Contact DHS

Division of Aging and
Adult Services
PO Box 1437
Slot 1412
Little Rock AR 72203

By Herb Sanderson, Director
Division of Aging & Adult Services

This column appears in the June 2001 edition of Aging Arkansas,
a publication of the Arkansas Aging Foundation and the
DHS Division of Aging and Adult Services

President Bush and Congress are giving states an unparalleled opportunity to make systemic changes in how and where long term care services are delivered. Over $60 million in federal grants will assist states in working with their disability and aging communities to improve their health and long term care (LTC) service systems so that people with a disability or chronic illness have better choices and support to live in the community.

These Federal grants will build on the successful work already taking place at the State level. In the past twenty years States have substantially expanded home and community-based services. For example, Medicaid HCBS waivers, home health, and personal assistance accounted for 10 of the total Medicaid long term support expenditures in 1988. In 1998 they accounted for 28 percent.

While these figures show progress has been made in the LTC system, there is plenty of room for improvement in meeting the needs and values of its consumers.

To this end, the Health Care Financing Administration (HCFA) is inviting proposals from States and others, in partnership with their disability and aging communities, to design and implement effective and enduring improvements in community long term support systems.

These systemic changes will be designed to enable children and adults of any age who have a disability or long term illness to:

1. Live in the most integrated community setting appropriate to their individual support requirements and their preferences;
2. Exercise meaningful choices about their living environment, the providers of services they receive, the types of supports they use and the manner by which services are provided; and
   
3. Obtain quality services in a manner as consistent as possible with their community living preferences and priorities.

Four distinct grant solicitations comprise the "Systems Change for Community Living" grants. They are:

• "Nursing Facility Transitions" grants: HCFA is making available between $10-$14 million to help States transition eligible individuals from nursing facilities to the community.
  
  
• "Community-integrated Personal Assistance Services and Supports" grants: Personal assistance is the most frequently used service that enables people with a disability or long term illness to live in the community. Grants totaling $5-$8 million are available to support States' efforts to improve personal assistance services that are consumer-directed or offer maximum individual control.
  
  
• "Real Choice Systems Change" grants: The goal is to help design and implement effective and enduring improvements in community long term support systems to enable children and adults of any age who have a disability or long term illness to live and participate in their communities. Approximately $41-$43 million is available in direct grants to States.
  
  
• "National Technical Assistance Exchange for Community Living" grant: This national technical assistance initiative will provide technical assistance, training, and information to States, consumers, families, and other agencies and organizations. Funding for the technical assistance will range from $4-$5 million.

The grants are to help States overcome a number of problems they face:

Problems of Expansion: Recruitment, retention, and career support for frontline workers is an example of one severe problem confronting States and service providers as they attempt to serve more people.

Expansion Does Not Always Equal Improvement: While more people may be served, the adequacy, the quality, and the practical choices available to users of those services has not necessarily improved. While more people may be served, the opportunities for community presence and participation, the interface with the informal caregiver system and generic community supports, and the support for individuals to sustain valued social and economic roles in the community have not necessarily improved. While more people may be served, the simultaneous increase in the general population needing assistance also means that expanded service capability has not necessarily translated into a lower probability of institutionalization.

Infrastructure: The State and community capacity to design, organize, implement, and manage services effectively is clearly strained. The expansion of HCBS programs in the past twenty years also coincided with a general downsizing of government relative to its responsibility. In States where this occurred without a corresponding increase in capacity for effective public-private partnerships, ability to manage a competent outsourcing program, or other methods of ensuring adequate management and oversight, the system is particularly challenged. Investments in the development of such public-private partnerships and other management capability can effectively address this problem.

Quality Assurance and Quality Improvement: Nowhere is the challenge faced by States more evident than in designing and maintaining an effective quality assurance and quality improvement system for community-based services. This is not simply a challenge of quantity, a challenge of serving more people. It is also a challenge of discerning newer, more cost-effective and consumer-oriented models of quality assurance.

Regarding any proposed grant activity, HCFA says the key question to be asked is: Will this activity promote an enduring systems improvement expanding the choices of people of any age with disabilities and long term illnesses to live in the most integrated community settings and participate in their communities?

By "enduring system change" HCFA means that the infrastructure and capacity of the community long term support system is so effectively enlarged that, long after the grant funds are fully expended, people with a disability or long term illness will still experience a substantially greater opportunity for community living and participation than existed previously.

Proposed enduring systems change activities should result in improvements to at least one of the following areas:

• Access: To what extent can we make our long term support systems simple, understandable, comprehensive, flexible and fair? To what extent can we ensure that people who need help have the right information at the right time to make key life decisions, to manage their services, and to manage their conditions or disability for the most positive outcomes possible?
  
  
• Availability And Adequacy of Services: To what extent can we ensure that services are adequate in terms of the amount available, the type and scope of services, and the time period or frequency of services?
  
  
• Quality of Services: To what extent can we ensure that services achieve the outcomes desired and are provided in a manner that meets with the consumer's expectations and preferences? To what extent can we ensure that there exists an effective quality assurance and quality improvement system in place that among other things, obtains real world data in real time regarding consumer experiences with the service system;
  
  
• Value: To what extent can we ensure that investments in services yield the highest value possible?
  1. Service Value: To what extent will purchases yield the most outcome from the service for each dollar spent?
  2. Individual Value: To what extent will public purchases promote the health and wellbeing of individuals, and promote dignity, independence, individual responsibility and choice, and self-direction?
  3. Community Value: To what extent will public purchases support the larger community capacity to enable people of all ages and disabilities to live and participate in the community? To what extent will the formal or the professional service system support informal caregiving by family, friends, and neighbors?

The "Systems Change" grants represent an expression of support for States' efforts to provide additional or improved support for community living. These grants support: the President's "New Freedom Initiative"; the States' efforts to fulfill the ADA; and the long-standing desire of people of all ages, who have a disability or long term illness, to live and participate in their communities with dignity and value.