Examining models for coordinating health-care to the elderly

0198-9715.81.060097-13502000 Psrgamon Press Lfd

EXAMINING MODELS FOR COORDINATING HEALTH-CARE TO THE ELDERLY BRUCE F. BERG Department of Political Science. Fordham

University,

Bronx,

NY 10458, U.S.A

Abstract-Overlap and coordination among four federal programs which are responsible for financing and/or delivering health services to the elderly (Medicare, Medicaid, Older Americans’ Act, Title XX of the Social Security Act) are examined in an attempt to assess the effectiveness of the overall federal policy toward elderly health. Reasons for poor coordination include reluctance on the part of the agencies involved to coordinate their efforts, intergovernmental programmatic arrangements, and the overall fragmentation of the national health system. Three local programs. Triage. Inc., of Connecticut. ACCESS of Monroe County, New York. and the Community Care Organization of Wisconsin. are presented as examples of organizations which have achieved a degree of coordination, and consequently effectiveness, in the delivery of health services to the elderly in their communities, Prospects and strategies for future coordination in the elderly health arena are discussed.

INTRODUCTION

One of the major obstacles to attaining effective service delivery in policy areas where there are multiple programs is the degree of coordination which must be achieved among these programs. To the extent that these programs overlap directly in the service being delivered or the target group being serviced, coordination becomes a factor not only in effective service delivery but also the efficient delivery of services. Such is the case with the present federal policy regarding the delivery of health services to the elderly. There are four programs administered by the federal government which have a major impact on the delivery and financing of health services to the elderly: Medicare, Medicaid, Older Americans’ Act, and Title XX of the Social Security Act. This paper will examine the degree of coordination between these four programs at the federal and local levels. In so doing, it will attempt to assess the impact of coordination or lack of coordination on the effectiveness of health service delivery to the elderly. Finally, it will examine some examples of local service providers who have achieved a degree of coordination, and consequently service delivery effectiveness, in the face of poor coordination among these four programs at the federal and local levels. Coordination is an incredibly vague term. In the area of service delivery, it may have a variety of meanings, each with totally different implications for the quality of service being delivered. In terms of delivering health services to the elderly, service coordination may be defined as an agency serving as an information and referral bureau for those elderly individuals seeking health care such that the elderly individual would only have to call a single agency or organization to find out the appropriate agency and location for the desired service. At a more extreme level of coordination though, a single agency may actually provide all the needed services or be able to provide for the delivery of all the needed services through different service agents in the health sector such that the elderly individual only has to communicate with one agency to receive all the needed care. In both of the above cases, the agency in question serves as a single point of entry for the elderly individual into the health care sector. Obviously though, an agency which provides or which can orchestrate the delivery of the necessary services to the elderly individual has gone much further in coordinating service delivery than an agency which simply acts as a referral for the elderly in need of health care. However, examples of either type of coordination in the elderly health sector are rare. So the achievement of either type should be viewed as a major accomplishment. For the elderly individual in search of health services or financing for health services, coordination at the local level, the level of delivery, is a crucial factor in service delivery 91

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effectiveness for several reasons. First, poor coordination in the delivery or financing of health services may result in hardship for the elderly person. To the extent that services or financing are not coordinated, the elderly individual will be forced to locate, communicate with. and;‘or travel to multiple agencies in order to receive an appropriate continuum of health care or comprehensive financing. This means that an elderly person not only has to be familiar with the maze of ambulatory, inpatient and long-term care facilities in the community, it also means that they must be able to travel from one type of facility to the other. often not centrally located. For the ‘frail’ or disabled elderly, the hardship is obvious. Second, lack of coordination in the delivery of health care may result in gaps in the health care delivery or financing system such that the elderly individual is not provided with or does not receive access to certain types of health care or health care financing simply because the service or financing in question falls through the cracks in the uncoordinated system, or the elderly individual is not eligible for the particular program. Financial fragmentation of the health care system means multiple financial and other eligibility requirements of which the elderly person must be aware. Many elderly rely on multiple sources of financing involving varying amounts of coinsurance. deductibles and benefit periods [I]. In the past. the family physician performed an integrating function since he was often a generalist who was most knowledgeable about the patient, family. and the community. But today. the more complex health system with numerous specialties and services makes it virtually impossible for the physician to know what is available to supplement and complement his.her own specialties. The lack of knowledge and complexity of the system’s problems are even greater for the family member trying to coordinate care for an elderly relative. Successful coordination would result not only in the establishment of a single point of entry for the elderly person into the health service network, but it would also help in creating a comprehensive continuum of health care for the elderly recipient. In addition, coordination may help rationalize health care financing and consequently result in less of a financial hardship for the elderly health care recipient. For reasons which this paper hopes to clarify, the four programs being discussed here have remained uncoordinated. Isolated examples of service, target group, and funding overlap may at times make them appear coordinated. But even in those instances of apparent coordination due to overlap, they are. for the most part. the result of ingenuity and innovation at the level of delivery, rather than the result of purposive policy design at the level of formulation. This paper will focus on one segment of the elderly health system. long-term care. Long-term care entails a series of medical and non-medical but health related services provided to the chronically ill and the disabled. Unlike acute illness, chronic conditions develop gradually and last longer. Some last a lifetime. Many chronic illnesses are difficult to treat medically. In addition, the disability which accompanies many chronic conditions creates other problems and consequently results in the need for services which go beyond what is offered by the normal medical model. A comprehensive set of longterm care services would have to include the following: Basic services Homemaker services--cooking. shopping, housekeeping. laundry, home management Chore services-less frequent tasks related to home maintenance, lawn care. Social services---guidance in social or emotional problems: advice in financial and legal matters; friendly visiting; transportation. Health related services Nutrition and health education. Personal care services-bathing, toileting. feeding. assistance in walking, exercise. medication. Occupational therapy-medically directed activities to promote the restoration of useful function.

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Skilled services Physical and speech therapy-use of physical or chemical agents and devices to relieve pain, restore function, and prevent loss of use of a part of the body or of speech and writing. Skilled nursing-administration of medicine, changing of catheter and dressings. evaluation of condition [2]. Most of the elderly receive long-term care from families with little or no public funding The quality of such services is unknown. The public funding which does exist is primarily focused on institutional care. Out of this environment two types of concerns have developed. First, there is a concern with the impact of unnecessary utilization of nursing homes and inappropriate placement of elderly in nursing homes on the rising cost of nursing home care and the physical and social health of the elderly individual who has been inappropriately placed. Second, there is a concern with the social and health needs of the elderly individual residing in the community. The achievement of a comprehensive and coordinated system of health care for the elderly would go a long way to alleviating both of the above mentioned concerns. Much of this may be achieved by eliminating the fragmentation among relevant public programs which control large segments of both service delivery and financing of health care to the elderly. THE

Medicare

PROGRAMS

arld Medicaid

Both Medicare and Medicaid have been attacked in the past in regard to problems such as fraud, the quality of care provided under their financing, over-utilization of services, and the programs’ contributions to the rise in the cost of health care in general. However, what is most interesting about Medicare and Medicaid as it impacts upon the elderly is that most experts are slowly coming to realize that in some areas of health care, Medicaid does a great deal more for the elderly, especially the low income elderly, than Medicare; even though Medicaid is designed for the elderly while Medicaid is designed for the poor. This is true particularly in the area of long-term care. There are several reasons for the relative strength of Medicaid over Medicare. First, nursing home benefits under Medicare are much less extensive than under Medicaid. With Medicare, financing is limited to services provided for in extended care facilities to cover post-hospital convalescence and rehabilitation only. In many states, Medicaid. a state run program. covers a wider range of long-term care benefits than Medicare. Second, Medicare not only allows physicians to charge patients in excess of what the program will pay but it also has significant deductible and coinsurance payments such that the elderly’s out of pocket health expenses as a percentage of total medical expenses has not changed since before Medicare’s implementation [3]. Medicaid plugs many of the gaps for those services to aged and aged poor not covered by Medicare. In fact, in many states, Medicaid pays the deductibles and coinsurance payments required by Medicare. In 1976. approximately one half of the Medicaid expenditures for the medically needy paid for the aged who had exhausted their Medicare benefits or who required services not covered by Medicare [3]. In effect, Medicaid acted as catastrophic health insurance for those on Medicare. Additionally, in most states, Medicaid purchases the Medicare Supplemental Health Insurance (Part B) for the elderly poor. The one major problem with Medicaid is that it varies from state to state. As previously stated, the biggest difference between Medicare and Medicaid can be seen in the area of long-term care. In 1975, Medicare accounted for less than three percent of the growth of the nursing home industry. Medicaid paid for more than half of all nursing home expenditures [3, p. 921. Medicare pays for only 20 days of nursing home care in full. After that, a coinsurance payment is required. After 80 days, the patient assumes full responsibility. Most states’ Medicaid plans are far more lemenr. tn addition, many Medicaid plans cover intermediate care facilities, a less costly alternative of longC!l,h? ,

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term care for people who do not need a full range of medical care. Finally, some states’ Medicaid plans have a far more flexible definition of home health care which unlike Medicare, covers some non-medical but still health related services, like homemaker services 1141. The fact that the Medicaid programs are administered from state capitals makes it easier for a local service provider or a local Area Agency on Aging to coordinate with the Medicaid officials than with the Medicare officials who, although are localized in financing mechanisms, are centralized in Baltimore as far as service regulations and programmatic changes are concerned. Much of Medicaid’s flexibility stems from the fact that Medicaid is a joint federal-state program. Since states are required to pay up to half of the cost of the program. they are willing to allow different types of services if it can be shown that the financing of these services reduces the total amount of public expenditures. Medicaid’s extended coverage of home health benefits, compared to Medicare’s and their coverage of both skilled care facilities and intermediate care facilities appears to have been adopted by various states due to cost considerations. In both cases, the changes have given Medicaid a more comprehensive set of benefits and services than Medicare, Title XX

qf Social

Security

Act

Title XX of the Social Security Act funds a collection of social programs which provide supplemental services such as day care, family planning, counseling, and transportation to welfare recipients, senior citizens, the blind, and the disabled. The goal of the program is to prevent or reduce the recipient’s dependence on welfare. Money under Title XX is distributed according to a formula matching grant. Title XX is unlike Medicare, Medicaid, and the Older Americans’ Act in that it is neither earmarked totally for health or totally for the elderly. However, Title XX gives the states incredible latitude in determining what services can he financed such that the grant can be used to provide a broad range of social services that can be health related or earmarked for the elderly depending upon the discretion of the social services or welfare agency. Title XX funds are so flexible regarding the services covered and the eligible target group that it has the potential to fifl in many of the gaps that Medicare and Medicaid create, especially in the area of home health care and related services. For instance, Medicare and Medicaid provide very limited funding, with numerous requirements, for personal care, homemaker services and home health aids. However, they will pay for similar services if offered in an institutional setting. The financial incentives of both the Medicare and Medicaid programs encourage families to put their elderly relatives in nursing homes where the government will pay most of the hilt, even if institutionalization is not necessary. Because of these limitations, many states have employed Title XX funds to deliver home health and homemaker services. In fact, given the differing Medicaid programs from state to state, some states fund in-home services out of Medicaid while others fund them out of Title XX funds [S]. However, whereas Medicaid regulations prohibit the employment of a family member to deliver these services. Title XX has no such restriction [5. p, 321. In addition, the fact that no clear de~nition of homemaker or home health aid services exists at the federal level adds to the flexibility in funding choices. With regard to target group eligibility. Title XX allows people above the poverty line to receive some of the funded social services. Advocates of the liberal eligibility requirements have argued that allowing low income non-welfare persons to receive social services under Title XX may help them remain off welfare. However, Title XX does require that at least 50”~ of the funds be spent on welfare recipients. In addition, since the establishment of a funding ceiling for Title XX by Congress, cutbacks have frequently resulted in the elimination of those above the poverty line as eligibles. The Older Americans’

Act

The Older Americans’ Act Amendments of 1973 mandated the establishment of Area Agencies on Aging. These bodies were mandated to plan and coordinate health related

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and other services for the elderly in their respective communities [6]. The goal of this coordinative strategy was to channel services to the elderly through federally funded local authorities that would plan and coordinate existing services as well as attempt to mobilize new services. Implicit in the Area Agency on Aging (AAA) concept was the assumption that when necessary the AAA’s would finance the delivery of services too. Although the primary role of the AAA’s was coordination, little was said about how this coordination was to take place. The staff of each new sub-state AAA was simply directed to develop an area plan that designed and developed comprehensive and coordinated programs. Most AAA’s have concentrated on community based services (e.g. senior centers, congregate meals) and in-home services (e.g. visiting nurses, homemaker services) because these have been the easiest to coordinate given the AAA’s sphere of control. Most have stayed away from the Medicaid and Medicare deliverers in the community. The most recent amendments (1978) to the Older Americans’ Act contain a mechanism through which coordination of programs to the elderly might be made easier. But they also contain elements which appear to mandate that the AAA’s go further than they have in the past in coordinating health services for the elderly. The new amendments give the Commissioner on Aging in HEW “the authority to review and comment on all federal policies affecting the elderly” [7]. They also require him to advise, consult and cooperate with the heads of other federal agencies that run programs involving the elderly. Furthermore, the amendments require other agency heads to consult with the Commissioner on Aging before establishing programs that substantially involve the elderly [7]. While these types of requirements have only had limited success in the past (e.g. Model Cities) in giving a specific agency coordinative power, they do mandate, at a minimum, the exchange of information which is obviously the first step in coordination. Moreover, although these requirements for review and comment exist at the highest bureaucratic level only, the possibility of such procedures taking place at the substrate level, directed by the AAA’s, is enhanced greatly by the amendment’s legislative intent. Several elements in the new amendments place the AAA’s in the position of having to include the Medicare and Medicaid programs in their coordination attempts. First, the new amendments appear to expand the purpose of the Older Americans’ Act to include providing a continuum of care for the ‘vulnerable’ elderly. Second, the new amendments require states to reserve 20 million dollars or one percent of the Older Americans’ Act Title III Social Service allotment, whichever is greater, to establish and operate long term care ombudsman programs. Third, the amendments require AAA’s to designate, where feasible, a focal point for ‘service delivery’ in order to improve the coordination of services. Fourth, the amendments authorize grants to organizations and agencies to develop comprehensive and coordinated systems of community long term care for the elderly. At present, HEW is preparing to initiate a National Long-Term Care Channeling Demonstration Program in which projects would be designed ‘to test the extent to which a local structure is able to manage, coordinate and arrange the provision of in-home, community-based, and institutional long term care services’ to those who need it, in a cost-effective manner [S]. One of the specific problems the demonstration program is supposed to address is the fragmentation and inaccessibility of long-term care programs. In particular, the demonstration program is supposed to capitalize on the innovations in the coordination of health care delivery to the elderly at the local level. This proposed project, as well as the above mentioned elements in the 1978 Amendments to the Older American’s Act touch upon or overlap with the present functions of Medicare and Medicaid. COORDINATION

PROBLEMS

The present lack of coordination among the four programs is significant for three reasons. First. as has been demonstrated, the four programs overlap not only in the potential target group served but also in the types of services financed. This is especially the case in the area of long-term care. Second, under the Older Americans’ Act, the

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Administration on Aging has been requested to engage in activities which would achieve coordination regarding various aspects of these four programs. Third, the fact that all four programs are administered out of the Department of Health, Education, and Welfare would seem to suggest that coordination, at some level, would be possible. However, little or no coordination has been achieved. This lack of coordination is reflected at the local level where the four programs may be administered by as many as four separate agencies. Medicare is administered directly from the federal level and administered at the local level by third parties (e.g. Blue Cross/Blue Shield) contracted by the federal government. State and local governments have had little control over Medicare. Medicaid is a federal-state program administered at the local level through health, social services. or welfare departments. Increasingly though, states are turning to third parties to administer the financial aspects of this program. To the extent that Medicaid is administered by social services agencies, it may be housed in the same agency as Title XX. The Older American’s Act is administered by Area Agencies on Aging designated by the State Agency on Aging. Whether coordination at the federal level would or could result in coordination at the local level is uncertain. But it does appear to be a prerequisite. Why has there been insuficient coordination? There are several possible reasons. First, there appears to be an unwillingness, or at least an inability, on the part of federal agencies involved (Administration on Aging, Health Care Finance Administration. Social Security Administration) to mount any full scale coordination attempt. According to the 1978 Older Americans’ Act Amendments, the Administration on Aging is supposed to coordinate selected aspects of the delivery of health care (e.g. long-term care) services to the elderly but has so far been unsuccessful. While it may be too soon to assess the impact of the 1978 Amendments, there are some obvious problems. The Administration on Aging and its local Area Agencies on Aging are the newest actors in the elderly-health environment. To many, they lack legitimacy and political power because of their youth. It may take some time before the AAA’s and the AOA gain enough stature or political power in the community to gain the cooperation of agencies who have been in existence for a much longer period of time. Moreover, while the AOA. and its AAA’s have been mandated to pursue coordination, none of the other relevant agencies such as the Social Security Administration or the Health Care Finance Administration have received similar directions from Congress, OMB. or the Secretary of HEW. Under such circumstances, it seems only natural that these other agencies would be reluctant to surrender control of any of their programs, or even cooperate, with AOA. Had the Medicare or the Medicaid programs been the ones with the mandate to coordinate health care delivery to the elderly. coordination might now be taking place given the established status of those programs, compared to the Older Americans Act. Despite the obvious disadvantages, the AOA has been successful in establishing several joint working agreements with other federal agencies [9]. However, it is unclear whether this cooperation at the federal level was ever realized at the local level. Another problem the AOA has had in facilitating coordination is the fact that its budget is so much smaller than the budgets of the other three programs. While this might appear to be a motivating force for the AOA to pursue coordination, in any cooperative effort involving the allocation of funds, AOA has proportionally much more to lose given its relatively smaller budget [lo]. A second major problem in the achievement of coordination is the previously mentioned intergovernmental connection. Given the nature of the intergovernmental system in this country, agreements made at the federal level regarding the coordination of service delivery, or cooperation between agencies, may not be easily implemented at the local level. Not only are the obvious communication and interpretation problems present in this case, but there is also the additional problem created by the fact that each of the programs is administered through different levels of government via a separate, and sometimes autonomous agency or organization at the local level. In such a situation, an administrative fix may be inadequate. Given the separate legal basis for each program’s intergovernmental status. cooperation, and consequently increased coordination at the

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local level may not be possible without making legislative changes in the programs” The lack of coordination at the state and local levels may involve many more agencies and organizations, and much more chaos, than exists at the federal ievel. In his study of organizations deating with the elderfy in Dallas, Stephen Weissman found that beyond the relevant federal agencies, there were four Departments of the Texas State Government, two County Agencies, six City Departments. and two City-run Authorities delivering services to the elderly [ 111. This type of organizational milieu may be impervious to any cooperative or coordinative arrangements made at the federal level. whether administrative or legislative. A third major problem in the achievement of coordination in the dehvery of health care to the elderly is the overall fra~enta~io~ of the health sector in the United States. The national health system in the United States lacks a coherent policy or any type of integrated set of relationships. Responsibility for care is divided among numerous separate individuals, agencies, and organizations, both private and public; each with a separate and independent purpose [l, p 31. There are two major types of fragmentation in the U.S. health system. First, ‘functional fra~entation is the division of responsibility for the provision of services in separately accountable programs’ [I]. For instance, there are separate legal and institutional frameworks in this country for the production of health manpower, the construction of health facilities, the production of drugs, appliances and equipment, the production of research, the financing of health care for the individual, and the delivery of health care to the individual. Moreover, there are equally autonomous and independent institutions charged with environmental health protection, ambulatory care, hospital care, and long term care. Within each one of these areas there is also a great deal of fra~entatio~. The second type of fra~entat~on is geographic. Many of the above mentioned functions are provided within numerous and often incongruent or overlapping geographic areas and political jurisdictions [1 J. At present. there does not appear to be any coordination attempt, initiated at the federal level or any other level. that can deal with this magnitude of fragmentation. In some cases fragmentation may be seen as an advantage. Increased fragmentation often means a plurafist system with no means of centralized control. Often these types of systems are credited with being the source of a great deaI of innovation. They are also credited with having the ability to produce different 1eveIs of the same service and consequently satisfying many different individuals who have varying tastes and preferences for health care. However, fragmentation in the financing and delivery of health services to the elderly appears to have two major negative impacts. First, some of the elderly receive far more comprehensjve care than others, creating an equity problem. Second, few elderly receive a comprehensive continuum of care. In those few instances where comprehensive care is received, it is usually due to the persistence or wealth on the part of the elderly individual which enables him/her to piece together a coordinated set of services out of a fragmented system of service providers.

Despite the fra~entation and a lack of coordination throughput the health system, there are some examples of local providers who have had some success in financing and delivering a comprehensive continuum of health care. This is true especially in the area of long term care where there are frequently gaps in what is available to the elderly individual. There are two important points about the three exampfes of successful coordination which wiil be discussed below. First, all three examples involve the participation of either Medicaid or Medicare. These two programs spend so much money on elderly health services that any program at the local level attempting to provide coordinated care will have to include one or the other, if not both. Second, none of the three examples falls under the total control of the local Area Agency on Aging as part of the Older Americans’ Act. Despite the mandate which the Older Americans’ Act gives the Administration on Aging and its subordinate Area Agencies to coordinate health care for

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the elderly, it appears that at least in the below discussed examples, a great deal of the successful coordination is taking place outside of the Older Americans’ Act. One of the most successful attempts at employing Medicare in a coordinated system of health care to the elderly is Triage, Inc., a private, voluntary, non-profit health services organization in Connecticut. The Triage Project has constructed a model for single entry into the “full spectrum of health, social and life support services” [12]. The project attempts to provide “humane and cost effective” long-term care, in the person’s home when possible, in the hopes of preventing inappropriate institutionalization. Triage was formed on the premise that since the ‘vast array of public and private agencies’ could not and probably should not be merged into a single agency, an organization with the management capability to act as a go-between for the individual client and the multiple service agencies should be established [ 12). Another motivation for the establishment of Triage was the fact that not only was there no comprehensive ,and coordinated system of care necessary for avoiding inappropriate institutionalization but also that most third party payers in the health area preferred to reimburse expensive yet highly skilled institutional care over less expensive and less technical home care [12, p. 91. Thus the establishment of a coordinated system of home based services for the elderly was seen as a major goal. Services are delivered to clients through either contract by Triage or referral. Triage delivers no services directly. Triage receives funding from several different sources at the state and federal levels including the Administration on Aging and the Social Security Administration. However, the most unique aspect about Triage’s funding is its relationship with Medicare. On an experimental basis, the Division of Direct Reimbursement in the Social Security Administration is serving as the fiscal intermediary for Triage, a role usually performed by insurance companies. Under this arrangement, the Division of Direct Reimbursement performs all required fiscal intermediary functions except that it has given Triage the power to verify the eligibility of clients to receive services and approve payment for services authorized by the Triage nurse-clinician/social caseworker teams [12, p. 163. This arrangement has allowed Triage to extend eligibility and benefits beyond what is traditionally allowed by Medicare. It is this ability which makes Triage unique and more etiective than other deliverers. The only thing which the Division of Direct Reimbursement really does is sign the checks. Because Triage offers a full spectrum of care including many services not covered by Medicare (e.g. companion, homemaker, meals, intermediate care facilities), it uses its other funding sources including Medicaid and Administration on Aging money to complement its Medicare arrangement. In addition, Triage has recently received coinsurance and deductible waivers from Medicare for inpatient hospital care. The Triage project has been successful on several counts. First, by developing and supporting home health care services in its community, Triage has not only filled in one of the gaps in providing a continuum of care to its elderly, but it has also provided a significant alternative to institutionalized care for its target group. While Connecticut’s Medicaid program spends almost 90% of its funds on institutional care, Triage spends a little over 52”/, [13]. Second, because Triage has been able to utilize home health care, they have been able to reduce the cost of health care per patient compared to other programs. However, Triage officials are convinced that significant cost reduction, due to appropriate placement of patients and overall service coordination, could not be achieved without staff determination of appropriateness, monitoring, and follow up [ 13, p. 371. It may be difficult to duplicate these program elements across the country, especially given the shortage of Mastered Degree Nurse-Clinicians on whom the Triage teams depended so heavily. Third, Triage has made available to its target group those services such as visiting nurses, physical therapy, and mental health counseling, that are often difficult, if not impossible for the individual to gain access [13, p. 361. Triage will encounter funding problems when the Medicare experimental period ends in 1981. Without a clear mechanism to pay for the extended services and eligibility, Triage will be dependent upon the ‘patchwork system of Medicare, Medicaid, Older

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Americans’ Act Title VII meals, and services available through Title XX to serve its clients,’ a system which to date has proven inadequate to provide a comprehensive continuum of care to the elderly [14]. Without the benefit of experimental status and other waivers, the scope of health care services delivered to the Triage target group will decline significantly. When the Triage project terminates, its clients will be serviced by the Strengthened Assistance for Independent Living Program (SAIL), a demonstration program sponsored by the Connecticut State Department of Aging and the State Department of Social Services. SAIL receives federal funding from Title XX and both Title III and Title VII of the Older Americans’ Act under which it has model project status. But to date, SAIL does not have any experimental or waiver arrangement with either Medicare or Medicaid. At present, it does not appear as though SAIL’s funding arrangements will enable it to continue the comprehensive health care delivery to Triage’s clients. A project which appears to have had some success dealing with Medicaid is the Community Care Organization (CCO) in Wisconsin. This is a demonstration program funded by private foundation funds and HEW. The goal of the program is to develop and operate a ~‘compr~h~nsive and coordinated system of in-home and community services for functionally disabled individuals which will make available to them alternatives to premature or inappropriate institutionalization in a nursing home” [ 151. The project is being administered through the Lieutenant Governor’s Office, the County Social Services Agencies, and the University of Wisconsin. The Community Care Organization is somewhat unique in that it can use Medicaid funds for the extended payment of non-medical as well as medical services in a home setting. This was achieved by getting certain sections of Wisconsin’s Medical Assistance State Plan (Medicaid) waived by HEW in order to create a stable funding source for the Project. The purpose of the waiver is to provide the means whereby a state can experiment with alternative modes of service delivery not usually funded by Medicaid 1161. Under the CCO, those disabled adults eligible for Medicaid can qualify for an expanded range of services if they require services to prevent unnecessary or inappropriate institutionalization. For the purposes of the demonstration, Medicaid regulations have been temporarily reinterpreted to permit financing of non-medical services in non-institutional settings [ 171. CC0 has added flexibility to the Medicaid system since providers need not be certified and no physician’s plan of care is necessarily involved. It should be noted however, that where the Medicaid waiver is in effect, only Medicaid patients are covered except for one of the smaller CC0 sites. Like Triage, the CC0 contracts out for specific services. They deliver no services directly. In some cases, the CC0 has developed services for the elderly and disabled when they did not exist in the community. To date, the following services are available: homemaker, home health aid, transportation, home delivered meals, home care skilled nursing, companion, chore services, advocacy services, and adult day care. Despite its successes, CC0 has not been without its problems. There have been instances in which performed services were not billed as well as instances in which.services which were not ordered, were performed and billed. When the CC0 staff has played a strong coordinative role, they have been met with resistance by local providers on several occasions. Providers have complained about the CC03 attempt to introduce centralized case management. They have argued that this procedure produces unnecessary duplication since their own workers must also assess and monitor the clients they serve. In addition, emphasis on ‘social service oriented home care services’ has been criticized by the more medically oriented agencies who assert that the social service agencies are not adequately trained to assess client’s health needs [18]. Although the Medicaid waivers have given the CC0 the potential to deliver a coordinated set of comprehensive services to the elderly and disabled, the presence of the waivers does not in any way solve all of the coordination problems of the CCO. Finally, given the data which the University of Wisconsin has uncovered in their interim evaluation of the CCO, there is little evidence that the expanded home care program has reduced institutionalizations [IS].

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The Community Care Organization’s Medicaid Waiver was recently terminated. Since 60% of the CCO’s funding was federal, the waiver termination created a significant gap in the organization’s resources. This gap would have caused a considerable cut back in both services delivered and the target group served if the State of Wisconsin had not entered the program and appropriated the necessary funding. Howlever, Wisconsin’s funding (now approximateiy 6.5 million dollars per year) cannot continue indefinitely. Unless federal waivers are granted, at some point, CC0 will be forced to cut back; at which time, much of the CC0 target group will be forced back into the patchwork system of heahh services delivery. Another organization which has had success in providing a continuum of care to the elderly is the ACCESS project of the Monroe County Long Term Care Program, Inc. (New York). ACCESS is a demonstration project under Title XI of the Social Security Act. MCLTCP has a contract with the New York State Department of Social Services and a less formal arrangement with the State Health Department. ACCESS uses its knowledge of existing community services to set up a plan of care for each of its clients employing the necessary providers on a contractual basis. Like the Wisconsin program, ACCESS owes much of its success to its ability to receive Medicaid f 115 waivers to permit reimbursement for non-Medicaid participants and coverage of health related home support services. This enables the organization to use a single funding source in coordinating the delivery of services to the elderly among the numerous providers in the community. It should be noted that the Monroe County Organization attempted to draw in the Medicare program as both a source of funding and a source of evaluation but was unsuccessful in achieving any cooperation. ACCESS officials felt that if Medicare participation could be achieved, ACCESS could engage in earlier assessment of many of its clients. At present, since ACCESS only has an agreement with the Medicaid program. it must wait until Medicare is cut off and Medicaid takes over for it to become involved in the client’s case management. Several other health delivery organizations around the country have also been able to obtain Medicaid waivers, but the extent of the waiver and the ultimate success of the programs vary considerably. For instance, the Geriatric Assessment and Resource Center of Boston, one of the recipients of an AOA model project grant, received a Medicaid waiver but it was only for the placement of nursing home patients in an adult day health program. ACCESS’ case management model ‘considers the client’s health, psycho-social, financial and environmental needs and resources,’ and extends case management beyond the traditional medical model [19f. Professional nurses, medical and psychiatric social workers, and clerical support persons are ail members of the case management teams. These teams conduct a pre-admission assessment, develop a service plan, arrange payment, and engage in a monitoring and follow up procedure. Most important though, they provide a single entry system with uniform assessment [ 19, p. 61. Preliminary evaluations have shown that the ACCESS program has relieved some of the demand on Monroe County’s already tight nursing home supply by offering a non-institutional alternative. In Monroe County, a greater proportion of Medicaid clients than self-paying clients remain in community settings rather than enter nursing homes, a direct reversal of national trends, In addition to its being more appropriate in many cases, the ACCESS home alternative has been shown to be at times as little as 50% of the cost of institutional care [19, p. 71. Why have these three above discussed organizations, and several others not discussed, been successful in drawing in the Medicare and Medicaid deliverers into their elderly health network? There are several possible reasons. First, most, if not all. of the Medicaid waivers and Medicare delegations of authority are experimental. As a result, neither the Medicaid nor Medicare providers have to be concerned about a permanent arrangement, if in fact they are concerned at all. Most of the arrangements are temporary with a pre-established termination date. Second, the Medicare and Medicaid providers may be slowly realizing that the inclusion of comprehensive home care coverage. despite

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some of its non-medical service aspects, is still less expensive to finance than long term institutionalized care; not to mention the fact that it may be psychologically healthier for the elderly or disabled patient. Several arrangements have attempted to ensure that home health services are less expensive than institutional care. For instance, the cost of in home care for Medicaid patients in the ACCESS program cannot exceed 75% of the cost of nursing home care [20]. While regulations such as this one assure that home health care will be less expensive than institutional care, there are no systematic studies which verify this relationship in the absence of regulations. In addition, the interim result from- the Wisconsin program shows that the availability of a home health care program does not necessarily decrease institutional enrollments. At present it does not appear as though AAA’s or local service providers can achieve a comprehensive continuum of care for the elderly without the assistance of Medicaid, Medicare, or both. Medicaid and Medicare control the bulk of funds in dealing with health care to the elderly and long-term care in particular. While Title XX funds appear to be more flexible than either Medicaid or Medicare monies. the recent Congressional ceiling on Title XX appropriations limits the utility of these monies. Comprehensive services can be provided using Title XX funds, but there is not enough Title XX money to service all the elderly in need. In addition, the elderly are not Title XX’s only target group. As a result. the AAA’s will have to gain the cooperation of the Medicare and Medicaid providers if they are to achieve the program objectives set up in the most recent amendments to the Older Americans’ Act. The previously discussed National Long Term Care Demonstration Project is an attempt by the AOA to get local service providers to link up with Medicaid and/or Medicare providers. However, since the request for proposals has not been issued yet, evaluation would be quite premature. At present it appears as though the Health Care Finance Administration is making little or no attempt to respond to the Older Americans’ Act Amendments which express the desire for greater coordination, especially in the area of long-term care. Given that they have not yet been directed either legislatively or administratively to cooperate completely with the AOA or its AAA’s, HCFA’s “wait and see” attitude appears to be the appropriate organizational response from their perspective. Simply stated. they have been given no incentive, or command, to cooperate. Under the present circumstances, the responsibility for cooperation and coordination rests with the Administration on Aging and its subordinate Area Agencies on Aging. There are several possible strategies which the Administration on Aging and its Area Agencies on .4ging can adopt to achieve greater coordination with Medicare and Medicaid. First, they can pursue more experimental waiver arrangements with Medicare and Medicaid providers in hopes that these experiments will demonstrate to the Health Care Finance Administration the advantages of more permanent arrangements. To date, the local elderly health providers have had more success in achieving cooperation with Medicaid than with Medicare. This is for the most part due to the fact that Medicaid is administered at the state level while programmatic decisions regarding Medicare are centrally located in Washington. However, Medicaid waivers must be obtained from the Health Care Finance Administration in Washington also. In addition, the proliferation of Medicaid waivers is beginning to create a base of support for their continuance at the local level. Faced with an ever growing constituency, the Health Care Finance Administration may be forced to increase or continue waivers on a more routine basis. One problem remains though. Increased Medicare or Medicaid waivers which allow local service providers to be reimbursed for non-medical home health services may meet with some opposition from the more medically oriented agencies and organizations in the elderly health network. A second strategy for the Administration on Aging is to seek changes in the Medicare and Medicaid legislation or regulations. Such an effort may be politically difficult unless the AOA can convince Congress that such changes, which would include more comprehensive and non-medical coverage, would save the programs money. To date, such data is non-existent. In fact, there is some evidence that although the changes would lower the

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per patient costs via deinstitutionalization, overall costs would increase due to the additional public funding coverage granted to those who are presently living in the community and who would be eligible for the expanded home or community based services [21]. In addition, such changes may meet with opposition from the medical end of the health industry who may view the inclusion of non-medical services as an incursion into their sphere of control. These groups have been successful in previous attempts to maintain their control over Medicaid and Medicare. However, some changes are already being considered. For instance, in spring 1980, the Senate Finance Committee voted to repeal the requirement that a Medicare beneficiary must be hospitalized for at least 3 days to qualify for Hospital Insurance Home Health benefits. In addition, several Senators have recently introduced a major change in Medicare legislation that would include a comprehensive home health package. At present, most of the national health insurance proposals being discussed in Washington are vague regarding their coverage of comprehensive health services for the elderly. Those that are clear offer little or no change from Medicaid’s and Medicare’s present coverage. Finally, it should be noted that although achieving the cooperation of Medicare and Medicaid is a significant and necessary step toward providing the elderly in this country with comprehensive health care, the CC0 experience in Wisconsin demonstrates that the inclusion of Medicaid providers in the community elderly health network is not sufficient to achieve a comprehensive continuum of care. AAA’s and local service providers will still have to obtain the cooperation of other relevant provider agencies and organizations in the community if their programs are to be effective without generating a great deal of duplication. However, the inclusion of Medicare and Medicaid in this network, with the necessary waivers, will enable the local service providers to employ a stable and continual single or dual funding source in their effort to coordinate health services for the elderly in their community. The presence of this stable funding source is a crucial element in obtaining the cooperation of relevant provider agencies, and may also be a means of obtaining quality service via certification which accompanies Medicaid and Medicare coverage. In addition, the fact that Medicare and Medicaid are established programs will lend legitimacy to the AAA’s and their service delivery organizations in the community. CONCLUSION The health services delivery system in this country suffers from fragmentation not only at the federal and local governmental levels, but also at the local market level also. At present no institution or organization is attempting to coordinate this fragmented system. It is doubtful that any attempt to rationalize the entire health system could be successful simply given the level of fragmentation, let alone the absence of political or administrative power that would be needed to achieve such a level of coordination. In the area of elderly health, there are four programs which cover much of the scope of the elderly health service needs. Achieving coordination among these four programs, and possibly any two of the programs as long as one was Medicaid or Medicare, at both the federal and local levels could work to fill in many of the gaps in the elderly health delivery system. As a result, federal policy in this policy area could be made more effective by providing a comprehensive continuum of care, and possibly more efficient by avoiding unnecessary and inappropriate institutionalizations of elderly who would be better off receiving home care and support services. At present, no overall coordination effort is taking place. However, two new elements in the elderly health delivery system offer hope. First, as weak as it is, the Administration of Aging and its Area Agencies on Aging have a legislative mandate to pursue coordination in the elderly health arena. Second, amidst fragmentation at all levels, several programs such as Triage, the Community Care Organization, and ACCESS of Monroe County, New York, have utilized one or more of the federal programs and achieved a degree of service coordination for their clients. At present, the latter of these two different strategies appears to be achieving greater success given AOA’s political and administrative environment. However, these decentralized efforts only cover a small and scattered group of elderly. Success by the

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AOA and its Area Agencies on Aging would mean a much more widespread coordination effort. REFERENCES I. Roemer R. et al. Planning Urban Health Services. p. 8. Springer. Berlin (1975). 2. United States Congress, Congressional Budget Office. Long Term Carefor rhr Elderly

U.S. Government, Washington D.C. (1977). 3. Davis K. and Schoen C. Health and the War on Poverty, p. 93. Brookings (1978). of Health. Education, and Welfare, Administration 4. United States Department ment Handbook

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11-3. Community Research Applications, New York (1977). 5. Moore F. M. New Issues for In-Home Services, Public Welfare. p. 32. Spring. (1977). Ill, Health Sercices: The Local Perspective. A. Levin 6. Gamm L. and Eisele F. The Aged and the Chronically (Ed.). The American Academy of Political Science. New York (1977). 7. Congressional Quarterly. October, 14, 1978. p. 2958. Washington D.C. 8. United States Department of Health, Education, and Welfare, Office of the Assistant Secretary for Plannmg and Evaluation, National Long Term Care Channeling Demonstration Program, Letter of Infent. p. I. U.S. Government, Washington D.C. (1980). D. G. Public Policy Analysis of Older Americans: Administration on Aging Linkages iIt Com9. Montgomery mumties. delivered at the 1976 Annual Meeting of the American Political Science Association, Chicago, p. Il. Imperatives: Prospects for Area Planning in Aging. The IO. Hudson R. Rational Planning and Organizational Annals of the American Academy of Political and Social Science 415, p. 43 (1974). Choices and Urban I I. Weissman S. The Distribution of Urban Services in Social Programs: Organizational Elderly Policy. delivered at the 1978 Meeting of the American Political Science Association, New York. p. 8. Triage, p. 7. Plaineville. Connecticut. 12. Triage, Incorporated, An Alternatiae Approach To Care For The Elderly 197441979, p. 18. Plaineville. 13. Triage, Incorporated, Connecticut. by 14. Quinn J. L. and Doherty N. Testimony: L’nited States Senate Special Committee O!I Aging, Reprinted Triage. Inc.. Plaineville, Connecticut, p. 13. (1977). Department of Health and Social Services. Project Description, The Community Care 15. State of Wisconsin. Organization,

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p. I. March, (1979). United States Department of Health, Education, and Welfare, Administration on Aging, Program Handhook. p. II-4 (1977). State of Wisconsin, Department of Health and Social Services, Project Description, p. 3. (I 979). Seidl F. et ul. The Wisconsin Community Care Organization: Interim Evaluation Report II, Faye McBeath Institute on Aging and Adult Life. Community Care Evaluation Project. University of Wisconsin. Madison. p. 48, May (1978). Eggert G. and Bowlyow J. Preliminary Findings-The ACCESS Model, Monroe County Long Term Care Program. Inc., Rochester, New York, p. 5. June (1979). Monroe County Long Term Care Program, Inc. Fact Sheet. Rochester, New York. Pollak W. Expanding Health Benefits for the Elderly. Vol. 1: Long Term Care. p. 34. Urban Institute. Washington D.C. (1979).