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questions if we start shifting funds from Medicaid into other types of services that may be more helpful for our senior citizens, is going to be what kinds of a case management do you have? What kind of targeting should there be? And then, who manages it? There is emerging consensus here that the States will do management; we are not going to manage that from Washington, DC.

But if you would submit in writing to the committee-I do not want you to have to do this orally now-your recommendations on that, we would appreciate it very much. We will be working with Senator Rockefeller, other members of this committee, and other Members of Congress, to try to devise a system that will work effectively.

Senator Durenberger, do you have some questions?

Senator DURENBERGER. No, I don't. Thank you very much, Mr. Chairman.

Senator ADAMS. Thank you all very much. We appreciate your testimony. As you can see, we have tried to move from the national picture, to those who are receiving services, to those who are directly involved with the OAA in supplying them. I congratulate all of you on doing an excellent job.

The fourth panel will examine how the aging network fits into the present and future long-term care system. They will present assessments on the strengths and weaknesses of the network in this regard. We will hear from two directors of long-term care resource centers, which are funded by the Administration on Aging.

Dr. John Capitman is a research professor at Heller Graduate School of Brandeis University. He also directs the National Aging Resource Center on Long-term Care at the university. He has researched and published extensively on the subject of long-term care, financing, organization and delivery.

Dr. Rosalie Kane is director of the University of Minnesota's Long-Term Care Decisions Resource Center in Minneapolis, MN. Dr. Kane received her doctoral degree in social work from the University of Utah. She previously worked with the Rand Corporation and was affiliated with the University of California at Los Angeles. Dr. Kane is the co-author of numerous books and articles on longterm care and ethics.

We can start with either one of you.

Senator DURENBERGER. Mr. Chairman, let me just make a comment, if I may, first.

Senator ADAMS. Yes, Senator Durenberger?

Senator DURENBERGER. It probably is only to expand what you and the staff already know. Dr. Kane and her husband, Dr. Robert Kane, are probably the greatest contributors to our knowledge base on long-term care or at least our exploration base on the issues of long-term care in this country.

I am sure you travel one of our airlines with some frequency to your home State of Washington.

Senator ADAMS. I do.

Senator DURENBERGER. And I am on Northwest Airlines with great frequency. And I must tell you that every single trip that I take there is either Rosalie Kane or Bob Kane or, about 50 percent of the time, both of them. Minnesota makes many contributions to public policy. Few of them are politicians. Most of them are people

like the Drs. Kane who are a national treasure and who never cease to amaze me, either one of them, with their availability to everybody in the field. So, I am just pleased to be able to represent them both and to have Rosalie here today on this very important topic.

She is also the recipient at the center of a Title IV grant which is running out this year. So, I hope that not only this contribution that she makes today, but the contribution she has made over the last 3 years will merit some attention to the value of those Title IV resource center contributions.

Senator ADAMS. With that statement, Dr. Kane, we just have to hear from you.

Dr. Kane.


Dr. KANE. Senator Adams and Senator Durenberger, thank you for having me here, and I very much appreciate those comments, Senator Durenberger. The Title IV grant that you are alluding to is, of course, the grant that made possible these long-term care resource centers which Dr. Capitman and I represent, and indeed, we are sorry that they are running out this year.

But in the course of working with the long-term care resource center in the last 21⁄2 years, we have had the opportunity to have close contact with many of the States. In fact, our center alone has worked in and with more than half of the State units on aging and their associated area agencies on aging. In the last 22 years, our particular focus as a center, because each of the six has its own foci, is our case management and assessment links between acute and long-term care and ethical issues in long-term care.

And so, it is from that perspective that I can comment on the Older Americans Act programs. I am just going to summarize my written testimony. I am grateful for the chance to put the entire testimony into the record.

Senator ADAMS. Without objection, your entire statement will appear in the record as though read, Dr. Kane.

Dr. KANE. Thank you.

Then in that case, I will try to rattle off a number of points. I want to make five points about the aging network and long-term


First of all, I would like to underscore what people have already said, that the aging network is already heavily involved in longterm care, often providing the ongoing leadership to evolve a system of community-based care despite the multiple funding streams and the complexities of doing it.

Second, I would like to say that the aging network organizations, the SUA's and AAA's, are heavily involved in developing the technology that is necessary for long-term care.

Third, I want to emphasize that I think that the aging network is particularly suited to this role because of its historic mission and its structure.

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Fourth, I want to say a few things about how times have changed since the original authorization of the Older Americans Act, which creates new challenges for the network, and say something about State variation.

If I have time, I will say something about the ethics issues. So, the first point is simply that States are enormously involved in long-term care. They are giving coordination. They are giving leadership. In many States, the State network and then the related AAA's are the lead agencies for the management of a great many kinds of funds, not just the small red columns on the charts that represent Title III funds, but also Medicaid funds and lots of State money. So, in many States that whole effort has been developed out of the Older Americans Act.

We have other kinds of models in States with strong county traditions like our own in Minnesota and Wisconsin. You may find different lead agencies, but you will find the aging network organization highly involved in oversight, in monitoring and trying to help with the training and making sure that the programs are functioning as they should.

And then in some States where the systems are less developed and coordinated at this point, Governors have appointed the SUA's to develop a statewide long-term care planning effort. So, all of that is going on.

My second point is about the technology development. Senator Rockefeller alluded to that. He said there is a lot more to learn about case management, and I think there is. I believe that the State units on aging and the AAA's, including those who were represented in the previous panel, have already learned a lot about it, and they are in a position to learn more.

And as a resource center, we have been contacted by many States. They are developing new and better assessment tools to try to make the allocation of service more appropriate, more equitable, more accurate. They are worrying about the targeting. They are trying to develop the proper kind of screening mechanisms.

Senator ADAMS. I will not take this out of your time, Dr. Kane, but I hope that you will supply in writing to the committee information of your recommendations and, Dr. Capitman, if you would also, on how we should establish a management system, and how we should ensure effective targeting systems. I am not going to take that out of your time, but I just wanted to be certain that we have that for the record.

Please proceed.

Dr. KANE. I would be delighted to do that. My colleague and husband calls case management the pixie dust that is scattered over long-term care these days, but I think it is much more than pixie dust. It is extraordinarily important and is going to be the glue to hold it together. I would be pleased to provide that kind of list.

I think other kinds of work that I am loosely calling technology development includes management information systems. It includes trying to develop quality assurance approaches. And also, looking at services per se, a good many of our aging network organizations are involved in trying to evolve the kinds of service arrangements, the kinds of housing where services could also be sup

plied that would result in the sort of place that Ms. Lee alluded to that might be nice to have if she ever needs it.

The third point is that the aging network is suited for this in its mission and its structure. It has the grassroots constituencies of seniors through the meal sites and senior centers. It has a capacity for information and referral, a mechanism for case finding and channeling. Then one can get into the more heavy-duty long-term care constituency. The AAA's tend to be well-respected organizations in the community. They serve all people regardless of income and they are well-suited to manage a range of services, each with different eligibilities. I think they are well-positioned to have that continuum.

I wrote about the changing demands of the 1990's, so I will not say anything more about it other than to emphasize that we do have a different constituency of elderly people, people who attended senior centers at the beginning of the act in their 60's and 70's are now in their 90's. New people in the community age 60 and above, as they retire, tend to have better income situations now thanks to previous work by legislators. But now while their health is goodthey are typically all right-and the subgroups among the old who now most need the advocacy and the coordination, which are both inherent in the Older Americans Act, are the people with functional impairments. So, without abandoning the traditional role of general advocacy for people, I think that it is really appropriate for the Older Americans Act agencies to be working in this area of long-term care.

I am not going to say anything about diversity because that has been mentioned already. There is so much variation that it is probably inappropriate to mandate one single system of long-term care at the State level for this country.

In terms of ethical issues, all I will say is that long-term care is definitely an arena that is fraught with ethical dilemmas. It invokes all the principals that ethicists and philosophers like to talk about, namely, autonomy, the principle that people should be able to run their own lives according to their preferences if they do not interfere with others. Beneficence. That is the principle we should do good for people. And justice. That means things should be fair. We should distribute rights, benefits and responsibilities fairly. And in regard to long-term care, there are a great many issues where these principles are invoked, and I described them in the written testimony.

I am very happy that the advocacy components of the Older Americans Act are going to be strengthened in the current reauthorization. At least I have heard that

I do want to iterate, because I was to address this, that I do not see any particular conflict in aging network agencies serving as case managers and also adhering to their advocacy function. I think it is through their active roles as case managers that they learn what they should be advocating about. In the written testimony, I gave some examples of the kinds of attention that case managers are now giving to the ethical concerns. So, I do not think that the aging network should avoid or withdraw from vital roles of case management. They will have to give attention to ethical ramifications of their work, such as the issues of informed consent

for case management, assessment, how you do it, how you assess values, how you deal with confidentiality, how you preserve contractual arrangements with agencies that are fair, and even the ethics of waiting lists for assessments.

I was pleased to hear about the legislation that you introduced for Senator Pryor. I had not heard about that before. I think a lot of these areas that I talked about in terms of the technologies_and also these ethically laden issues could be the stuff of the demonstrations that you are proposing.

I think I better stop. I have overdone my time. Thank you for having me.

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

Dr. Capitman.

Dr. CAPITMAN. Thank you. I am pleased to have this chance to speak before the committee about the current and potential roles of the Older Americans Act and the aging network in home and community-based care.

If I may, I would like to enter my written testimony and focus on five points.

Senator ADAMS. Without objection, your full statement will appear in the record as though given.

Dr. CAPITMAN. There are really five points that I would like to make today.

The first is that although there is a lot of room for improving our knowledge about clinical practice and the details of care delivery in long-term care, we have come to know a lot about the necessary administrative structures and the range of necessary services of an adequate delivery system.

The second is that while we may have learned these things, the task of building that basic infrastructure nationally is unfinished.

The third point is that the best systems, the systems that appear to be strongest in this country, are those that are built on a coalition between the Older Americans Act, the aging network services, and the Medicaid programs in their States.

Fourth, we need to continue our attention to capacity building, and I think that the Older Americans Act, the aging network is the place where that attention has to be centered.

And finally, I think there are two other key issues that nave to continue to be featured in discussions of long-term care. The first is the crucial need to continue developing the labor force for home care, and the second is continue to think about and put effort into how we are going to accommodate increasing cultural diversity among the aged in service approaches.

I want to talk about this first point, about what we do know. We have come to understand that in order to provide equitable access to affordable and high quality services for older people, we need to recognize the full ways in which older people are diverse when they come to long-term care, not only the diversity related to gender, race, ethnicity, region of the country, but also the diversity of service needs.

I suggest in the written testimony four basic kinds of community care service needs: assistance with household maintenance, home and community-based assistance with personal care, skilled atten

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