Concept of a Single Entry Point: Creating a single entry point (SEP) to the long-term care system is not the same as totally integrating that system. Therefore, arguments cited as disadvantages of total system integration do not necessarily apply to the creation of an SEP. As mentioned several times in previous chapters, total system integration is an extreme measure. However, the system can be integrated by varying degrees. For example, system coordination can entail less than full-scale integration, as with the creation of an SEP.

It is important to remember that an SEP is only one component of the long-term care system and is only a first step. Thus, an SEP coordinates access to long-term care, but does not necessarily integrate other components of the long-term care system. An SEP often involves the coordination or consolidation of screening, assessment, case management, and authorization of services functions. Occasionally, an SEP also involves pooling of different categorical funding streams. Although it is an obvious option, states have used SEP systems without undertaking major governmental reorganization. Several SEP states have not had to create new single-purpose agencies or abolish multiple existing long-term care agencies to accommodate a coordinated system of access.

On the other hand, creating an SEP for several populations does imply a shift in policy away from a categorical approach toward a generic approach based on individuals' common functional limitations. Many states have not had to fully face this problem because their SEP systems focus on only one major population -- the elderly. An SEP for multiple populations makes more sense when common functional criteria are used. Accordingly, arguments pro and con for an SEP parallel those for a generic approach to dealing with multiple populations.

Advantages of a Single Entry Point: A good SEP may make it easier for members of targeted populations to gain initial entry into the long-term care system. If an SEP can adequately handle and process multiple populations, entry should be easier and more equitable for members of all populations. Access is facilitated to the extent that those in different categorical populations are not turned away or required to undergo multiple screenings and assessments in an SEP. Access is made more equitable in that all members of designated populations can enter the system with equal ease. However, this assumes that a solid foundation has been successfully laid for the operation of the SEP process. A key, and difficult, task is the working out of uniform screening and assessment criteria among all involved parties that adequately account for the needs of multiple populations.

A local or regional SEP providing centralized access may make access easier. However, centralized access cannot mean the use of only one central site or the use of sites located only in centralized areas. Routing everyone this way would create unnecessary bottlenecks and may actually reduce ease of entry. Obviously, more than one site is needed, including access points located in remote areas. Instead, centralized access means access through a centralized system.

However, ease of entry does not depend entirely on an SEP process. Effective publicity in a multiple-point access system may also facilitate entry. In other words, effective publicity and outreach activities are appropriate in all entry systems, including an SEP.

A good SEP can also simplify the entire process of obtaining appropriate services, beginning with entry into the system. An SEP is conducive to the coordination of the inter-related functions of pre-admission screening, assessment, case management. SEP systems usually locate these inter-related functions in the same local agency so that the entire process is simplified. Pre-admission screening for multiple populations simplifies financial and categorical or functional eligibility determination. Subsequent assessment builds on the previous screening; and case management follows from the prior two steps. This means clients need not be subject to multiple screens and assessments administered by different agencies, each of which may have a slightly different mandate or service orientation. Neither will they need to be repeatedly referred to other more appropriate agencies and possibly go through additional screens. Case managers are often empowered to authorize services although most are not allowed to also provide direct services to preclude conflicts of interest. Service authorization by the case manager adds to the overall degree of coordination in the system.

Concomitantly, if an SEP is implemented successfully, long- term care program resources can be more efficiently allocated. The different services of various agencies and providers become available on the continuum of services to multiple populations as necessary. Although an SEP makes the most sense if based on a generic approach, an SEP need not necessarily require the consolidation of categorical funding streams. If it should be decided to do so, this funding consolidation would make it easier to allocate long-term care funding resources more efficiently. However, this is a very difficult task. Funding consolidation involves coordination of a type that is different from the coordination of screening, assessment, and case management, which are inherently inter-related.

However, an SEP that espouses a generic approach encourages the consolidation or coordination of resources to meet the needs of multiple populations. This is true regardless of how the population universe is limited by policy to some combination of sub-populations (e.g., the elderly, disabled children, and non- elderly) eligible for generic coverage. Any movement toward cost savings that may be possible through such coordination and consolidation of functions and funding should be welcome as state revenues continue to lag.

Upon exposure to the system at entry, prospective clients will be more likely to become better informed of all appropriate and available alternatives. A family reluctantly seeking nursing home admission for a frail elderly relative may discover that a package of home supports may enable that person to remain at home and at less expense. In addition, because an SEP is amenable to dealing with multiple categorical needs, there is a greater chance that a client will receive appropriate services from a full continuum of services. Without a coordinated SEP, seeking and obtaining precisely the right service or mix of supports can be a hit-and-miss prospect. An SEP also facilitates the flexible delivery of services along this continuum according to changes in a client's level of care needs. As needs change for the better or worse, an SEP client need not exit one program and be screened, assessed, and evaluated for another. Through the case manager, a client can more easily switch to more appropriate services or supports. This may include switching from a nursing home to community supports and vice versa. Or it could entail the removal of transportation or chore services as a person improves with physical therapy. Another example involves young disabled persons who are making the transition to real life after a period of special education and training:465

A coordinated SEP can provide the required coordination of all family support-related activities undertaken by various agencies to help them make the transition.

An SEP can also contain costs by acting as a gatekeeper in a managed care system. Through clearly articulated screening and assessment criteria, the case manager can authorize only those services that are needed to reduce excessive service utilization. The gatekeeper function depends on articulated criteria -- the tighter they are, the fewer people will receive services, or the fewer services will be authorized and vice versa.

A good SEP encourages the achievement and maintenance of uniform standards for services while remaining flexible in responding to differing needs:466

One charge sometimes leveled at SEPs is that they do not assure quality of care. However, this type of objection may be somewhat off the mark. An SEP is not specifically designed to assure quality, just as it is not specifically designed as a mechanism to assure the adequacy of long-term care funding, although both are desirable. One could charge the status quo with the same shortcomings. On the contrary, one could actually argue that an SEP is conducive to quality assurance because of the emphasis on coordinated screening, assessment, and case management. As one researcher points out:467

An SEP also enhances efficiency and equality in the delivery of long-term care services. All procedures in an SEP are carried out usually by the same staff under a standardized concept that coordinates the inter-related tasks of screening, assessment, and case management. This reduces inconsistencies in eligibility and functional assessments at all the various points of entry throughout a state. More consistent and coordinated screening for eligibility determination should result in more equitable access for multiple populations. More consistent and coordinated functional assessments should result in more efficient and appropriate provision of care.

A standardized SEP concept could designate one regional agency (with local offices throughout the region) as the entry point. It could also designate a group of agencies, especially if private agencies are contracted for this purpose. Each agency may have a tradition of serving a specialized population. For example, one may have focused on the provision of personal care services to developmentally disabled adults. Another may have specialized in case management of home- and community-based services for the frail elderly. Still another may have adult day care as its core service. Yet, when and if they are designated as entry points under a standardized SEP process, that process uses a uniform approach to entry, screening, assessment, authorization of services, and case management. This allows entry point agencies to process clients more equitably and efficiently and with less inconsistency. Standardized procedures militate against bias by entry point staff who are used to serving only a certain population. Of course, this assumes that all entry point staff are continuously and adequately cross- trained.

Disadvantages of a Single Entry Point: Arguments against an SEP are often actually directed at the disadvantages of adopting a generic approach to long-term care. It is true that a generic approach benefits more from an SEP process than a categorical one. It makes little sense to coordinate service delivery and still retain the many categorical differences among the multiple populations processed through a single entry point. Much of the work of coordination would be wasted. Furthermore, as mentioned on numerous occasions previously, an SEP, even generically-based, does not necessarily require total system integration. Rather, processes can be coordinated without wasting the benefits. In other words, implementing an SEP is not the same as, and does not necessarily require, total system integration, even if based on a generic approach to care.

Even so, examining the difficulties of achieving total system integration in long-term care sheds light on how an SEP, which requires a lesser degree of coordination, may possibly incur disadvantages. Thus, the disadvantages of total system integration may apply in some cases, and to a lesser degree, to the implementation of an SEP. With this in mind, the following summarizes what have been identified as obstacles to true, total system integration:468

1. No single federal or state program comprehensively finances the needed range of long-term care services so that multiple programs and funding sources have been used;
2. Many public and private programs finance one or more services, adding to the fragmented patchwork system of care;
3. Each provider and funding source has its own eligibility rules and types of eligible services, making it difficult to coordinate with other providers for different populations;
4. Funding is directed to specific categorical long-term care populations causing gaps in coverage. In addition, various long- term care populations try to access financing and services not originally meant for them, adding to the confusion;
5. Various funding streams have shaped the development of numerous agencies in the administration of different long-term care eligibility and service delivery components, for example, Medicaid must be administered by a single agency;
6. Turf issues generate fights between providers and agencies over scarce resources to serve various long-term care populations served by different players;
7. The existence and work of advocacy groups can obstruct integration because each group focuses on its own population's needs even though they may share needs with other populations;
8. Technical issues relating to different populations are difficult to resolve, for example, different definitions of "disability" for each population and different eligibility criteria for services need to be resolved;
9. A lack of information and communication among agencies and between government and the public hinder integration; and
10. The lack of explicit state long-term care policies, goals, or commitment to implement that policy or goal can make integration hard.

Disadvantages may accrue to an SEP to the extent that it acknowledges the need to draw from a full continuum of services for multiple populations. In the current fragmented service environment, this implies the existence of many different service programs that operate with differing eligibility criteria, rules, and services. Programs are supported by different funding streams meant for differing, specific populations. They espouse their own philosophical and programatic goals dictated by dedicated funding or agency tradition or directives tailored to serve specific target populations. As a result, differing eligibility criteria and services often create both overlaps as well as gaps in coverage. Thus, to the extent that an SEP is intended to resolve or accommodate philosophical and programatic goals -- and possibly to consolidate funding streams -- for multiple populations, implementation will be difficult. This is not a disadvantage stemming from the operation of an SEP. Rather, the disadvantage lies in pre-existing conditions that make it difficult to achieve programatic coordination of any sort, including that achievable with an SEP.

A service population may also have unique needs and problems that are not easily or adequately addressed by programs tailored to address the needs of a different population. For example, some may feel that use of community-based supports may be inappropriate for profoundly disabled individuals for whom institutional care may be more appropriate. A common fear is that a system which is required to handle more than one population may dilute the strength of an individual program dedicated to serving only one specific population. The fear of a service system descending to the lowest common denominator is understandable. To the extent that the system recognizes that many long-term care populations share common needs, the operation of an SEP will be made easier. However, to the extent that certain long-term care populations have unique conditions and needs for services not shared by other populations, these differences make coordination in an SEP difficult.

Some believe that an SEP does not assure quality of care. The coordination of screening, assessment, service authorization, and case management is conducive to creating uniform standards, including standards of quality care. However, it is true that monitoring of services and service delivery is not an inherent part of the SEP process. It is often necessary to add a quality of care component to an SEP. This need is magnified if an SEP, or any other coordinating system, makes liberal use of in-home personal care services and supports which, because they are performed "hidden away," are inherently difficult to monitor.

An SEP could possibly reduce system access for certain people residing in remote areas. This could happen if locally available traditional entry points such as rural physicians are not part of the designated regional or local entry point. The fear of restricting entry to one, or a few, centrally located sites is less well-founded. Well-thought out SEP systems should not leave rural areas uncovered nor would they cause greater inconvenience in terms of additional time and travel to a smaller number of entry sites. To the extent that an SEP is poorly designed, this can be a disadvantage.

Concern is also expressed over the issue of possible conflicts of interest when case managers authorize services that they themselves directly provide. This is a valid concern and a distinct disadvantage in an SEP system that allows it. However, many SEP systems explicitly prohibit case management agencies that authorize services from being direct service providers as well. In those states, agencies choose to either remain service providers or become part of the entry system that performs screening, assessment, service authorization, and case management.

A further disadvantage of implementing a successful SEP is the difficulty of actually translating coordination objectives and policies into actual working protocols and tools. It is one thing to say all parties must be involved and consulted and to require that all differences be resolved. Compromises must be reached regarding both philosophical as well as operational approaches, generic vs. categorical beliefs, reconciliation of funding streams, differing categorical definitions and eligibility criteria, differing methods of evaluation and assessment, and different preferences for institutional vs. community-based services. It is quite another to actually work out the necessary compromises on these issues so that staff have usable concrete tools with which to work. On the one hand, they must be comprehensive enough to address the needs of multiple populations. On the other, they cannot be cumbersome to the point of being useless. The task is not impossible but it is not easy.

Related to this is the difficulty of cross-training entry staff. It is very difficult to imagine a huge cadre of intensely and comprehensively cross-trained staff equally expert in the needs of multiple populations. Such staff would be extremely qualified, if not over-qualified for other work in the long-term care field. There may be several possible solutions. First, the work expected of highly cross-trained staff can be transferred to planners and expert practitioners who work out screening and assessment tools on the front end. That is, the necessary sophistication and knowledge can be built into the tools themselves so that entry staff need not be relied upon for the requisite expertise on the back end. Alternatively, the SEP system can be designed to be flexible enough so that a person or team with the appropriate expertise is always required and available to conduct assessments. For example, staff can be required to seek and defer to another if the assessing staff is not knowledgeable about the client being assessed. In addition, follow-up specialist assessments can also be required if necessary.

Operationally, an SEP can create a bottleneck in the entry process. For example, some states have generated waiting lists of people to be processed through a single entry point system up to two years long. Authorization and delivery of services must be delayed until all required screenings and assessments have been carried out. A state can either recommend or require either all or certain persons seeking long-term care services to use an SEP process to enter the system. If an SEP entry is required and not merely recommended or available, more people will go through the SEP. Similarly, if all populations are required to do so, the chances are that more people will be processed. If a goal is to increase the numbers of people accessing the system, an SEP should help achieve it. However, there is a possibility that the system can be overloaded, especially if there is insufficient funding to perform all required screenings and assessments.

An SEP is weak to the extent that states cannot mandate, but only persuade, physicians and hospital discharge planners to refer patients to non-medical community care programs. In the eyes of acute care facilities, pre-admission screening programs are often seen as:469

1. Unnecessary bureaucracy;
2. A challenge to physicians' authority; and
3. Duplication of discharge planners' ongoing responsibilities which include some form of long-term care pre-admission screening.

A condition inherent in most public bureaucracies is that of interagency rivalry manifested in "turf wars." The empire- building, battles for leadership, and jurisdictional expansion engaged in by public agencies are to be expected in the normal give and take of government. At times, this dynamic serves to stimulate new ideas and approaches to solving problems through productive contention in otherwise moribund bureaucracies. However, they can also work against coordination. Thus, dysfunctional turf wars among public agencies serve to hinder coordination that may be a goal of an SEP. Turf wars may also be partly caused or exacerbated by a lack of communication among agencies which may generate misunderstanding and heighten unfounded suspicions.

This situation is mirrored in turf wars in the private sector. The activities and attitudes of various advocacy groups, each of which promotes the interests of a certain target population, work against coordination. Each contends for a piece of the funding pie for its own population. It is understandable for an advocacy group to cite its population's unique needs and problems in partial justification of their advocacy efforts. Commonalities shared by populations tend to be glossed over. Thus, an SEP that attempts to coordinate services, and possibly funding, for different populations may be seen as a threat that dilutes an advocate's "proprietary" program.

The likelihood of successfully creating and operating an SEP is also weakened by a lack of clearly articulated public policy that sets priorities and goals for a unified statewide effort to coordinate the system. To the extent that an SEP is expected to coordinate entry and provision of services to multiple populations, it will be at a disadvantage in the absence of such an overarching policy. Discrete programs may have clearly stated policy goals. However, to the extent that their philosophies, objectives, and operational procedures may be categorically mutually exclusive, a coordinating SEP will suffer without clear governing policy.

It is, however, one thing to state policy and quite another to make an actual commitment to carrying out that policy. Lack of executive leadership and commitment to coordinate the system through an SEP would be a major disadvantage. Mandating a new policy of coordination would be greatly hindered operationally without the full support of the executive and the public agencies involved. Strong leadership must be brought to bear to facilitate cooperative efforts among the executive agencies responsible for long-term care. Without such leadership and cooperation, an SEP would be difficult to successfully implement.

Assuming that policy is articulated and commitment and executive leadership are forthcoming, a client's coordinated access through an SEP needs to be routed to adequate services. It would make no sense to invest the tremendous amount of effort required to overhaul the long-term care system in terms of coordinated access and service delivery if there are not enough services to deliver. This is a common caution that has surfaced in various jurisdictions.470 The lack of funding support for both institutional and home- and community-based long-term care services is not a disadvantage, per se, of an SEP. As mentioned earlier, program funding is independent of the type of access model. It is a disadvantage to the entire system that must be faced by any approach to long-term care reform. Thus, a general lack of funding for underlying long-term care services could be a disadvantage to the entire system in the sense that scarce funds that could otherwise have gone to bolster actual services may be used for an SEP.

Cautions: There seems to be no disagreement that long-term care services can and should be better coordinated for at least the elderly population. However, there is doubt as to whether the provision of long-term care for the three designated populations may be successfully coordinated. There is also disagreement over the benefits of establishing an SEP for the three populations. In addition, it is the consensus that implementing an SEP, should it be decided to do so, will be a very difficult task.

Various cautions have also been raised, regardless of the decision to implement an SEP or not. The most critical of these is for adequate funding to be made available for both institutional and home- and community-based long-term care services. A second caution is that effective information and referral activities that include active outreach need to be added or incorporated into an SEP design or other coordination efforts. A third caution is that hospital discharge planning must be consistently available that conforms to any SEP process. A fourth is that the more pressing problem lies perhaps not in deciding whether or not to implement an SEP but in providing adequate funding for long-term care beds.

If it is decided to implement an SEP, several other cautions need to be heeded. The first is that experience in the six states studied by Justice, et al., points to incremental change. All added program components over several years. For example, pre-admission screening programs often were added after the supply of community care services was expanded so that community options offered by screeners made for viable choices.471 Hand in hand with this go-slow approach is the need for prior broad- based, intensive and extensive planning involving all players. Their full working cooperation is necessary to make an SEP successful. For example, acceptable compromises must be fashioned on definitions, eligibility and assessment criteria, client needs, continuum of services availability, and possibly consolidation of funding streams. For the six states studied by Justice, et al.:472

A third related caution is that turf wars may continue despite apparent coordination of services for multiple populations if factions are not creatively accommodated.473 A further related caution is the desirability of operationally testing the SEP in some way. This could take the form of a pilot project in one geographical area. Alternatively, a pilot project can be run statewide but focusing on only one population. The mix of programs, services, and funding and how they are administered within each state's organizational structure is not always the same. Consequently, the feasibility of any model should be tested on a limited basis in each state before full program implementation. A final warning is the need to develop an effective audit and evaluation system because services and expenditure authorization in an SEP most probably will have been delegated to non-governmental agencies.

Support for System Coordination: Federal budget cuts and program re-structuring may force the State to better coordinate the delivery of long-term care services to multiple populations. It is possible that such federal pressure to conserve fiscal resources may not materialize. Even so, efforts to optimize the use of funds merit serious consideration due to depressed local fiscal conditions and the prospect of increased demand for long- term care in the future. Certain programatic benefits, although not unanimously agreed upon, may accrue from a more coordinated long-term care system. On the other hand, it is clear that the path to an SEP system will be liberally strewn with obstacles and difficulties requiring intensive and extensive good-faith cooperation and negotiation among multiple parties.

The thrust of an SEP is not for total system integration, but only for a degree of system coordination. There seems to be more consensus on use of the term "coordination" than "single entry point." The Executive Office on Aging (EOA), for example, recommended in 1988 "[t]he implementation of interdepartmental coordinating mechanisms . . . to ensure the coordination of services, systems, policies, and programs."474 In support of this coordination effort (and implicitly supporting a cabinet model), the EOA further recommended that:475

Although not envisioned for multiple populations, this coordinating council could serve precisely that role in a cabinet model where existing departments continue to provide services in a coordinated fashion. The EOA believes "that better coordination will result in easier access for all clients. . . . [and] improvements could include better coordination with agencies and providers, expanded use of technology for sharing information, standardized intake and/or referrals forms, etc. A movement towards some form of consolidation could be a cost saving measure [although the EOA is not sure this would work for combined groups]."476

The Department of Health (DOH) also recommended a form of coordination (which may not be incompatible with an SEP):477

The DOH also pointed out the need for consistently available, quality, hospital discharge planning. An SEP can conceivably incorporate this as it coordinates entry from all places, including from acute care hospitals.

Two-Phase Pilot Project: Despite the obvious difficulties, it is nevertheless worthwhile to pursue the concept of an SEP but, at least for the time being, only on a limited pilot project basis. This can be done in two phases.

Phase One: In the first phase, a coordinating committee should be created to perform the ponderous preliminary tasks required to create and implement a successful SEP process. Subject to broad guidelines (see following section), the committee should have substantive power to design and develop the trial SEP system subject to a single proviso. This proviso would allow the committee, based on the results of actual negotiations among all relevant parties, to modify the SEP -- even to the extent of finding it not feasible under local conditions. After all, the objective of a pilot SEP project is to find out whether or not an SEP can generate the anticipated benefits in the manner envisioned. If, after good faith negotiations, the committee should find that workable compromises cannot be reached or if strong executive leadership and support is found lacking, it may recommend terminating or modifying the project. In the latter case, consistent with its mandate to design a system that works, the committee should be allowed to recommend some other form or level of coordination that may not be encompassed in a formal SEP system.

Broad Guidelines: During its preliminary work, the committee should be subject to certain broad guidelines. The first is that it must consider a system to accommodate all three designated populations. The committee must also adopt, on an experimental basis, a flexible generic approach to determine eligibility and assess clients based on functional limitations. Third, the committee must design a system that makes the most efficient use of resources. Fourth, the system must attempt to benefit the greatest number while reasonably accommodating individuals with extreme needs. Lastly, the pilot project should be geographically limited to an area in which all three populations are likely to reside or receive services. Within these general guidelines, the committee should have broad latitude in shaping the form of the actual SEP, if one is ultimately found feasible.

At a minimum, during actual negotiations, the committee should specifically attempt to determine whether:

1. Differing financial eligibility criteria can be reconciled, including whether differing funding streams can be usefully consolidated and made available to support services for all three populations;
2. Sufficient common ground exists for the use of standardized functional assessments for the three populations and if provisions for supplementary specialist assessments are necessary, feasible, and can be made available;
3. Cross-training for entry staff is feasible or can be made adequate to handle the needs of all three populations or, alternatively, whether sufficient "expert" knowledge and sophistication can be built in to whatever standardized tools that will be used;
4. Case management can be consolidated for the three populations;
5. If the power to authorize services is given to case management agencies, whether case managers will be allowed to provide direct services; and
6. Existing services can be placed in and accessed from a continuum of services available to all three populations through the SEP or coordinated system;

The committee should include representatives of all public agencies involved in the provision of long-term care to the three designated populations, including at least:

1. The Executive Office on Aging;
2. The Department of Budget and Finance;
3. The Department of Commerce and Consumer Affairs;
4. The Department of Education;
5. The Department of Health;
6. The Department of Human Services;
7. The Department of Labor and Industrial Relations;
8. The Department of Transportation;
9. The University of Hawaii;
10. County agencies in the pilot project county providing relevant care to the three populations;
11. Acute care hospitals, long-term care institutions, adult day health centers, adult day care centers, and adult residential care homes;
12. Other relevant profit and nonprofit providers of care; and
13. Advocacy groups including consumers from each of the three designated populations.

Flexibility Must Be Maintained: Although based on an experimental generic approach, the pilot project should remain flexible enough to adapt to real needs and conditions as encountered by the committee during actual negotiations. A rigid posture negates the purpose of the project -- to find out what elements will work and how. The underlying goals to be kept in mind should be those previously enumerated as advantages. Thus, the committee should be flexible in designing and developing the project to best achieve those goals. For example, the committee should be able to expand its membership to include other participants if it feels necessary. It should identify the relevant issues to be negotiated and decided upon; set up its own substantive working sub-groups to achieve consensus; set project milestones and deadlines; schedule timely meetings; and make interim reports.

Phase Two: The coordinating committee should be allowed sufficient time to work out the numerous difficult issues previously enumerated. Accordingly, the committee should be given one year until June 30, 1997 to accomplish this. If the committee wishes to proceed with either the originally envisioned SEP or an alternative, it should prepare proposed legislation to implement actual field operation of the pilot project in phase two. Because proposed legislation must be prepared by late December, 1996, the committee will actually have only about six months in which to resolve the major issues. However, the committee should have the flexibility to request an extension of time. The committee can either hold off requesting an appropriation to fund implementation of the pilot project or proceed to make such an appropriation request in the proposed legislation, pending the completion of its preliminary work by June 30, 1997. This proposed legislation should be prepared by the convening of the regular session of 1997 so that field operation can begin by July 1, 1997, or earlier. Generally, the pilot project should be in operation for at least two full years.

Funding for Phase One: The work of the coordinating committee should not require an appropriation of general funds. Most members of the committee will be from the public sector carrying out duties on the committee as part of their jobs. Participation is voluntary for private sector representatives. However, incidental expenses for necessary intra-island travel should be reimbursed. This should not amount to much, especially if the pilot project focuses on only one island, say, Oahu. The committee can be temporarily attached to either the Department of Health, the Department of Human Services, or the Executive Office of Aging for administrative purposes only. Alternatively, it can be attached to the Governor's office. Wherever it is located, necessary travel expenses can be reimbursed from the sponsoring agency's budget.

Funding for Phase Two: In phase two, assuming that the committee recommends moving forward to implement an actual SEP or other coordinating measures, funding will most likely be needed. The magnitude of this funding cannot be known until the committee has conducted its preliminary work of broad-based planning and negotiations in phase one. The committee should include a request for funding in the proposed legislation to carry the project out to fruition. Assuming that funding is necessary and forthcoming, the committee can then move on to actual implementation including final project evaluation and recommendations for project termination or expansion.

Funding, of course, for both nursing home beds and home- and community-based supports must not be neglected even as plans to coordinate the long-term care system proceed with a pilot SEP project. On a more general level, it would make less than no sense to more effectively route more people through the system to a dead end with inadequate nursing home beds and community supports. On a more specific level, it would similarly make no sense to legislate this pilot project if there is no broad-based support and strong executive leadership and commitment to carry it through.

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