A two-year study of long-term care for the aging has focused on 14 facets of the problem, rated them according to importance and feasibility for improvement and concluded that the No. 1 issue is case management: the process of determining need and the best way to fill it.
A hundred, give or take one or two, experts met recently at the University Hilton for the "Staying at Home" conference that was a part of the study. Their mission was to discuss feasibility of implementation and to vote for the four items that they consider not only important but possible to achieve.
In addition to case management, the experts chose care-givers supports, meaning community help to those who care for the frail elderly; home-care incentives, ways to make it cost-effective to keep the aged at home; and levels of care, a balanced continuum between independent living and a skilled nursing facility.
Raymond M. Steinberg, who holds a doctorate in social work, was director of the project conducted by the Institute for Policy and Program Development of USC's Andrus Gerontology Center. He emphasized that the study covered facets of the long-term care system, "not just a single program but a look at the system as a whole. We needed to see how things connect or do not connect."
The result was the selection of 14 possible goals, what Steinberg called "14 'shoulds' " that ranged from equal access to long-term care services to how to educate physicians about the need--or absence of need--for institutionalized care.
Steinberg explained the matter of case management, not surprisingly deemed the No. 1 goal by the professionals, mostly social workers, who ranked the issues.
"Case management involves service brokers, someone to assess the need and to indicate what resources are available to the client," he said. "Someone needs to recommend change as the situation changes, for example to have home-delivered meals for the client when needed but to not have that service go on forever.
"Some multiservice centers claim they are doing case management, but they do not hire a skilled person, a nurse or a social worker, because that person would be paid more than the center director. There is a growing number of private managers, some of them good, some bad.
"There is the matter of labeling: senile, Alzheimer's disease--Alzheimer's is the flavor of the month. Yet no one asks if the person has ever had a CAT (brain) scan or if he or she can prepare meals. You can't just match a need and a resource without digging deeper."
Steinberg, who emphasized that the study entailed the efforts of many professionals, also spoke of the group's second choice for attention, support for those caring for the frail elderly at home. These include tax concessions, reimbursement or subsidy for home-care costs and respite arrangements to relieve the care givers.
"A General Accounting Office study in Cleveland showed that 80% of the help for the frail elderly came from the family," Steinberg said. "That's 80% of help, not 80% of cases. We ought to nurture that informal care giving. There are a lot of resources, but they are being underutilized. In some cases people have called a community services agency and the agency itself didn't know what respite meant."
Third choice of the professionals for implementation was home-care incentives, governmental and private health insurance policies to provide financial incentives--as opposed to the present disincentives--for caring for the elderly at home.
"We need to revise the payment policies of insurance, which do not cover long-term care or home care," Steinberg said. "Employer associations and labor groups are now looking at their coverage (with this in mind).
"In Palo Alto the Veterans Administration made an offer to care givers that if they would care for the person at home they could put the person back in the hospital to provide respite to the care giver. Some VA people thought the care givers would abuse the plan, but surprisingly they didn't use it a lot.
"It is not easy to change this on a local level. We need to get the state to apply for more waivers for Medicare, especially since Congress is convinced that home care is less costly."
The fourth goal selected as feasible for implementation was levels of care, a goal that calls for more gradations between placement in a skilled nursing facility and being at home. Board and care homes, a step between independent living and a skilled nursing facility, may need to be defined in special categories according to the special needs of clients, entailing additional reimbursement from government, insurance or consumers, the report said.
"Theoretically, we have an intermediate facility between skilled nursing and home care," Steinberg said, "but the state reimburses for home care or a board-and-care facility at a much lower rate. So there are 38,000 skilled nursing beds in Los Angeles County and only 633 intermediate care beds.