Concept of a Single Entry Point (SEP): An SEP can be viewed in several ways. Basically, it is a "one-stop shop" process providing people with access to long-term care services. However, the concept of "access" can be extended beyond merely how one enters the system to how one actually receives services and follow-up monitoring. Consequently, an SEP -- as a process -- can operate independently of the actual types of services provided. That is, an SEP is the funneling process through which potential clients of long-term care services can be screened, assessed, advised, and directed to appropriate services, whatever those services are. Thus, the myriad long-term care services available to the three target populations are not, in themselves, of inherent interest to this study. That is, whether one type of service is better or more appropriate than another is not the issue. (See section titled "Focus of Study" in chapter 1.) Rather, the long-term care services provided become pertinent when they demonstrate the ease or difficulty of implementing an integrated SEP process serving all three designated populations. It is in this spirit that the examination of various long-term care services is done throughout this study.

Horizontal and Vertical Integration: An SEP can also be thought of as either horizontally or vertically integrated, or both. Horizontal integration results from a single access to long-term care services across various service departments or agencies. In some states, these may include a state department of aging, department of health, department of human services, other governmental bodies, and perhaps private organizations. Sometimes, services may fill in gaps where different populations are targeted. At other times, services overlap unnecessarily while creating unfilled service gaps.

System Fragmentation: Characteristically, long-term care services delivery is fragmented and mostly a function of how legislation on the federal, state, and local levels has evolved historically. To illustrate, Rivlin and Wiener (1988) evidence fragmentation in just one area of service (home care services) for just one target population (the elderly):2

• [M]any programs and agencies at the federal, state, and local levels fund some home care services, creating a highly fragmented financing and delivery system. At the federal level, funding for elderly home care services is available from medicare, medicaid, the social services block grant, the Veterans Administration, and the Older Americans Act. Each program has its own eligibility requirements, benefit coverage, regulations regarding provider participation, administrative structure, and service delivery mechanisms. The result is that it is difficult to coordinate a comprehensive set of home care services.

The effect of long-term care service fragmentation on an SEP process is compounded by the mix of other services in addition to home care. In turn, this is magnified by the addition of two other target populations, each burdened with similar historical problems of fragmented funding of services.

The Executive Office on Aging makes a similar observation in its 1988 report entitled Long Term Care Plan For Hawaii's Older Adults:3

• More than eighty Federal, State, and local government programs offer direct or indirect assistance to persons with long-term care needs. Help may be in the form of cash, in-kind assistance, or goods and services. Five programs (Medicaid, Medicare, Social Services Block Grant, the Older Americans Act, and Supplemental Security [Income] offer major Federal financial support for both community based and institutional long-term care.

According to the Executive Office on Aging, at the level of program administration, multiple funding sources cause fragmentation of services in Hawaii which, in turn, gives rise to various negative consequences:4

• Unfortunately, the existence of multiple funding sources has resulted in the proliferation of different, often confusing and frustrating sets of eligibility requirements and program designs. In specific terms, some of the service and system difficulties [among others] can be described as follows:
  • Service providers have developed and apply different service definitions and standards.
  • There is irregular or little coordination of services among the majority of providers.
  • Standardized service records and complete client information are not available on a Statewide basis.
  • Access to services is often limited due to geographical constraints, particularly on the Neighbor Islands and in the rural Oahu communities, and to the fact that many services are not widely advertised or located in such resources as the phone book.
  • Eligibility requirements vary by program and are inconsistent across the board.
  • There is a lack of full public awareness and understanding of services and programs.
  • Services are often fragmented and do not provide adequate follow-up.

SEP as One Component of an Integrated Long-Term Care System: Discussion of fragmentation normally refers to the entire long- term care system. An SEP is only one component of that system. The concept of an SEP implies some degree of integration of the overall system. However, the existence or the establishment of an SEP neither implies nor guarantees an integrated long-term care system in its entirety. The commonly cited characteristics of a long-term care system are:5

1. Planning and policy development;
2. System access, client assessment, and local service delivery;
3. Cost containment and private sector involvement; and
4. Quality assurance and consumer protection.

An SEP involves the second component (system access, client assessment, and local service delivery) in which equal and easier access is sought for the greatest number. The Executive Office on Aging identified six major components of the long-term care system as follows:6

1. Clients;
2. Informal support systems made up of family members and friends;
3. Formal health, social, personal, and other supportive services;
4. Coordination or linkages between clients and the service, finance, and program and policy spheres;
5. Public awareness and consumer education; and
6. Long-term care finance mechanisms.

According to the latter set of system components, several items (1) through (5) have something to do with an SEP process although an SEP concept itself is not clearly articulated. Components (4) and (5) come closest. Although more than an SEP process is involved in a truly integrated system, it is not within the scope of this study to address full system integration. The four characteristics listed above usually describe state-level system integration. At the local level, integration more fully involves the SEP process. At the local level, one local agency serving a specific geographic area is identified and is given the responsibility to:7

• Serve as the central access point for clients for all publicly funded long-term care services. This one-stop shopping means that a client's many needs can be met without requiring each client to individually search among all the agencies for needed services.
• Matching the appropriate services to the individualized needs of the client and monitoring their provision through case management.
• Act as the gatekeeper in deciding who will be served by all funding sources. This is done through clear eligibility criteria, client assessments, and preadmission screening programs.
• Conducting local needs assessments and planning activities and encouraging or coordinating development of needed services and programs.
• Assuring the quality of services.

Even at the local level, the SEP process still accounts for only several components of an integrated system. These are the first three items: central access, appropriate services provided through case management, and assessments and screening for multiple purposes including cost containment. However, an SEP is an inherently integrative process. Thus, it works to enhance these multiple and reciprocal activities either at the local or state levels.

At any level, the individual seeking help from a fragmented long-term care system needs easier access:8

• The person who is not knowledgeable about the full array of services available for a particular problem needs guidance to reach the appropriate service. Persons in need may reach out to a service because of its prominence or because acquaintances have used it. Selecting an agency or service in this manner would be somewhat like wearing a pair of corrective glasses prescribed for a neighbor because they were helpful to the neighbor's vision. Because of the complexity of chronic illnesses, there may be a combination of services that would be more helpful than one or another service alone.

A Horizontally Integrated SEP Process: In any case, a horizontally integrated SEP would attempt to either consolidate or coordinate access to diverse services across authorizing agencies and providers. The difference between consolidation and coordination is one of degree. It is important to remember that an SEP is only a first step to true system integration. As an initial process, an SEP can coordinate, rather than totally consolidate, the process of access to long-term care among agencies. This is particularly true under the "cabinet" model of state administration. Under this model, existing cabinet level agencies retain their long-term care responsibilities but function under an official interagency coordinating committee, or the like. Such an interagency coordinating committee would be the natural locus for development of any integrated long-term care state policy. There is no need for departmental reorganization. It is generally acknowledged that this form of structure lends itself least to true service integration and coordination, largely being dependent upon personal effort and informal agency head consensus. Support of a state's governor is key under this model. However, this structure requires the least amount of change; the umbrella model requires much more, and the consolidation model entails wholesale governmental reorganization.9

Under the "umbrella" model of state administration, all long-term care services are provided under one single agency, usually a department of health and social services. Different long-term care programs and functions are dispersed among various divisions and bureaus within the umbrella department. Internal responsibilities are shifted in order to increase inter- divisional coordination. An intra-departmental coordinating structure is usually developed to integrate planning, policy development, and resource allocation among the different divisions. Integration of services is fostered by assigning responsibility for programs to one division, using one local access and delivery system, and developing an intra-departmental planning and coordinating committee. Thus, regardless of whether categorical or functional criteria are used to define target populations, all services are channeled through the various divisions of one umbrella agency. (See chapter 3 for discussion of functional vs. categorical approaches.) Horizontal integration for system entry is achieved, then, across various state divisions by channeling access through one supervising department.

For example, Governor Bayh of Indiana proposed a plan in 1990 to create a new Department of Health and Family Services under the umbrella model. Three departments -- Human Services, Mental Health, and Public Welfare, and the Board of Health were proposed to be merged. While not specifically addressing long- term care, the plan would result in the umbrella structure necessary to accommodate the coordinated umbrella model. A new Division of Health would administer the Medicaid program, take over facility regulation formerly carried out by the Board of Health, and operate Indiana's sole state-run nursing home. A new Division of Family Services would operate most of Indiana's community-based and social service programs and functions.10

Obstacles to Service Integration: However, Indiana wisely acknowledges that under a coordinated umbrella or consolidation model (see following section), integration of either the single entry process or of the entire long-term care system does not occur automatically:11

• Simply having all long-term programs under one departmental structure or model however, does not guarantee an integrated state long-term care system. The Governor's plan would need to include the following specific actions to ensure that this integration takes place:
  • Agreement on common assessment tools for preadmission screening for nursing homes and for eligibility for community care programs;
  • Coordination of a long term care information management system designed to produce usable information for policy development, planning, and resource allocation;
  • Coordination of planning, policy development, and resource allocation to ensure that all decisions that impact the long- term care system are made with the full knowledge and participation of affected programs and divisions; and
  • Use of a single local client assessment and delivery system for community care services.

All long-term care responsibilities, both institutional and community-based, are placed within one sole-purpose agency under the "consolidation" model. This normally requires a major reorganization of state government including the possible creation of a new superagency and the dismantling of existing departments. Alternatively, the sole-purpose agency could be incorporated under a larger umbrella department. Long-term care responsibilities and programs that are consolidated may include:12

1. One budget for all long-term care expenditures, including Medicaid and general fund community care funds;
2. Responsibility for quality assurance and consumer protection for all long-term care recipients served by nursing homes and community and in-home agencies;
3. Planning, policy development, and resource allocation for all long-term care;
4. Traditional aging programs funded through the federal Older Americans Act (OAA) funds. Traditionally, Area Agencies on Aging (AAA) case management is funded through Title III of the OAA and through Social Services Block Grants. However, the OAA bars AAAs from directly providing services. AAAs can receive a waiver to provide services if no other provider is available. Rather than provide direct services, AAAs are to perform a planning, coordinating, and funding role, leveraging local dollars with state and federal funds to expand available services. Typically, AAAs provide congregate and home-bound meal programs and transportation services. To a varying extent, AAAs also provide some in-home services;
5. Certificate of need programs (for example, for new nursing beds); and
6. Responsibility for administering the local service delivery system, including preadmission screening and case management.

Access to the long-term care system for eligible populations must be through the consolidated-purpose entity. In Oregon, the Senior Services Division manages Medicaid payments to nursing homes, Medicaid home and community services waivers, services provided under the Older Americans Act, and federal and state community care funds for the elderly. All long-term care expenditures for the elderly are consolidated into one budget. Oregon uses AAAs affiliated with local units of government to administer all community care programs. These programs include Medicaid waiver programs and case management and preadmission screening services. AAAs also determine Medicaid eligibility for both nursing home and community care clients. In exceptional cases where no AAAs are available, state district offices carry out case management and screening.13

Regardless of the model of governmental structure, an SEP does not necessarily require all eligible individuals seeking care to enter through a single, physical, geographic location. On the one hand, a single local or regional agency with multiple locations statewide can be designated as the entry point. Alternatively, multiple agencies can be designated. In the latter case, the different agencies can retain responsibility for their respective services while coordinating with each other to integrate access to those services through a single, standardized entry process. This standardized process is developed interactively and with the cooperation of all parties involved in the provision of long-term care. It is then administered and overseen by either by a single superagency (consolidation model), an interagency coordinating committee (cabinet model) or by an umbrella agency. The point is: a tremendous amount of work needs to be done to develop integrated and standardized entry procedures for multiple target populations before such an SEP can be implemented.

A Vertically Integrated SEP Process: Vertical integration of the entry process links all services from all sources from the time a consumer becomes aware of available services up to the provision and monitoring of those services. This is a more extended view of the entry process than the mere making of initial contact and taking the first step to obtain services. To make sense, any entry process, SEP or not, involves the following component tasks:

1. Pre-admission screening for program eligibility (functional and financial);
2. Assessment (social and medical); and
3. Case management, including creation of a care or treatment plan, coordination or direct provision of program services, and follow-up monitoring of services.

To these, some would include public awareness and education efforts and information and referral help, ideally prior to a consumer's initial contact at an access point. These, of course, may also be offered when a consumer first enters the system. In any case, the three essential components -- screening, assessment, and case management:14

• [a]re inseparable and can be viewed as a triangulation of three processes that are mutually interdependent and supportive of one another. They are not intended to function independently. All three components should come into the process when any one is considered. The application of this process on behalf of any client should result in the most appropriate assignment of services and resources available within the context of any program or community.

States have begun reorganizing community delivery systems to overcome the fragmentation of programs as well as make better use of the new resources allocated to long-term care.15

• Usually the components of statewide community care systems are designed to give clients better access to care while adding more control and rationality to the allocation of individual services. These components include client functional preadmission screening, case management and nursing home assessments to determine the need for community care. All are interrelated and are undertaken frequently by the same local agency and staff.

Some express the view that the three processes may be applied to more than just the elderly population:16

• It is important to acknowledge, however, that [groups other than the chronically ill elderly] who suffer from chronic illnesses could also benefit from coordinated programs designed to respond to their special needs. Identification of such groups -- including people of all ages with physical and developmental disabilities and chronic mental illness -- is helpful in illustrating the broad scope of the problem. The coordinated systems of care for the elderly . . . should be equally useful as models for chronic care services for these other groups as well.

What is less clear is how successful a system can be when dealing with several long-term care populations within that one system.

Nonetheless, coordination of these tasks would seem to lead to more complete and appropriate assessments for the provision of appropriate needed care. An integrated process should also help to ensure a smooth and timely transition from one step in the process to the next. The chances of a consumer not being referred to the appropriate agency (cabinet or umbrella models) should be reduced.

Again, coordinating the entry process tasks of screening, assessment, and case management within a single system does not imply a single physical locus. The key is operating under a single entry point concept that is based on coordinating or consolidating the various entry process tasks -- whether among different agencies, under one umbrella agency, or within one sole-purpose superagency. Whatever the scenario, it would be naive to predicate an SEP on a single geographical location. That is not to say that an SEP is not susceptible to bottlenecks. The greater obstacle -- and the greater reward -- lies not in maximizing the number of geographical entry points but in the challenge of standardizing multiple criteria for multiple target populations:17

• Regardless of the organizational approaches adopted, the issues which must be examined across various programs are the same. They include: designing a single delivery system supported by multiple funding sources; developing eligibility criteria for individual programs to ensure equitable treatment of persons with similar needs and resources; and examining the mix of community care services supported by each funding stream. Ultimately, the goal of these efforts is to create the continuum of care which each individual program rhetorically has embraced but cannot by itself achieve.

Regardless of the model of state government, a coordinated SEP process should help reduce service fragmentation at the level of the individual consumer:18

• How programs are organized at the local level is even more important than how state responsibilities [i.e, which state organization models] are organized. Older people come in direct contact with local agencies and their differing eligibility criteria, service packages, and funding sources. If state policies are successful, the elderly will have access to appropriate care without having to contact multiple agencies to receive services for which they are eligible. Therefore, most of the study states [Arkansas, Illinois, Maine, Maryland, Oregon, and Wisconsin] have designated a single local agency in each part of the state to serve as the client access point for receipt of all publicly financed community care programs. Centralizing entry helps make the system less fragmented from the perspective of older people in need of assistance, while helping states gain better control of total program costs. Client assessments, pre-admission screening programs, and case management are the key components of access systems for community based care programs. [Emphasis added]

Gatekeeper in a Managed Care System: As just noted, an SEP process can also be seen to serve a gatekeeper function in a managed care system. Even without an SEP, because "[o]lder people actively seek community based care services, while going to great lengths to avoid nursing home placement" and because of the accompanying "piecemeal financing of community services" great service demand is generated.19 As a result, there is a need to contain costs by controlling utilization through setting priorities for individual access to care. In addition, one goal of an SEP is to create greater access and thus potentially increase the overall number of consumers. On the other hand, an SEP is well suited to function as a management control over allocation of services. Routing all potential consumers through one system of standardized screening, assessment, care planning, and authorization of services effectively acts to control service utilization.

Some insurers feel that the cost of administering multiple community long-term care services is too high. They also fear uncontrollably high utilization rates, expecting the elderly to actively seek these services while trying hard to avoid nursing homes. In response to these fears, the 1988 study of long-term community care systems in six states by Justice, et al., found that "[i]mproved assessment techniques can effectively limit the eligible population and that case management structures can allocate services to individual clients within overall budget limits.20

However, the authors offer a caveat to the automatic assumption that just because case management under an SEP process is conducive to controlling service utilization, that case managers, in fact, will do so. One distinctive feature of the community care systems in the six states studied is the case managers' responsibility to authorize services. Not only do they assess consumers, but they also directly authorize appropriate services for them. Justice, et al., found that:21

• State officials note that case managers in entitlement systems may have the opposite incentives, resulting in a tendency to authorize more services than needed. State sponsored training programs can help case managers be more aware of cost containment concerns. Staff of Illinois' Case Coordinating Units report that case managers have slowly become more comfortable with limiting services instead of authorizing a complete package of all potentially available services. As they gain more experience in monitoring the implementation of care plans, case managers get firsthand feedback on the scope of services needed and can make any necessary adjustments.

It appears, then, that overuse of services may result from a case manager's lack of expertise and knowledge of the appropriate long-term care needs of consumers. In a system that incorporates several target populations which may not have identical needs, it may be difficult to perform an accurate assessment. How well an assessment is done and services managed by the case manager depends on how well the SEP process is initially developed. Specific and flexible guidelines within the framework of a standardized process can enable accurate and equitable assessments and authorization of services. If left inflexible, an SEP system may result in excessive service authorization, exacerbated by a fear of not authorizing enough services. A lack of concern for cost containment in entitlement systems may also contribute to the problem.

Preadmission Screening -- Financial Eligibility Determination: The first formal step in the entry process is usually called preadmission screening. It can be defined as:22

• [a]n assessment used to determine the need or appropriateness of nursing home care that goes beyond financial eligibility determination and physicians' certification of need to include an on- site evaluation of many aspects of a client's status.

Screening is more than just a "loose consideration of 'medical necessity' for nursing home care (as is done in the absence of screening programs)" but is a "comprehensive examination . . . of a person's functional, psychological and medical status with a bias toward determining whether informal supports combined with formal community services could meet the individual's long term care needs."23

First, a potential consumer's financial eligibility is determined. States have not opted for universal long-term care systems that offer care for all regardless of income. Rather, they have consistently chosen to address the long-term care needs only of those, in general, with the greatest financial need:24

• In none of the six states was there a philosophical inclination to provide universal public support for community based care without regard to a client's income. . . . There were no protracted debates over whether services should be provided on an ability to pay basis; the only question was how to translate this philosophy [that excludes universal community care] to operational policy.

States have rarely enjoyed the luxury of adequate funding for long-term care, especially community- and home-based care. During a time of federal cuts, initiatives to replace entitlement programs with capped block grants, and struggling state economies, it is hard to imagine extending publicly-funded services to those who can afford them. Aside from financial constraints, some object on philosophical grounds to the government's role in linking consumers to services purchased in the private market. However, some states do partly subsidize sliding-scale fee programs in which private-pay individuals not ordinarily financially eligible may participate. For example, Justice, et al. (1988) argue for the publicly-supported use of case management services by private-pay clients. Case management can help family caregivers sustain their informal care to delay the eventual need of individuals, income-eligible or not, for more intensive, publicly-funded care. Such use of case management services will also avoid a two-class system with two separate entry points.25

Nonetheless, screening programs,26

• [are] part of an organized access point for long term care services . . . [and] are a logical component of state policies designed to curb the growth of Medicaid institutional expenditures [by avoiding inappropriate placements in nursing homes] and [by apply[ing] the cost savings to an expanded community care system.

In some states, preadmission screening determines financial eligibility not only for persons eligible for Medicaid, but also for those estimated soon to be Medicaid-eligible. Typically, the "countdown" to Medicaid eligibility is set at 60, 90, or 180 days, thus "90-day eligibles" and "180-day eligibles." For example, Maryland's target population is screened for both Medicaid- and 180-day eligibles. Screening in Oregon targets both Medicaid- and 90-day eligibles.27

• (Note: According to the Select Committee on Aging of the United States House of Representatives in a 1987 publication, 50 percent of persons aged 75 and older and living alone would spend down income and assets to federal poverty guidelines within 13 weeks of entering a nursing home. Within one year, almost 70 percent would be impoverished. For married couples aged 75 and older, 28 percent would reach poverty income levels within 13 weeks and 51 percent within one year. The vast majority of persons entering a nursing home is over age 75 and live alone.)28

Table 2-1 outlines how six states screen clients; whether participation is mandatory or voluntary; and whether findings are binding or advisory only.29

                            Table 2-1

                CHARACTERISTICS OF PRE-ADMISSION
                       SCREENING PROGRAMS

                                Mandatory or
                                  Voluntary      Binding or
          Target Population     Participation Advisory Findings

     AR       Medicaid            Mandatory        Binding
     (one quarter
     of state)
     IL     Medicaid and          Mandatory        Binding
              eligibles

     MD   Medicaid and 180        Mandatory       Advisory
            day eligibles

     ME       Medicaid            Mandatory        Binding

     OR    Medicaid and 90        Mandatory        Binding
            day eligibles

     WI       Medicaid            Mandatory       Advisory

                 All              Voluntary       Advisory

Medicaid Payments for Home Health Services and Nursing Homes: Medicaid eligibility, of course, refers to nursing home reimbursement. Medicaid is required to cover most nursing home services for people over the age of 21. The thrust of many state community- and home-based long-term care programs is to divert entry into costly and highly restrictive institutions. For those financially needy, Medicaid has become the largest payer for institutional long-term nursing home care. Medicaid payments accounted for 51.7 percent of all payments to nursing homes, followed by out-of-pocket payments by private residents amounting to 33 percent.30 In 1990, Medicaid payments to all nursing home vendors in the nation amounted to about $17.7 billion, or 27.3 percent of all Medicaid vendor payments. In Hawaii, these payments amounted to $78,502,328, or 41 percent of all State Medicaid vendor payments.31

For people who are eligible for nursing homes, Medicaid must also cover home health services. Medicaid payments to all home health service vendors in 1990 amounted to $3,403,955,203 for the country as a whole, or about 5.2 percent of all Medicaid vendor payments (which amounted to about $65 billion). Hawaii's Medicaid home health vendor payments amounted to $635,089 in 1990 or only 0.4 percent of all State Medicaid vendor payments.32 This means that Hawaii's Medicaid payments to nursing home vendors was 124 times larger than the amount paid to home health service vendors in 1990 ($78,502,328 / $635,089).

States may opt to provide non-medical personal care to all Medicaid-eligible persons through their state plans. In addition, states may obtain waivers for such services which may include personal care, homemaker, and adult day care services.33 According to the American Association of Retired Persons, 48 states have received waivers to provide home- and community-based (HCB) long-term care services. In addition, 32 states use the personal care or case management option to provide at least one type of HCB long-term care; 30 states have opted to use both programs.34

For 1993, Medicaid expenditures for nursing homes accounted for 62 percent of its long-term care spending. Intermediate care facilities for the mentally retarded (ICF-MR) spending accounted for 22 percent. The Home and Community Based waiver accounted for 7 percent, closely followed by 6 percent for personal care services. Home health services accounted for the remaining 3 percent of Medicaid expenditures.35 In 1990, the federal government spent about $4.5 billion for all state Medicaid programs in Region 9 comprising the four states of Hawaii, California, Arizona, and Nevada. About seven-eighths of this amount was spent in California. Federal Medicaid expenditures for Hawaii in 1990 amounted to $121,441,000 while California received $3,869,906,000.36 Per capita federal expenditures for Medicaid for the United States in 1990 was $161.94, but only $109.58 for Hawaii. Corresponding per capita figures for the other three states in Region 9 amounted to: $130.04 for California, $111.40 for Arizona, and $61.24 for Nevada.37

Almost one-third of the $450 billion spent annually on health care in the United States goes towards treatment of the elderly aged 65 and older, who represent just 12% of the population. The elderly represent two-thirds of the 8 million Americans who require long-term care. Three-fourths of the disabled elderly live at home and rely on family members or other unpaid caregivers. Some 1.6 million persons or 5% of the over-65 population lived in nursing homes in 1985 at a cost of more than $35 billion. Half of the elderly who enter homes eventually wind up on Medicaid. Private insurance covered only 1% of nursing home costs in 1985.38

However, even though the subject is Medicare expenditures, according to a 1989 article in State Government News:39

• [I]t is not the elderly per se who are the heavy users of health care financing. It is the very sick and terminally ill, many of whom are also very old. In fact, analysis reveals that a very small percentage of the elderly are responsible for the high Medicare bills. According to the Health Care Financing Administration, in 1983 . . . 2.3 percent of the 65 and older Medicare beneficiaries accounted for 33.9 percent of program expenditures. Less than 10 percent of the beneficiaries accounted for more than 72 percent of the costs. A large portion of these expenditures is laid out for the terminally ill: 28 percent of the Medicare budget -- approaching $25 billion -- is spent on patients who are in the final year of life.

Screening and Functional Eligibility: In addition to financial eligibility, preadmission screening also involves functional eligibility determination. However, in addition to medical need, many state programs also look at a person's functional, psychological, and social status. In many states, one becomes eligible for community care programs only if one is already nursing home-eligible and, in most cases, the community care costs no more or less than nursing home care. The aim is to determine if a person can remain in the community and function successfully with the benefit of formal and informal community support services. Thus, community care programs -- of which screening is a part -- aim to integrate client access to both community and institutional care. Preadmission screening determines eligibility for nursing homes and informs of community alternatives. "Locating these screening programs in the same local agency that serves as the entry point for community care services increases the potential that clients will receive advice on a range of possible alternatives."40

In addition to cost containment, screening for clients' functional capacity allows the system to appropriately allocate long-term care resources through the use of a single entry point. For example, 21 percent of those seeking nursing home entry in Oregon in 1986 were diverted to home care while Illinois diverted 18 percent.41 Effective assessment can curb inappropriate use of services, conserve scarce resources, and help avoid imposed disability resulting from inappropriate diagnosis and labeling of persons. For example, labeling a person "senile" without a proper assessment may prevent useful rehabilitation. Appropriate assessments may achieve some, if not all, of the following:42

• More accurate [medical and social] diagnosis
• More appropriate placement
• Reduced dependence on skilled nursing facilities
• Improved functional status of [clients]
• More appropriate use of medications.

It is only logical for an SEP to locate both types of screening, assessment, and case management in the same local or regional agency where system entry takes place. Doing so enhances system integrity. It also increases the likelihood that clients will receive advice on all the alternatives, thus enhancing the chances of appropriate assessments and provision of services, including nursing home care if necessary. Preadmission screening programs, as a part of an SEP, can help curb the growth of Medicaid nursing home expenditures by offering alternative community care. By placing tighter restrictions on access to nursing homes, an SEP complements many states' efforts to control the supply of long-term care beds.

Assessment -- Capacity for Independent Functioning: After a person is financially screened, capacity to function independently in the community is assessed to see whether the person's level of impairment meets nursing home criteria. The performance measures most often used to identify areas of dependence are the so-called Activities of Daily Living (ADLs). These normally include eating, dressing, bathing, toileting, and transferring (mobility). Instrumental ADLs (IADLs) include activities such as cooking, shopping, and doing laundry.43 Measures of basic functional capacities are said to be more accurate predictors of the need for long-term care than medical conditions.44 According to a 1990 evaluation audit by the Indiana Legislative Services Agency:45

• Seven ADLs are most commonly used to evaluate functional capabilities. These are the personal care activities: bathing, dressing, eating, getting in and out of bed and chairs (transferring), walking, getting outside, and toileting.46 Six other activities, or instrumental activities of daily living (IADL), are also utilized. These measure capabilities of home management: meal preparation, shopping for personal items, managing money, using the telephone, doing heavy housework, and doing light housework.

On the one hand, ADLs and IADLs are used to diagnose a person's capacity to function independently. On the other, they also indicate the types of support services a person needs in order to continue functioning independently in the community. For example, an elderly person may exhibit difficulty in the ADLs of dressing and toileting and the IADLs of cooking and shopping. Upon such an assessment, a case manager may authorize personal care services, chore assistance, and meal preparation services -- those that correspond to the relevant ADLs and IADLs.

Of course, an assessment would be incomplete if limited to only ADLs and IADL performance measures. The following are also generally included in an assessment:47

1. Cognitive capacity;
2. Social interaction;
3. Family support;
4. Resources in the physical environment;
5. Mental health functioning.

Sample Assessment Tool: Attached as Appendix B is a sample assessment tool used by the Wisconsin Department of Health and Social Services entitled the "Model Long Term Care Assessment Tool," dated May 1995. In addition, the Arizona Department of Economic Security uses a tool entitled the "Arizona Minimum Assessment." This latter form covers the following broad topics:

I. IDENTIFYING INFORMATION:

1. Personal identification data
2. Marital status
3. Educational level
4. Ethnicity
5. Primary language spoken
6. Referral source
7. Personal/legal status
8. Current living arrangement (including subsidized housing)
9. Household composition
10. Financial eligibility
11. Current use of housekeeper, home health aide, visiting nurse
12. Source and amount of income

II. INSTRUMENTAL ACTIVITIES OF DAILY LIVING -- STATUS, SOURCE OF HELP, USE OF ASSISTIVE DEVICES, AND CLIENT NEEDS, WITH SPACE FOR ADDITIONAL COMMENTS, FOR:

1. Medication use
2. Meal preparation
3. Shopping
4. Financial management
5. Telephone use
6. Transportation
7. Housework
8. Laundry

III. PERSONAL ACTIVITIES OF DAILY LIVING -- STATUS, SOURCE OF HELP, USE OF ASSISTIVE DEVICES, AND CLIENT NEEDS, WITH SPACE FOR ADDITIONAL COMMENTS, FOR:

1. Bathing and grooming
2. Dressing
3. Ambulation (out-of-home)
4. Transfer, in-home and out-of-home (moving from chair to bed moving from chair to couch)
5. Eating
6. Toileting, in-home and out-of-home

IV. PHYSICAL IMPAIRMENT AND ILLNESS:

1. Incontinence of bladder or bowels -- none, periodic, or complete
2. Vision
3. Hearing
4. Medical conditions including the following broad categories of disorders:
   • Hematological
   • Cardiovascular
   • Musculoskeletal
   • Neurologic
   • Pulmonary
   • Urologic
   • Psychiatric
   • Gastrointestinal
   • Ophthalmologic
   • Gynecological
   • General Medical
   • Metabolic
5. Emergency notification data
6. Previous year hospitalizations, including medications and special diets

V. PROGNOSIS FOR SUPPORT (SOURCES OF SUPPORT, THEIR FREQUENCY, AND ANTICIPATED CHANGES IN SIX MONTHS):

1. Spouse
2. Parent
3. Daughter
4. Son
5. Sibling
6. Other relative
7. Friend or neighbor
8. Privately paid help
9. Community volunteer
10. Agency

VI. ASSISTIVE DEVICES -- NEED FOR AND PROBLEMS WITH USE:

1. Eyeglasses
2. Hearing Aid
3. Phone amplifier
4. Dentures
5. External prosthetic device
6. Cane/quad cane
7. Walker/crutches
8. Wheelchair
9. Tub/shower seat
10. Raised toilet seat
11. Commode chair
12. Urinal bed pan
13. Handrails, grab bars
14. Transfer equipment
15. Medication reminder system
16. Colostomy/Ileostomy equipment
17. Foley catheter equipment
18. Oxygen therapy equipment
19. Hospital bed
20. Emergency notification equipment
21. Other assistive devices

VII. PSYCHOSOCIAL:

1. Cognition (memory, concentration, orientation, functioning and self care)
2. Adequacy of social contacts
3. Language comprehension
4. Speech impairment
5. Behavior -- as noted by client, assessor, significant other, professional or paraprofessional, including:
   • Loneliness
   • Grief/sadness
   • Possible depression
   • Possible anxiety state
   • Verbal abuse
   • Physical assault against others
   • Intentional self-harm
   • Verbalization of suicidal thoughts
   • Unintentional self-harm
   • Wandering
   • Public disrobing and sexual behavior
   • Probable undue suspicions of others
   • Probable hallucinations
   • Emotional instability

VIII. ENVIRONMENTAL CONDITIONS:

1. Housing problems (20 itemized potential problems including hot water, heating, home security, stairs, etc.)
2. Transportation -- availability and affordability of public or private transport for:
   • Shopping
   • Visiting
   • Obtaining medical care
   • Other
3. Current services being received:
   • None
   • Adult day care
   • Attendant care
   • Chore maintenance
   • Counseling
   • Emergency notification system services
   • Energy assistance
   • Errand services
   • Escort to medical care
   • Escort to other services
   • Financial budget assistance
   • Friendly visitor service
   • Guardianship/conservatorship
   • Home delivered meals
   • Home health aide
   • Home health nurse
   • Home maintenance
   • Home repair
   • Hospice
   • Housekeeping
   • Laundry
   • Legal services
   • Medical care
   • Medical social services
   • Nursing care
   • Nutrition services
   • Occupational therapy
   • Ombudsman
   • Personal care
   • Physical therapy
   • Protective services
   • Public fiduciary
   • Recreation/socialization services
   • Respite sitter
   • Shopping service
   • Speech therapy
   • Telephone reassurance
   • Transportation
   • Visiting nurse
   • Weatherization
   • Other

Standardized Assessments -- Difficulties: It is obvious that the task of accurately assessing even just one population (the elderly) in order to formulate appropriate service plans can be quite complex. It stands to reason that standardizing assessment of multiple populations increases this complexity. Although different populations, for example, developmentally disabled (DD) children and non-elderly adults, may share many functional limitations with the elderly, clearly some are not universal, particularly IADLs. A six-year-old DD child is not expected to shop, do laundry, or manage a household budget. Neither is an incontinent older person who needs help dressing, bathing, and toileting expected to need special DD education and support to get and keep a first job in the community.

The task of capturing both the shared and unique needs of different populations in any standardized assessment tool is a daunting one. Long-term care community-based programs in most states are dominated by just one population -- the elderly. Even with single, dominant populations:48

• 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 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 (Illinois, Maryland, and Oregon allow assessments to be done solely by social workers while Maine requires a nurse review only in its waiver component.)54 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 assessment.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 home-based 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 long-term care ombudsman services.58 For 1991, total OAA Title III 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 III OAA funds, followed by 39 percent for supportive services. Home-delivered 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 III 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 services, homemaker services, shopping services, escort services, reader services, and letter-writing services, through resource development and management to assist such individuals to live independently in a home environment."60 Although the OAA program is not means-tested, states are required to target those with the greatest social or economic need. In fiscal year 1994, federal OAA funds were spent for the following:
  • Title III-B supportive services: $306,711,000;
  • Title III-C1 congregate meals: $375,809,000;
  • Title III-C2 Home-Delivered Meals: $93,655,000;
  • Title III-D Frail Elderly Services (for in-home care): $7,075,000; and
  • Ombudsman Program/Elder Abuse: $9,018,000.]61

In carrying out client assessments, Oregon uses very specific measures to determine functional eligibility. Along with Illinois, Oregon employs an assessment tool to generate a numeric score. (See above regarding a Wisconsin county opting for a computerized assessment scoring system.) Aside from developing care plans and authorizing services, these scores are used as threshold points below which individuals become ineligible. This type of system allows the state more control over utilization rates in response to the availability of funding, care service, and caseload size. For example, Oregon raised the threshold score in 1986 because of limited funds and a growing caseload.62 This is an example of the gatekeeper role of an integrated SEP process (through use of the assessment tool) that helps control waste and manage the allocation of scarce resources within the long-term care system.

Although numeric scores tend to make assessments more objective and uniform, there is a danger this method may foster rigidity and a sense of complacence. First, assessment staff may feel hampered by a numeric tool in tailoring individualized care plans. Certain scores in certain assessment areas may begin to dictate the development and use of "cookie-cutter" plans. Useful creativity may be stifled: it is not easy to go against hard numbers. Second, standardized rather than individualized care plans may emerge because of the ease of direct cross-referencing between certain scores and set plans. The feeling may arise that a numeric "black box" assessment tool, especially if computerized, is unerringly comprehensive. That is, the work has already been done and there is no need for the case manager to further investigate or fine tune a package of services routinely used in response to a certain scoring pattern.

A lack of standardization, on the level of the assessment tool, may not be a bad thing. It may, in fact, promote needed flexibility. Again, the integrating factor in an SEP is a standard but flexible concept, not necessarily a rigidly uniform way of dealing with varying populations with needs that sometimes make a difference. Numeric-scoring assessment tools have their good points. There is no evidence that Oregon's numeric scoring system has compromised individual care plans.63 Nonetheless, their advantages should be balanced against the potential harm to quality of care. A simple way to offset any built-in rigidity of numeric scoring is to moderate it with additional non-numeric bases for assessment. However, funding will become scarcer for all states for the foreseeable remainder of the decade. As a result, one major challenge will be to balance ever tighter assessment-eligibility tools to contain costs with continued provision of quality long-term care.

Case Management: The third major component of an SEP process, performed after screening and assessment, is case management. Some prefer to term this "care coordination" to describe the "integration of the many services required by chronically ill individuals."64 The federal Office of Technology Assessment defines the process of case management according to the five core functions of case management:65

1. Assessing a client's needs;
2. Developing a plan of care;
3. Arranging and coordinating services;
4. Monitoring and evaluating the services delivered; and
5. Reassessing the client's situation as the need arises.

Case management is one of several components in new care systems that have reorganized the management of long-term care services to establish a single entry point for client services:66

• The creation of uniform assessment tools, explicit financial eligibility criteria and case management services all make access to community care more predictable from a client's perspective and more standardized as viewed by program administrators.

One view of case management is the following:67

• Care coordination is the process of organizing and supervising the delivery of services to persons whose chronic problems require a program of care that is both comprehensive and coordinated. It provides access to the entire service system and ensures the coordinated delivery of multiple services to individual clients. Basic to care coordination is an initial broad-based assessment of the client's needs. In addition, the care coordination process ensures that a service plan that considers all the available service solutions is written, and that the client is reexamined at intervals.

Some believe that effective case management is the most important component of an integrated long-term care system:68

• Case management fulfills two roles: it serves a facilitating role in matching the unique needs of clients with appropriate services and resources to meet these needs, and it serves a gatekeeper function in controlling access to public funds and the costs of services provided.

Typical activities involved in case management includes:69

1. Client outreach and screening for service eligibility;
2. Assessment to determine client strengths and unmet needs;
3. Care planning to meet client needs identified during the assessment;
4. Implementation of the care plan and linkage of the client with needed services;
5. Advocacy70 on behalf of the client to promote the delivery and/or development of services needed by the client;
6. Monitoring the care plan and client progress to ensure services are appropriate to the client's needs; and
7. On-going evaluation of the client and care plan to identify continued needs and needed changes in the care plan.

Long-term care populations generally have multiple problems often requiring an individual to search out and remain in contact with several providers at one time. Case management helps with this burden as well as providing for continuous care coordination. The following is another typical description of case management functions:71

1. Making collaborative arrangements to assure continuity of services regardless of the auspices of the provider;
2. Making necessary care arrangements;
3. Referring to appropriate services and coordinating their delivery;
4. Arranging for items and services covered by insurance;
5. Maintaining a continuous relationship with the individual;
6. Acting as a service broker by matching individual needs and resources; and
7. Ensuring delivery of services.

One observer concludes that "[t]he goals of improved care and control of costs can be directly attributable to the processes inherent in a comprehensive assessment and [case- managed] program."72 The goals of effective case management systems typically include:73

1. Enhancing quality of care as a result of the coordination and continuity of services;
2. Access to all other services available within the system;
3. Provision of appropriate services that are neither more nor less than needed at any one time by modifying the treatment plan as required in response to changing needs;
4. Allocation of care resources on the basis of clients' needs;
5. Efficient use of community resources; and
6. Reduction in the incidence of more costly hospitalization or institutionalization.

The task of carrying out case management functions fall to various types of case management agencies. They can be either public or private. This distinction becomes relevant when agencies that perform assessments and case management can also authorize services, as in the six states studied by Justice, et al. A state can designate a case management agency to act as agent of the state in long-term care programs funded with general funds and state-administered federal Medicaid funds. This designation serves both to help integrate the system and to enhance the managed care approach. In terms of an SEP, this designation of private case management agencies limits access to one entry point that is also not overly stigmatized by being perceived as a public welfare program. Whether public or private, case management agencies generally function similarly.74

• Specific functions assigned by the six states to case management agencies vary. However, general areas of responsibility include developing cost effective individual care plans, authorizing needed services, and following up to ensure needed services actually are provided. Most importantly, case management and assessment agencies are the only client access point for receipt of services financed through the major community care programs in the study states. [Emphasis added]

The core functions of case management agencies are to:75

1. Link people with needed community care provided by a variety of providers -- care is no longer provided by one institution under one roof; and
2. Control utilization of publicly funded services -- unlike nursing homes, community care services can be packaged in many ways, not all or nothing. The implication is that the package can be tailored and unnecessary parts can be omitted for efficiency.

The case management system brokers fairly similar services over the six states studied by Justice, et al. In general, they include personal care (assistance with dressing, bathing and other aspects of personal care); homemaker services (light housekeeping, meal preparation); and chore services.76

According to Justice, et al., the scope of case management activities is affected by:77

1. The locus of responsibility for financial and functional eligibility determination;
2. The range of existing services and providers;
3. The emphasis placed on utilization controls through service authorization; and
4. Whether case management is explicitly defined as a universal benefit for all older people with long term care needs or is limited to those persons financially eligible for publicly funded services.

Functional and Financial Eligibility Determination: Placing financial and functional eligibility determination within case management agencies "creates a single service entry point for older people in need of long term care."78 Not all states do this. For example, in Arkansas, one of the six study states in Justice, et al., case management is done by the Area Agencies on Aging (AAAs), which also perform financial eligibility determination for state-funded programs. However, Medicaid financial eligibility is determined by the Arkansas Department of Human Services while functional assessments are performed by client assessment teams. Similarly, in Maine and Illinois, Medicaid financial eligibility is determined by the states' Departments of Public Aid and Human Services, respectively. In these two states, both functional assessments and state-funded financial eligibility are performed by the case management agencies ("Care Coordination Units" and AAAs, respectively). In Wisconsin and Oregon, all financial and functional eligibility determinations for both Medicaid and state-funded programs are carried out by the case management agency. In Wisconsin, it is the Department of Health and Social Services; in Oregon, it is the AAAs.79

However, in Oregon:80

• [l]engthy discussions with HCFA [United States Department of Health and Human Services, Health Care Financing Administration] were necessary to achieve this single entry point since normal Medicaid rules permit a state to either determine eligibility through state employees or through local governmental employees, but not through a combination of both. With the Medicaid program being administered through local offices of the state for all other populations, the case management agencies (part of local government) would not be permitted to determine financial eligibility for the elderly long term care population. Ultimately, Oregon was allowed to create a single entry point, but had to agree to a state level paper review of eligibility decisions conducted retroactively.

However, it is not always easy to combine both financial and functional eligibility determination within one access system. It was found that:81

• Medicaid financial eligibility determination seems to be the function which is the most difficult to integrate with other access activities. . . . In states with multiple entry points, [attempts to maximize the use of state funds by trying to obtain Medicaid payment when clients appear to be Medicaid-eligible] means that clients must be referred by the case manager to another agency for Medicaid eligibility determination. . . . Depending on the complexity of the eligibility process, significant amounts of a case manager's time can be expended on this task [of assisting older people to complete the required paperwork for Medicaid enrollment]. . . . Older people themselves are the most negatively affected by these multiple referrals in most of the study states. Elderly long term care clients have . . . limited capacities to maneuver through the process.

Service Authorization -- Advocacy and Cost Control: The six state community care systems reviewed in Justice, et al. place the power to authorize services within the local agency performing the entry process tasks of screening, assessment, and case management.82 Because the assessment process leads to service authorization, the study states have consciously placed this function in agencies that do not directly provide publicly financed long term care services. In four of the six states, assessments are performed by the same agency (and sometimes by the same staff) that provide ongoing case management.83

Being empowered to authorize services, case managers doubling as assessment staff reduce necessary bureaucracy and also directly affect program costs and service utilization:84

• In managed systems of care financed by state resources and state administered federal funds such as Medicaid, state government can designate case management agencies to act as agents of the state in authorizing needed services. Without an explicit delegation of this authority case management agencies can help older people locate services but cannot directly allocate public resources to individual care plans.

However, service authorization is almost always separated from actual service delivery. This helps to avoid conflicts of interest where case managers are also capable of providing direct services for clients they have assessed. This separation also serves a cost containment function by requiring case managers to act as gatekeepers to control service utilization. At the same time, case managers (and assessment staff) can continue to fulfill an advocacy role by managing and coordinating needed long-term care services for their clients.

However, it is the former function of cost containment that is in the ascendancy. This is so because more and more community long-term care is being offered under Medicaid waivers. Medicaid waiver policy specifies that community care services for program clientele can be no more costly than nursing care. Besides limiting the average cost per case, some waiver programs also place a ceiling on expenditures for individual care plans. Such limits have also been adopted for some state-funded care programs.85 In some cases, these waiver ceilings have been placed at some lower proportion of nursing home care. For example, Maine had at one time limited per case expenditures to 75 percent of nursing home costs. Arkansas had set the dollar cap at an amount equal to 80 percent of nursing home care. Wisconsin does not impose a ceiling on the cost of services by "requires within each county that on the average, program expenditures per client not exceed the state share of Medicaid nursing home costs" or 42 percent of nursing home care.86 Although this seems low, Wisconsin has very generous nursing home reimbursement rates and 42 percent is "still adequate to finance the care of most community clients."87

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