Long Term Care Redesign:
Executive Summary

As our population continues to age, government and health care providers will be faced with the need to find a system that brings cost effective health services, including long term care services, to their citizens.

While the State of Wisconsin already has a strong long term care system, changes are necessary because of problems inherent with that system. These problems include limited consumer choice, public dollars not spent in a cost effective way, the inability of some people with significant needs to receive services, the fragmentation of long term care funding, a confusing number of programs with conflicting policies/requirements, inadequate and inconsistent quality assurance mechanisms, and the tendency of government to make long term care policy changes without sufficient supporting research and data analysis.

Given the limitations and disadvantages of the current long term care system, the Wisconsin Association of Homes and Services for the Aging (WAHSA) strongly advocates for a redesigned delivery system which "maximizes an individual's choice of services, providers, and care settings as long as such care is necessary and meets a minimum level of quality standards and is cost-effective." Further, the future delivery system should integrate acute and primary care, long term care, and supportive services in order to provide, finance, and manage the health and long term care needs of clients.

To achieve this desired goal, WAHSA is proposing three models or programs to initiate changes in the present system. The first and preferred model is one that would provide vouchers to people who qualify for public funding. The value of the vouchers would be determined according to the care needs of each recipient. They could be utilized by the person (or the person's family or guardian) to directly purchase care and services or to enter into a managed care arrangement with other voucher holders.

The second model is one in which the State of Wisconsin would utilize managed care organizations to purchase long term care services for publicly funded clients. In this model, the State would decide how much it would pay each managed care organization for the care of the clients it serves. The State also would be responsible for quality assurance monitoring of the managed care organizations.

The third model proposes a number of modifications to Wisconsin's current long term care system. These changes would improve an already strong system and would serve as a transition from our present system to one of the two models noted above. This model offers ways to reduce excess institutional capacity, consolidate multiple long term care programs, build better data collection and analysis systems, and more cost-effectively allocate scarce public funds.

All three models contain elements that the Association believes are essential features to any new long term care system. These elements include a single point of entry. The organization or entity serving as the single point of entry would determine a person's potential eligibility for public funding, do an assessment of need, gather health maintenance information, and provide information about available services and volunteer programs. While the services of the single point of entry are intended specifically for those in need of public funding, they also would be available to those able to pay for their own care.

The second element of the proposed models is a comprehensive assessment. This assessment would include a person's health, socioeconomic, functional, and cognitive status. The assessment also would identify informal support systems available to the client.

The third element of the models is a fully integrated range of services. While there are considerable state and federal legal and regulatory roadblocks to achieving a fully integrated health care delivery system for our older adults, the Association believes that integration of primary and acute care, long term care, and supportive services is the best way to provide, finance, and manage the health and long term care needs of our citizens. A system that includes Medicare, Medicaid, state waiver programs, and community-based programs will reduce the incentives for health care providers within the system, or the system itself, to shift costs outside the redesigned program.

The fourth element of the models is an outcome-based quality assurance program. This new quality assurance program would define quality of care in terms of outcomes rather than process as in the present system. Outcome measures would focus on health status (such as avoidance of unnecessary hospitalization, contraindicated drug use, range of motion, and increased mobility), quality of life (including timeliness of services, availability of services, and client satisfaction), cost effectiveness (that is, the provision of necessary services in a way that best utilizes scarce financial resources along with the maximum use of informal support systems) and other performance measurements (such as technical competency of the health care provider's staff, staff turnover, and the effectiveness of the provider's internal quality assurance processes).

The fifth element of the models is the availability of a wide range of services. The Association's plans would not favor one type of service over any other service (for example, nursing homes over home care, or vise versa). Rather, the needs of clients within the system, as determined by the comprehensive assessment, would dictate the type of service provided.

The sixth element of the models includes procedures to insure the integrity of the new system. These procedures would include state monitoring of all managed care organizations; a review of the accuracy of client comprehensive assessments; a system for responding to formal complaints of clients, families, and providers; and a prohibition against excess profit-taking.

The final element of the models requires enforcement of divestment, estate recovery, and co-payments. Under any redesigned system, the State would retain responsibility for enforcing existing divestment prohibitions, estate recovery, and lien programs.

As the population of the country and the State of Wisconsin continues to age, service demands will outstrip governmental resources available. It is imperative that the State find a way to maximize the use of those resources while insuring proper attention and care to the needs of older and disabled adults. At the same time, we must work towards better coordination of the care and services provided throughout the spectrum of care. To best provide, finance, and manage the health and long term care needs of our aging and disabled populations while best utilizing scarce financial resources, the State must work now to integrate acute and primary care, long term care, and supportive services. The models for redesign offered by the Wisconsin Association of Homes and Services for the Aging can move us in that direction.

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WAHSA 204 South Hamilton Street Madison, WI 53703
Telephone: (608)255-7060 FAX:(608)255-7064