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Expanding Long-term Care Choices for the Elderly

Systems that Meet Needs


Christine Gianopoulos, M.P.A., Director, Maine Bureau of Elderly and Adult Services, Augusta, ME.

Dann Milne, Ph.D., Manager of Delivery System Development, Colorado Department of Health Care Policy and Financing, Denver, CO.


The reform of Maine's long-term care (LTC) system came as a result of a budget crisis in 1993. Too many nursing facility (NF) beds existed, and Medicaid had minimal eligibility criteria and generous reimbursement rates. Christine Gianopoulos described what's working in the revised LTC system:

  • Increased number of people receiving home and community care: In 1999, the number of disabled and older adults who received services at home or in residential care facilities was double the number served in 1995.
  • Shift in spending on home and community care: Thirty-four percent of the State's LTC budget goes to home and community care, compared with 16 percent in 1995, while NF spending dropped from 84 percent in 1995 to 66 percent in 1999.
  • Reduced reliance on nursing facilities: Between 1995 and 1999, the number of people in NFs was cut in half, while the number of people receiving services through home care doubled. The average NF length of stay has been reduced by half. Ms. Gianopoulos noted that the largest difference is that people admitted to NFs are discharged earlier.
  • Increased options in residential resources: Maine now has more kinds of residential alternatives than ever before.
  • Conversion of NF beds to other uses: Through the State's creative use of the certificate of need process, more than 1,300 NF beds have been de-licensed since 1994, and 43 NFs now offer multiple levels of care (from 9 in 1995).
  • Implementation of standardized LTC assessments: Maine uses a single, statewide contractor for assessing eligibility for all LTC programs and for developing care plans, and a uniform tool for assessing the need for either NF or home care.
  • Better home care coordination: The State contracts with two agencies to arrange and pay for home care services statewide. The statewide Independent Living Center manages consumer-directed programs. An Area Agency on Aging manages agency-based, consumer-directed, and surrogate models.
  • Integrated LTC and acute health services: The MaineNET pilot is a Primary Care Case Management (PCCM) model for dually eligible persons that partners primary care physicians with the home care coordination agency.
  • Equity and cost containment: Revised home care program policies better align eligibility standards, regulatory requirements, and reimbursement. State and Medicaid LTC spending increased in 1999 for the first time in more than 5 years.

Current challenges to Maine's LTC system include:

  • Labor shortage: Shortages in both professional and paraprofessional staff.
  • Waiting lists: Lists for State-funded home care because consumers and families generally seek services in a crisis.
  • Inconsistent quality assurance efforts (although most home care participants are satisfied when asked): Ms. Gianopoulos noted that Maine has traditionally taken the position that if a person is receiving care in the home, then he/she is receiving quality care.
  • Insufficient support structure for family caregivers: Many report that getting into the LTC system is daunting.
  • Costs of assisted living: The system needs to be affordable for consumers and payers.
  • Meeting the needs of special populations: Populations include groups such as elders with mental illness, mental retardation, and acquired brain injury.
  • Sustainability: How to finance, staff, assure quality, and manage costs in an environment of rising consumer expectations and growing demand for publicly funded services.

What worked in revising the LTC system included:

  • The budget crisis provided momentum.
  • Term limits brought new legislators who would look at issues differently.
  • The State's NF association was in disarray.
  • The State had support from elders.
  • Accurate, credible data was critical. Ms. Gianopoulos noted that partnership with the University of Southern Maine enhanced the credibility of the data.
  • Medicaid, Aging, and Licensing were all within the same State agency, which facilitated strong partnerships.
  • Staff worked very hard to pull off this effort.

What didn't work as well included:

  • Originally, the program did not have enough funds for residential alternatives (this is no longer the case).
  • The State didn't do enough to educate consumers and family members.
  • The State created rising expectations about what the revised system would do; consequently, keeping expectations realistic has been a problem.


Colorado has 10 home and community-based services waivers providing a spectrum of service choices. Dr. Milne asserted that "system" is the key word in a "manageable system of LTC" (defined as one that increases accountability, measurement, and use of data to enhance budgeting, policymaking, monitoring, and evaluation functions).

Colorado's Long-term Care System Plan began in 1989. Planners first identified problems with the existing system (or lack thereof), then established principles and values, and developed infrastructure. The goal was to consolidate the State's fragmented "LTC nonsystem" and to help clients navigate it better by minimizing confusion. The guiding principles include two that depend on strong data systems:

  1. The LTC system shall provide managed services that are systematically monitored and evaluated for appropriateness, cost-effectiveness, quality of service, and client satisfaction.
  2. When LTC resources are not sufficient to meet all LTC needs, priority shall be given to those clients most in need of services. Consideration of need shall include functional capacity, alternatives, support available, and appropriateness of final care.

Infrastructure development had four facets:

  1. The Uniform Client Assessment Instrument was implemented Statewide in 1992 to assess eligibility and develop care plans for clients in all LTC programs.
  2. A single entry point (SEP) system for all LTC services. When a potential client calls 1 of these 25 SEPs, a case manager does a brief phone assessment to determine if the person needs information and referral or a more in-depth assessment. If the latter, an in-home assessment is done using the Uniform Client Assessment Instrument on a laptop.
  3. A level of care/preadmission review, in which the SEP electronically sends the client's assessment information (through dedicated phone lines) to a Professional Review Organization to determine the best level of care.
  4. The integrated LTC database, with data that are used by several different State agencies (following appropriate security and privacy measures).

The purpose of the integrated LTC database is to provide the State with accessible client assessment information. It is the only computerized source of LTC information that tracks clients across programs. It includes information from the Professional Review Organization about each client's assessment and plan/level of care. Monthly reports generated from the database successfully answer the following questions:

  • Related to budgeting: Who are the clients? What are their characteristics? What is the need for and value of LTC expenditures?
  • Related to policymaking: What happens to the continuum of care when program enrollments are suspended (e.g., through waiver program caps)? How do clients flow into and between services?
  • Related to monitoring: Are we processing more assessments per person over time? What is the client's living situation at the time of assessment? Why do clients discontinue a program?
  • Related to evaluation: Are clients in an LTC program becoming more impaired over time? Is the need for supervision growing? How do clients' characteristics compare across programs?

Credible answers to these questions have resulted in better management and accountability as well as improved service delivery. Client satisfaction has greatly improved. Moreover, more people are being diverted to home and community based services from NFs, and overall NF admissions are decreasing.


Colorado Foundation for Medical Care. Long-term care client assessment certification and transfer packet. Denver (CO): The Foundation; 1992 Jul.

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