Citation URL: http://www.urban.org/JaneTilly

From the roles of regional long-term care ombudsmen to the effect of the nursing shortage, this edition of the Urban Institute series on "Public Interest" looks at the Washington region’s nursing homes and ways to measure the quality of care.

As part of a Centers for Medicare and Medicaid Services-funded study, case studies were conducted in AL, IN, WA, WI, MD, MI, and KY to assess the major features of the home and community-based services system for older people and younger adults with physical disabilities in each state. The case studies analyzed the financing of services; administrative systems; eligibility, assessment and case management structures; the services provided; cost containment efforts; and quality assurance. The role that Medicaid plays in home and community-based services is a major focus of the study. (Health Care Financing Review 2002 Spring; 23(3); 89-114).

Recent projections indicate that it will be nearly ten years before demographic changes in the population and the aging of the existing workforce converge to create a severe shortage of nurses. Therefore, the country has the time and an opportunity to address the problem and avert a crisis situation. This paper reviews current research as well as a selection of promising practices and concludes that the country needs to adopt a multi-pronged approach that addresses recruitment, retention, and training. Policies should seek to retain those already trained in the profession, attract new entrants to the labor market, and tap into the pool of workers already employed in health care that, with further training, can enter the nursing profession.

Colorado's health care safety net is under increasing stress because of a declining economy, state budget deficits, constitutional limits on state revenues and spending, and rapidly increasing Medicaid expenditures. Colorado has focused on using managed care plans to contain cost growth in its health care programs. These programs include Medicaid, programs for those with mental health conditions, and the Children's Basic Health Plan. While not inclined to expand eligibility for publicly-funded health care programs, Colorado has been innovative in some aspects of service delivery, particularly in long-term care.

To contain Medicaid costs during the late 1990s, Michigan shifted from a fee-for-service system to a system dominated by HMOs. While Medicaid cost increases have moderated under managed care, state officials worry about growth in pharmaceutical expenditures. These currently absorb 15 percent of the Medicaid budget and are increasing more rapidly than any other Medicaid service. In 1998, Michigan received approval for a Medicaid waiver to establish a statewide Medicaid managed care program for long-term recipients of mental health, substance abuse, and developmental disability services. The Department of Community Health contracts with local or regional Community Mental Health Service Programs (CMHSPs) to manage and provide Medicaid mental health, substance abuse, and developmental disability services and supports under a prepaid, shared-risk arrangement.

Medicaid provides health- and long-term care coverage to children, young adults, and older people with low incomes and few assets, or those impoverished by the high costs of health care. Especially through its funding for long-term care services - such as nursing home, home care, and hospice - Medicaid is a major source of financing for end-of-life care, the period of time when patients are terminally ill.

The need for long-term care assistance affects people of all ages, not just elderly populations. Accordingly, this chart book provides relevant information on long-term care assistance for all people with disabilities, using a variety of state and federal data sources. Using this chart book, policymakers, researchers, advocates, and practitioners will be able to understand the scope of the long-term care system. Information is organized into three major categories: consumers, providers, and financing.

Kentucky, a fairly small Southern state with about 4 million people in 1999, provides home and community services to a substantial number of aged and physically disabled adult beneficiaries through its Medicaid home health benefit and the Home and Community-Based Services (HCBS) waiver. In 2000, the state expects to serve over 18,000 beneficiaries through the home health benefit and over 15,000 beneficiaries through HCBS waiver. These two programs can be characterized as traditional in that they rely largely on an agency-based model for provision of services. The state also has a large, agency-based, state-funded Home Care program, along with several other smaller state-funded programs. Despite the size of Kentucky’s home and community services programs, nursing home care dominates the state’s long-term care system.

Maryland, a fairly small mid-Atlantic state with about 5 million people in 1999, has 12 home and community services programs for older persons and adults with physical disabilities. Maryland’s Medicaid program provided home and community services to approximately 5,100 beneficiaries through the optional personal care benefit and 4,600 beneficiaries through its optional medical day care program in fiscal year 1999. The state has one currently operating Medicaid waiver for older adults with 135 slots, which will be expanded to 1,135 slots in 2001. The state will implement another waiver in 2001 with 150 slots in the first year for non-elderly adults with physical disabilities. The state also has eight small, state-funded home and community services programs designed to serve adults who are not eligible for Medicaid. The state has a complex administrative structure for its home and community services programs, with several state and local agencies involved.

Indiana, a midwestern state with about 6 million people in 1999, provides home and community services to about 2,300 beneficiaries through its Aged/Disabled Medicaid waiver and an additional 10,000 persons with disabilities through its state-funded Community and Home Options to Institutional Care for the Elderly (CHOICE) program. The Medicaid waiver and the CHOICE program rely on an agency-based model for provision of home care services; with CHOICE providing a particularly flexible set of services. The state also funds two small programs that provide supplemental payments to people in board and care homes.

Return to list of authors