Senate Concurrent Resolution No. 33 and Senate Resolution No. 27: Senate Concurrent Resolution No. 33 (Appendix A) directs the Bureau to study "the merits of establishing a single entry point for long term care services used by elderly adults and families of disabled children and disabled younger adults in Hawaii." The Bureau "may use models of systems from other states in exploring a system appropriate for Hawaii's environment and population."

   The two Resolutions state that:

• [A] "single point of entry" for long-term care services is a method which may simplify access to long-term care services because it provides a local or regional access point where consumers receive information and assistance, assessment of needs, care planning, and authorization of services.

   The Resolutions further elaborate that a single entry point ("SEP") also involves "help[ing] individuals become aware of the services available." The focus of the Resolutions appears to be improving access to the system. From the perspective of potential consumers, this means an easier, simpler, and faster way to get at long-term care services. From the State's point of view, it may also mean a more efficient way to deliver services.

   Limitations and Focus of Study: Both Resolutions specifically recognize that an SEP is "only one component of a comprehensive long-term care system." This is a very important point. The focus of the Resolutions, and therefore of this study, is a single entry point system and does not encompass the entire panoply of issues of interest in the long-term care field.

   Any long-term care system, even if targeted to just one discrete population such as the elderly, is hugely complex and multi-faceted. These complexities are compounded by the addition of two other categorical populations: disabled children and the disabled non-elderly. The many components, precisely because they form part of a system, are necessarily inter-related and inter-dependent. Therefore, it is only natural, upon examining one component, to want to look at the next related component. However, the Resolutions clearly did not intend for an all- encompassing exegesis of a comprehensive long-term care system to be done and, thus, none is attempted.

   Although this study focuses on access to a care system which happens to be long-term in nature, interesting long-term care issues abound, however tangentially related to the concept of an SEP. Worthy though they may be, many issues, including those listed here, are examined only if and to the extent that they shed light on a single entry point system:

• The philosophical differences between long-term institutional care and community- and home-based long-term care support services; and differences within the community- and home-based model itself, for example, the merits of using support services in congregate housing vs. group homes vs. own-home situations.
• Long-term care reform: the merits of private vs. public strategies, including the use of private continuing care retirement communities, capitated, managed care, social/health maintenance organizations, individual medical accounts, home equity conversions, PACE programs (programs for all-inclusive care for the elderly), and substitution of lower-cost hospice care for skilled nursing facility care.
• Long-term care financing, including private or public long-term care insurance, or a mixture of both.
• Quality assurance, including standards and licensing of facilities, programs, and personnel at the federal, state, and local levels and services, including the elusive monitoring of home health and care services, especially in a client's own home.
• Equity issues, including the disparity between rural and urban access to care.
• Programs and efforts to prevent or delay the need for institutional care, including prenatal care programs to reduce developmental delays, thus reducing overall eventual long-term care expenditures for the disabled.
• Funding sources, per se, especially maximizing of Medicaid funds through the use of various waivers, rates, and reimbursement methodologies.
• Client rights, including guardianship programs.
• Housing assistance for the disabled and elderly.
• Special education, training, and assisted employment for the disabled.

   Regardless of any particular service approach or the actual services provided, consumers must access those services in some way. The focus of the Resolutions and thus of this study is not necessarily what the end-product services are, but how those services are accessed.

   Organization of the Study: Chapter 2 reviews the concept of a single entry point, system fragmentation, an SEP as one component of an integrated long-term care system, and how an SEP process can be integrated horizontally and vertically. Three models of administrative structure ("consolidation," "umbrella," and "cabinet") seen in long-term care reform, and which often include an SEP component, are discussed. Next, this chapter examines various obstacles to system integration. How an SEP can act as a gatekeeper in a managed care system is also examined. The heart of any SEP process, and key to efforts at system coordination, are the three inter-related processes of pre- admission screening, assessment, and case management, each of which are examined in turn. However, standardized assessment presents difficulties, which are discussed. Finally, functional and financial eligibility determination and service authorization are examined.

   In chapter 3, various types of long-term care services are examined, including Medicaid-funded nursing home care and home- and community-based supports and services. Various long-term care populations are also reviewed. Next, this chapter looks at long-term care services as supports for an individual's functional limitations. The long-term care services continuum, including both institutional and home- and community-based supports is then examined from a variety of perspectives. Home care as informal support by family caregivers is described. Home care as paid personal care and homemaker services follows. Various other alternative services such as adult day care and adult day health services, including a look at the original PACE (Program of All-Inclusive Care for the Elderly) program (On Lok Center in San Francisco) is examined. Hawaii's PACE program and the concept of social/health maintenance organizations are also discussed. Finally, various alternative living arrangements, including congregate housing, adult foster homes, board and care homes, and adult residential care facilities (ARCHs) are looked at. The Maluhia Waitlist Demonstration Program which routes nursing home-level patients staying in acute care hospitals to certain Hawaii ARCHs is introduced. The thorny issue revolving around the categorical vs. the generic, or functional, approaches to long-term care access, and their respective advantages and disadvantages, are examined. The disabled of all ages, including the developmentally disabled (DD), can also be considered using either approach. How the perception of long-term services may affect the ease of integration or coordination of the long-term care system is examined. Next, living arrangements and various federal programs for the DD population are described. Following this, services to the developmentally disabled are examined. Finally family support services for DD individuals are examined.

   Chapter 4 reviews the situation in other states and begins with a discussion of the dearth of literature on single entry point systems for the three designated target populations. Material from Colorado, Indiana, North Dakota, and Texas are presented. In addition, material from a well-known six-state (Arkansas, Illinois, Maine, Maryland, Oregon, and Wisconsin) study is discussed.

   Chapter 5 examines the provision of publicly-funded long- term care services in Hawaii to the three designated populations. Services provided by or through the Departments of Human Services and Health and the Executive Office on Aging are presented. The opinions of the three agencies on the pros and cons of an SEP in Hawaii are also reported.

   Chapter 6 offers a brief summary of the concept of a single entry point and the implications for a policy choice between a generic and a categorical approach. It summarizes the advantages and disadvantages of an SEP process. This chapter also offers a number of cautions that policymakers should be aware of regardless of whether an SEP is to be implemented or not. In addition, if an SEP is decided upon, further cautions are raised. Next, existing support for some sort of system coordination is reviewed. Finally, chapter 6 makes recommendations for a two- phase pilot project.

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