Long-term care services for older and seriously disabled people are absorbing an ever-larger share of the Medicare and Medicaid program costs. The Federal Government and States are searching for new managed care strategies, such as capitated financing and coordinated case management, to better integrate the financing and delivery of primary, acute, and long-term care services. The goal is to encourage substitution of less costly and more appropriate home and community-based services for high-cost and long-term care services. For rural communities, this approach may help address long-standing problems of limited access to long-term care services.
The rural long-term care delivery system has relied more heavily on nursing home care and has been characterized by more limited service options, particularly in the areas of rehabilitation, residential care, and home care. Participants at two conferences, supported in part by the Agency for Healthcare Research and Quality (HS09850), explored current research on the integration of rural long-term care. Three articles arising from these conferences examined the barriers to and opportunities for integrating rural long-term care services, as well as fledgling model programs developed to accomplish this. They are summarized here.
Beaulieu, J., Rowles, G.D., and Kuder, L.C. (2001, December). "Current research in rural models of integrated long-term care." Journal of Applied Gerontology 20(4), pp. 379-385.
Rural regions have both barriers to and opportunities for implementing integrated long-term care, according to these authors. For example, the small population pools found in rural areas make risk contracts difficult to implement but are an advantage for coordinating care across providers. In that sense, coordination, rather than integration per se, may be more appropriate for developing rural long-term care systems. Cooperation is hampered, however, when professionals lack the skills to work in teams and when long-term care and acute care providers do not understand each others' language. Small rural hospitals also can expand their role. For example, between 1987 and 1996, they provided 25 percent more swing beds, skilled nursing beds, or hospice beds and increased services to the elderly, such as assisted living or retirement housing.
The objectives of long-term care models that integrate multiple sources of financing (Medicaid, Medicare, and private funds) are to modify eligibility requirements that differ by payment sources, reduce service discontinuity caused when benefits are exhausted, and build incentives for providing the right types of services in the right amount. States' Medicaid programs historically have borne the burden of public long-term care financing. In fact, many States have implemented Medicaid demonstration programs to reduce or stabilize the rate of increase in long-term care expenditures.
Demonstration program features in some rural communities can be generalized to service development in other rural communities: local leadership and local control, cooperation and trust among partners, communication between medical providers and long-term care providers, limits on competition, efficient program management for small populations, and favorable Federal and State policy. Case management systems specifically serving rural long-term care clients, which can coordinate care across social and health services, across service providers, and across funding sources, have not been sufficiently demonstrated. Best practices that capitalize on the opportunities in existing rural service systems build innovative teams for client advocacy and coordinate services in a timely manner, often including the family in long-term care decisions.
Coburn, A.F. (2001, December). "Models for integrating and managing acute and long-term care services in rural areas." Journal of Applied Gerontology 20(4), pp. 386-408.
This author points out that development of integrated long-term care programs requires an intensive investment of capital and organizational leadership that often is lacking in rural areas. Also, development of the organizational, administrative, and clinical systems needed to integrate and manage care, especially in a capitated or risk-based financing system, is well beyond the capacity of the average rural provider or health system. What's more, rural providers have limited managed care experience and are not likely to be inclined or prepared to participate in managed care programs for high-risk, vulnerable populations such as the frail elderly. Finally, there are limited services (for example, physical therapists or psychiatrists) and service delivery mechanisms in rural areas.
In States like Minnesota and Wisconsin, where the Medicaid and State long-term care programs have been active in developing new financing and managed care arrangements for the chronic care population, there is a far greater likelihood of rural participation and experimentation with different integrated models of acute and long-term care financing and service delivery. The key features of State programs involved in long-term care system reform efforts include: expansion of noninstitutional care alternatives for at-risk individuals (for example, home care and nonmedical residential care); development of financing approaches that support better management of complex medical and social support needs and problems; and better coordination or integration of services across primary, acute, and long-term care systems.
However, the author cautions that integration is not necessarily the gold standard for improving the care of the elderly. Other strategies that involve linkage or coordination approaches may be just as effective and certainly more feasible in most rural areas. Coordination strategies can range from coordination of benefits to the development of mechanisms that share clinical information among providers.
Kuder, L.C., Beaulieu, J., and Rowles, G.D. (2001, December). "State and local initiatives on research questions for rural long-term care models." Journal of Applied Gerontology 20(4), pp. 471-479.
This paper describes a few rural long-term care models. One is the Mountain Empire Older Citizens (MEOC) in rural Appalachia, which has integrated multiple health and social services under one organizational umbrella. The MEOC is designated to serve as the area agency on aging and public transit provider for four extremely isolated areas with limited community resources. MEOC's goal is to prevent the unnecessary and inappropriate institutionalization of at-risk individuals and provide support to families caring for them. Through partnering and building on local strengths to meet identified community needs, MEOC has amassed a $5 million budget from sources ranging from Medicare and Medicaid to State transportation, job training, and local nutrition funds. It offers more than 25 different services, ranging from adult day care to wellness programs for seniors, all with outreach programs.
The Oregon Senior and Disabled Services Division is the most advanced State effort to provide integrated acute and long-term care services. The State mandates coordination of community services, creation of health and social services for all seniors, preventive and primary health care services, and prevention of inappropriate or premature institutionalization. A single State agency was created to administer Medicaid long-term care, the Older Americans Act, and services for the disabled and to work in partnership with local governments, including rural communities, to develop a system of community-based programs.
Oregon's success in decreasing the number of nursing home beds exemplifies the success of substituting home- and community-based services for more expensive nursing home and other institutional-based care. The system has spurred a redesign of community-based home care options such as adult foster homes and residential care facilities, as well as assisted and specialized living facilities. Oregon's 18 area agencies on aging are the focal point of the delivery system.