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

Managing Demand


Richard Ladd, Ladd and Associates, Turner, OR.

Charles Reed, Former Assistant Secretary Washington Department of Social and Health Services, Olympia, WA.

Richard Ladd described how Oregon's initiative was originally developed by a State agency but was opposed by advocacy groups who had not been involved in its development. A task force was formed to develop a new proposal that combined responsibility for long-term care services in one agency, created a single entry system using State regional offices or Area Agencies on Aging, and created a statewide home care program to give Medicaid beneficiaries choices for receiving long-term care services in the community.

Mr. Ladd contends that the process succeeded because it started with a philosophy for long-term care services that guided all policy decisions and the people who use the system were involved in developing the policy.

The proposal emerged while State agencies were asked to reduce spending by 20 percent. The program achieved the savings by reducing nursing home use and expanding home care services. Mr. Ladd cited as lessons learned:

  • The importance of nurse delegation.
  • Working with advocates.
  • Targeting services to those most in need.
  • Developing residential options.
  • Reviewing all nursing home residents to determine their ability to move to community settings.

Washington took a similar path. Charles Reed described the importance of developing core values built around choice, privacy, and dignity. He also stressed the benefits from consolidating responsibility for regulation, licensing, home and community based services, and all State long-term care funding in one agency. This initiative developed over a decade but began in response to shrinking State revenues and rising long-term care costs.

Mr. Reed cautions that once established, States must invest in maintaining their system through:

  • Training.
  • Dealing with staffing shortages.
  • Operating a quality assurance program.
  • Promoting nurse delegation.
  • Countering the nursing home lobby.

As a result, nursing home use has declined and the savings have enabled Washington to serve more people in the community.

Additional Resources

Ladd RL. Oregon's Long-term Care (LTC) System: a case study by the national LTC mentoring program: case report number 1. Minneapolis (MN): University of Minnesota; 1996 Apr.

Reed C. State should invest in long-term care. Seattle (WA): Seattle Post Intelligencer 2002 Feb 13.

Smith RW. A decade of progress: long-term care in Washington state 1987-1997. Washington (DC): U.S. Department of Social and Health Services; 1998 Apr.

Coleman B. New directions for state long-term care systems: volume IV: limiting state Medicaid spending on nursing home care. Washington (DC): American Association of Retired Persons, Public Policy Institute; 1997 Apr.

Medicaid long-term care, successful state efforts to expand home services while limiting costs. Report to the Chairman, Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, House of Representatives. Washington (DC): U.S. General Accounting Office; 1994 Aug.

Wiener JM, Lutzky SM. Home and community-based services for older people and younger persons with physical disabilities in Washington. Washington (DC): U. S. Department of Health and Human Services; 2001 Jun.

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