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Home and Community Care of the Elderly: Research and Policy Issues Bruce C. VIadeck Twill address We policy issues that ~ think are of great importance in ~ home and community care of the elderly: "high" and "low" technol- ogy, service development, and financing. HIGH AND LOW TECHNOLOGY The distinction between high technology and low technology is implicitly made in public policy an the time. To take an example from far outside the field of geriatrics of how policy favors high technology, we are willing to spend unlimited amounts of dollars, I believe appropriately, on premature, seriously iB infants born to crack-addicted mothers in New York City. By me time neonatal intensive care is finished, the mother has disappeared. Because we win not spend money on "Iow-technology" social workers to develop foster homes or other placements for these children, we have the phenomenon of "boarder,' babies in our hospitals. Providing low technology is not always the only solution, of course, but we tend to be substantially more generous toward high tech- nology than low technology throughout health care and human services. More money is available for high tech than for low tech. Physician reimbursement policy provides another example- we will pay more for procedures and not much for"cogn~tive services." We see it in home care as well, where we pay an extremely him price per visit for professional services when, in fact, me bulb of me care is given by aides who we pay $3.75 an hour without fringe benefits and without much supervision. Then we wonder why the quality of services is not as high as we would lime it to be. 65

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66 BRUCE C. VLADECK Two points are important to understand if we are going to achieve better public policy about home care and community-based care. First, the low-technology care needs of frail elderly people, frail chronically ill people, or frail disabled people of whatever age are as much the result of pathology or illness as are the high-technology care needs of the acutely in. It is illness that causes chronically anbritic, elderly persons, because of Weir medical conditions, to require a homemaker or home careg~ver. Second, we are no more or less scientific In detennining needs for low- tech services than we are for high-tech services. We have learned a lot in the last two decades about commuruty-based care and home care. For example, we have learned that we can assess an ~ndividual's need for services using relatively standardized instruments. Even if those assess- ments do not produce exact duplicates of necessary services, they are reasonably good predictors of needs; in fact, they have been used with great success by state Medicaid agencies and by many home care pro- grams. We must not fall into the trap, however, of concluding that a given score on one's assessment form entities one automatically to, for example, x hours and y minutes of skilled nursing or physical therapy. Assessment is a developing technology that lets us say something about the kinds of help people might need. We are probably nearly as sophisticated in measuring personal needs in teens of chrome illnesses as we are In measuring many aspects of acute illness, where we pay lots of money very blithely. We can no longer use as an excuse for not paying for low-tech care that need is not definable or that services are not iNness-related. SERVICE DEVELOPMENT We completed a study early in 1987 that showed that in New York City in 1980, more Medicaid clients were in long-term care in the commu- nity than were in nursing homes, by a ratio of about 1.2- or I.3-to-~. This situation was the result of a very conscious policy decision made by the state of New York in the late 1970s (as in several other states and localities). The decision was to change the character of long-tenn care from an institution-dominated system to a community-dominated sys- temto make commun~ty-based services the service of choice and to make nursing homes the alternative to community care, not the other way around. Policies were undertaken to stop feeding the growth of institu- tionaDy based services in order to make funds available for home-based

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HOME AND COMMUNITY CARE: RESEARCH AND POLICY ISSUES 67 services. The policies worked; as a result, substantially more people are cam for in communities than in nursing homes. We are proud of that accomplishment Alp. When ~ was doing research on nursing homes in the late 1970s we used to say that 40 to 60 percent of all people in nursing homes were there inappropriately (2~. This meant that, with a modicum of service in the community, many persons comb be maintained in the community. We no longer Wink in terms of people being in nursing homes who do not belong there. Many communities have more people who really need to be in nursing homes than can get in. Problems in Community Care Now that we have accomplished many of the goals of the past decade, we have to cope with the implications and the problems created by our success. For communities that have not yet swung toward commu- n~ty-based care, we might be able to prevent some of the problems that we experienced. For example, now mat nursing homes are fined with sicker people Wan ever before, we realize mat nursing homes, as they are now constituted, are not vely capable of talking care of many very sick people. To some extent nursing homes, dunng We past 20 years, have based their staffing, reimbursement, and organization on the assumption that half of the patients who were there did not really need skilled care. Whatever finite resources were available could be spread over the other half who really needed services. Now that most people in nursing homes truly need more intensive care, many nursing homes do not have the capacity to render it, nor is the system prepared to cope with either the service organization or the economic implications of developing facilities that are adequately equipped to take care of sick people. In home care, a number of analogous problems crop up. In historical perspective, they are the kinds of problems that one has when any kind of relatively new service or set of organizations develop. They are the classic problems of getting past the infancy stage and into maturity in the organization of We services. Because the problems are not unex- pected does not make them any less important. Home and community care is characterized by lack of organization in much of We field. Not only is it an immature industry, but it is also fragmented in teams of patterns of organization and ownership. The regulatory apparatus is virtually nonexistent in most instances. Problems

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68 BRUCE C. VL4DECK are particularly severe in oversight and supervision when, out of neces- sity, services are being given in private settings of one sort or another. AU of this is made more important because the clientele is particularly vuiner- able. Providers of Home Care Who are He people providing home care? What is their training? What is their background? How do we keep Hem in home care when Hey hardy get any wage increases or opportunities for advancement? We have not even begun to address questions of supervision or organizational structure in home care. In most communities, forma] supervision of a home health aide or a home attendant is done by a registered nurse who is an employee of another agency, an organization Hat has only a contrac- tual relationship win He employer of the aide. Serious questions must be raised about the kind of professional supervision Hat results from Hat relationship. I want to suggest a hypothesis that might circumvent a lot of research on optimal ways of matching certain kinds of settings and certain kinds of clients and certain kinds of delivery pattems. I think that we win find, over a period of time, that if competent people and a well-motivated family situation or a wet/-motivated surrogate family are providing serv- ices, then the precise mix of personnel providing the service matters little. And the precise site probably does not matter greatly either whether it is the patient's home, a day care center, supported housing, congregate housing, or a nursing home. The exact professional skill levels of He care providers might make lithe difference if the patient's needs are under- stood and an effort to meet them is made by people who have some knowledge and some reason to be motivated to do a good job. Human beings are remarkably resourceful and remarkably capable of coping. We should not become bogged down in turf fights and secondary questions that promote the interests of one particular way of doing business over another and thereby lose sight of the main problem. FINANCING Service costs and financing policy are the key factors that will determine the future of home and community care. We tend to get sidetracked on questions that are fundamentally misleading. In 1986, ~

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HOME AND COMMUNITY CARE: RESEARCH AND POldCY ISSUES 69 attended an excellent conference on development of commun~ty-based long-tenn care sponsors by the National Governors Association in Port- land, Oregon. The big question was, How are we going to pay for long- tenn care? I responded, "cash, check, or credit card." To my mind, how we pay for long-term care is not me problem the problem is who is going to pay for long-term care. The dynamics of long-term care policy during the past 10 years have demonstrated that everybody wants more care as long as somebody else pays for it. Another fundamentaBy misleading question is, How is society going to afford to pay for aB He services Hat people win need in the future? A more rational question would be' How can we best use the allocated amount of doBars that the policy and decision makers determine that we can afford? ~ propose that He way to gain control over expenses and allocation decisions in providing long-term care is to have, for want of a better word, a budget. Without going into great detail, if you do not want a society to spend more Can x doDars on a service, then you decide that we are going to spend x doBars. If you have to make explicit, aBocative, public- ration~ng decisions ofthe kind Dr. Donabedian caned ford about who can get what, then you must start with a budget and make budgetary decisions. This does not mean Hat ad the money has to originate In the same place, or that a single bureaucratic mechanism should control the budget. It does not mean that one particular set of actors has to receive aD the revenue from the budget. A budget can be implemented in many different ways, but it does mean that somewhere in the system there must be some coordination. ~ believe not only that a budget is the key to many of our questions about financing, but also that it will result in better services, clinical coordination, service integration, and many other benefits as web. Once a budget process is in place, we will be able to address two other issues. The first is rethinking the role of the general hospital in the system. In particular, we may begin to do something about our obsession with the length of stay. This nation already has the shortest length of hospital stays of any nation in the world. Although it seems to be the only device anybody is able to agree on for reducing health care costs, we should now, four years into the prospective payment system (PPS), have very convincing evidence that it does not reduce costs at all. We are ~ See Avedis Donabedian, "Quality of Care and the Health Needs of the Elderly Patient," in this volume.

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70 BRUCE C. ~LADECP: pushing people out of hospitals because we believe that we are saving money but we are doing it in a way that is costing us a lot of money. If we really believe in continuity of care, if we really believe in moving people in some rational and cl~n~caBy beneficial way from the hospital setting (which is where most people enter the long-tenn care system) into home care or community-based care and then to institutional care, enough time must be aBowed for the process to take place. For many years, hospitals were indifferent to that process and never had the incentive to do it right. We have a lot to team about how to do it better. However, a 5- or 6-day hospital stay is not enough time to plan the steps of a long-term care program. There is no benefit, either to me patient or to the total expenditure package, fiom being in such a hurry for no DartiCU- larly good reason. . . A perfect example of inappropriately rushing patients out of the hospital is the patients who are discharged on Friday afternoon where home care had been authorized, but home care workers are not available on Saturday and Sunday. You end up paying for the clinical conse- quences of the patients, spending their first two days without the services they need, at a time when keeping those patients in the hospital on Saturday and Sunday would not cost the institution much money. Nor would it cost Medicare anything under PPS. The second issue, once a budget process is in place, is to recognize that one of the principal elements in providing home care is homes, and one of the ways that we create surrogate families is by the character of peoples' housing arrangements. Data suggest Hat if individuals are in good congregate housing, then they require fewer formal services because they get them informally from the community in which they reside. There is a growing body of data on He length of time people in continuing care communities remain in their residence rather than entering into He formal care system. Longer residence in communities results pardy because of the capacity of Lose communities to bring services to people, and pardy because He community itself provides a set of supports that is not avail- able when people's housing situations are significantly more isolated. REFERENCES 1. United Hospital Fund of New York. Home care in New York City: Providers, payers, and clients. Paper Series 6, 1987. 2. Vladeck, B.C. Unloving Care: The Nursing Home Tragedy. New York, Basic Books, 1980.