Long-Term Care Reform: States' Views on Key Elements of Well-Designed
Programs for the Elderly (Letter Report, 09/06/94, GAO/HEHS-94-227).

The state agencies agree widely on the key components of well-designed
programs for the elderly. State agencies believe that an elderly
person's ability to perform activities of daily living is the best way
to identify persons with the greatest need for services, although states
do not uniformly define such activities. To determine service needs,
state agencies generally agree that case/care management, a standard
assessment instrument, and involvement of the elderly person in the
process are most useful. State agencies report that the largest number
of severely disabled elderly persons need nonmedical services, such as
personal care. State agencies agree that a variety of cost control
methods are effective, although there is less consensus about which
specific methods work best. Regarding the private sector role in
long-term care, state agencies believe that the private sector role
could probably reduce government costs, and government interventions
might spur private sector activity.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-227
     TITLE:  Long-Term Care Reform: States' Views on Key Elements of 
             Well-Designed Programs for the Elderly
      DATE:  09/06/94
   SUBJECT:  Long-term care
             Elderly persons
             Handicapped persons
             Health insurance
             Home health care services
             Cost control
             Medicaid programs
             State-administered programs
             Community health services
             Elder care

             
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Cover
================================================================ COVER


Report to the Ranking Minority Member, Special Committee on Aging,
U.S.  Senate

September 1994

LONG-TERM CARE REFORM - STATES'
VIEWS ON KEY ELEMENTS OF
WELL-DESIGNED PROGRAMS FOR THE
ELDERLY

GAO/HEHS-94-227

Key Elements of Programs for Elderly


Abbreviations
=============================================================== ABBREV

  ADL - activity of daily living
  CCRC - continuing care retirement community
  IADL - instrumental activity of daily living
  IRA - individual retirement account

Letter
=============================================================== LETTER


B-256199

September 6, 1994

The Honorable William S.  Cohen
Ranking Minority Member
Special Committee on Aging
United States Senate

Dear Senator Cohen: 

Today, about 7 million elderly persons need long-term care.  Many
more will need long-term care in the future as the elderly population
continues to grow.  The elderly prefer home and community-based
services rather than nursing home care, and approximately 75 percent
of those needing long-term care live outside nursing homes.  To a
great extent, care for elderly persons with disabilities is provided
today by family and friends, mostly women. 

Total long-term care spending for the elderly in 1993 was estimated
to be $79.2 billion, $20.6 billion of which was for home and
community-based services.  Assuming the continuation of current
spending patterns under current law, it is estimated that total
expenditures will more than double by 2020.  But the future demand
for government spending may grow at an even faster rate because the
rising number of women in the workforce, smaller family size, more
frequent divorce, and geographic dispersal of families are likely to
decrease the ability of informal caregivers to provide the same
proportion of unpaid care. 

A number of proposals to reform long-term care have been introduced
in the Congress as part of the health care reform debate.  While
these proposals cover various long-term care populations and
services, almost all include home and community-based services for
the elderly as a major component of their reform strategies.\1 To
help inform this debate, you asked us to survey state agencies on
aging and state Medicaid agencies to obtain their views on how best
to design and administer public programs to provide home and
community-based long-term care services for the elderly.  Through
these agencies, many states have been innovators in trying to develop
programs that more effectively identify persons in need, determine
the types of services needed, and control costs. 


--------------------
\1 The current long-term care reform debate covers persons of all
ages--children, adults, and the elderly--with severe physical or
cognitive disabilities or both.  However, our work and its results
are limited to the elderly population. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Congressional deliberations on long-term care reform have focused on
key program components--who should receive services, what services
should be provided, and how costs can be controlled.  Another topic
of debate is how responsibility for long-term care should be shared
between the public and private sectors.  This report offers insight
on how the states view these issues for the elderly. 

Collectively, the state agencies' responses showed significant
agreement on key components of well-designed programs.  First, state
agencies agreed that an elderly person's ability to perform
activities of daily living (ADL)\2 is the best way to identify
persons with the greatest need for services.  However, ADLs are not
uniformly defined by the states, and most of the states use ADLs in
combination with other indicators to determine need.  The other best
indicators of need are cognitive disability and access to care from
family.  For determining service needs, state agencies generally
agreed that case/care management,\3 a standard assessment instrument,
and involvement of the elderly person in the process are most useful. 
Second, state agencies reported that the largest proportion of
elderly persons with severe disabilities need nonmedical services,
such as personal care.  Third, state agencies agreed that a variety
of cost control methods are effective, although there was less
consensus about which specific methods are most effective.  The most
frequently identified cost-control method was case/care management,
followed by limits on total individual costs, capitation with
providers at risk,\4 and fixed program allocations. 

State agencies believed that encouraging a greater private sector
role could reduce government long-term care spending for the elderly. 
For example, many state agencies believed that government
interventions could increase the use of private long-term care
insurance and private residential care alternatives, which might
reduce government long-term care spending for the elderly.  State
agencies agreed that informal or family care could reduce government
long-term care spending.  However, they did not believe that
government interventions would be likely to increase the use of this
approach. 


--------------------
\2 ADLs generally include bathing, dressing, eating, using the
toilet, continence (bowel or bladder control or both), getting in or
out of a bed or chair, and mobility. 

\3 Case management generally is a process that assists people in
defining their service needs, locating and arranging services, and
coordinating the services of multiple providers.  Case managers may
also be responsible for containing costs by controlling client access
to services, especially high-cost services. 

\4 Capitation with providers at risk is a financing arrangement in
which an organization receives a fixed amount of money for each
person who is enrolled in a care program in exchange for guaranteeing
the services needed by each person for a fixed period of time.  In
addition, the organization receiving the payments is financially
responsible for the costs of such services if total costs exceed per
capita payments. 


   BACKGROUND
------------------------------------------------------------ Letter :2

State governments, through their respective state agencies on aging
and Medicaid agencies, administer most home and community-based
services for the elderly and have been leaders in developing
strategies to provide more appropriate, integrated, and flexible
services to meet the long-term care needs of individuals with severe
disabilities and to identify methods to control costs.  Some states
have also been involved in efforts to establish public/private
efforts to meet long-term care needs.  As a result, state agencies'
views based on these experiences may help inform the congressional
debate on long-term care reform. 

The two types of agencies we surveyed--state agencies on aging and
Medicaid agencies--have different perspectives on administering
public programs and providing home and community-based services to
elderly persons with severe disabilities.  State agencies on aging
provide a broad range of general aging and advocacy services, such as
congregate programs, home meals, and ombudsman programs, for persons
60 years of age and older, targeting services to those most in need. 
Medicaid agencies, on the other hand, administer the Medicaid program
that was intended to pay primarily for low-income persons' medical
care but has also become the primary public funding source for
long-term care.  Evolving from the medical model, Medicaid's primary
long-term care role has been to pay for nursing home care.  Medicaid
agencies also administer funding for some coverage of nonmedical home
and community-based services to persons with severe disabilities. 
Compared with Medicaid agencies, state agencies on aging tend to
administer or oversee a larger number of other federal and state-only
funded home and community-based service programs for the elderly. 
Also, almost half of the state agencies on aging administer or
oversee at least some part of Medicaid home and community-based
program funds for their states. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :3

This study focuses on states' experiences in providing home and
community-based services to elderly persons with severe disabilities. 
This group includes those whose physical impairments are so great
that they are unable to carry out essential everyday activities
without assistance from others and those whose cognitive impairments
are so great that they need frequent or continuous supervision. 
Because younger persons with disabilities were not included in the
scope, the survey results do not apply to them. 

To do our work, we surveyed state agencies on aging and state
Medicaid agencies in the 50 states and the District of Columbia.  We
asked the agencies questions related to what they believed would be
the best approaches in providing home and community-based long-term
care services to elderly persons who are severely disabled,
considering limited resources.  We also asked the state agencies for
a copy of the assessment instruments they used to identify persons in
need of home and community-based long-term care services.  As agreed
to with your staff, we did not ask the state agencies to report their
current methods and practices for administering and designing home
and community-based services to elderly persons.  Also, we did not
independently verify state agency responses to the survey since the
survey focused on the state agencies' views. 

In designing the survey we drew on our previous long-term care
work,\5 reviewed the literature, and interviewed experts.  We then
pretested the survey instrument with state agencies and made
revisions as needed.  We mailed the survey on May 20, 1994.  We
received responses from all 51 state agencies on aging and from 50 of
51 state Medicaid agencies.  (See app.  I for the survey tables and
frequencies.) We received assessment instruments from 28 state
agencies on aging and 29 state Medicaid agencies. 


--------------------
\5 A forthcoming report, Long-Term Care:  Other Countries Tighten
Budgets While Seeking Better Access (GAO/HEHS-94-154), looks at other
countries' experiences with similar service and cost-control issues
in providing home and community-based long-term care.  For other
related products, see p.  32. 


   STATE AGENCIES GENERALLY AGREED
   ON KEY COMPONENTS OF HOME AND
   COMMUNITY-BASED SERVICE
   PROGRAMS FOR THE ELDERLY
------------------------------------------------------------ Letter :4

State agencies we surveyed generally agreed on key components of home
and community-based service programs for elderly persons who are
severely disabled.  These agencies generally agreed on key aspects of
how a public program would best determine which elderly persons are
most in need of home and community-based services and how a public
program would best identify services to meet these persons' needs. 
They also shared common views about the types of services needed by
the elderly who are severely disabled.  Finally, although they
reported that a variety of cost-control methods are effective, there
was less consensus about which methods are most effective. 


      AN ELDERLY PERSON'S ABILITY
      TO PERFORM ADLS IS THE
      LEADING INDICATOR OF NEED
---------------------------------------------------------- Letter :4.1

State agencies on aging and state Medicaid agencies almost
unanimously agreed that an elderly person's ability to perform ADLs
is the leading indicator for public programs to use in determining
need for home and community-based services, although ADLs are not
uniformly defined by the states (see fig.  1).  Moreover, most of the
state agencies' assessment instruments we received in response to our
survey used ADLs in combination with other indicators to determine
need. 

   Figure 1:  Best Indicators to
   Identify Elderly Persons With
   Severe Disabilities Who Have
   the Greatest Need for Home and
   Community-Based Services

   (See figure in printed
   edition.)

Note:  Maximum number of respondents:  51 state agencies on aging, 50
state Medicaid agencies.  Respondents each identified their top three
indicators. 

Source:  GAO survey of state agencies (July 1994). 

Many state agencies also regarded an individual's cognitive
disability and access to care from family as the best indicators of
need.  State agencies believed that several other indicators are
important to identify need for services among the elderly, although
agreement was less marked and varied between aging and Medicaid
agencies.  These indicators included an individual's (1) ability to
perform instrumental activities of daily living (IADL),\6 (2) medical
condition, and (3) need for supervision to avoid risk to self and
others.  Other indicators mentioned much less frequently included an
individual's income and assets, geographic isolation, request for
nursing home placement, and social isolation. 


--------------------
\6 IADLs generally include preparing meals, doing laundry, doing
heavy work, grocery shopping, managing money, taking medicine, making
telephone calls, doing light work, and going places beyond walking
distance. 


      THREE METHODS ARE MOST
      USEFUL FOR DETERMINING
      SERVICE NEEDS
---------------------------------------------------------- Letter :4.2

State agencies on aging and Medicaid agencies generally agreed that
three methods are most useful for public programs when determining
which services elderly persons with severe disabilities need.  These
methods are (1) case/care management, (2) a standard assessment
instrument, and (3) involvement of the elderly person in the process
of determining services (see fig.  2).  State agencies on aging,
however, more often identified these methods as most useful than did
state Medicaid agencies.  Some state agencies also believed that
other methods are most useful, including (1) interdisciplinary
assessment teams, (2) involvement of the elderly person's family, and
(3) periodic assessment of needs.  Only three agencies reported that
a physician's recommendation is one of the most useful methods of
determining need. 

   Figure 2:  Most Useful Methods
   to Determine Home and
   Community-Based Services Needed
   by Elderly Persons With Severe
   Disabilities

   (See figure in printed
   edition.)

Note:  Maximum number of respondents:  51 state agencies on aging, 50
state Medicaid agencies.  Respondents each identified their top three
methods. 

Source:  GAO survey of state agencies (July 1994). 


      THE LARGEST PROPORTION OF
      ELDERLY PERSONS WITH SEVERE
      DISABILITIES NEED NONMEDICAL
      SERVICES
---------------------------------------------------------- Letter :4.3

State agencies reported that the largest proportion of elderly
persons with severe disabilities need nonmedical services.  State
agencies most often cited (1) personal care; (2) housekeeping, meal
preparation, and other home chore services; and (3) case/care
management as the services needed by the largest proportion of
elderly persons with severe disabilities (see fig.  3).  Other
services mentioned by several states included home health care,
transportation, supervision for cognitively impaired persons, respite
care, and assistance for family caregivers such as training,
counseling, or support groups.  Adult day care, companion and
visitation services, and housing modifications were mentioned much
less often. 

   Figure 3:  Home and
   Community-Based Services Needed
   by the Largest Proportion of
   Elderly Persons With Severe
   Disabilities

   (See figure in printed
   edition.)

Note:  Maximum number of respondents:  51 state agencies on aging, 50
state Medicaid agencies.  Respondents each identified their top three
services. 

Source:  GAO survey of state agencies (July 1994). 


      VIEWS OF STATE AGENCIES
      SHOWED LESS CONSENSUS ABOUT
      WHICH COST-CONTROL METHODS
      ARE MOST EFFECTIVE
---------------------------------------------------------- Letter :4.4

Views of the state agencies showed less consensus about which methods
are most effective for controlling spending on home and
community-based services for the elderly.  The most frequently
identified cost-control method was case/care management (see fig. 
4).  Other frequently identified cost-control methods included limits
on total individual costs, capitation with providers at risk, fixed
program allocations, and consumer co-payments.  In addition, some
state agencies identified limits on the number of service units for
an individual,\7 rate setting for individual services, and limiting
the number of individuals receiving services as the most effective
methods for controlling costs.  A few states also reported that
setting limits on the number of providers and other methods would be
most effective for controlling costs. 

   Figure 4:  Most Effective
   Cost-Control Methods for Home
   and Community-Based Services
   Needed by Severely Disabled
   Elderly Persons

   (See figure in printed
   edition.)

Note:  Maximum number of respondents:  51 state agencies on aging, 50
state Medicaid agencies.  Respondents each identified their top three
methods. 

Source:  GAO survey of state agencies (July 1994). 

The views of state agencies on aging and state Medicaid agencies
differed more on cost-control methods than in the other areas we
surveyed.  State agencies on aging reported more frequently than
state Medicaid agencies that (1) case/care management, (2) consumer
co-payments, and (3) fixed program allocations would be effective
cost-control mechanisms.  State Medicaid agencies reported more
frequently that (1) limits on total individual costs, (2) limits on
the number of service units to individuals, (3) rate setting for
individual services, and (4) limiting the number of individuals
receiving services would be most effective for controlling costs. 


--------------------
\7 Limits on service units cap the number of hours or days of care a
person may receive in a defined period of time.  These caps may limit
the total cost of care for any single individual and help limit total
costs of care for the types of services included. 


   STATE AGENCIES BELIEVED PRIVATE
   SECTOR ROLE COULD PROBABLY
   REDUCE GOVERNMENT COSTS AND
   GOVERNMENT INTERVENTIONS MIGHT
   INCREASE PRIVATE SECTOR
   ACTIVITY
------------------------------------------------------------ Letter :5

State agencies believed that the private sector role could probably
reduce government long-term care costs for nursing home and home and
community-based services.  Since we did not ask to what extent the
various private sector approaches could help to reduce publicly
funded services, our results do not address the potential magnitude
of cost reductions.  State agencies also reported that government
interventions--other than additional funding--might increase the use
of a number of private sector approaches to long-term care. 

State agencies reported most frequently that informal or family
caregiving--a common private sector approach--could reduce total
government long-term care spending for the elderly (see fig.  5 and
tables 1 and 2).  Four other approaches were also mentioned with some
frequency:  (1) private long-term care insurance, (2) private
residential care alternatives, (3) employer-sponsored elder care, and
(4) other private sector financing mechanisms.  Other private sector
financing mechanisms included reverse annuity mortgages,\8 long-term
care medical individual retirement accounts (IRA), and life insurance
conversions.  Some state agencies also believed that volunteer
service banks and activities as well as other private sector
approaches could reduce government spending for long-term care. 

   Figure 5:  Most Effective
   Private Sector Approaches to
   Reduce Government Long-Term
   Care Spending for Elderly
   Persons With Severe
   Disabilities

   (See figure in printed
   edition.)

Note:  Maximum number of respondents:  51 state agencies on aging, 50
state Medicaid agencies.  Respondents each identified their top three
approaches. 

Source:  GAO survey of state agencies (July 1994). 



                                     Table 1
                     
                         State Agencies on Aging Views on
                         Effectiveness of Private Sector
                     Approaches to Reduce Government Spending
                     for Nursing Home and Home and Community-
                                  Based Services


                                                                              No
                                          Defini                  Defini   basis
                                            tely  Probab  Probab    tely      to
Approach                                     yes  ly yes   ly no      no   judge
----------------------------------------  ------  ------  ------  ------  ------
Informal or family caregiving                 27      10      13       1       0
Employer-sponsored elder care programs         5      31      13       0       2
 for employees who are caregivers
Private, long-term care insurance             12      27       7       2       3
Other private financing mechanisms such        5      29       9       1       6
 as reverse annuity mortgages, long-
 term care medical IRAs, and life
 insurance conversions
Residential care alternatives, such as        12      26      11       1       1
 continuing care retirement
 communities,\a and other private,
 assisted living options
Volunteer service banks and other              2      17      24       2       6
 volunteer activities to provide
 services
Other                                          4       2       0       0       0
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  51 state agencies on aging. 

\a Continuing care retirement communities (CCRC) are organized to
provide independent residential units and social and health services
in one setting.  This may include nursing home care in or near the
community.  Residents usually pay entry and monthly fees to CCRCs to
receive care for the rest of their lives. 

Source:  GAO survey of state agencies (July 1994). 



                                     Table 2
                     
                           Medicaid Agencies' Views on
                         Effectiveness of Private Sector
                     Approaches to Reduce Government Spending
                     for Nursing Home and Home and Community-
                                  Based Services


                                                                              No
                                          Defini                  Defini   basis
                                            tely  Probab  Probab    tely      to
Approach                                     yes  ly yes   ly no      no   judge
----------------------------------------  ------  ------  ------  ------  ------
Informal or family caregiving                 28      15       5       1       1
Employer-sponsored elder care programs        11      27       8       1       3
 for employees who are caregivers
Private, long-term care insurance             18      26       4       0       2
Other private financing mechanisms such        6      32       9       0       3
 as reverse annuity mortgages, long-
 term care medical IRAs, and life
 insurance conversions
Residential care alternatives, such as        15      24      11       0       0
 continuing care retirement communities,
 and other private, assisted living
 options
Volunteer service banks and other              7      22      12       0       9
 volunteer activities to provide
 services
Other                                          5       2       0       0       1
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  50 state Medicaid agencies. 

Source:  GAO survey of state agencies (July 1994). 

State agencies also reported that government interventions--other
than additional funding--might increase the use of a number of
private sector approaches in long-term care (see tables 3 and 4). 
Government interventions include consumer education and information,
technical assistance, quality assurance, avoidance of overly
restrictive regulation, and national standards.  Private long-term
care insurance was most often cited as an approach that government
could encourage without spending additional funds.  Other approaches
reported with some frequency were private residential care
alternatives, other private financing mechanisms, employer-sponsored
elder care, volunteer service banks and activities, and informal or
family caregiving. 



                                     Table 3
                     
                         State Agencies on Aging Views on
                     Government Interventions to Increase the
                         Use of Private Sector Approaches


                                                          Somewh
                                          Somewh      As      at    Very
                                    Very      at  likely  unlike  unlike   Don't
Approach                          likely  likely  as not      ly      ly    know
--------------------------------  ------  ------  ------  ------  ------  ------
Informal or family caregiving          5      16       8       9      12       0
Employer-sponsored elder care         11      14      14       7       1       4
 programs for employees who are
 caregivers
Private, long-term care               15      21       6       5       2       2
 insurance
Other private financing               10      21       8       4       2       4
 mechanisms such as reverse
 annuity mortgages, long-term
 care medical IRAs, and life
 insurance conversions
Residential care alternatives,        13      18      14       4       0       2
 such as continuing care
 retirement communities, and
 other private, assisted living
 options
Volunteer service banks and            7      14       9      10       5       6
 other volunteer activities to
 provide services
Other                                  4       1       0       1       0       0
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  51 state agencies on aging. 

Source:  GAO survey of state agencies (July 1994). 



                                     Table 4
                     
                      Medicaid Agencies' Views on Government
                       Interventions to Increase the Use of
                            Private Sector Approaches


                                                          Somewh
                                          Somewh      As      at    Very
                                    Very      at  likely  unlike  unlike   Don't
Approach                          likely  likely  as not      ly      ly    know
--------------------------------  ------  ------  ------  ------  ------  ------
Informal or family caregiving          4       8      16      11      10       1
Employer-sponsored elder care          6      26      10       3       2       3
 programs for employees who are
 caregivers
Private, long-term care                9      29       6       2       1       3
 insurance
Other private financing                9      24       8       3       2       4
 mechanisms such as reverse
 annuity mortgages, long-term
 care medical IRAs, and life
 insurance conversions
Residential care alternatives,        18      15      11       3       2       1
 such as continuing care
 retirement communities, and
 other private, assisted living
 options
Volunteer service banks and            7      12      12      10       3       6
 other volunteer activities to
 provide services
Other                                  3       2       0       0       0       1
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  50 state Medicaid agencies. 

Source:  GAO survey of state agencies (July 1994). 


--------------------
\8 Reverse annuity mortgages permit elderly homeowners to take out
loans, which they receive in the form of monthly payments, based on
the equity in their homes.  At the time of the homeowner's death, the
loan is repayed through the sale of the house. 


   CONCLUSION
------------------------------------------------------------ Letter :6

The views of state agencies on aging and Medicaid agencies showed
wide agreement on key components of well-designed programs.  State
agencies agreed that an elderly person's ability to perform ADLs is
the best way to identify persons with the greatest need for services,
although states do not uniformly define ADLs.  To determine service
needs, state agencies generally agreed that case/care management, a
standard assessment instrument, and involvement of the elderly person
in the process are most useful.  State agencies reported that the
largest number of severely disabled elderly persons need nonmedical
services, such as personal care.  State agencies agreed that a
variety of cost control methods are effective, although there was
less consensus about which specific methods are most effective. 
Regarding the private sector role in long-term care, state agencies
believed the private sector role could probably reduce government
costs, and government interventions might increase private sector
activity. 


---------------------------------------------------------- Letter :6.1

We did not obtain agency comments since our work was focused on the
state agencies' views rather than their current program practices. 

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report for 3 days. 
At that time, we will send copies of this report to other
congressional committees and members with an interest in this matter;
the Secretary of Health and Human Services; the Assistant Secretary
for Aging; the Administrator, Health Care Financing Administration;
the Assistant Secretary for Planning and Evaluation; Directors of
State Agencies on Aging; Directors of State Medicaid Agencies; and to
others upon request. 

Should you or your staff have any questions about this report, please
call me on (202) 512-7215.  Other major contributors are listed in
appendix II. 

Sincerely yours,

Jane L.  Ross
Associate Director,
Income Security Issues


SURVEY TABLES WITH FREQUENCIES
=========================================================== Appendix I



                                    Table I.1
                     
                         State Agencies on Aging Views on
                     Indicators for Determining Service Needs
                          of Elderly Persons With Severe
                                   Disabilities

                                                                      Of
                                                  Modera  Somewh  little
                                            Very    tely      at   or no
                                  Essent  import  import  import  import   Don't
Indicator                            ial     ant     ant     ant    ance    know
--------------------------------  ------  ------  ------  ------  ------  ------
Ability to perform activities of      47       4       0       0       0       0
 daily living, such as
 toileting, dressing, and
 bathing
Ability to perform instrumental       24      18       8       0       0       0
 activities of daily living,
 such as balancing a checkbook,
 shopping, managing medication,
 or using transportation
Cognitive disabilities                28      23       0       0       0       0
Medical condition                     16      17      13       4       1       0
Income and assets                      6      14      12      11       7       0
Geographic isolation, such as          4      13      14      16       4       0
 living in a sparsely populated
 area
Social isolation or being              4      16      14      14       3       0
 socially disadvantaged
Need for supervision to avoid         24      21       3       3       0       0
 risk to self or others
Request for nursing home               7      16       7      13       6       2
 placement
Access to care from family,           28      18       3       1       1       0
 friends, and other community
 sources
Other                                  4       3       1       0       0       0
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  51 state agencies on aging. 

Source:  GAO survey of state agencies (July 1994). 



                                    Table I.2
                     
                      Medicaid Agencies' Views on Indicators
                     for Determining Service Needs of Elderly
                         Persons With Severe Disabilities

                                                                      Of
                                                  Modera  Somewh  little
                                            Very    tely      at   or no
                                  Essent  import  import  import  import   Don't
Indicator                            ial     ant     ant     ant    ance    know
--------------------------------  ------  ------  ------  ------  ------  ------
Ability to perform activities of      46       3       0       0       0       0
 daily living, such as
 toileting, dressing, and
 bathing
Ability to perform instrumental       18      21       6       3       1       0
 activities of daily living,
 such as balancing a checkbook,
 shopping, managing medication,
 or using transportation
Cognitive disabilities                24      20       4       1       0       0
Medical condition                     24      18       4       3       0       0
Income and assets                      9      13      16       8       2       0
Geographic isolation, such as          1      19      15       8       4       2
 living in a sparsely populated
 area
Social isolation or being              2      14      16      11       4       1
 socially disadvantaged
Need for supervision to avoid         21      19       7       1       1       0
 risk to self or others
Request for nursing home               4      10      19      10       4       2
 placement
Access to care from family,           25      17       4       3       0       0
 friends, and other community
 sources
Other                                  4       0       1       0       0       1
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  50 state Medicaid agencies. 

Source:  GAO survey of state agencies (July 1994). 



                                    Table I.3
                     
                         State Agencies on Aging Views on
                     Usefulness of Methods to Determine Types
                                of Services Needed

                                                                      Of
                                                  Modera  Somewh  little
                                            Very    tely      at   or no   Don't
Method                                    useful  useful  useful     use    know
----------------------------------------  ------  ------  ------  ------  ------
Standard assessment instrument or             48       2       1       0       0
 protocol
Case/care management                          47       3       0       0       0
Interdisciplinary assessment team             20      18       8       4       0
Involvement of the elderly person in          46       4       1       0       0
 identifying services needed
Involvement of elderly person's family        32      17       2       0       0
 members in identifying services needed
Physician's recommendation on services         7      14      16      12       0
 needed
Periodic assessment or reassessment of        44       7       0       0       0
 needs
Other                                          9       0       0       0       0
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  51 state agencies on aging. 

Source:  GAO survey of state agencies (July 1994). 



                                    Table I.4
                     
                      Medicaid Agencies' Views on Usefulness
                         of Methods to Determine Types of
                                 Services Needed

                                                                      Of
                                                  Modera  Somewh  little
                                            Very    tely      at   or no   Don't
Method                                    useful  useful  useful     use    know
----------------------------------------  ------  ------  ------  ------  ------
Standard assessment instrument or             39       9       1       0       1
 protocol
Case/care management                          41       6       1       0       0
Interdisciplinary assessment team             23      18       8       0       1
Involvement of the elderly person in          42       5       3       0       0
 identifying services needed
Involvement of elderly person's family        30      17       2       1       0
 members in identifying services needed
Physician's recommendation on services         9      19      18       4       0
 needed
Periodic assessment or reassessment of        37      12       1       0       0
 needs
Other                                          5       1       0       0       1
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  50 state Medicaid agencies. 

Source:  GAO survey of state agencies (July 1994). 



                                    Table I.5
                     
                         State Agencies on Aging Views on
                        Proportion of Elderly Persons With
                      Severe Disabilities Who Need Specific
                                     Services

                                  All or
                                  almost           About          Few if   Don't
Service                              all    Most    half    Some     any    know
--------------------------------  ------  ------  ------  ------  ------  ------
Home health care                       9       9      10      18       0       4
Housekeeping, meal preparation,       30      15       4       1       0       0
 and other home chore services
Personal care such as assistance      24      19       5       2       0       0
 in bathing, toileting, eating,
 and mobility
Transportation                        18      16       9       4       0       1
Housing modifications                  3       5       5      32       3       2
Congregate programs such as            2       4       9      26       5       1
 meals and social interaction
Adult day care                         2       0       8      35       3       1
Companion and visitation               3       8      15      20       2       0
 services
Supervision for cognitively            6       5       8      28       1       1
 impaired persons at home
Case/care management                  26      20       1       3       0       0
Respite care                           5      10      14      19       0       1
Assistance for family caregivers       6      12      18      13       0       1
 such as training, counseling,
 or support groups
Other                                  3       3       3       6       0       2
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  51 state agencies on aging. 

Source:  GAO survey of state agencies (July 1994). 



                                    Table I.6
                     
                      Medicaid Agencies' Views on Proportion
                          of Elderly Persons With Severe
                     Disabilities Who Need Specific Services

                                  All or
                                  almost           About          Few if   Don't
Service                              all    Most    half    Some     any    know
--------------------------------  ------  ------  ------  ------  ------  ------
Home health care                       9      13      13      13       0       2
Housekeeping, meal preparation,       20      22       5       1       0       2
 and other home chore services
Personal care such as assistance      25      21       1       1       0       2
 in bathing, toileting, eating,
 and mobility
Transportation                         9      14       9      15       0       3
Housing modifications                  1       3       6      29       7       4
Congregate programs such as            2       6      11      24       2       5
 meals and social interaction
Adult day care                         3       3       9      32       1       2
Companion and visitation               4       9       8      20       2       6
 services
Supervision for cognitively            6       7      10      17       3       7
 impaired persons at home
Case/care management                  22      18       6       1       0       2
Respite care                           5       8      13      18       1       5
Assistance for family caregivers       6       9       9      17       1       8
 such as training, counseling,
 or support groups
Other                                  3       2       5       6       0       4
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  50 state Medicaid agencies. 

Source:  GAO survey of state agencies (July 1994). 



                                    Table I.7
                     
                         State Agencies on Aging Views on
                     Effectiveness of Methods in Controlling
                         Government Spending for Home and
                             Community-Based Services

                                                                  Slight
                                                  Modera  Somewh   ly or
                                            Very    tely      at     not
                                          effect  effect  effect  effect   Don't
Method                                       ive     ive     ive     ive    know
----------------------------------------  ------  ------  ------  ------  ------
Fixed program allocations, sometimes          22      12       8       7       1
 called global budgets
Capitation with providers that are at         15      18      12       3       2
 risk for excess costs
Rate setting for individual services           3      20      21       5       1
Setting limits on the number of               13      11      14      11       1
 individuals receiving services
Setting limits on the numbers or types         3       8      10      27       2
 of providers through mechanisms such as
 licensure or certification of need
Case/care management to keep program          27      17       5       2       0
 costs within budget
Setting limits on service units               10      12      14      13       1
 available to an individual
Setting limits on total cost for an           22      13       8       7       1
 individual
Consumer co-payments                          21      15      10       4       1
Other                                          3       1       0       0       0
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  51 state agencies on aging. 

Source:  GAO survey of state agencies (July 1994). 



                                    Table I.8
                     
                           Medicaid Agencies' Views on
                     Effectiveness of Methods in Controlling
                         Government Spending for Home and
                             Community-Based Services

                                                                  Slight
                                                  Modera  Somewh   ly or
                                            Very    tely      at     not
                                          effect  effect  effect  effect   Don't
Method                                       ive     ive     ive     ive    know
----------------------------------------  ------  ------  ------  ------  ------
Fixed program allocations, sometimes          14      16       7       7       3
 called global budgets
Capitation with providers that are at         17      17      11       2       3
 risk for excess costs
Rate setting for individual services          18      12      11       9       0
Setting limits on the number of               16      10       9      14       0
 individuals receiving services
Setting limits on the numbers or types         8      10      10      20       2
 of providers through mechanisms such as
 licensure or certification of need
Case/care management to keep program          27      12       8       2       1
 costs within budget
Setting limits on service units               13      17       8       8       1
 available to an individual
Setting limits on total cost for an           25      11       7       6       0
 individual
Consumer co-payments                           8      13      18       9       1
Other                                          4       0       0       0       1
--------------------------------------------------------------------------------
Note:  Maximum number of respondents:  50 state Medicaid agencies. 

Source:  GAO survey of state agencies (July 1994). 


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix II

William J.  Scanlon, Associate Director
Cynthia A.  Bascetta, Assistant Director, (202) 512-7207
James C.  Musselwhite, Jr., Senior Social Science Analyst
Connie J.  Peebles, Senior Evaluator
Benjamin C.  Ross, Evaluator
Susan Lawes, Senior Social Science Analyst
Eric R.  Anderson, Senior Evaluator
George H.  Bogart, Attorney-Advisor


RELATED GAO PRODUCTS
=========================================================== Appendix 0

Medicaid Long-Term Care:  Successful State Efforts to Expand Home
Services While Limiting Costs (GAO/HEHS-94-167, Aug.  11, 1994). 

Survey of Long-Term Care for the Elderly (GAO/HEHS-94-214R, July 21,
1994). 

Older Americans Act:  Funding Formula Could Better Reflect State
Needs (GAO/HEHS-94-41, May 12, 1994). 

Long-Term Care Reform:  Program Eligibility, States' Service
Capacity, and Federal Role in Reform Need More Consideration
(GAO/T-HEHS-94-144, Apr.  14, 1994). 

Long-Term Care:  The Need for Geriatric Assessment in Publicly Funded
Home and Community-Based Programs (GAO/T-PEMD-94-20, Apr.  14, 1994). 

Long-Term Care:  Demography, Dollars, and Dissatisfaction Drive
Reform (GAO/T-HEHS-94-140, Apr.  12, 1994). 

Long-Term Care:  Status of Quality Assurance and Measurement in Home
and Community-Based Services (GAO/PEMD-94-19, Mar.  31, 1994). 

Long-Term Care:  Private Sector Elder Care Could Yield Multiple
Benefits (GAO/HEHS-94-60, Jan.  31, 1994). 

Health Care Reform:  Supplemental and Long-Term Care Insurance
(GAO/T-HRD-94-58, Nov.  9, 1993). 

Long-Term Care Insurance:  High Percentage of Policyholders Drop
Policies (GAO/HRD-93-129, Aug.  25, 1993). 

Long-Term Care Reform:  Rethinking Service Delivery, Accountability,
and Cost Control (GAO/HRD-93-1-SP, July 13-14, 1993). 

Massachusetts Long-Term Care (GAO/HRD-93-22R, May 17, 1993). 

Long-Term Care Case Management:  State Experiences and Implications
for Federal Policy (GAO/HRD-93-52, Apr.  6, 1993). 

Long-Term Care Insurance Partnerships (GAO/HRD-92-44R, Sept.  25,
1992). 

Long-Term Care:  Projected Needs of the Aging Baby Boom Generation
(GAO/HRD-91-86, June 14, 1991). 

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