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2
Joint Committee to Study
Long-Term Care Alternatives
STATE OF
JOINT COMMITTEE TO STUDY
LONG-TERM CARE ALTERNATIVES
Suzette Ashworth, Director
230-S Exchange Park
7800 Shoal Creek Boulevard
Austin, Texas 78757
(512) 459-4291
CONTENTS
PANEL MEMBERS
1
SENATE BILL 548
4
EVALUATION DESIGN
9
PROGRAM DESCRIPTION
17
CURRENT STATUS
21
MARGIN INDEX
back cover
ii
Panel Members
PANEL MEMBERS:
JOINT COMMITTEE TO STUDY
LONG-TERM CARE ALTERNATIVES
Senate Bill 548 of the 65th Legislature established a nine-
member panel to guide the evaluation activities mandated by the
legislation. The President of the Senate, William P. Hobby, and
the Speaker of the House of Representatives, Billy Clayton,
appointed three members each from their respective legislative
bodies. The Board of the Texas Department of Human Resources (DHR)
appointed the remaining three members.
SENATE
Sen. Chet Brooks, Chairman
Sen. 0. H. Harris
Sen. Bill Meier
HOUSE OF REPRESENTATIVES
Rep. Hugo Berlanga
Rep. Frank Collazo, Jr.
Rep. Mike Ezzell
DEPARTMENT OF HUMAN RESOURCES
Emmett W. Greif, M.D.
Merle E. Springer
Lloyd Sterling
2
Senate Bill 548
The State of Texas
SECRETARY OF STATE
I, MARK WHITE, Secretary of State of the State of
Texas DO HEREBY CERTIFY that the attached is a true
and correct copy of Senate Bill Number 548, passed by
the 65th Legislature, Regular Session, 1977, signed by the
Governor on May 27, 1977 and filed in this office on
May 28, 1977.
IN TESTIMONY WHEREOF, / have hereunto
signed mv name officially and caused to be im-
pressed hereon the Seal of State at my office in
the City of Austin this
31st day of May
A .D.19 77
Wash Make
Secretary of State
fecomes effective any 29,1977
4
Enrolled
S.B. No. 548
1
AN ACT
2
relating to a report by the State Department of Public Welfare or
3
its successor agency on the alternate care program, containing an
4
evaluation of the program and recommendations and the effect on
5
nursing care costs under medical assistance programs; and declaring
6
an emergency.
7
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8
Section 1. The State Department of Public Welfare or its
9
successor agency responsible for alternate care programs shall,
10
before January 1, 1979, report to the legislature on the alternate
11
care program. The reporting panel shall be made up of three
12
persons from the State Department of Public Welfare appointed by
13
the board of directors of the State Department of Public Welfare,
14
three members of the house of representatives to be appointed by
15
the speaker of the house, and three members of the senate to be
16
appointed by the lieutenant governor. The report must include a
17
complete evaluation of the effectiveness of the program and its
18
effect on the number of persons receiving and the quality of care
19
given under nursing home care programs. The report must also
20
contain recommendations relating to whether or not alternate care
21
is a suitable substitute for some kinds of nursing home care and
22
whether there is a continuing need for minimum level nursing care
23
programs, such as Intermediate Care Facility II programs.
24
Sec. 2. The importance of this legislation and the crowded
25
condition of the calendars in both houses create an emergency and
5
S.B. No. 548
1
an
imperative public necessity that the constitutional rule
2
requiring bills to be read on three several days in each house be
3
suspended, and this rule is hereby suspended.
6
S.H. No. 548
WPHolly
President of and SAFFED
J. terr Spedker Clayton of the House
I hereby certify 0.1. No. 544 passer the senate on March
16,
1977, on
the
following VOTA: Yeas 2h, laws 0; May 12, 1977,
sellate concurred in house assendments by the following verse: Yeas
30, Lays U.
Secretary of the Senate
: hereo: certify that S.R. No. 548 passed the house, with
amendments, or MAY 10, 1971, my 5 non-record vote.
English Chief Clerk of the
House
Approved:
27 Date 1977
Linen
FILED IN THE OFFICE OF THE
SE BETARY OF
%overn
MAY 28 1977
Mark White
Secretary of State
7
Evaluation Design
EVALUATION DESIGN
(Adopted November 17, 1977)
BACKGROUND
Senate Bill 548
Senate Bill 548, passed by the 65th Legislature in May, 1977,
requires the Texas Department of Human Resources (DHR) to report to
the legislature before January 1, 1979, on the alternate care programs
sponsored by the Department.
Specifically, the bill requires the report to evaluate the follow-
ing issues:
The effectiveness of the alternate care program
The effect of the alternate care program on the number of
persons receiving nursing home care and on the quality of care
under the nursing home care program.
1
The bill also requires recommendations about the following ques-
tions:
Is community care a suitable substitute for some forms of
nursing home care?
Is there a continuing need for minimum-level nursing care pro-
grams, such as Intermediate Care Facility (ICF) II?
Medicaid Task Force
In addition to the mandate represented by Senate Bill 548, the
Texas State Board of Public Welfare in January, 1977, organized a 47-
member citizens committee, the Task Force for Evaluation of Medicaid in
Texas, to find ways to enable the Medicaid program to operate within its
financial constraints. The report of the Nursing Homes and In-Homes Care
Subcommittee of the task force noted that over one-half of the State's
Medicaid outlay was for various aspects of care for the elderly, and yet
large numbers of senior citizens were receiving inadequate services, or
none at all. To improve this situation, the subcommittee made 18 recom-
mendations, the first of which called for a major study to further define
the extent of an alternate care program.
1. With the enactment of Senate Bill 9 in July, 1977, and following
further clarification in the form of a letter of October 21, 1977, from
Senator Brooks to Commissioner Chapman, the quality of care given under
the nursing home care program has been excluded from the scope of this
study.
9
Overview of the Present Study
In response to these directives, the Department will conduct a
comprehensive study of the alternate care programs under its aegis de-
signed to serve elderly and disabled Texans. Findings of the study will
be submitted to a reporting panel 2 The panel will issue the final report
to the legislature and will formulate the recommendations as required in
Senate Bill 548.
The study will contain two major components. The first is a
comparative evaluation of alternate care, which will provide information
on four closely defined and interrelated questions about the program. The
study's second component will gather information across a broader spectrum,
which is equally important to decisions about the program's future direc-
tions.
Comparative Evaluation. The four closely defined questions about
alternate care may be restated as follows:
How effective is the alternate care program?
What is the program's effect on the number of people receiving
nursing home care?
Is alternate care a suitable substitute for some kinds of nurs-
ing home care?
Is there a continuing need for minimum-level nursing home care?
The methods by which these questions will be answered are discussed in
detail in the following subsection (subsection 2).
Environmental Analysis. The study's second component, which in-
volves gathering data over a broad range, is referred to as an "Environmental
Analysis" and is discussed in detail in subsection 3. Briefly, the Envi-
ronmental Analysis will provide information on availability of resources,
utilization of services, and projected costs and demand for services. A
fourth element will consist of input gathered at public hearings from a
diverse body of persons interested in alternate care programs.
2. The panel is chaired by Senator Chet Brooks of Pasadena. Senate
members are Senator 0. H. (Ike) Harris of Dallas and Senator Bill Meier
of Euless. Panel members from the House of Representatives are Rep. Hugo
Berlanga of Corpus Christi, Rep. Frank Collazo, Jr. of Port Arthur, and
Rep. Mike Ezzell of Snyder. DHR members are Emmett Greif, M.D., Merle
Springer, and Lloyd Sterling.
10
COMPARATIVE EVALUATION OF ALTERNATE CARE
The Comparative Evaluation will entail the collection and analysis
of both analytic and descriptive data from numerous sources, including
both recipients and nonrecipients in the eligible service population,
providers and support staff involved in service delivery, and peripheral
populations (e.g., families, physicians, and guardians of persons in the
service population). Secondary data will also be utilized in the form of
existing statistical reports and the reporting system implemented as a re-
sult of the evaluation.
Effectiveness of the Program
The first step in assessing the impact of alternate care services on
recipients will be accomplished by comparing representative numbers of
clients and nonclients over a period of time. In June of 1976, over 4,100
recipients of Supplemental Security Income (SSI) throughout the State were
interviewed concerning needs, health characteristics, functional levels,
available resources, and other sociodemographic characteristics. Approxi-
mately 12 percent of these recipients were DHR clients in the alternate
care program at the time. Longitudinal information will be obtained through
follow-up interviews with a stratified sample of these individuals. In
addition, DHR records will be searched to determine any changes in status
of all recipients involved in the 1976 survey. Possible status changes are:
moved, institutionalized, or deceased. Data collected on the two groups
will then be compared by key variables including living arrangement, health,
functional capacity, and attitudes.
The major question addressed will be, Do alternate care clients ex-
hibit fewer negative status changes (functional or health deterioration,
institutionalization, etc.) than similar SSI recipients not receiving alter-
nate care services?
Three Interrelated Questions
The other three questions within the comparative evaluation are closely
interrelated and will require the collection of data on and from all levels
of nursing home residents in addition to the comparative data gathered from
SSI recipients in the evaluation's first step.
Effect of Alternate Care on Number and Type of Persons Receiving
Nursing Home Care. Key characteristics of alternate care clients and
nursing home patients will be ascertained, compared, and analyzed as an
indicator of the alternate care program's effect on the number and types
of individuals receiving nursing home care. Another possible indicator of
the program's effect may be found in clients who had been receiving alter-
nate care prior to entering a nursing home. If alternate care serves to
delay the rate of institutionalization, alternate care clients should theo-
retically require a higher level of care at the time of entry than do
nonclients--the possible impact of alternate care thus being to allay the
need for entry at lower levels of care.
11
Alternate Care as a Substitute for Some Nursing Home Care. The ques-
tion of whether alternate care is a suitable substitute for some forms of
nursing home care will also be approached initially through comparison of
the two groups' key characteristics. Since previous studies indicate that
these characteristics are very similar, it will be necessary to identify
other variables that help determine why one person is a nursing home pa-
tient and the other not. Information on resource availability, awareness
of alternatives, the decision-making process of physicians, and attitudes
and preferences of the family and the individual will be examined to meas-
ure the impact of such variables upon the final determination.
Need for a Minimum Level of Nursing Home Care. The question of whether
there is a continuing need for minimum-level nursing home care will be
examined by comparing characteristics and medical needs of patients in Inter-
mediate Care Facility (ICF) II's and III's. The interrelationship of these
care levels and the unique characteristics of patients in nursing homes that
offer Skilled Nursing Care also will be identified for use in the formula-
tion of the panel's final recommendations.
Figure 1 represents the groups that constitute the basic design of
the Comparative Evaluation.
ENVIRONMENTAL ANALYSIS*
An Environmental Analysis of the factors involved in the need for and
delivery of alternate care and nursing home care will be included in the
study's findings. This analysis will include demographic profiles of ser-
vice populations and providers, and an identification of available resources.
In addition, information will be gathered on alternate care programs
in effect in other states or areas of the country for purposes of possible
comparison and future adaptation.
Availability of Resources
Available community care and nursing home resources will be mapped
statewide to identify the areas and extent of available services. Services
stemming from sources other than DHR also will be identified, and mechanisms
designed to coordinate or link service delivery will be noted. Target popu-
lations and service priorities of both the community care and nursing home
programs will be identified to determine possible gaps or overlaps of these
resources.
Service Mix and Utilization
The types of services offered within the alternate care program and
nursing homes and their distribution pattern will be analyzed and described.
Particular attention will be devoted to community profiles of four low-
resource counties (counties with few care alternatives) and to four high-
resource counties (counties offering a number of service providers and a
range of services).
*This component's name later was changed to "Resource Inventory."
12
Skilled
Nursing
Patients
SSI
Recipients
Nonclients of
Alternate
Care
Change in status
ICF III
from original sur-
Patients
vey (June 1976-
January 1978)
SSI
Recipients
(DHR Alternate
Care Clients)
ICF II
Patients
Level at which
alternate care
clients enter
institutional care
Legend
= personal interviews
= secondary data
Figure 1. . Comparative Evaluation Groups
13
In these areas, interviews will be conducted with physicians, key rela-
tives of both alternate care clients and nursing home patients, and service
providers.
Attention also will be directed at the decision-making process in-
volved in choosing either alternate care or placement in a nursing home.
Areas of inquiry will include awareness of services, preferences, economic
considerations, and other factors important in arriving at the placement
decision.
Projected Costs and Caseload
Data representing past and anticipated trends in the expenditures
and caseloads of the alternate care and institutional programs will be
developed. Per capita costs and other comparative cost information will
also be produced. Trends and projections for the elderly population of
Texas will be presented in conjunction with projected income distribution
patterns by age group.
These elements, combined with data from prior years, will offer some
indication of the future need for these programs in the State.
Public Hearings and Site Visits
To futher augment the technical evaluation, the reporting panel elected
to sponsor public hearings and site visits. The public hearings will pro-
vide an opportunity for testimony from all concerned parties on a broad
range of issues. The site visits will provide panel members with an oppor-
tunity for first-hand experience and interaction with both recipients and
providers.
Hearings. The public hearings will provide a forum for views on care
of the elderly from providers, recipients, professional associations, ad-
vocate groups, and the general public. Specifically, the following types
of persons will be invited to give testimony.
Service Providers--including nursing home operators, hospital
administrators, physicians, home health care providers, adult
day care center operators, foster home providers, and others
Recipients and the General Public--including nursing home patients,
clients receiving home health and community care services, family
members, and others
Experts and Staff--including gerontological experts, representa-
tives from educational and research groups, agency staff, and
others
Testimony received at the public hearings will be analyzed and presented
as part of the Environmental Analysis.
Site Visits. Site visits will provide panel members an opportunity
for first-hand observation of recipients and service providers. Such
personal interaction will better clarify the specific needs of the elderly
14
and will help to explain the kinds of community and institutional care that
are being provided. Visits to recipients homes and to congregate facilities
will provide direct input from recipients in a way that otherwise would be
difficult to obtain. Visits can be expected to include the following types
of sites or activities: family care, chore and homemaker care, foster care
homes, Meals-on-Wheels programs, ICF II and III nursing homes, rehabilita-
tive day care centers, home health nursing care operations, adult day-
activity centers, and hospital discharge-planning units.
Table 1 summarizes the locations and dates of hearings and visits.
TABLE 1
LOCATIONS AND DATES OF
PUBLIC HEARINGS AND SITE VISITS
LOCATION
DATE
Harlingen
January 12-13, 1978
San Antonio
February 22, 1978
Dallas
March 6-7, 1978
Longview
March 8, 1978
Port Arthur
April 13-14, 1978
Big Spring
May 26, 1978
E1 Paso
July 6-7, 1978
TASK SCHEDULE
The study's multifaceted approach, utilizing both original and exist-
ing data, with heavy emphasis on comparative and output measures, will
not only answer the mandate of Senate Bill 548 but also will provide valu-
able information on the alternate care program to the administrative staff
within the Department of Human Resources.
The collection of secondary data for the development of the Environ-
mental Analysis began in October 1977 and will continue through the
summer of 1978.
Collection of primary data will extend from January through July of
1978.
The initial draft of the findings will be submitted to the panel by
October 1, 1978--subject to the panel members' review and revisions.
15
Program Description
PROGRAM DESCRIPTION
COMMUNITY CARE FOR THE AGED, BLIND, AND DISABLED (CCABD)
The CCABD program's main goal is to help aged, blind, and disabled
persons remain independent and self-sufficient for as long as possible.
In order to accomplish this goal, the program provides a variety of
services within the home and community.
Protective services are designed to prevent or remedy neglect,
abuse, or exploitation.
In-home services, provided to the client in his home, consist
of the following:
-- Chore services (ordinary household tasks)
- Family care services (ordinary household tasks)
--- Homemaker services (personal care to the client and
some household tasks)
-- Home-delivered meals
Out-of-home services, provided in the community but not
to the client's home, include the following:
Day activity services (personal care in a group
setting)
- Congregate meals
Foster family homes (a room and board environment
in certified homes)
-- Health-related services (generally include information
and referral assistance to medical facilities or home
health agencies)
Funding
The CCABD program is a social service provided through Title XX
funds. The State pays 25 percent of the total and the Federal government
pays the remaining 75 percent.
Eligibility
The CCABD program is directed to serve current, former, and potential
recipients of Supplemental Security Income (SSI). Historically, the
17
program has concentrated on the lowest income level, the current SSI
recipient. With the service demand exceeding funding levels, the CCABD
program was forced to establish the following service priorities for
recipients of SSI and Medical Assistance Only (MAO) :
1. SSI or MAO* clients who are leaving a nursing home
2. SSI or MAO clients age 65 or over who will either have
to enter a nursing home within 30 days or who are in a
life-endangering situation
3. SSI or MAO clients age 18-64 in the same conditions as
Priority 2
4. Income-eligible aged, blind, or disabled adults in the
same conditions as Priority 2 and 3
Utilization FY 1977
34,000 clients per month
$54.1 million annual budget
Current Status
Funding. Title XX funds have a fixed ceiling beyond which the
expenditures will not be matched. Texas funds five social service
programs out of Title XX money and is now spending at the ceiling.
Contracting. Due to Social Security Administration rulings, it
is now necessary to contract with agencies to provide the in-home
services that were once provided by individuals under individual
service contracts.
INSTITUTIONAL CARE
The Institutional Care program is designed to provide nursing facility
care to individuals whose health problems require medically oriented care
that can best be delivered in an institutional setting.
Levels of Service
The Institutional Care program offers four different levels of
service.
*MAO and "income-eligible" are roughly equivalent in that they earn more
then SSI recipients are allowed to but less than 65 percent of the State's
median income.
18
1. Intermediate Care Facility (ICF) II--for people who need help
in daily living but who do not need more than simple medical
care. ICF II patients mostly need supervision by a licensed
nurse on a daily basis and help for their safety and well-
being because they cannot live alone or independently.
2.
Intermediate Care Facility III--for persons unable to care for
themselves who need the services of a licensed nurse on a day-
to-day basis. ICF III patients require some regular medical
treatment but not to the degree of those who need skilled
nursing care.
3. Skilled Nursing Care--for persons whose condition requires
care under the direction of a registered nurse, 24 hours
a day.
4. Intermediate Care Facility for the Mentally Retarded--provided
through the State Schools and some private nursing homes.
Patients are admitted to a nursing facility only upon the recom-
mendation of a qualified physician and are reviewed periodically in
order to be certified for a continuation of stay.
Funding
Institutional Care is a medical service provided for by Title XIX
(Medicaid) funds. At present the State pays 39 percent of the total
and the Federal government pays 61 percent.
Eligibility
All Medicaid recipients are eligible for Institutional Care. This
includes SSI recipients and those individuals with resources and monthly
incomes low enough to qualify them for Medical Assistance Only.
Utilization FY 1977
61,000 ICF and Skilled patients monthly
$362.4 million annual budget
19
Current Status
CURRENT STATUS-AUGUST 1978
In response to Senate Bill 548, an evaluation design was developed
by support staff, presented to the reporting panel, and adopted in Nov-
ember of 1977. The evaluation contains several components aimed at
responding to the study's mandate: surveys that compare alternate care
clients and nursing home patients; an analysis of the decision-making
process that takes place when persons are placed in nursing homes; and
a description of the services available to elderly and handicapped
Texans and the environment--social, economic, and demographic--in which
those services are delivered. This technical evaluation is augmented by
input received at a series of seven public hearings and site visits spon-
sored by the reporting panel.
Figure 2 is a current time schedule, summarizing the status of
major evaluation components. As indicated, technical reports are scheduled
for production during August and September, with the final report and
panel recommendations due for review in mid-October.
Table 2 lists the major surveys conducted in response to S.B. 548,
their sample sizes, completion rates, and current status. Table 3
describes the type of witness and general focus of testimony in each of
the seven public hearings.
21
Figure 2.
Project Time Schedule
PROJECT COMPONENT
GALENDAR YEAR 1978
JFMAMJJASON
D
SSI/ABD CLIENT SURVEY
NURSING HOME ANALYSIS & SURVEY
--Records Analysis
--Personal Interviews
ANALYSIS OF DECISION-MAKING PROCESS
--Physicians
--Service Providers
--DHR Program Staff
RESOURCE INVENTORY
--Availability of Services
--Service Trends in Other States
22
--Population & Cost Projections
MEETINGS
--Public Hearings & Site Visits
--Quarterly Panel Meetings
--Symposium/Seminar
DOCUMENTATION
--Technical Reports
--Final Report (DRAFT)
--Panel Recommendations
--Printing & Distribution
LEGEND
= Sample, Instrumentation, Pretest, Training
11111
Prospective
Time Period
=
Data Collection
= Report
Analysis
= Approx. Date
TABLE 2. MAJOR SURVEYS IN RESPONSE TO S.B. 548
Data
Collection
Size of
Present
Completion
Survey
Technique
Sample
Area
Status
Rate
SSI/Community Care
personal
data
Total=87.4%
Client Survey
interview
1,764
statewide
analysis
Community Care Client=93.8%
Nursing Home
sample
data
Records Analysis
of files
14,000
statewide
interpretation
100%
Nursing Home
personal
data
Patient Survey
interview
157
statewide
collection
incomplete
Physicians' Survey
mailout
eight
report
questionnaire
2,656
counties
development
32%
Providers' Survey
mailout
report
questionnaire
123
statewide
development
70%
Staff Survey
mailout
report
questionnaire
76
statewide
development
88%
TABLE 3. TESTIMONY AT PUBLIC HEARINGS
ON LONG-TERM CARE ALTERNATIVES
LOCATION OF HEARING
TYPE OF WITNESS
Har-
San
Long-
Port
Big
E1
Dallas
lingen
Antonio
view
Arthur
Spring
Paso
PROVIDERS
Community/Home Care
Public
7
3
8
11
12
6
11
Private/Voluntary
4
3
2
1
1
0
1
Individual
6
2
9
24
22
0
2
Nursing Homes
1
0
2
4
1
1
1
CONSUMERS
Recipients/Pvt. Citizens
231
14
72
70
221
4
15
Advocacy Groups
Handicapped
2
3
2
2
3
0
0
Elderly
0
3
4
2
2
0
4
FEDERAL GOV'T AGENCIES
0
0
1
0
0
0
0
STATE GOV'T AGENCIES
Health
0
0
0
0
0
0
0
Social Services (DHR)
1
1
1
4
3
1
2
Mental Health, Retardation.
1
4
0
2
2
0
0
Aging
0
0
0
0
0
0
0
Other
0
0
0
0
0
0
0
LOCAL PLANNING AGENCIES
HSAs
0
0
0
0
0
0
0
AAAs
0
1
0
2
2
0
0
COGs
0
0
0
0
3
1
0
Other
0
0
0
0
1
0
2
COMMUNITY ORGANIZATIONS
Voluntary
0
2
4
0
0
0
2
Church-Affiliated
0
1
2
2
4
0
1
Community Action Agency
0
0
0
2
1
0
0
ELECTED OFFICIALS
State
0
0
0
0
0
0
0
District
0
1
0
0
0
0
0
City/County
0
1
0
0
2
1
0
LABOR UNIONS
1
0
1
0
0
0
0
HEALTH PROFESSIONS
1
1
3
0
1
0
0
THIRD-PARTY PAYOR
0
0
0
0
0
0
0
EDUCATORS/RESEARCHERS
0
2
2
1
1
2
0
OTHER
0
0
0
0
0
2
0
TOTAL
262
46
113
127
282
18
41
Oral
44
40
42
70
107