WHAT WORKS
Oregon
For the first time ever, a state is spending more on home and community-based care than on nursing home care. Oregon, which as recently as 1995 was spending $6 of every $10 long-term care funds on nursing home care, will spend $455 million-or 55 percent of its 1999-2001 long-term care budget-on community-based care and $379 million-or 45 percent-on nursing home care. More than three-quarters of Oregon's Medicaid clients now receive care in home and community-based care settings, and the proportion continues to increase.
Oregon has been a leader in home and community-based care since the early 1980s. Oregon received a Medicaid waiver in 1981 from the federal government shortly after creation of the Senior and Disabled Services Division in the Department of Human Resources; the waiver provided initial authority for spending Medicaid funds on a wide range of home and community-based long-term care. All states have some kind of waiver to use federal money to cover services not traditionally covered by Medicaid, but in many cases, the waiver programs are relatively small. The division brings together funds from Medicaid waivers, Medicaid, the Older Americans Act and other public and private sources to create a single, comprehensive system of long-term care financing, avoiding repetition and duplication of payments.
Because nursing home care typically runs double or triple the cost of in-home care-monthly costs in Oregon are $3,060 per case for nursing facilities, $1,981 for assisted living, $1,641 for residential care and $1,143 per case for home services-there are savings associated with in-home care. As evidenced by the numbers, Oregon has witnessed a dramatic per case cost savings with a move to home and community-based services. The long-term care system on the whole, however, has not felt a decrease in overall expenditures because the state essentially has reinvested the savings in the system. "The reinvestment has enabled us to serve more people. If the system served only the same number of people who were served before home and community-based services were widely available, we would see a tremendous savings," said Douglas Stone, manager of health and long-term care planning in the division.
Beyond Medicaid, the expansion of home and community-based care has had benefits for private payers as well. "The ability of people to pay privately for less expensive home and community-based services is really a savings to the Medicaid system, yet it is hard to quantify," added Stone. Because clients who pay for their own care, either in whole or in part, are able to take advantage of the less costly alternatives to nursing home care, he noted, the number of people who spend down their assets to qualify for public assistance is greatly reduced.
In 1981, the Oregon legislature reorganized the state's long-term care system, creating the Senior and Disabled Services Division to centralize the state's long-term care efforts. The division centralizes funding sources and administration of long-term care services to provide an all encompassing system. Since the 1981 reorganization, Oregon has worked to provide long-term care services in home and community settings, with nursing home placement a last resort. As a result of that policy, there has been a decrease in overall nursing home caseloads, and in length of stay, as well. Nursing homes in Oregon now are primarily used for rehabilitative periods or end-of-life care.
By integrating the administration, financing and delivery of many different services, Oregon has successfully created a one-stop-shopping approach to long-term care. "Through consolidation, you get a broader range of potential services. The values and strategies of many different programs come together and can better serve those in need," commented Stone.
Not all people in need of long-term care require the same degree or specificity of care. Thus, the case management system developed by the state has assisted people in need of services by creating individualized care programs. That system has contributed a great deal to the success and quality of community-based care programs and has effectively decreased unnecessary institutionalization.
A person in need of long-term care services works with a team of case managers, registered nurses and social workers, as well as family members, if available, to create an individual plan of care. Case managers acquire available funds for needed services-including private funds-and help their clients gain access to those services and make use of health screening and prevention opportunities. Because of the broad range of services provided, there is no "typical" client. People served by Oregon's home and community-based long-term care programs include not only the elderly but people of all ages with functional disabilities.
Long-term care options include a range of services such as respite care, adult day care, in-home services, adult foster care, residential treatment and nursing facility care. Among the most popular are in-home services, which range from assistance with personal and health care needs to food shopping and household chores.
Oregon has continually worked to strengthen the quality of its home and community-based programs, with the legislature actively involved in issues such as licensing, monitoring and developing the overall service delivery system. "A partnership between case management and the administrative structure is important in assuring quality," said Stone. The state also has bolstered its caregiver training programs and worked to increase informal caregiver assistance and efforts to train nonmedical caregivers on proper care procedures. Those training programs-as well as technical support and administration-have helped to strengthen the quality of Oregon's home and community-based programs.
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