in carrying out the agreement;

-Support and participate with the National Institute of Education in establishing and operating an interagency panel on research and development in adulthood;

-Promote the appointment of representatives of the elderly on education councils and of educators on councils for the aging;

-Promote the development of policies and programs designed to eradicate ageism, stereotyping, and discrimination;

-Encourage and support the use of volunteers of all ages in education activities for older persons;

-Encourage the development of agreements between agencies at regional, State, area and local levels; and

-Support joint research and demonstration projects and the development of technical assistance materials.

Office of Education major program activities for the older American are concentrated in four areas: Adult education, community services and continuing education, public library services, captioned films and television.

1. ADULT EDUCATION

The adult education program authorized under the "Adult Education Act of 1966," as amended, provides undereducated adults (persons 16 years of age and older) an opportunity to continue their education to at least the level of completion of secondary school and makes available the means to secure training that will enable them to become more employable, productive, and responsible citizens.

The program is a State grant operation administered by State education agencies according to State plans submitted to the U.S. Office of Education and approved by the U.S. Commissioner of Education. States are allowed grants to pay the Federal share of the cost of establishing or expanding adult education programs in local educational agencies and private nonprofit agencies. The matching requirement for the State grant program is 90 percent Federal funds and 10 percent State and/or local funds.

The regulation of the adult education State grant program requires an annual review of priorities in the field in order to examine and update currently established priorities, identify new areas of national concern, and recommend new priorities for programs of national significance. For fiscal year 1976, the following priority statement was distributed to the States for their guidance:

INVOLVEMENT OF OLDER CITIZENS IN ADULT

EDUCATION

The Congress, the National Advisory Council on Adult Education, and other interested persons and groups have recommended to us (Office of Education) that we find ways of improving educational opportunities for adults who are 45

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