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State Long-term Care Programs: Balancing Cost, Quality, and Access

Workshop Brief for State Executive Branch Health Officials

This workshop was designed for policymakers in the legislative and executive branches of State and local governments who where interested in long-term care, especially those who manage publicly funded programs delivering, financing, or regulating long-term care. The workshop was held in Indianapolis, Indiana, May 6-8, 2002.

About the Workshop Sponsor.



At the completion of this workshop, participants were expected to be better able to develop policies and programs that provide choices for Medicaid beneficiaries who need long-term care services and to understand:

  • The impact of and opportunities created by economic and fiscal trends.
  • How States can balance their long-term care system through the organization, delivery, and reimbursement of home and community based services.
  • Approaches to quality assurance and quality improvement.
  • Strategies to create a stable and trained workforce.

Session Summaries

Economic and Fiscal Climate

Medicaid comprises one of the largest components of State spending, and it is, therefore, vulnerable to declines in State revenues during economic recessions. The impact varies on the structure of State revenues. As revenues continue to decline, States have analyzed Medicaid spending patterns and strategies to reduce spending through rate adjustments, eligibility and benefit changes.

Projecting Service Need

As budgets are constrained, States need to be able to project potential demand and to anticipate how different policy alternatives will affect costs. The Lewin Group has developed a computer simulation tool, available on their Web site, to help States project demand, manage waiting lists, or plan for implementation of the "Olmstead decision."

Managing Demand

Times of crisis present unique opportunities to introduce policy and program changes. Presentations from former officials in Oregon and Washington described system changes that were implemented during a recession and declining State revenues that parallels today's environment.

Budgeting for Home Care

Home care services are typically outlined in a care plan that is authorized for individual clients based on their assessed needs. A method of allocating resources based on the presence of characteristics that predict poor outcomes was presented.

Workforce Shortages

The long-term care system has endured shortages of workers, high turnover and vacancy rates, and considerable movement among workers within long-term care settings. Labor market studies by the Paraprofessional Healthcare Institute project that the ratio of women aged 25 to 54, the prime source of caregivers, relative to the 65+ group will decline from 1.7 per thousand to 0.92 per thousand between 2000 and 2030.

Comprehensive Delivery Systems

Creating central access points, or "one stop shopping," for information about and access to Long-term care services is a frequent goal of State system reorganization. In a demonstration program, Wisconsin has combined funding for all Medicaid long-term care services and created Aging and Disability Resources Centers and Care Management Organizations to improve access for people who need supportive services.

Cashing Out Services

The traditional menu based, agency provided service system may lack the flexibility and responsiveness preferred by consumers. The Cash and Counseling Demonstration allows consumers to purchase goods and services that best meet their needs and to hire family members, neighbors, and friends to provide supportive services. Early research findings suggest that the program receives very high consumer acceptance, experiences lower Medicaid costs per hour of service, and has cost Medicaid no more per month for each recipient when comparing the control group and the treatment group in the demonstration.

Quality of Nursing Home Care

Good standards, strong survey and oversight activities, and availability and use of a range of remedies are the building blocks for achieving effective regulation and high quality nursing home care. On an operational level, high quality can also be achieved when costs are contained or when total costs of care are even reduced. The presence of and commitment to a quality improvement strategy was ultimately more important than any single strategy for achieving quality care.

Home Care Quality Indicators

Quality indicators and effective satisfaction surveys yield useful data for improving home care quality. The Resident Assessment Instrument for Home Care (RAI-HC) collects clinical data for care planning that form the basis for quality indicators. The Home Care Satisfaction Measure is a 60-item survey currently used by over 20 States and programs and has been adopted by the Administration on Aging as a key performance outcome measure.

Federal Quality Assurance Initiatives

State of the art quality strategies, consumer directed satisfaction tools, standard oversight protocols, technical assistance, and improved data are new initiatives of the Centers for Medicare & Medicaid Services (CMS) to improve quality in home care programs.

Federal/State Partnership

Covering transition expenses for Medicaid beneficiaries leaving nursing homes and de-linking intermediate care facilities for the mentally retarded (ICF-MR) and home and community based services (HCBS) functional requirements are two CMS initiatives to make it easier for States to service people with disabilities in community settings.

For More Information

Audiotapes of the workshop are available for purchase. If you would like to order audiotapes of the 2-½ day ULP workshop titled State Long-term Care Programs: Balancing Cost, Quality, and Access ($25), please call the AHRQ Publications Clearinghouse at 1-800-358-9295.

AHRQ's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of Federal, State, and local policymakers, and other health services research users, such as purchasers, administrators, and health plans.

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