 Table of Contents
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Endnotes
1. Diane Justice, et al., State Long Term Care Reform:
Development of Community Care Systems in Six States, National
Governors' Association Center for Policy Research, Health
Policy Studies, Washington, D.C., April 1988, p. 90.
2. Alice M. Rivlin and Joshua M. Wiener, Caring for the Disabled
Elderly: Who Will Pay?, (Washington, D.C.: The Brookings
Institute) 1988, p. 9.
3. Hawaii, Long Term Care Plan For Hawaii's Older Adults,
Executive Office on Aging, Office of the Governor, July, 1988,
(hereafter "Hawaii's Older Adults") p. 14.
4. Ibid., p. 19.
5. Indiana, Long-Term Care and the Elderly, Evaluation Audit,
Indiana Legislative Services Agency, May 1990, (hereafter
referred to as "Indiana 1990"), p. 46.
6. Hawaii's Older Adults, p. 9.
7. Indiana 1990, p. 55.
8. Theodore H. Koff, New Approaches to Health Care for an Aging
Population: Developing a Continuum of Chronic Care Services,
Jossey-Bass Inc., Publishers, 350 Sansome Street, San
Francisco, California 94104, 1988, pp. 166-167. [Koff is
Director of the Arizona Long-Term Care Gerontology Center,
Director of Public Sector Programs, and Professor of
Management and Policy at the University of Arizona in Tucson.]
9. Material on "consolidated," "umbrella," and "cabinet" models
from Justice, et al., p. iii.
10.Indiana 1990, p. 42.
11.Ibid.
12.Op. cit., pp. 39 & 60.
13.Ibid.
14.Koff, p. 166.
15.Diane E. Justice, "What States are Doing to Help Elderly," in
State Government News, Council of State Governments, vol. 32,
no. 3, March, 1989, p. 24.
16.Koff, p. vii.
17.Justice et al., p. iii.
18.Op. cit., p. iv.
19.Op. cit., p. 68.
20.Op. cit., pp. ix-x.
21.Op. cit., p. 87.
22.Op. cit., p. 90, citing Laura Hines Iverson, A Description and
Analysis of State Pre-Admission Screening Programs,
Interstudy, 1986.
23.Justice, et al., p. 90.
24.Op. cit., p. 69.
25.Op. cit., p. 87.
26.Op. cit., p. 90.
27.Op. cit., p. 91.
28.Indiana 1990, p. 16, citing U. S. Congress, Long-Term Care and
Personal Impoverishment: Seven in Ten Elderly Living Alone at
Risk, Select Committee on Aging, U. S. House of
Representatives, October, 1987.
29.Justice, et al., p. 91.
30.American Association of Retired Persons, "Medicaid and Long-
Term Care for Older People," Public Policy Institute, fact
sheet FS18R, January, 1995, Figure 2 "Sources of Nursing Home
Payments, 1993."
31.Brason Lee, State Long-Term Care System: Region IX Profile,
American Association of Retired Persons, Public Policy
Institute, Center on Elderly People Living Alone, 1992, p. 39.
32.Ibid.
33.AARP fact sheet FS18R.
34.American Association of Retired Persons, "Home and Community-
Based Long-Term Care," Public Policy Institute, fact sheet
FS13R, May, 1994.
35.AARP fact sheet FS18R.
36.Lee, pp. 10-11.
37.Ibid.
38.Justice article, p. 25, citing Michael H. McCabe, Long-Term
Care for the Elderly: The Search for Solutions, The Council of
State Governments, 1989.
39.Ken Dychtwald and Joe Flower, "Calling a Truce in the Age
Wars," in State Government News, Council of State Governments,
vol. 32, no. 3, March, 1989, p. 8.
40.Justice article, p. 25.
41.Justice, et al., p. 91 & 93.
42.Koff, pp. 167-168.
43.AARP fact sheet FS13R.
44.Justice article, p. 24.
45.Indiana 1990, p. 19.
46.The Indiana Legislative Services Agency also cited the 1984
National Health Interview Survey by the National Center for
Health Statistics which reported that the ADLs posing the
greatest difficulties were walking, getting outside, and
bathing.
47.Koff, p. 168.
48.Justice, et al., p. 76.
49.Koff, p. 169.
50.Ibid., p. 167.
51.Ibid., pp. 167-168.
52.Telephone interview of October 3, 1995 with John Lorimer,
Director, Bureau of Long Term Support, (Community Options
Program), Wisconsin Department of Health and Social Services,
608-267-7284.
53.Lorimer interview. It was also pointed out that one county
insisted on having an attorney as part of the assessment team.
54.Justice, et al., pp. 76-77.
55.Lorimer interview.
56.Hawaii's Older Adults, pp. 8 & 16.
57.Koff, p. 156.
58.Alfred J. Chiplin, Jr., "The Older Americans Act: Current
Problems and Developments," in Clearinghouse Review, vol. 23,
no. 6, October, 1989, pp. 677-678.
59.Lee, pp. 16-17.
60.Koff, p. 154.
61.American Association of Retired Persons, "The Role of Older
Americans Act in Providing Long-Term Care," Public Policy
Institute, fact sheet FS12R, November, 1994.
62.Justice, et al., pp. 77 & 85.
63.Ibid., pp. 77-78.
64.Koff, pp. xiii & 18-19.
65.Maryland, Report of the Governor's Commission on Health Care
Policy and Financing: Joint Recommendations of the Governor's
Commission and the Committee on Long-Term Care, Governor's
Commission on Health Care Policy and Financing, vol. V,
December 20, 1991, (hereafter "Maryland Report"), p. 45.
66.Justice, et al., p. 95.
67.Koff, p. 176.
68.Indiana 1990, p. 57.
69.Ibid.
70.According to Koff, p. 179: Advocacy on behalf of the client
is a inherent part of [case management], as the staff member
seeks the appropriate service, the funds to provide the
service, and assurance that the person will benefit from the
service provided."
71.Ibid., p. 177, citing J. J. Callahan, Jr., ed., Major Options
in Long-Term Care (Waltham, Mass.: University Health Policy
Consortium, Brandeis University) 1979.
72.Ibid., p. 179.
73.Ibid., pp. 177-178.
74.Justice, et al., pp. v & 79.
75.Ibid., p. 68.
76.Ibid., p. v.
77.Ibid., p. 79.
78.Ibid.
79.Ibid., p. 80.
80.Ibid., pp. 80-81.
81.Ibid.
82.Ibid., p. 87.
83.Ibid., pp. 75-76.
84.Ibid., p. 87.
85.Ibid., p. 83.
86.Ibid., pp. 83-86.
87.Ibid., p. 86.
88.American Association of Retired Persons, "Long-Term Care,"
Public Policy Institute, Fact Sheet FS27R, April, 1995
hereafter "AARP Fact Sheet FS27R."
89.Ibid.
90.Indiana, Long-Term Care and the Elderly, Evaluation Audit,
Indiana Legislative Services Agency, May 1990, (hereafter
"Indiana 1990") p. 22.
91.Diane Justice, et al., State Long Term Care Reform:
Development of Community Care Systems in Six States, National
Governors' Association Center for Policy Research, Health
Policy Studies, Washington, D.C., April 1988, pp. i-ii.
92.Theodore H. Koff, New Approaches to Health Care for an Aging
Population: Developing a Continuum of Chronic Care Services,
(San Francisco: Jossey-Bass) 1988, p. 17, citing Theodore H.
Koff, Long-Term Care: An Approach to Serving the Frail
Elderly, (Boston: Little, Brown) 1982, p. 3.
93.AARP Fact Sheet FS27R.
94.Maryland, Report of the Governor's Commission on Health Care
Policy and Financing: Joint Recommendations of the Governor's
Commission and the Committee on Long-Term Care, Governor's
Commission on Health Care Policy and Financing, vol. v,
December 20, 1991, hereafter referred to as "Maryland Report,"
p. 9.
95.Ibid., p. 43, citing the Maryland Long-Term Health Care
Committee's An Inquiry into Maryland's Long-Term Care Needs.
96.Wisconsin, Information: Community Options Program, Department
of Health and Social Services, Bureau of Long Term Support,
no. 103 b, January 27, 1994, p. 1.
97.Justice, et al., p. 68.
98.Ibid., p. 86 citing Maryland, Review and Comparison of Four
In-Home Service Programs, Department of Budget and Fiscal
Planning, September, 1984.
99.Ibid., p. 86.
100.Ibid., p. 67.
101.Hanns G. Pieper, The Nursing Home Primer: A Comprehensive
Guide for Nursing Homes And Other Long-Term Care Operations,
(White Hall, Va.: Betterways Publications) 1989, p. 23.
102.Justice, et al., p. 99.
103.Ibid., p. 110.
104.Ibid., p. 95, and AARP Fact Sheet FS27R.
105.Ibid., p. 95.
106.Brason Lee, State Long-Term Care System: Region IX Profile,
American Association of Retired Persons, Public Policy
Institute, Center on Elderly People Living Alone, 1992, p. 91.
107.Justice, et al., p. 95.
108.Koff, p. 27.
109.Justice, et al., p. 96.
110.Indiana 1990, p. 27.
111.Koff, pp. 56, et seq.
112.Ibid., p. 84.
113.Ibid., pp. 65-66.
114.Ibid., p. 36 et seq.
115.Indiana 1990, pp. 28-29. The service continuum was based in
part on the Continuum of Care in Indiana, prepared by the
State Board of Health, and A Complete Continuum of Care for
Older Hoosiers, prepared by the Indiana Association of Area
Agencies on Aging.
116.Maryland Report, pp. 13-14.
117.Justice, et al., p. 97.
118.Ibid., Table V-1 "Major Services Supported by State Community
Care Programs" p. 98.
119.Pieper, p. 23.
120.Justice, et al., p. 98.
121.Pieper, pp. 14, 18, & 19.
122.AARP Fact Sheet FS27R.
123.American Association of Retired Persons, "Home and Community-
Based Long-Term Care," Public Policy Institute, Fact Sheet
FS13R, May, 1994.
124.Justice, et al., p. 103.
125.Ibid.
126.Ibid., p. 104. These are: (1) Wisconsin's Community Options
Program; (2) Maine's Home Based Care Program; (3) Maryland's
Gateway III; and (4) Oregon's Project Independence and the
waiver program in Oregon.
127.Pieper, p. 27.
128.Justice, et al., pp. 104-105: In 1988, ADCC services cost
from $20 to $35 a day.
129.Pieper, pp. 27-28.
130.Justice, et al., pp. 105-106.
131.Lee, pp. 90, citing the U.S. Bipartisan Commission on Health
Care, 1990.
132.Ibid., pp. 90-91.
133.H. B. No. 337, S.D. 1, Eighteenth Legislature, 1995, State of
Hawaii; vetoed by the Governor on June 21, 1995.
134.1992 Haw. Sess. Laws, Act 211, section 1.
135.Koff, p. 82.
136.Ibid.
137.Koff, p. 83.
138.H.B. No. 337, S.D. 1, Eighteenth Legislature, State of
Hawaii, 1995.
139.Colorado, Report to the Colorado General Assembly:
Recommendations for 1990, Legislative Task Force on Long-Term
Health Care, research publication no. 344, December, 1989, p.
18.
140.Alice M. Rivlin and Joshua M. Wiener, Caring for the Disabled
Elderly: Who Will Pay?, (Washington, D.C.: The Brookings
Institute) 1988, pp. 98-99.
141.Ibid., p. 97.
142.Lee, p. 32.
143.H. B. No. 337, S.D. 1, Eighteenth Legislature, 1995, State of
Hawaii.
144.1992 Haw. Sess. Laws, Act 211, section 1.
145.Ibid.
146.Justice, et al., p. 106.
147.Pieper, p. 14.
148.Justice, et al., p. 107.
149.Ibid., p. 108.
150.Ibid.
151.Jan Ferris, "Trained in Care" Honolulu Advertiser, October
26, 1995.
152.1995 Haw. Sess. Laws, Act 70.
153.1994 Haw. Sess. Laws, Act 165. The MWDP was extended for two
more years until June 30, 1998 by 1995 Haw. Sess. Laws, Act
65.
154.Ferris article.
155.Telephone interview, September 7, 1995 with Dr. Cullen
Hayashida, Assistant Administrator, Maluhia Hospital.
156.Lee, p. 71.
157.According to Koff, p. 11, citing J. Firshein, "Geriatric
Evaluation Units Found to Benefit Elderly Patients," in
Hospitals, 1985, vol. 59, no. 3, p. 32: "Almost 8 percent of
acute care hospital patients 65 years of age and older are
discharged from hospitals to nursing homes annually. About
half of these could go home if appropriate support services
were available. In fact, about 200,000 persons per year could
avoid nursing home care if they had access to a geriatric
evaluation unit."
158.1994 Haw. Sess. Laws, Act 165.
159.Ibid.
160.Maryland Report, pp. 17-18.
161.Ibid., p. 18.
162.Ibid., p. 21.
163.Ibid.
164.Ibid., pp. 18-19.
165.Ibid., p. 22, citing Fernando Torres-Gil and Jon Pynoos,
"Long-Term Care Policy and Interest Group Struggles," in The
Gerontologist, vol. 26, no. 5, 1986, pp. 488-495.
166.Ibid., p. 22.
167.Ibid., p. 19.
168.Ibid., p. 19, citing Robyn I. Stone and Christopher M.
Murtaugh, "The Elderly Population with Chronic Functional
Disability: Implications for Home Care Eligibility," in The
Gerontologist, vol. 26, no. 5, 1986, pp. 488-495; and
Washington, Report and Recommendations to the Legislature,
Washington State Long-Term Care Commission, January, 1991.
169.Koff, p. 179.
170.Peter G. Pan, Care of High Risk Infants in Hawaii,
Legislative Reference Bureau, Report No. 9, (Honolulu: 1989),
p. 53: The Children with Special Health Needs Branch of the
Hawaii Department of Health ". . . believes that the
definition of children with special health needs (formerly
crippled children) is a subset of a broader definition of the
developmentally disabled . . ."
171.Hawaii Rev. Stat. sec. 333F-1.
172.Barbara Wright and Martha P. King, Americans With
Developmental Disabilities: Policy Directions for the States,
NCSL Task Force on Developmental Disabilities (National
Conference of State Legislatures: Denver) 1991, p. 1.
173.Louise Bauer, "Supporting Families," in Legislative Report,
vol. 19, no. 13, August, 1994, p. 4.
174.According to Wright & King, p. 2: In 1990, Congress
reauthorized the landmark Education of the Handicapped Act and
renamed it the Individuals with Disabilities Education Act.
175.Wright & King, p. ix, citing personal communication of
October 9, 1990 between the authors and Robert M. Gettings,
Executive Director, National Association of State Mental
Retardation Program Directors.
176.Louise Bauer and Gary Smith, "Community Living for the
Developmentally Disabled," in State Legislative Report, vol.
18, no. 12, December, 1993, p. 2.
177.Ibid.
178.Ibid., citing Gary A. Smith and Robert M. Gettings,
Medicaid's ICF/MR Program: Present Status and Recent Trend,
(Alexandria, VA.: National Association of State Directors of
Developmental Disabilities Services) May, 1993, p. 9.
179.Siobhan Sullivan, "Home Alone: Community Living Fosters
Independence," in State Legislatures, vol. 21, no. 5, May,
1995, p. 31.
180.Ibid., p. 32.
181.Ibid., p. 33.
182.Wright and King, p. 2.
183.Ibid., p. 3.
184.According to Wright and King, p. 3: "Part B" of IDEA is also
known as the Education for All Handicapped Children Act of
1975 (P.L. 94-142).
185.Wright and King, p. 3.
186.Ibid.
187.Bauer and Smith, p. 2.
188."Four States Test Medicaid Managed Care for Disabled," in
State Health Watch, January, 1995, p. 2.
189.Ibid., p. 11.
190.Wright and King, p. 4.
191.Ibid.
192.Ibid.
193.Ibid., p. 1.
194.Pan, p. 60.
195.Hawaii Rev. Stat., sec. 333F-1.
196.Bauer and Smith, p. 1.
197.Ibid., pp. 2-3.
198.Wright and King, p. 10.
199.Bauer, p. 3.
200.Ibid.
201.Wright and King, p. 10, citing Wright & King's telephone
conversation with Gary Smith, director of special projects,
National Association of State Mental Retardation Program
Directors, October 16, 1990.
202.Wright and King, p. 10.
203.Bauer, p. 3.
204.Bauer and Smith, p. 3.
205.Ibid., p. 4.
206.Ibid.
207.Wright and King, p. 10 and Bauer, p. 3, citing Linda Hall,
Medicaid Home Care Options for Disabled Children, National
Governors' Association, Washington, D.C., 1990, p. 6.
208.Bauer, p. 3, citing Bauer's telephone communication of
February 1994 with Gary Smith, director of special projects,
National Association of State Mental Retardation Program
Directors.
209.Wright and King, p. 32.
210.Ibid., p. 33.
211.Bauer and Smith, p. 3.
212.Bauer, p. 1.
213.Ibid.
214.Wright and King, p. 11.
215.Bauer, p. 2, "What Do We Mean by 'Family Support,'" citing
Human Services Research Institute, "Family Support Services in
the United States: An End of Decade Status Report," February
1990, p. 40.
216.Wright and King, p. 11.
217.Ibid., p. 11, citing Angela Novak Amado, K. Charlie Lakin,
and Jan M. Menke, 1990 Chartbook on Services for People with
Developmental Disabilities (Minneapolis, Minn.: University of
Minnesota, Center for Residential and Community Services)
1990, p. 56.
218.Ibid., pp. 9-10.
219.Indiana, Long-Term Care and Local Service Delivery, Indiana
Legislative Services Agency, Evaluation Audit, May 1991
(hereafter "Indiana 1990"), p. 42, referring to the 1988 6-
state study of Arkansas, Illinois, Maine, Maryland, Oregon,
and Wisconsin by Justice, et al.
220.Colorado, Report to the Colorado General Assembly:
Recommendations for 1990,
Legislative Task Force on Long-Term Health Care, research
publication no. 344, December, 1989, p. 5.
221.Ibid., p. 27.
222.Ibid., p. 3.
223.Ibid.
224.Ibid., p. 5.
225.Ibid., p. 3.
226.Ibid., p. 8. Also, (p. 23): The Task Force recommended
considering the special needs of Alzheimer's Disease
("dementia") patients in the development of rules for a single
entry point, thus addressing the need for a more intensive
needs assessment for dementia patients.
227.Ibid., p. 4.
228.Ibid., p. 27.
229.Ibid., p. 11.
230.Ibid., p. 17.
231.Ibid., p. 27.
232.Ibid., p. 28.
233.Ibid., p. 19.
234.Indiana 1990, p. 34.
235.Ibid.
236.Indiana 1990, p. 35.
237.Ibid., p. 59.
238.Ibid., p. 35.
239.Indiana, Long-Term Care and Local Service Delivery, Indiana
Legislative Services Agency, Evaluation Audit, May 1991
(hereafter "Indiana 1991"), p. 44: The funding level for
CHOICE is established by the legislature. The cost of a
statewide CHOICE program is a legislative decision based on an
evaluation of the need for the program, as well as a
determination of how much Indiana can afford to spend.
240.Indiana 1990, pp. 31-32.
241.Indiana 1991, p. 37.
242.Ibid., p. 39.
243.Ibid., p. 40.
244.Ibid., p. 50.
245.Indiana 1990, pp. 32-33.
246.Ibid., p. 33.
247.Ibid., Exhibit 13. "Indiana Long-Term Care Responsibilities,"
pp. 33-34.
248.The preadmission screening process began operation in 1984.
(p. 77)
249.Indiana 1990, p. 3.
250.Indiana 1991, p. 2.
251.Ibid., pp. 27-28.
252.Ibid., pp. 5-6.
253.Ibid., p. 63.
254.Ibid., p. 64.
255.Ibid., p. 9.
256.Ibid., p. 4.
257.Ibid., pp. 29, 30, & 72.
258.Ibid., p. 30: Previously, separate assessment tools were
used for PAS, CHOICE, the Medicaid Waiver, and Title III/SSBG
services [Title III is Older Americans' Act 1965 funds for
support services.] The Eligibility Screen is designed to
minimize unnecessary paperwork. The case manager works
progressively through the Screen, so if a person meets one of
seven severe medical conditions criteria and, thus, is
eligible for PAS, CHOICE, or the Medicaid Waiver, eligibility
questions regarding activities of daily living or informal
supports can be skipped.
259.Ibid., p. 73.
260.Ibid. However, (p. 76) it is reported that "only a very
small number of PAS applicants" are denied admissions to
nursing homes. "In FY 1990, only 219, or 1% of all PAS
applications for admission to nursing homes were denied."
261.Ibid., p. 76.
262.Ibid., pp. 76-77.
263.Ibid., 1991, p. 78.
264.Ibid., p. 79.
265.Ibid.
266.The DPW would become involved only when the placements were
denied, when the applicants are Medicaid-eligible, and when
Level 2 assessments (more comprehensive assessment for clients
who may be mentally ill or developmentally disabled) are
required.
267.Indiana 1991, pp. 30-31.
268.Ibid., pp. 31-32.
269.Ibid.
270.Ibid., p. 32.
271.Ibid.
272.Ibid.
273.North Dakota, Long Term Care: Issues and Recommendations,
January 1987, Interagency Task Force on Long Term Care,
Bismarck, North Dakota, January, 1987 (hereafter "North Dakota
study"), p. I-1.
274.Ibid.
275.Ibid.
276.Ibid., pp. i - ii.
277.Ibid., pp. iii-iv.
278.Ibid., p. II-6.
279.Ibid., p. II-7.
280.Ibid., p. II-13.
281.Ibid., p. II-14, citing: Comptroller General's Report to the
Congress of the United States, Entering a Nursing Home, Costly
Implications for Medicaid and the Elderly, PAD - 80 - 12,
November 26, 1979, pp. iv, 66-70.
282.Texas, Program Audit of Long-Term Care Services to the Aged
and Disabled, Department of Human Services, Office of the
State Auditor, Austin, Texas, May, 1992, (hereafter "Texas
Audit") p. 29.
283.Ibid., p. 33.
284.Ibid.
285.Ibid., p. 53.
286.Ibid., p. 15: In 1979, the TDHS was ordered to close its ICF
II nursing home program and expand community care services in
an effort to delay institutionalization.
287.Ibid., p. 16.
288.Ibid.
289.Ibid., p. 17.
290.Ibid., p. 19 and in a letter dated May 5, 1992 by Lawrence F.
Alwin, Texas State Auditor, to the Legislative Audit
Committee.
291.Texas Audit, p. 33.
292.Ibid., p. 18.
293.Texas, Report on Crippled Children's Services Program, Senate
Committee on Health and Human Services, report to the 70th
legislature, 1987 (hereafter "Texas children's study"), pp. 1
& 3.
294.Ibid., p. 3.
295.Ibid., p. ii.
296.Ibid., p. 6.
297.Ibid.
298.Ibid., pp. 8-9. However, the study also mentions that
disabled children who do not need special education classes
may need "related services." According to federal law,
"related services" can be used only to assist a disabled child
to benefit from special education classes. Therefore, such
services are not required for those who can function in a
regular classroom. Nevertheless, Texas rules do authorize
local school districts to provide special support for such
children while attending regular classes. An example of
"related services" is transportation. (p. 14)
299.Ibid., pp. 6-7.
300.Ibid., p. 12.
301.Ibid., p. 17.
302.Diane Justice is the Director of the Center for the
Advancement of State Community Care Programs, National
Association of State Units on Aging.
303.The study was supported by a grant from the Office of the
Assistant Secretary for Planning and Evaluation through an
interagency cooperative agreement with the Office of Research
and Demonstrations of the Health Care Financing
Administration, United States Department of Health and Human
Services.
304.Diane E. Justice, "What States are Doing to Help Elderly," in
State Government News, Council of State Governments, vol. 32,
no. 3, March, 1989, p. 23.
305.Diane Justice et al., State Long Term Care Reform:
Development of Community Care Systems in Six States, National
Governors' Association Center for Policy Research, Health
Policy Studies, Washington, D.C., April 1988, p. iv.
306.Ibid., pp. iv-v.
307.Ibid., p. vii.
308.Ibid.
309.Ibid., p. ix.
310.Material in this section is from Justice, et al., pp. 5-10.
311.Unless otherwise noted, material in this section is from
Justice, et al., pp. 10-14.
312.Justice, et al., p. 96: Illinois uses a tightly defined list
of three services supported by its CCP. However senior
companion and home health services are also provided on a very
limited basis as part of demonstrations funded with state
general revenue funds.
313.Material in this section is from Justice, et al., pp. 14-18.
314.Justice, et al., p. 107.
315.Unless otherwise noted, material in this section is from
Justice, et al., pp. 18-22.
316.Eugene M. Feinblatt, chairman, Maryland Governor's Commission
on Health Care Policy and Financing, in letter dated December
30, 1991, to Governor Donald Schaefer.
317.Maryland, Report of the Governor's Commission on Health Care
Policy and Financing: Joint Recommendations of the Governor's
Commission and the Committee on Long-Term Care, Governor's
Commission on Health Care Policy and Financing, vol. v,
December 20, 1991, (hereafter "Maryland Report") p. 1.
318.Ibid., p. 51, citing Justice, et al.
319.Ibid., p. iii.
320.Ibid., pp. 56-59.
321.Ibid., pp. 61-62.
322.Ibid., p. 8, citing A. E. Benjamin, "Perspectives on a
Continuum of Care for Persons with HIV Illness," presented at
New Perspectives on AIDS: Progress in Health Services
Research, May 17-19, 1989, Miami, Florida; and John Douard,
Chronic Illness: A Problem of Passive Injustice, unpublished,
1991.
323.Ibid., p. 8.
324.Ibid.
325.Ibid., p. 9.
326.Ibid., pp. 20-21.
327.Ibid., p. 21.
328.Ibid., p. 54.
329.Ibid., p. 19.
330.Ibid., p. 73, citing: (1) West Virginia Research and Training
Center, College of Human Resources and Education, Statewide
Assessment of the Needs of Severely Handicapped Individuals in
Maryland: Final Report, Morgantown, West Virginia, August,
1989; and (2) Office of Technology Assessment, Confused Minds,
Burdened Families: Finding Help for People with Alzheimer's &
Other Dementias, United States Congress, OTA-BA-403
(Washington, D.C.: U.S. Government Printing Office, July 1990.
331.Ibid., citing Maryland State Department of Education,
Division of Library Development and Services, "Focus:
Information and Referral," in Library Keynotes, vol. 7,
January 1976.
332.Ibid., p. 73.
333.Ibid., p. 80. Two other models for information and referral
systems are those of Illinois and Massachusetts. The Illinois
DIAL system defines its target population as anyone with a
physical, mental, or emotional disabling condition, and the
Massachusetts Information Center for Individuals with
Disabilities defines it clientele as the Massachusetts
resident "of any age who has a disability, illness, injury or
special need." (p. 84)
334.Ibid., pp. 82-83.
335.Ibid., p. 86.
336.Unless otherwise noted, material in this section is from
Justice, et al., pp. 23-27.
337.Maryland Report, p. 48, citing the Institute of Medicine,
Health Services Integration: Lessons for the 1980s, A Report
of the Committee of the Institute of Medicine, June, 1982.
338.Ibid., p. 49.
339.Justice, et al., p. 96.
340.Texas Audit, p. 42.
341.Justice, et al., p. 89: Oregon funds risk intervention case
managers for private pay clients who receive less intense
services.
342.Texas Audit, p. 42.
343.Justice, et al., p. 25.
344.Unless otherwise noted, material in this section is from
Justice, et al., pp. 27-32.
345.Maryland Report, p. 49.
346.Indiana 1990, pp. 40-41.
347.Wisconsin, Community Options: Guidelines and Procedures,
Department of Health and Social Services, Division of
Community Services, Bureau of Long Term Support, October,
1994.
348.Wisconsin, "Information," Department of Health and Social
Services, undated, p. 4.
349.Ibid.
350.Telephone interview of October 3, 1995 with John Lorimer,
Director, Bureau of Long Term Support, Wisconsin Department of
Health and Social Services, 608-267-7284.
351.Lorimer interview.
352.Wisconsin, "Information," Department of Health and Social
Services, No. 103b, January 27, 1994, (hereafter "Wisconsin
'Information' 103b"), p. 1.
353.Ibid., p. 2.
354.According to the Department of Health and Social Services,
the Medicaid waivers allow the use of both the state and
federal parts of what Medicaid would pay for nursing home care
to be used for community care. Several other state and/or
federally funded long-term care programs are now in place
(Family Support Program, Community Support Program, Katie
Beckett program, Community Integration Programs, Community
Supported Living Arrangements, Exceptional Expense Supplement
to SSI, etc.).
355.Wisconsin, "Comparison of Some Long Term Support Programs in
Wisconsin" February 1995 (hereafter "Comparison chart").
356.Ibid.
357.Ibid.
358.Ibid.
359.Ibid.
360.Ibid.
361.Ibid.
362.Wisconsin "Information" No. 103b, p. 7. The figures exclude
developmentally disabled residents but include mentally
retarded residents. The decline in the nursing bed census was
also attributed to termination of medical assistance funding
for ICF-III and ICF-IV levels of care and a moratorium on new
medical assistance-funded nursing beds in 1981.
363.Ibid., Figure 8 "Range of Monthly Community Options Service
Costs," p. 10.
364.Lorimer interview.
365.Lorimer interview.
366.Lorimer interview. For example, an anecdotal illustration:
an unsteady elderly person was seen by a social worker who
triggered an Occupational Therapy assessment (which is much
more specialized) that recommended home modifications and
mobility appliances.
367.Justice, et al., p. 32.
368.Texas Audit, p. 43.
369.Keon S. Chi, "New Approaches Aid Elderly," in State
Government News, Council of State Governments, vol. 32, no. 3,
March, 1989, p. 17.
370.Ibid., p. 25.
371.Ibid.
372.Memo dated November 17, 1995 from Jeanette C. Takamura,
Ph.D., Deputy Director of Health, to Wendell Kimura, Director,
Legislative Reference Bureau, p. 4.
373.Ibid., p. 5.
374.Hawaii Rev. Stat., sec. 333F-2(c)(5).
375.Takamura memo, p. 6.
376.Takamura memo, Maluhia attachment, p. 1.
377.Ibid. A condition must exist whereby there exists a normal
inability to leave home. Leaving would require a considerable
and taxing effort, absences must be infrequent or attributable
to the need to receive medical treatment. Such absences do
not indicate that the client has the capacity to obtain the
health care outside rather than in the home.
378.Ibid., p. 2.
379.Takamura memo, p. 7.
380.The MWDP was established by 1994 Haw. Sess. Laws, Act 165.
381.There are 400 waitlisted for nursing homes in acute care
hospitals each incurring daily costs of about $2,000.
Telephone interview with Cullen Hayashida, Assistant
Administrator, Maluhia Hospital, September 6, 1995.
382.Hawaii, Maluhia Waitlist Demonstration Project: 1995
Legislative Report, Maluhia Long-Term Care Health Center,
Department of Health, January, 1995 (hereafter "Waitlist
Report"), p. 1.
383.Contracts with the Department of Human Services to train 12
ARCH [Boperators have been approved and a memo of agreement
with Medicaid and the DHS regarding payment has been signed.
(Hayashida interview)
384.Waitlist Report, Attachment C-2.
385.Hawaii, PACE Hawaii at Maluhia (Program of All-Inclusive Care
for the Elderly), annual report, Department of Health,
Community Hospitals Division, 1995 (hereafter "Maluhia annual
report"), executive summary.
386.Ibid.
387.Ibid.
388.Almost all (99 percent) of PACE program participants use the
adult day health center but, of course, they are not limited
to the day health center's services. Hayashida interview.
389.About 36 percent of PACE participants receive home care
services on a regular basis. This includes bathing, grooming,
meal preparation, and light chore services. Grocery shopping
and escort services are also available especially to those who
live alone. Maluhia annual report, p. 2.
390.Ibid., pp. 2-3.
391.Hayashida interview.
392.Takamura memo and Hayashida interview.
393.Hayashida interview.
394.Takamura memo, pp. 8-9.
395.Hawaii Rev. Stat., sec. 323-68.
396.Takamura memo, pp. 9-10.
397.Ibid., p. 11.
398.Hayashida interview.
399.Takamura memo, p. 11.
400.Takamura memo, Disabled Children Attachment, p. 1.
401.Ibid., p. 3.
402.Ibid.
403.Peter G. Pan, Care of High Risk Infants in Hawaii,
Legislative Reference Bureau, Report No. 9, (Honolulu: 1989),
pp. 52-53:
Services for children with special health needs in Hawaii
are based on medical categories. Coverage is restricted due
to limited funds and is shaped by historical funding
precedent. Patients up to age 20 receive services under the
following medical categories:
(1) Severe asthma;
(2) Heart disease;
(3) Eye surgery;
(4) Hearing loss;
(5) Myelodysplasia;
(6) Birth defects;
(7) Seizure disorder;
(8) Orthopedic problems;
(9) Cleft lip & palate;
(10) Metabolic disorders;
(11) Cerebral palsy; and
(12) Genetic conditions.
404.Takamura memo, pp. 12-13.
405.Takamura memo, Disabled Children Attachment, pp. 1-2.
406.Ibid., p. 2.
407.Takamura memo, p. 14.
408.Ibid., pp. 14-15.
409.Challenging behaviors range from self-injury such as biting
or hitting oneself, to physical or sexual aggression toward
others. Takamura memo, p. 15.
410.1995 Haw. Sess. Laws, Act 189.
411.The DD Division provides match funds for the Medicaid-funded
ICF/MR(c) facilities as well as for the HCBS waiver program
while private providers deliver actual services. Takamura
memo, p. 16.
412.Ibid., p. 15.
413.Ibid., p. 17.
414.Hawaii, Annual Report, Department of Human Services, Long
Term Care Branch, 1993, p. 9.
415.Hawaii Rev. Stat., sec. 333F-1.
416.Long Term Care Branch annual report, p. 10.
417.Ibid., pp. 10-11. The DHS acknowledges that its use of this
definition overlaps the "handicapped" with other populations.
418.Ibid., p. 11, partially citing Birnbaum 1978, p. 7.
419.Ann Botticelli, "Home-care program cuts protested," in
Honolulu Advertiser, August 1, 1995.
420.Long Term Care Branch annual report, p. 12.
421.Ibid., p. 13.
422.Ibid.
423.Ibid., pp. 14-15.
424.Ibid., p. 5.
425.Interview of September 27, 1995 with Department of Human
Services staff: Alan Matsunami, Community Long-Term Care
Branch Program Director and Leslie Tawata, Community Long-Term
Care Branch Acting Administrator: The DOH selects clients and
sends application forms to the DHS. DHS then certifies
clients at the ICF/MR level. Clients then choose from nine
providers and DHS pays the bills. DOH is responsible for
finding providers. However, because of Medicaid, it is the
DHS that signs contracts with providers. The DHS has done
some monitoring but intends to relinquish this role and have
the DOH resume monitoring in the future. Clients are placed
variously in care homes, foster homes, and natural homes.
426.Ibid., p. 24.
427.Botticelli article.
428.Hawaii, Progress Report of Project Malama, May 1982 - August
1983, Department of Social Services and Housing, Long Term
Care Channeling Demonstration Project, Contract
#HHS-100-80-0137, December, 1983 (hereafter "Project Malama
report"), pp. 2-3.
429.Ibid., p. 5.
430.Ibid., p. 7.
431.Botticelli article.
432.Ann McDuffie and Christopher Neil, "Budget ax wounds elderly,
immigrants," in the Honolulu Advertiser, August 7, 1995.
433.Letter to the Honolulu Advertiser from Donna Grain, September
6, 1995.
434.Project Malama report, p. 6.
435.McDuffie and Neil article.
436.DHS staff interview.
437.Memo of September 14, 1995 from Marilyn R. Seely, Director,
Executive Office on Aging, to Wendell Kimura, Director,
Legislative Reference Bureau, p. 1.
438.Hawaii, Four-Year Area Plan on Aging, Executive Office on
Aging, (for the period October 1, 1995 to September 30, 1999)
p. 43. Many other services are also listed ("not an
exhaustive list") that are provided at differing geographic
sites throughout the State. These are described by each
county submitting their respective four-year plans which are
compiled by the EOA into the state plan and include: case
management, chore, respite, adult day health, Alzheimer's day
care, personal, escort, transportation, information and
assistance, housekeeping, outreach, education/training,
recreation, telephone reassurance, visiting, volunteer, elder
abuse and neglect, legal, health maintenance/promotion, adult
day care, Alcoholics Anonymous, Ke Ola Pono No Na Kupuna,
AARP, Kuakini Parkinson's disease, diabetes education and
support, Mended Hearts/Stroke Club, day hospital, exercise,
self-help, interpretation, comprehensive individualized
services, housing assistance, Lanakila Multipurpose Senior
Center, money management, Emphysema Hui, asthma education,
Long Term Care Ombudsman, credit counseling, literacy, home-
delivered meals, Senior Community Service Employment, hospice,
emergency response, outpatient and family interdisciplinary
consultation, nutrition counseling, shopping, companion,
immigrant, advocacy, mediation, guardianship, veterans, foster
care, adult protective, retirement, home health, and mental
health services. (pp. 44-63)
439.Seely memo, p. 1.
440.Hawaii Rev. Stat., sec. 349-3.
441.Hawaii Rev. Stat., sec. 349-5(b).
442.Hawaii Rev. Stat., sec. 349-5(c).
443.Seely memo, p. 2.
444.Seely memo, Attachment.
445.Takamura memo, pp. 1 & 3.
446.Ibid., pp. 1-2. On March 10, 1995, the DOH submitted
testimony on S.C.R. No. 33 and S.R. No. 27 stressing that the
needs of those requiring long-term care are diverse, implying
that an SEP may have difficulty in successfully addressing
those needs. On April 7, 1995, the State Planning Council on
Developmental Disabilities warned in testimony that an SEP "is
only one component of a comprehensive long-term care system,
but a very important one that has impact on improving
consumers' access to appropriate levels of health care
services."
447.Takamura memo, pp. 2-3.
448.Ibid., pp. 3, 4, 5, & 10.
449.Nursing home beds must receive a certificate of need (CON)
approval from the State Health Planning and Development Agency
pursuant to chapter 323D, Hawaii Revised Statutes.
450.Ibid.
451.Ibid., pp. 6-7.
452.DHS staff interview.
453.Ibid.
454.Testimony submitted by the DHS on Senate Concurrent
Resolution No. 33 and Senate Resolution No. 27, Eighteenth
Legislature, State of Hawaii, April 18, 1995.
455.DHS staff interview.
456.Seely memo, p. 2.
457.Testimony submitted by the Executive Office on Aging on
S.C.R. No. 33 and S.R. No. 27, Eighteenth Legislature, State
of Hawaii, March 10, 1995.
458.Hawaii, Long Term Care Plan For Hawaii's Older Adults,
Executive Office on Aging, Office of the Governor, July, 1988,
p. 8.
459.Seely memo, p. 2.
460.Ibid., pp. 2-3.
461.Ibid., p. 2.
462.Ibid.
463.Ibid., p. 3.
464.Theodore H. Koff, New Approaches to Health Care for an Aging
Population: Developing a Continuum of Chronic Care Services,
Jossey-Bass Inc., Publishers, 350 Sansome Street, San
Francisco, California 94104, 1988, pp. 166-167.
465.Barbara Wright and Martha P. King, Americans With
Developmental Disabilities: Policy Directions for the States,
NCSL Task Force on Developmental Disabilities (National
Conference of State Legislatures: Denver) 1991, pp. 15-16.
466.Diane Justice et al., State Long Term Care Reform:
Development of Community Care Systems in Six States, National
Governors' Association Center for Policy Research, Health
Policy Studies, Washington, D.C., April 1988, p. vii.
467.Justice, et al., p. 113.
468.Maryland, Report of the Governor's Commission on Health Care
Policy and Financing: Joint Recommendations of the Governor's
Commission and the Committee on Long-Term Care, Governor's
Commission on Health Care Policy and Financing, vol. V,
December 20, 1991, p. 54.
469.Justice, et al., p. 93.
470.According to Teresa Tritch, "Best Ways to Beat the Cuts in
Medicare and Medicaid," in Money Magazine, December, 1995, p.
95: "In Oregon, for example, since 1981 the number of
Medicaid-sponsored seniors in nursing homes has declined to
7,300 from 8,400, as the growing demand for elder care has
shifted to home- and community-based options. Unfortunately,
the Oregon experience also exposes the danger in state
experimentation. Last year [1994], the Oregonian newspaper
reported conditions of filth, neglect and cruelty in dozens of
adult foster-care homes. In a rush to accommodate growing
numbers of needy elderly, the state licensed many more homes
than it could effectively monitor."
471.Justice, et al., p. viii.
472.Indiana, Long-Term Care and the Elderly, Evaluation Audit,
Indiana Legislative Services Agency, May 1990, p. 43.
473.For example, it has been recounted that various advocacy
groups were initially united in Wisconsin's efforts at
coordination because they could not be played off against each
other. However, after the Community Options Program began to
operate, the groups again began to fight over the amount of
funding to be made available to each's traditional target
population. Wisconsin attempted to solve this by mandating
the program to serve persons from the major target groups in
proportions which approximate the percentages served in
nursing homes prior to the program's inception. Telephone
interview of October 3, 1995 with John Lorimer, Director,
Bureau of Long Term Support, Wisconsin Department of Health
and Social Services.
474.Hawaii, Long Term Care Plan For Hawaii's Older Adults,
Executive Office on Aging, Office of the Governor, July, 1988,
pp. x & 25.
475.Ibid., p. 28.
476.Memorandum from Marilyn R. Seely, Director, Executive Office
on Aging, to Wendell Kimura, Director, Legislative Reference
Bureau, September 14, 1995, p. 2.
477.Memorandum from Jeanette C. Takamura, Ph.D., Deputy Director
of Health, to Wendell Kimura, Director, Legislative Reference
Bureau, November 17, 1995, p. 2.
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