Kaiser Permanente's manifesto 2005 demonstration: the promises and limits of devolution

In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on "unprofitable" populations, for example, those who are chronically ill, poor, and/or disabled.     

HMOs and the Future of Student Mental Health Services

Abstract

The health maintenance organization (HMO) is likely to have a prominent position under national health insurance, which will have a strong systematizing effect on the nation's health services. Over the past two years the University of Massachusetts mental health services have provided benefits at both the university and a private medical group practice. Experience has shown that a university which already provides broad services to a large student population can extend itself to the university community including its faculty and staff. Several advantages of this development, as well as some significant problems, are discussed. As the HMO grew and quality services were established, it became feasible for the private medical group to develop its own mental health component. Based on this and other experiences in mental health delivery systems, certain conclusions are drawn about the ways universities can develop HMOs and some recommendations are made for national mental health planning.     

A Consumer Cooperative Association Specializing in Services for the Elderly

Summary

Over the past 10 years, a Japanese cooperative association named Fukushi Club Seikyo (FCS) has developed a unique, non-profit business specializing in services for the elderly. It aims to promote a reciprocal support system among neighborhood community members. FCS has successively organized its active members, mainly homemakers, into workers' collectives and successfully provided various life support services at a very small charge. Their human-touch service appears in sharp contrast to bureaucratic public services and profit-making private services. The civil initiative presented by FCS suggests a potential for a community-based social service system that may guarantee quality services without raising taxes and premiums for social insurance.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Home Is Where the Help Is

Abstract

Policy regarding long-term care has been an issue of rising national concern. In this paper we examine the transition of Danish long-term care policy with special attention to Skævinge, the first community in Denmark to integrate institutional and community-based services for the elderly. Recent studies on the variation between costs and services in Danish communities and the results of U.S. studies on community-based care suggest that successful implementation of integrated institutional and community-based long-term care is feasible in the United States. Lessons from Denmark highlight conditions that will facilitate success in this endeavor.     

Distribution and Utilization of Home- and Community-Based Long-Term Care Services for the Elderly in North Carolina

ABSTRACT

Provision of home- and community-based long-term care is a growing concern at the national, state, and local levels. As more persons grow old, the need for these services is expected to rise. This analysis examines the distribution and utilization of three home- and community-based long-term care programs in North Carolina for each of the state's 100 counties. Maps were generated to examine how counties differed in respect to service utilization among the elderly. Great variability was found in number of elderly utilizing the services across the state as well as the percent of Medicaid- and/or age-eligible persons who utilized the programs. Multivariate modeling for associations to service utilization was only possible for one of the long-term care programs. Results indicated that living alone, being non-white, and having a mobility and self-care limitation were all positively related to utilization. Percent of persons 85 years or older and the ratio of institutionalized long-term care beds were negatively associated with utilization. It was concluded that states must engage in concerted efforts to ensure equity in access to home- and community-based long-term care.     

Where Do We Stand? Testing the Foundation of a Shared Site Intergenerational Program

Abstract

Shared site intergenerational care programs provide ongoing services simultaneously to old and young community members at a single facility, thereby, meeting the care needs of multiple generations. However, they face the challenge of sustainability common to all community-based programs. We employed the results management model to identify program elements that may enhance or inhibit sustainability of intergenerational programming at a shared site facility involving a child development lab school and adult day services program. The 4-step results management approach is a strengths-based model that supports community capacity and achievement of community and program goals. The current paper describes the first step in the results management approach, mapping the terrain, which involves gathering evidence of community needs and strengths. Focus groups were conducted with eleven staff members from both programs after a 4-month intergenerational program. The focus groups targeted the needs and strengths related to intergenerational programming. Respondents identified strengths that enhanced staff members' and clients' capacity for collaboration. These included affective and developmental benefits for both generations and strong partnerships between staff members. Respondents also identified factors that limited collaboration, such as the need for greater authority support and cross-training opportunities. Findings from our study have been used by program administrators to continue using the results management approach to further build intergenerational community and expand the scope of evaluating intergenerational shared site programs. Other intergenerational programs may utilize the results management model to enhance intergenerational programming and increase program sustainability.     

Children with Special Health Care Needs

Abstract

The health care model presented in this paper is a non-linear, systems approach to service delivery. The model was a by-product of three ethnic-specific conferences that were convened to discuss strategies for improving access to care and the quality of services provided to children with special health care needs (CSHCN) from diverse cultural backgrounds. The model evolved as insights regarding the common values and norms held by parents, health care providers, and cultural representatives were shared. Content analysis was used to identify core themes identified by participants. These themes were incorporated into a model that included the following elements: community-based, culturally competent, health-oriented, resiliency-focused, and family-centered care. At the fourth Consensus Conference, selected participants from the previous ethnic specific conferences reviewed the proposed model and deemed it a vehicle for facilitating health care service utilization by culturally and linguistically diverse CSHCN and their families.     

Medicaid Managed Care Programs for High-Risk Older People in Massachusetts

The Commonwealth of Massachusetts has undertaken a major initiative in the development of comprehensive managed health care programs for two sets of high-risk older people: those who are frail and homebound and those who reside in nursing homes. This effort has been coordinated by the state's Department of Public Welfare (DPW; Medical Assistance [Medicaid] Program) and Executive Office of Elder Affairs, and expedited ba a set of Health Care Financy Administration (HCFA) waivers and by the state's revised Nurse Practice Act (MGS Chapter 56). Than act allows nurse-practioners and physician assistants expanded roles as primary providers in home care and nursing home settings. The managed care initiatives have supplemented other efforts (1) to coordinate health and social services for older people, (2) to provide as broad a range as possible of community-based services for older people, and (3) to enroll as many older adults as possible in Health Maintenance Organization (HMO) "Senior Plans" and other similar "Competive Medical Plans."

Though there is still no evidence of the managed care programs' effects, this article summarizes some of the possible risks and benefits of managed care programs for those kinds of populations and presents an agenda of questions that evaluations of managed care programs must address.     

Met needs and unmet needs, and satisfaction among Social HMO members

This article reports on a survey of 800 members of four Social HMO demonstration sites, who were receiving home-based, community-based, and short-term institutional services under the demonstration's expanded community care benefits. The survey asked whether members needed help in 11 areas, whether they received help in each area from an informal caregiver, whether they wanted more help from the Social HMO, and whether help provided by both was adequate. Satisfaction with the program and with service coordination was also assessed. The adequacy of informal care differed by problem area, as did the help desired from the Social HMO and its responsiveness. Members were less satisfied when they had weaker informal care, were African American, and when they received inadequate help from the plan with ADLs, transportation, medical access, and managing money. Members were more satisfied when they were professionals, home owners, knew their service coordinator's name (or how to contact her), and received help with their problems. The findings point to the importance of clarifying divisions of labor with informal caregivers, as well as possible expansions in responsibilities for service coordinators and benefits beyond traditional boundaries.     

Broadening the Array of Services: Integrating Legal and Social Work Services for Youth and Families

ABSTRACT

The Community Justice and Legal Assistance Clinic (CJLA) is a unique community-based legal clinic developed through a partnership between a law school and a child and family service agency embedded within a low-income community. This article describes the development of this clinic through a community assessment process; its unique multidisciplinary features; the services provided to clients in three of the agency's service areas; the benefits of the partnership for clients, the social service agency, the participating law students, and the law school; and lessons learned for replication of this type of clinic in other communities.     

Hidden Epidemic

Abstract

Rates of HIV infection among the seriously and persistently mentally ill contradict the widely held belief that this population is not at high risk for HIV exposure. The literature suggests that, in part, due to pervasive misconceptions around issues of sexuality and illicit drug use, HI V-positive, mentally ill individuals are not receiving appropriate care. This article focuses on the interplay of mental illness, HIV infection, and service provision through a review of the literature and the presentation of a case study. Available services are detailed and barriers to their success discussed. The importance of comprehensive community-based services specifically designed to address the multifaceted needs of this population is highlighted.     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

Coordinating Health,Extended Care,and Community Support Services

Abstract

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.     

Emerging Services for Community-Based Long-Term Care in Urban China

Abstract

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.     

Finding Our Way

Abstract

In the fall of 1992, a community needs assessment on the problem of family violence was completed in the Aboriginal community of Conne River, Newfoundland, Canada. This article reports both the process and findings of the study which was guided by two important principles. First, community participation was a critical component of all aspects of the assessment and, second, the assessment was based on multiple sources of data.

The data were collected from face-to-face interviews with key informants (community experts) and consumers/potential consumers of services, focus groups with youth and women, and informal contact and discussion with interested members of the community, some of them professionals.

The findings indicate that the people of Conne River are knowledgeable about the types of family violence that occur in the community and the various sources of support and help. There was also a high level of interest in the topic and a genuine concern that some positive action would result from this assessment.

The assessment identified the need for more supports for women with families in crisis, not just crisis intervention during incidents of violence but a more holistic network of supports. These supports need to be community-based, operating within existing agencies. The study identified the need for a community-based committee to undertake the planning of emergency services for women and families in crisis and long-term planning for a support network and/or community centre for women.     

Evaluation of Adult Protective Services: Perspectives of Community Professionals

ABSTRACT

Due to challenges associated with client characteristics, funding, and the expectation of poor outcomes, few studies have evaluated the services provided by Adult Protective Services (APS). The article reports community-based professionals' satisfaction with APS when investigating cases of suspected elder abuse. Results from a 12-item quantitative survey indicate respondents were most satisfied with the intake process, followed by assessment, and case management. Satisfaction was higher than expected, though areas for improvement are identified. This survey and its results should serve as a starting point for more extensive evaluation methodologies needed to enhance the delivery of services provided by APS.     

Quality Assessment Study of Brief Psychotherapy at a University HMO Setting

Abstract

This paper describes the results of a short-term psychotherapy (four to fifteen sessions) quality assessment study conducted at the University of Massachusetts Mental Health Service. The outcome measures devised and the process of their administration are described. The positive outcome results of this study are encouraging and supportive of the impression that high quality brief psychotherapy can be provided at university counseling services. Student and health maintenance organization (HMO) member consumer evaluation opinions were positive and their utilization of services was found to be psychologically sophisticated and appropriate. A frequency table lists the most common presenting problems of this population. Practical modifications are suggested for future quality assessment research of brief psychotherapy.     

Chapter 2. Intervention Continued

SUMMARY

This chapter describes the case management process-a process for assisting individuals and families with multiple service needs-and its use in various fields of practice including mental health, human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS), and services for older adults. It addresses the role of the case manager as the person responsible for ensuring the timely and adequate delivery of suitable community-based services. The integration of formal services with informal care by family and friends as an intervention strategy is also discussed.