long-term care - Legislative Reference Bureau

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CONCEPT OF A SINGLE ENTRY POINT Using a standard assessment tool to determine need for community long term care services may seem rather straightforward. However, its development generally entails months of disagreement among health professionals, social workers, and various program administrators over the factors that are most likely to indicate need for their individual programs. Koff (1988), cites a 1980 study that discussed the difficulty of constructing a single assessment tool :49 - Baker (1980), who reviewed fourteen assessment instruments, notes that the proliferation of such instruments -and the difficulty in developing a single assessment methodology is understandable in the absence of clearly delineated treatment or care programs and the difficulty of translating assessment findings into care plans. In contrast to acute care, chronic care of the aged shifts from a focus on disease or pathology to a focus on function, and then from function to intervention. Each of these transitions increases exponentially the factors to be considered in a comprehensive assessment, which is further complicated by the many possible variations in intervention. These difficulties dealing with the elderly population may increase with the addition of other populations requiring similar long-term care. Koff, however, acknowledges that assessments, however difficult to administer, are necessary and beneficial: 50 Rubenstein (1983, 1984) suggests that assessment can circumvent inappropriate use of health care services, prevent waste of scarce resources and contribute to avoidance of imposed disability resulting from inappropriate diagnosis and labeling of older persons. For example, being simply labeled "senile" without the benefit of a proper assessment may prevent useful rehabilitation of that person. A successful assessment may result in a more accurate diagnosis, more appropriate placement, reduced dependence on nursing homes, improved functional status of those assessed, and more appropriate use of medications. 51 In any case, the construction of a viable assessment tool, especially for multiple populations, requires a tremendous amount of cooperative effort among the relevant providers and agencies. The key, however, appears to lie in operating under a standardized concept liberally laced with flexibility, rather than adhering to a rigid assessment tool or entry process. For example, a state may begin by mandating minimum substantive standards by which local SEP agencies must perform screening, assessments, and case management. Beyond such mandated guidelines, local agencies can be given flexibility to tailor care plans according to individualized assessments appropriate to, and perhaps unique for, each locale. For example, in Wisconsin, local county agencies, which make up the sites for a single entry system for five different long-term care populations, are required to address 12 areas of community living. As long as they adhere to these guidelines, they are free to employ their own assessment tools. On the one hand, an urban county opted to adopt a computer-scored assessment tool. On the other hand, a rural county decided that long-term care assessment requires more than computer scoring of ADLs. Instead, it required a social worker to write up a two-page assessment in narrative form of the client that includes addressing the mandated 12 areas of community living. 52 Wisconsin does not require a standardized assessment tool (although that state has made available the use of a recommended one). However, Wisconsin does require that the person conducting the assessment be the appropriate one. Therefore, although Wisconsin 20
SINGLE ENTRY POINT FOR LONG-TERM CARE SERVICES does not mandate any particular combination of assessment personnel, if a nurse, physician, or other person is required in addition to a social worker, they will participate in the assessment. 53 (l!Iinois, Maryland, and Oregon allow assessments to be done solely by social workers while Maine requires a nurse review only in its waiver component.j54 This flexibility allows initial assessments to be followed up by further specialized assessments, if necessary. For example, a social worker on a site visit may notice not only several ADL impairments but also a need for various physical therapies and home modification. A subsequent specialized "OT" (occupational therapy) assessment is then carried out detailing mobility and transferring impairments. As a result, appropriate therapy services and assistive devices can be authorized. In other states as well, applying a standard assessment tool is often not the only assessment performed. They can function to sort out those with more routine service needs who can be helped with information and referral from those needing more detailed assess me nt. 55 Numerical Assessments -- Gatekeeper Function: Oregon is a "consolidation" model state where all components of long-term care programs, both community and institutional, are placed into a single state agency. That state's Senior Services Division within the Human Resources Department manages all such programs and places local administration into the hands of the Area Agencies on Aging. [Note: Area Agencies on Aging (AAAs) carry out the provisions of The Older Americans Act (OAA) of 1965 at the local level. At the state level, the program is administered by offices on aging. In Hawaii, the OAA fixes the responsibility for the development of a coordinated, comprehensive statewide system of older adult programs and services and for statewide planning, advocacy, program development, and policy formulation upon the Executive Office on Aging. Concomitantly, it establishes parallel coordinating, planning, and leadership roles for the Area Agencies on Aging at the county level. In each of the four counties, an Area Agency on Aging is responsible for program development and administration. 56 AAAs have a primarily social care, rather than medical care, orientation. 57 The OAA provides for a variety of community and social services for persons aged 60 and over. Nursing home care is not included although supportive services that are often thought of as components of community- and homebased long-term care are provided. These include nutrition, transportation, information and referral, outreach, legal assistance, in-home supportive services, senior employment opportunities, elder abuse protection, and longterm care ombudsman services. 58 For 1991, total OAA Title 11/ funds amounted to $750,066,000. Of this, Hawaii received $3,855,000, or about one-half of one percent while California received 9.3 percent. Nationally, programs for congregate nutritional services accounted for 48 percent of Title 11/ OAA funds, followed by 39 percent for supportive services. Homedelivered nutritional services accounted for 12 percent and in-home services, about 1 percent. Ombudsman and elder abuse prevention activities received less than one-half of one percent. The proportion of funding allocation for Hawaii's Title 11/ services closely matched the national allocation. 59 1984 amendments to the OAA specify that the Area Agency on Aging should be involved in "services designed to assist the older individual in avoiding institutionalization and to assist older individuals in long term care institutions who are able to return to the communities, including client assessment through case management and integration and coordination of community services such as pre-institution evaluation and screening and home health 21
Page 1 and 2: LONG-TERM CARE: A SINGLE ENTRY POIN
Page 3 and 4: TABLE OF CONTENTS Page FOREWORD....
Page 5: Community Long-Term Care Branch (CL
Page 8 and 9: SINGLE ENTRY POINT FOR LONG-TERM CA
Page 10 and 11: Chapter 2 CONCEPT OF A SINGLE ENTRY
Page 12 and 13: CONCEPT OF A SINGLE ENTRY POINT .Ex
Page 14: CONCEPT OF A SINGLE ENTRY POINT •
Page 28 and 29: CONCEPT OF A SINGLE ENTRY POINT ser
Page 35 and 36: .42. Koff, pp. 167-168. 43. AARP fa
Page 37: Chapter 3 LONG-TERM CARE SERVICES O
Page 46: FIGURE 3-2 40
Page 49 and 50: LONG-TERM CARE SERVICES Categorizin
Page 51: LQNG-TERM CARE SERVICES ADCCs do no
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Page 59 and 60: LONG-TERM CARE SERVICES • Some pe
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Page 68 and 69: Traditional Developmental Services
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SINGLE ENTRY POINT FOR LONG-TERM CA
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OTHER STATES purchased with state a
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OTHER STATES The main impetus for t
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OTHER STATES long-term care, includ
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34. Ibid., pp. 5-6. 35. Ibid., p. 6
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79. Ibid. SINGLE ENTRY POINT FOR LO
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Chapter 5 HAWAII Organization: Part
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HAWAII (2) Case Management: Continu
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HAWAII (5) A geriatric psychiatry t
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HAWAII As mentioned above, there is
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HAWAII • Home maintenance • Nut
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HAWAII the time of its closing, Pro
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HAWAII (2) Conducting public affair
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50. Ibid., p. 13. 51. Ibid. 52. Ibi
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85. Seely memo, p. 2. SINGLE ENTRY
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SINGLE ENTRY POINT FOR LONG·TERM C
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SINGLE ENTRY POINT FOR LONG·TERM C
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THE SENATE EIGHTEENTH LEGISLATURE,
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Appendix B Model Long Term Care Ass
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ASSESSMENT FACE SHEET The assessmen
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PHYSICAL HEALTH r------------------
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MedicationsfTreatments/Services/Sup
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Physical Health (con't) Note any di
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ACTIVITIES OF DAILY LIVING Completi
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INSTRUMENTAL ACTIVITIES OF DAILY LI
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SOCIAL HISTORYIRESOURCES Please tel
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Social HistorylResources (con't) Wh
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PHYSICAL ENVIRONMENT How long have
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EMOTIONAL FUNCTIONING This section
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COGNITIVE FUNCTIONING This section
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FAMILY SCREEN To what extent has th
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ALCOHOL AND DRUG ASSESSMENT TOOL AL
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GERIATRIC DEPRESSION SCALE 1. Are y
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INSTRUCTIONS FOR HOME SAFETY CHECK-
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