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Abstracts of DALTCP REPORTS--"C" Titles

This section gives abstracts for reports produced through DALTCP-funded research or through research done by DALTCP staff. Links to Executive Summaries and/or Full Reports immediately follow most descriptions, as well to Project Descriptions (if available). (We are working towards putting ALL Full Reports online.) Reports can be ordered from the Office of Disability, Aging and Long-Term Care Policy, unless stated otherwise. Requests can be made by Fax (202-401-7733) or through email (webmaster.DALTCP@hhs.gov).

NOTE: Because of the large number of DALTCP reports, abstracts are divided into several files. Also, number of pages can vary from that given after the abstract when printing HTML versions, depending on your printer setup.

Remember, the Site Index section includes an alphabetic list of keywords you can choose to find information that is referenced throughout the DALTCP website.

CAREGIVER BURDEN AND INSTITUTIONALIZATION, HOSPITAL USE, AND STABILITY OF CARE

ABSTRACT: This study assessed a variety of longitudinal models to examine the effect of different types of caregiver burden on outcomes important to policymakers: nursing home admissions, hospital use, and stability of the family and formal care networks. Analyses were carried out on the 1982 National Long-Term Care Survey (NLTCS) and the 1984 NLTCS Longitudinal Follow-up, along with the 1982-1983 Informal Caregiver Survey. Among some of the findings: informal caregiver networks were found to be highly stable over time; formal caregiver networks fluctuated more, apparently responding more to time-specific needs. Caregivers who reported higher levels of "personal burden" (a dimension that included a number of elements such as lack of free time, having to provide care when the caregiver was sick, the caregiver experiencing worsening health, having to provide constant attention, etc.) were more likely over time to use or increase use of formal services. Caregivers who reported higher levels of "interpersonal burden" (a dimension that measured stress-producing characteristics of the care recipient such as senility, forgetfulness, yelling, and embarrassing behavior) were more likely over time to seek institutional placement for the elderly disabled care recipient.

CARING FOR FRAIL ELDERLY PEOPLE: POLICIES IN EVOLUTION

ABSTRACT: In Chapter 14 (U.S.), the long development of long-term care policy is described, giving particular emphasis to the functioning of the main programs introduced in the 1960s, and their progressive modification up to the 1990s. An outline is also given of the main reform debates of the late 1980s and 1990s. [Order this report from National Technical Information Service (NTIS), Department of Commerce, 5285 Port Royal Road, Springfield, VA 22161, Website http://www.ntis.gov, Accession #OECD-0692]

CASE MANAGEMENT TRAINING FOR CASE MANAGERS: A TRAINER'S GUIDE

ABSTRACT: Case management involves working with a client and family to agree upon problems, goals, and services necessary to support the client in the community. Data collected from an assessment is used to develop a care plan. Case management includes arranging services, monitoring the client's situation on an ongoing basis and adjusting the service package as needed. This guide presents an outline and course content for a three-day training program in case management utilizing the tools, documents and techniques developed for the Channeling Demonstration. The course utilizes a case study method designed to give workers experimental training in the techniques of case management. Included is the Case Management Forms Set (also available separately) containing the care plan and reassessment forms and guidelines for their use.

CASE STUDIES OF ELECTRONIC HEALTH RECORDS IN POST-ACUTE AND LONG-TERM CARE

ABSTRACT: This study was focused on electronic health records (EHRs) and information systems that are used to exchange clinical information across providers. However, the only clinical information systems that we were able to identify that exchanged information across settings that include PAC/LTC providers were health delivery systems that were highly integrated either because of their geographic location (large, rural health systems) or financial structure. The sites selected for this study were sites that used EHRs in the course of providing care and also used their EHRs to exchange clinical information with other health care providers. To learn more about the most advanced EHR systems in PAC/LTC, case studies were conducted at four sites with connectivity to acute hospitals, pharmacies, and/or ambulatory care. The goal was to emphasize sites representing the various PAC/LTC settings, types of affiliations, and both organizational and payment arrangements. [138 PDF pages]

CASE STUDIES OF SIX STATE PERSONAL ASSISTANCE SERVICE PROGRAMS FUNDED BY THE MEDICAID PERSONAL CARE OPTION

ABSTRACT: The Survey of Medicaid Personal Care Program examined how states have used Medicaid's Personal Care Services Optional Benefit (or PC Option), assessed whether coverage regulations for these services be revised, and discussed the ways in which the program might affect public debate about the expansion of public funding for long-term care. The project entailed reviewing survey data and conducting case studies of six states' PC Option programs. This report describes the site visit methodology and the programs interviewed in each of the six states.

CASH AND COUNSELING: CONSUMER'S EARLY EXPERIENCES IN ARKANSAS

ABSTRACT: This paper describes the experiences of 194 early clients in the Arkansas Cash and Counseling Demonstration, IndependentChoices. The description is based on the clients’ responses to a telephone survey conducted about nine months after they applied to enter the program and were randomly assigned to the demonstration’s treatment group to receive a monthly cash allowance. After briefly describing the Arkansas project, data and methods used, and client characteristics, this paper discusses client outcomes in four areas: (1) program participation; (2) uses of services, goods, and cash; (3) hiring of caregivers and revision of cash expenditure plans; and (4) satisfaction.

CASH AND COUNSELING DEMONSTRATION: AN EXPERIMENT IN CONSUMER-DIRECTED PERSONAL ASSISTANCE SERVICES

ABSTRACT: No abstract available at this time.

CATASTROPHIC ACUTE AND LONG-TERM CARE COSTS: RISKS FACED BY DISABLED ELDERLY PERSONS

ABSTRACT: The repeal of many provisions of the 1988 Medicare Catastrophic Coverage Act was due to subjective impressions about the usefulness to many elderly persons of the services covered by the law and to the omission of long-term care services. In the wake of the repeal of the Act, many legislators have promised that the issue of catastrophic health care costs would be revisited and that long-term care costs as well as acute care costs would be considered in their deliberations. This paper presents an empirical analysis of the extent to which acute and long-term care cause disabled elderly persons to incur catastrophic costs. The authors found that the proportion of these people whose out-of-pocket costs exceed 20% of income rises from 20% when only acute care costs are measured to 30% when long-term care costs are included.

CHANGES IN ELDERLY DISABILITY RATES AND THE IMPLICATIONS FOR HEALTH CARE UTILIZATION AND COST

ABSTRACT: Recent research has provided promising evidence that aggregate age-adjusted disability among older Americans has decreased. There also is evidence that cognitive impairment and physical limitations, such as lifting 10 pounds, walking short distances, and climbing a flight of stairs, which may be precursors to disability, may have declined in recent years. On the other hand, some studies show increases in chronic disease, increases in the use of paid long-term care, and increasing disability levels within the disabled population. This study was undertaken in order to better understand these trends and their potential implications for use of acute and long-term care. [44 pages]

CHANGES IN MARRIAGE AND FERTILITY BEHAVIOR: BEHAVIOR VERSUS ATTITUDES OF YOUNG ADULTS

ABSTRACT: This report examines a variety of data regarding current trends in adolescents' sexual, fertility, and marital behavior and discusses evidence regarding the permanence of these trends. Behavioral data are compared with attitudinal measures to conclude that there are significant differences between the conduct and values of young adults. The report suggests that policies which can bring adolescents' actions in line with their attitudes may be able to affect the disturbing increases in adolescent sex, premarital sex, abortion, non-marital childbearing, and divorce.

CHANGING FACE OF INFORMAL CAREGIVING--A NATIONAL CONFERENCE ON POLICY DIRECTIONS FOR THE 1990s

ABSTRACT: This national conference on informal caregiving was organized to assess the state-of-the-art in policy research with respect to such issues as work/caregiving conflicts, stress and satisfaction among family caregivers, integration of formal and informal services, and the role of volunteers and community organizations. The conference was sponsored by ASPE's then Division of Long-Term Care and Aging Policy (now DALTCP) and included researchers, federal and state regulatory officials, and experienced practitioners in the field. This package, which was given to the conference participants, includes papers describing caregiving issues.

CHANNELING CASE MANAGEMENT MANUAL

ABSTRACT: Case management is the process of integrating and synthesizing information from an assessment into a care plan. It involves working with a client and family to agree upon problems, goals, and services necessary to support the client in the community. Case management also includes arranging for services, monitoring the client's situation on an ongoing basis, and adjusting the service package as needed. This manual contains an overview of the core functions of the Channeling Demonstration and the role of the case manager, and describes support functions such as record keeping. It is a basic primer covering the principles of good practice for case managers.

CHANNELING EFFECTS FOR AN EARLY SAMPLE AT 6-MONTH FOLLOWUP

ABSTRACT: A preliminary analysis of interview data at 6-month follow-up for a sample of approximately 3,000 early enrollees in Channeling indicated the following. (1) The population served was old and frail. (2) The intervention was implemented largely according to design. (3) Substantially more of the treatment group received case management and formal services than did the control group. (4) Treatment-control differences were not statistically significant with respect to hospital use, nursing home use and mortality. (5) There were indications that Channeling improved the self-perceived well-being of treatment group members compared to controls. Channeling did not significantly reduce the amount and type of informal care provided. These findings are subject to modification based on analysis of the full research sample and additional data collection.

CHANNELING EFFECTS ON FORMAL COMMUNITY-BASED SERVICES AND HOUSING

ABSTRACT: Both the treatment group and control group members in the Channeling Demonstration used community services extensively. Channeling increased the use of services by the treatment group compared to the control group. The expectations at the outset of the demonstration were that such increases would be due to the fact that greater numbers of the elderly would remain in the community, as well as increased use of services by those already in the community. In reality, all the observed service use increases were due to the latter effects, since no impact was observed on mortality or institutionalization. The largest increases in service use were observed for personal care and housekeeping services, which are the ones usually not covered by existing public programs or private insurance. There were increases in public and total costs. At the same time, there is evidence that in the Financial Control Model projects were able to use their purchasing power to reduce the per-unit costs of some services.

CHANNELING EFFECTS ON HOSPITAL, NURSING HOME AND OTHER MEDICAL SERVICES

ABSTRACT: The impacts of the Channeling Demonstration on hospital, nursing home and other medical service use as well as mortality can be summarized as follows. Channeling had no impact on mortality; death rates for the treatment and control groups were very high but not statistically significant. The population served was not at high risk of institutionalization. Private persons and Medicaid were the major payers for nursing home care. Nursing home use and expenditures were lower for the treatment group and the control group but the differences were not large and generally not statistically significant. Reductions in nursing home use in the Basic Case Management Model were concentrated in one site (Southern Maine). Channeling reduced nursing home use for persons in a nursing home at the time of their screen for Channeling eligibility. Control group hospital use and expenditures were very high, although they fell over time. The control group exhibited a high use of and expenditures on other medical services. Channeling had no impact on the use of or expenditures on hospital, physician and other medical services.

CHANNELING EFFECTS ON INFORMAL CARE

ABSTRACT: Channeling was expected to increase the use of formal community-based care by the frail elderly. However, if this led to substitution of formal for informal care, the public sector would then be paying for services otherwise provided by family and friends. There was no evidence that such substitution occurred in the Basic Case Management Model. In the Financial Control Model, Channeling did lead to modest substitution of certain services, but there is no evidence of widespread substitution. Nor is there evidence of reductions in informal care by primary caregivers. The effect appears to be due to withdrawal by some friends and neighbors. Additionally, Channeling improved the well-being of primary caregivers by some measures, such as reducing caregiver worry about receiving sufficient help and increasing overall life satisfaction.

CHANNELING EFFECTS ON THE QUALITY OF CLIENTS' LIVES

ABSTRACT: This report presents the impact of the Channeling Demonstration on the quality of clients' lives. Channeling was expected to affect life quality through two mechanisms: (1) the provision of case management and expanded services to people who would have stayed in the community even without Channeling, and (2) reduced institutionalization. Even though Channeling had no significant impact on institutionalization rates, the results generally bear out these expectations. For both the Basic Case Management Model and the Financial Control Model at 6 and 12 months, treatment group members reported more satisfaction with service arrangements, more confidence about receiving needed services and fewer unmet needs than did the control group. There were no substantial differences between the two Channeling models on these dimensions.

CHANNELING FINANCIAL CONTROL SYSTEM

ABSTRACT: The ten sites of the National Long-Term Care Channeling Demonstration provided case management to very impaired elderly clients who wished to remain in the community. Five of the sites that developed the Financial Control Model could pay for services from a pool of waiver dollars and state and local funds. This report describes the computerized and manual cost control system that was used by the five Financial Control Model sites to keep service expenditures for clients below a pre-determined level or "cap." The system's strengths and weaknesses are described and recommendations are included.

CHARACTERISTICS OF NURSING HOME RESIDENTS UNDER AGE 65

ABSTRACT: It is commonly held that those aged <65 in nursing homes are substantially different from elderly residents. This study uses data gathered using the Resident Assessment Instrument's Minimum Data Set to describe these relatively rare residents.

CHARACTERISTICS OF PERSONS WITH DEVELOPMENTAL DISABILITIES: EVIDENCE FROM THE SURVEY OF INCOME AND PROGRAM PARTICIPATION

ABSTRACT: In spite of the growth in federal programs affecting the developmentally disabled, there is little comprehensive information about this population. The Survey of Income and Program Participation (SIPP) is one available source of information. SIPP is a nationally representative longitudinal survey of the adult civilian non-institutionalized population in the U.S. One topical module in the 1984 SIPP Panel collected data on health conditions and functional limitations. Estimates of persons with developmental disabilities were made using these data. Based on varying definitions of developmental disability, the prevalence is estimated to range from 1.3 million (narrow definition) to 1.7 million (middle definition) to 4.6 million (broad definition). SIPP is limited to persons aged 16-72. It focuses mainly on work limitations and does not ask age of onset. Nevertheless, in the absence of more focused surveys, it does provide useful insights into the size and characteristics of the developmentally disabled population. Prevalence rates derived from SIPP are generally consistent with current estimates derived from other sources.

CHILD CARE CHALLENGE: WHAT PARENTS NEED AND WHAT IS AVAILABLE IN THREE METROPOLITAN AREAS

ABSTRACT: This report presents the findings of a survey conducted to meet the informational needs of the Teenage Parent Demonstration and to address the broader issues associated with the nature of child care markets. The Teenage Parent Demonstration, initiated in 1986, is a study designed to learn more about child care needs and available supply of care for low income and welfare mothers. The report describes the sample design of the survey, its results concerning the supply of child care and the need for child care, and a multivariate analysis of child care mode choice and expenditures. Data for the analysis was gathered in Camden, New Jersey, Newark, New Jersey, and South Chicago, Illinois.

CHILD CARE USED BY WORKING WOMEN IN THE AFDC POPULATION: AN ANALYSIS OF THE SIPP DATA BASE

ABSTRACT: This paper presents the Survey of Income and Program Participation data on child care for working guardians on AFDC. These guardians use care by relatives 58% of the time for their youngest children under 6. They are thus using informal care arrangements which are generally free or low cost instead of more formal arrangements, for which one generally must pay. As expected from this pattern of usage, the data show they pay less often for child care. In addition, when they do pay, they pay less money than non-AFDC recipients, averaging $22.50 per week. Because the sample of working guardians on AFDC is very similar to the SIPP's sample of non-working AFDC recipients, the authors expect that these data can help work/welfare program planners in determining child care requirements for new initiatives encouraging AFDC recipients to work. Arguments are presented to suggest that about half of new program participants will choose relative care, and that the amount participants will need to cover their payments for care will be similar to current expenditures.

CHILDREN WITH SEVERE CHRONIC CONDITIONS ON MEDICAID

ABSTRACT: Many children with special health care needs depend on the health and supportive services provided by Medicaid. It is important that policymakers have a sound understanding of these children's patterns of health care use, especially given the shift to managed care. Previous studies of children on Medicaid with severe disability and/or chronic illness have focused on "SSI-related" children, or children with extremely high health care costs. This study provides further analysis of Medicaid expenditures for SSI children, and adds to the literature by applying diagnostic and utilization-based criteria to claims data to identify children with severe chronic illness. This methodology enables analysis of the service use patterns and expenditures for children with severe chronic conditions who are receiving Medicaid, but are not enrolled in SSI.

CLARIFYING THE DEFINITION OF HOMEBOUND AND MEDICAL NECESSITY USING OASIS DATA: FINAL REPORT

ABSTRACT: This study assesses the feasibility of using information routinely collected as part of the Outcome Assessment and Information Set (OASIS), as well as other patient data, to develop objective and consistent tools for evaluating a beneficiary's homebound status and his/her need for skilled care under the Medicare home health benefit.

COMMUNITY CHOICE: NEW JERSEY'S NURSING HOME TRANSITION PROGRAM

ABSTRACT: This paper--which is one of a series of Appendices included in the demonstration's final report--describes New Jersey's nursing home transition program, called Community Choice. Community Choice is one of the first permanent, publicly funded nursing home transition programs in the United States. In addition to describing Community Choice as a whole, this case study describes how New Jersey improved Community Choice using a federal Nursing Home Transitions Demonstration grant. [23 pages]

COMMUNITY SERVICES AND LONG-TERM CARE: ISSUES OF NEGLIGENCE AND LIABILITY

ABSTRACT: Agencies operating under the National Long-Term Care Channeling Demonstration program had complex assignments to assess the needs of older people requiring long-term care, to determine what services met such needs and to arrange for the delivery of services. Responsibility for a client was spread across several agencies, organizations, and individuals. This paper examines the liability, and avoiding or minimizing risks of negligence.

COMPARABILITY OF TREATMENT AND CONTROL GROUPS AT RANDOMIZATION

ABSTRACT: This report analyzes the treatment and control groups in the National Long-Term Care Channeling Demonstration and concludes that the randomization procedure resulted in groups that are very similar on observable characteristics. Even for site level comparisons, where larger differences were expected because of smaller sample sizes, the number of statistically significant differences was no larger than would be expected by chance. These findings imply that the Channeling control group provided a reliable measure of what would have happened to the treatment group in the absence of the Channeling intervention. Additionally they imply that other investigations which rely on screening data to assess other possible sources of non-comparability of data (e.g., non-comparability of baseline assessment data or differential sample attrition) would not be confounded by differences between groups at randomization.

COMPENDIUM OF CURRENT FEDERAL INITIATIVES IN RESPONSE TO THE OLMSTEAD DECISION

ABSTRACT: This report is intended to serve as a compendium of selected projects which are currently operational at the federal level to promote the expansion of long-term supports and services in community-based settings. Some of these initiatives (e.g., the Cash and Counseling Demonstration Program) were initiated even prior to the ruling of the Supreme Court in Olmstead v. L.C. but all reflect the guiding principles enumerated above. For each project, the authors present information on both the funding and implementing organization, the purpose of the project, a brief description of the activity, and contact information on where people can go to obtain more detailed information about the project. While they have tried to identify the major projects currently in operation at the federal level to support states' efforts to expand long-term supports and services for persons with disabilities, the report undoubtedly fails to include all of the activities going on at the federal level in response to the Olmstead decision. [51 pages]

COMPENDIUM OF HHS TECHNICAL ASSISTANCE ACTIVITIES RELATED TO THE ADMINISTRATION'S COMMUNITY-INTEGRATION INITIATIVE

ABSTRACT: To fulfill a Presidential mandate, the Department of Health and Human Services established the New Freedom Initiative Workgroup to review efforts that have been initiated in response to the Olmstead decision, and to recommit and refocus the Administration's efforts in promoting the full participation of adults with disabilities in community life. As part of this effort, Workgroup members felt it would be helpful to compile a compendium of selected projects which are currently operational at the federal level to promote the expansion of long-term supports and services in community-based settings. For each project, the following is presented: information about the funding and implementing organization, the purpose of the project, a brief description of the activity, and information on where people can go to obtain more details about the project. The Workgroup plans to update this compendium on a quarterly basis. [93 pages]

COMPENDIUM OF INTERVENTION AND DESCRIPTIVE STUDIES DESIGNED TO PROMOTE THE HEALTH OF CAREGIVERS FOR OLDER ADULTS

ABSTRACT: An important component of the ASPE Health Promotion and Aging Project is the development of such an inventory of health promotion, disease prevention, and health education activities targeted at informal caregivers for HHS. The specific focus of this report is to highlight some state and local initiatives that have developed promising programs to support, educate, and motivate caregivers of persons age 60 and older to maintain and improve their health and functioning. [38 pages]

CONDITIONS AND IMPAIRMENTS AMONG THE WORKING AGE POPULATION WITH DISABILITIES

ABSTRACT: Written as part of the Proceedings of the Annual Meeting of the American Statistical Association.

CONFERENCE ON SUCCESSFUL FAMILIES

ABSTRACT: At this conference, 13 of the leading researchers in the field came together to describe their work and define outstanding research issues. Discussions included issues of defining successful families and measures which can be used to identify them, methodological issues in research regarding families, and issues relevant to the application of findings. The Literature Review focuses primarily on studies specifically on successful families research.

CONFRONTING THE NEW HEALTH CARE CRISIS: IMPROVING HEALTH CARE QUALITY AND LOWERING COSTS BY FIXING OUR MEDICAL LIABILITY SYSTEM

ABSTRACT: With rapidly rising health care costs, reforms are needed to make high-quality, affordable health care more widely available. A critical element for providing real relief for both patients and physicians is comprehensive reform of our current medical liability system. Multimillion-dollar judgments have steadily increased insurance premiums for many specialty areas and prompted many physicians to engage in "defensive medicine". As a result, for many states, there have been significant reductions in quality and access to care for many Americans because doctors are forced to move, retire, or restrict their practices. Some states have already taken the initiative and reformed their own medical malpractice systems by capping non-economic damages to $250,000 and $350,000. Over time, this has resulted in comparatively smaller increases in physician's insurance premiums and more reliable access to care and services for the patients who reside in those states. Further federal and state action is currently being sought, through legislative action, to expand such provisions and standards across the nation. [29 pages]

Two updates on this subject are also now available. UPDATE #1 discusses the Special Update on Medical Litigation Crisis. UPDATE #2 provides an Update on the Medical Litigation Crisis: Not the Result of the "Insurance Cycle".

CONSIDERING CHILDREN WITH DISABILITIES AND THE STATE CHILDREN'S HEALTH INSURANCE PROGRAM

ABSTRACT: This brochure is intended to familiarize state decisionmakers with low income uninsured children with disabilities so that they have essential information about these children as they develop and implement CHIP plans. It describes uninsured children with disabilities, their numbers, their needs, and how opportunities presented by CHIP can help. [6 pages]

CONSTRAINED INNOVATION IN MANAGING CARE FOR HIGH-RISK SENIORS IN MEDICARE + CHOICE RISK PLANS

ABSTRACT: This case study of four well-regarded managed care organizations (MCOs) found that they made numerous innovations to improve care delivery for elderly Medicare beneficiaries with chronic illnesses and disabilities. In presenting the findings, the report starts with an overview of the policies that are shaping Medicare managed care and an analytical framework for thinking about that program and how it serves beneficiaries with disabilities or chronic illnesses. The authors then describe the data and methods. In Chapter III, special features of high-risk seniors are examined that will challenge care systems that seek to serve them. Chapter IV reviews the processes and structures the four MCOs have developed for serving high-risk seniors. Chapter V provides more details about the experiences of a sample of high-risk seniors in three of the case-study MCOs, specifically, their satisfaction with their providers and plans and their perceptions of care management. Chapter VI looks at a particularly vulnerable group, elderly beneficiaries with a recent hip fracture or stroke. Finally, Chapter VII lays out some recommendations that emerge from this case study. [181 pages]

CONSUMER CHOICE AND THE FRONTLINE WORKER

ABSTRACT: No abstract available at this time.

CONSUMER DIRECTED CARE AND NURSE PRACTICE ACTS

ABSTRACT: This paper examines the current state nurse practice acts and their implementing regulations to determine the extent to which they permit more consumer direction in home and community based services. This analysis may be helpful to consumers and states that are seeking ways to better balance state policies to support consumer-directed care.

CONSUMER DIRECTION IN HOME AND COMMUNITY-BASED SERVICES: RESEARCH PROJECT DESCRIPTIONS

ABSTRACT: No abstract available at this time.

CONSUMER-DIRECTED ATTENDANT SERVICES: HOW STATES ADDRESS TAX, LEGAL AND QUALITY ASSURANCE ISSUES

ABSTRACT: Consumer-directed care is a model of financing and delivery of personal care assistance that allows the elderly or disabled consumer to have greater choice and control over all aspects of their attendant care. This control may extend to hiring, firing, paying, training, and supervising the personal care attendant or homemaker, and participating in the determination of their own needs or developing their own care plan. This report examines how ten states manage their consumer-directed care attendant programs. It considers payment issues, employer-related taxes, legal liability, and quality assurance issues related to these programs. The report also describes theoretical optimal consumer-directed models for in-home care. It finds that, from the state perspective, an optimal program would (1) allow states or their designees to be primary care planners and gatekeepers; (2) distinguish attendants from state or county employees; (3) allow states to purchase attendant services at a considerably lower price than traditional in-home services; and (4) allow for low-cost workers' compensation of autonomy, depending upon the wishes of the consumer. Finally, the consumer must be designated as the employer of record, unless the attendant is an independent contractor.

CONSUMER-DIRECTED MODELS OF PERSONAL CARE: LESSONS FROM MEDICAID

ABSTRACT: In this article, the authors compare and contrast alternative approaches to administering programs, financed under the Medicaid personal care services optional (PC Option) benefit, that make attendant services available to low income elderly and disabled persons in need of help with daily living tasks. The analyses address the following issues: (1) By how much do state Medicaid PC Option programs vary in terms of their administrative features that promote greater consumer choice and control or, conversely, in their emphasis on professional oversight and accountability? (2) To what extent have program administrators actively fostered consumer-directed care models? (3) What are the decisionmaking trade-offs in terms of Medicaid PC Option costs per hour of attendant service, coverage for high-need clients, perceived risks to quality, or other liability concerns associated with consumer direction versus professional management of attendant services? (4) To what extent do clients report having greater choice and control over attendant services in some states' Medicaid PC Option programs as compared to others? (5) Does greater client choice and control result in higher client satisfaction with attendant services? (The Milbank Quarterly, Volume 74, Number 3)

CONSUMER-DIRECTED PERSONAL ASSISTANCE SERVICES: KEY OPERATIONAL ISSUES FOR STATE CD-PAS PROGRAMS USING INTERMEDIARY SERVICE ORGANIZATIONS

ABSTRACT: This final report provides practical advice to state program administrators regarding the implementation of consumer-directed personal assistance service (CD-PAS) programs and intermediary service organizations (ISOs). In particular, Chapters III, V, and VI, taken together, constitute an informal manual of advice from which state program administrators can design optimal CD-PAS programs using ISOs which are based on sound, regulatory principles and well-drafted contracts. Overall, this final report assists state program administrators in designing CD-PAS programs with ISOs that: (a) comply with applicable federal tax and labor laws; (b) make available supportive services that some consumers may want or need; and (c) allow for the application and enforcement of any limitation or restrictions on consumer direction that may be required by state laws and regulations. [95 pages]

CONTINUING CARE RETIREMENT COMMUNITIES: A BACKGROUND AND SUMMARY OF CURRENT ISSUES

ABSTRACT: Continuing Care Retirement Communities (CCRCs) are presently becoming a more viable option for seekers of long-term care for the elderly. CCRCs have been recognized for their unique strategy of combining various levels of health care within one community setting, as well as their potential for providing cost-effective care. As the industry undergoes tremendous growth and as many CCRCs gradually lose their reputation for being "financially unstable", more elderly individuals are finding this long-term care option more attractive. However, because the costs of a community are most often too high, the majority of the elderly population are not able to afford them. This problem has drawn the attention of many both in and outside the industry who hope to discover how the benefits of a CCRC can be accessible to more of the elderly population. Most present research on CCRCs deals with defining a CCRC or describing its structure. This paper analyzes CCRCs in a somewhat broader sense by focusing not only on the internal workings of CCRCs, but by also looking at issues currently surrounding the industry, such as affordability, managed care and regulation.

CONTRIBUTION OF MEDICATION USE TO RECENT TRENDS IN OLD-AGE FUNCTIONING

ABSTRACT: The purpose of this study is to explore the extent to which changes in medication use account for improvements in functioning among older Americans. Using several waves of the Health and Retirement Study, a nationally representative survey of non-institutionalized Americans ages 51-61, the authors examine changes between 1992 and 1998 and between 1994 and 2000 in the prevalence of functional limitations and medication use associated with five highly prevalent and often debilitating chronic conditions: hypertension, diabetes, lung disease, stroke, and arthritis.

COORDINATION OF CARE FOR PERSONS WITH DISABILITIES ENROLLED IN MEDICAID MANAGED CARE: A CONCEPTUAL FRAMEWORK TO GUIDE THE DEVELOPMENT OF MEASURES

ABSTRACT: The purpose of this document is to present a conceptual framework to guide the development of measures of care coordination that would be both feasible to apply and meaningful in assessing the performance of Medicaid managed care organizations (MCOs) that enroll people with disabilities. Although there are no explicitly required care coordination systems now in place, some states are providing systems of coordination and doing it with existing resources. This document presents a structure for defining and measuring good care coordination for states that have systems and want to measure them, and for those who may wish to implement systems in the future.

COST ESTIMATES FOR THE LONG-TERM CARE PROVISIONS UNDER THE HEALTH SECURITY ACT

ABSTRACT: This document describes the methodology and assumptions used in developing the cost estimates for the long-term care provisions under the Health Security Act.

COST OF CARE FOR MEDICAID-ENROLLED CHILDREN WITH SELECTED DISABILITIES

ABSTRACT: The purpose of this study is to estimate and compare costs of care for children with 11 selected chronic conditions, to compare these costs with costs of care for children without any of these conditions, and to identify whether selected demographic variables are associated with cost variation. The focus was on Medicaid-enrolled children with chronic conditions. This population presents particular challenges to states as they consider implementing managed care programs for the Medicaid population, and a disproportionate number of children in Medicaid have chronic health conditions.

COST-EFFECTIVENESS OF HOME AND COMMUNITY-BASED LONG-TERM CARE SERVICES

ABSTRACT: No abstract available at this time.

Last revised: September 16, 2004

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