Home and Community-Based Services for Older People and Younger Adults with Physical Disabilities in Wisconsin

This research was supported by Health Care Financing Administration Contract No. 500-96-0005. In this contract, the Urban Institute is a subcontractor to the Lewin Group. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of the Health Care Financing Administration, the Urban Institute, or the Lewin Group. We gratefully acknowledge the many people in Wisconsin who generously answered our many questions.

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Table of Contents

Introduction

The Long-Term Care System in Wisconsin

Administrative Structure

Eligibility and Assessment

Case Management

Nonmedical Residential Services

Consumer Direction

Quality Assurance

Cost Containment

Redesigning Long-Term Care: Family Care

Challenges for the Future

Introduction

Wisconsin is a relatively small Midwestern state with a total population of 5.3 million people in 1999, of whom 13.2 percent were age 65 and over.¹ The state's economy is strong and only about 8.5 percent of the total population lives in below the federal poverty level, well below the national average.² Wisconsin provides home and community-based services to a substantial number of older people and younger adults with physical disabilities through the Medicaid home health and personal care benefit, a fairly large Medicaid home and community-based services waiver, and some significant state-funded programs. Wisconsin has a national reputation as a leader in innovative and flexible home and community-based services, relying heavily on consumer-directed home care and nonmedical residential services. Despite these innovations, of the approximately 71,000 elderly and disabled Wisconsin residents receiving publicly funded long-term care in the 1998/1999 budget period, two-thirds of clients were receiving care in an institutional setting rather than in the community.³ Wisconsin is currently embarking on an ambitious "Family Care" demonstration project that will provide the full range of long-term care through capitated, county-run Care Management Organizations, which the state hopes will create incentives to provide more home and community-based services and create a more balanced financing and delivery system.

The long-term care policy environment in Wisconsin is shaped by four factors. First, while Wisconsin has explored the integration of acute and long-term care services and other approaches relying on capitated payment methods, the bedrock of state policy is "aging in place" and a social rather than medical model of home and community-based services. Second, although the state has a very well organized and politically effective nursing home industry, strong consumer advocates, especially for older people, have provided an effective counterbalance and a strong voice in favor of noninstitutional options. Consumer advocates have provided much of the political will to redesign the long-term care system. Third, despite the prosperousness of the state, budget priorities have favored tax cuts and services other than long-term care, leaving the home and community-based service system with large, politically controversial waiting lists for services. And fourth, counties play an extremely important role in designing and administering home and community-based services in Wisconsin, with the state providing most of the funding, but recognizing that counties will vary in their approaches.

This paper analyzes the home and community-based service system for older people and younger adults with physical disabilities in Wisconsin, and focuses on the state administrative structure, eligibility and assessment, case management, services covered by Medicaid and other public programs, cost containment strategies, and quality assurance mechanisms. This study does not address home and community-based services for people with developmental disabilities or mental retardation or children. Information was obtained from the following sources: public documents; state of Wisconsin websites; and interviews with federal and state officials, provider associations, consumer advocates, and other stakeholders. In-person interviews were conducted in Madison, Wisconsin, during March 2000, followed by telephone interviews in June 2000. Questions were asked using an open-ended interview protocol. To encourage candor in their answers, respondents were told that they would not be quoted by name.

1. "Wisconsin," http://quickfacts.census.gov/qfd/states/55000.html.

2. "State Poverty Rates and Standard Errors: 3-Year Averages, 1980-82 Through 1997-99," http://www.census.gov/hhes/poverty/povanim/pumaptxt.html.

3. Wisconsin Legislative Audit Bureau, An Evaluation: Community Options Programs: Department of Health and Family Services, (Madison: Wisconsin Legislative Audit Bureau, 1999). In 1997, 82 percent of public spending for long-term care for older people was for institutional care and 18 percent for home and community-based services. Wisconsin Department of Health and Family Services, "Why Older People Need Family Care," http://www.dhfs.state.wi.us/LTCare/whyolder.htm. For younger persons with physical disabilities, 40 percent of long-term care spending was for institutional care, 21 percent for Medicaid home and community-based services waiver services, and 39 percent on other Medicaid services. (Wisconsin Department of Health and Family Services, "Why People With Physical Disabilities Need Family Care," http://www.dhfs.state.wi.us/LTCare/whypd.htm).

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