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Future options for providing health and social services to the indigent elderly in metropolitan Denver

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Title:
Future options for providing health and social services to the indigent elderly in metropolitan Denver a Delphi survey
Creator:
Grey, Hilda K
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English
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xv, 235 leaves : illustrations ; 29 cm

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Subjects / Keywords:
Social work with older people -- Colorado -- Denver Metropolitan Area ( lcsh )
Older people -- Medical care -- Colorado -- Denver ( lcsh )
Poor -- Services for -- Colorado -- Denver Metropolitan Area ( lcsh )
Older people -- Medical care ( fast )
Poor -- Services for ( fast )
Social work with older people ( fast )
Colorado -- Denver ( fast )
Colorado -- Denver Metropolitan Area ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 184-191).
General Note:
Submitted in partial fulfillment of the requirements for the degree, Doctor of Public Administration, Graduate School of Public Affairs.
General Note:
School of Public Affairs
Statement of Responsibility:
by Hilda K. Grey.

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University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
16855505 ( OCLC )
ocm16855505
Classification:
LD1190.P86 1985d .G74 ( lcc )

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Full Text
FUTURE OPTIONS FOR PROVIDING HEALTH AND
SOCIAL SERVICES TO THE INDIGENT ELDERLY
IN METROPOLITAN DENVER:
A DELPHI SURVEY
by
Hilda K. Grey
B.A., University of Colorado, 1973
M.H.A., University of Colorado, 1975
A thesis submitted to the
Faculty of the Graduate School of Public Affairs of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Doctor of Public Administration
Graduate School of Public Affairs


This thesis for the Doctor of Public Administration
degree by
Hilda Kasoff Grey
has been approved for the
Graduate School
of Public Affairs
by

iriam Orleans

Leonard Heilman



Date


^Copyright by Hilda Kasoff Grey 1985
All Rights Reserved


Grey, Hilda Kasoff (D.P.A., Public Administration)
Future Options for Providing Health and Social Services to the
Indigent Elderly in Metropolitan Denver, Colorado: A Delphi Survey
Thesis directed by Professor Roger Durand
The purpose of this study was to examine what experts see as
the future options for providing health and social services to the
indigent elderly in Metropolitan Denver, Colorado. This study
emerged out of a concern that there exist many problems with long-
term care programs throughout the United States. In order to
develop options for the indigent elderly in Metropolitan, Denver,
a Delphi procedure was used. This study was limited to include
twenty experts: five administrators, five clinicians, five
consumers, and five policy-makers, all of whom are active in long-
term care.
The findings revealed the strongest consensus pertained to
the need for specialty facilities for providing health and social
services; namely, the increased need for skilled nursing
facilities, congregate living housing, personal care boarding
homes, adult day care facilities, and multipurpose senior
centers. Problems with existing programs and the growth in the
numbers of indigent elderly point to a need for better planning and
new -solutions in long term care. The study suggests appropriate
actions to be taken in the future at the community level in
developing a systematic and comprehensive long-term care community
program,


V
The form and content
its publication.
of this abstract are
Signed
Faculty member in charge^ of thesis


Preface
Research of this nature could not have been conducted
without the assistance of many individuals who gave freely of their
time and special skills during the course of this study. I am
especially grateful to my dissertation advisor, Roger Durand, who
has read and commented on this study and has contributed greatly to
its refinement and to my continuing intellectual growth. Grateful
acknowledgement is made to the members of my dissertation
committee: Eileen Tynan, Miriam Orleans, and Leonard Heilman for
their cooperation and scholarly guidance. Their suggestions and
advice were invaluable to this study.
Sincere appreciation is extended to the twenty expert
panelists who took the time out of their busy schedules to respond
to three rounds of questionnaires.
A special thanks goes to Phillip Harlow and the Arthur
Andersen Co. and the American College of Hospital Administrators
for their assistance in the development of the questionniare.
Lynne Murphy provided friendship as well as assistance in
the editing phase of this study. Todd Kubo is much appreciated for
his assistance with the graphics in the findings section of the
study. Kelly Bakke typed countless drafts of the manuscript and
deserves a great deal of appreciation for her understanding
efforts.
A special thanks goes to my colleagues, Euphemia Williams
and Robert Lander who provided needed encouragement throughout the
development of this study.


vii
Immense gratitude goes to my children, Allen, Stuart, and
Harry who endured my frustrations and supported me with their
encouragement. Most important, I wish to express my deepest
gratitude to my husband, Howard, for his understanding,
encouragement and love.
Hilda Kasoff Grey
Denver, Colorado
June 1985


CONTENTS
CHAPTER I
INTRODUCTION
Overview........................................................1
Purpose of the study............................................4
Existing programs in long-term care.............................5
Problems with existing programs.................................7
Rapidly rising public and private
expenditures............................................ 8
Fragmentation among services and financing...................11
Lack of case management functions............................12
Bias toward institutional care...............................13
Excessive burdens placed on families.........................17
Growth in aging population.....................................19
Demographics in Colorado.......................................21
Categorical population estimates
in Colorado.............................................. 26
Demographics of metropolitan Denver..........................27
Problems of the indigent elderly...............................34
Current service delivery systems......................... ....37
Health and medical care......................................39
Housing.................................................... 46
Income
55


ix
Summary of gaps and barriers to service
delivery systems.........................................67
Organization of the study....................................69
CHAPTER II
LITERATURE REVIEW
Introduction.................................................70
Options for financing long-term care........................71
Cash payments..............................................72
Vouchers...................................................72
National health insurance..................................73
Mixed financing insurance............................ ....73
Separate social insurance program..........................73
Specialization of program funding for
long-term care by type of care setting...................74
Specialization of program funding for
long-term care by type of need or cost...................74
Bloc Grant Program.........................................75
National Compulsory Insurance Program.................... 76
Federal Disability Program.................................76
Range of care options........................................77
Long-term care........................................... 78
Local long-term care organizations.........................78
Case management system.....................................79
Single agency model........................................80
Social and health maintenance organization.................80
Long-term care institutions................................ 81
Colorado's nursing home population.........................82


X
Medicaid nursing home utilization
and costs.................................................84
Family support services.......................................94
Alternative services..........................................95
Funding under Medicare..................................100
Funding under Medicaid..................................101
Funding under Social Security Act.......................102
Funding under Older Americans Act..................... 103
State Center Grants Program................................103
Housing and Urban Development Programs.....................103
Problems with funding......................................104
Problems of quality assurance..............................108
Restructuring Medicaid................................... 110
Summary.................................................... Ill
CHAPTER III
RESEARCH METHODOLOGY
Introduction............................................. 113
Key characteristics of Delphi......... ......................113
Steps in Delphi..............................................115
Results in Delphi............................................118
History and previous applications of Delphi..................119
Strengths and limitations of Delphi..........................122
Objectives............................................. .124
Formulation of the problem regarding
indigent elderly...........................................124
Test and interpretation regarding indigent
elderly
127


xi
Limitations..................................................131
Summary .....................................................132
CHAPTER IV
FINDINGS
Introduction.................................................133
Problems of the indigent elderly........................... 134
Hypothesis 1...............................................135
Hypothesis 2...............................................142
Hypothesis 3...............................................153
Hypothesis 4...............................................155
Hypothesis 5......................................... ..163
Summary .....................................................167
CHAPTER V
CONCLUSIONS AND RECOMMENDATIONS
Conclusions.............................................. 169
Recommendations.......................................... 180
REFERENCES ..................................................... 184
APPENDICES
A. Round one questionnaire and cover letter.................192
B. Round two questionnaire and cover letter.................195
C. Round three questionnaire and cover letter................209
D. Round three results..................................... 223


TABLES
TABLE
1. Population by Age, Colorado and
the U.S. 1980..............................................23
2. Population Counts by Age and Sex
in Colorado, 1970-1980.....................................24
3. Changes in Age Distribution of Colorado
Population, 1970-1980.................................... 25
4. Estimate of Colorado Populations in Need of Some
Level of Support Services by Category......................26
5. Total Persons and Persons 60 and Over
Below Poverty Level........................................29
6. Summary of Unrelated Individuals and Householders
65 and Over Below Poverty Status......................... 30
7. Summary: Total Persons by Race by
Poverty Status.............................................32
8. Ratio of Medicare Expenditure from 1966-1975...............40
9. Availability of Home Health Agency Services................43
10. Utilization and Need Projection for Ages
65 and Over Home Health Care...............................44
11. Poverty Guidelines for 1979................................55
12. Elderly Persons With Income Below Poverty Level............58
13. Income Before Taxes.................................. 59
14. Sources of Income..........................................61
15. Percentage Increase in the Consumer Price Index............63
16. Public Assistance in Denver Region
During 1976-77
65


xiii
17. Medicaid Nursing Home Population and Cost............... 88
18. Characteristics of Indigent Elderly.......................129
19. Solutions for Indigent Elderly............................129
20. Problems of the Indigent Elderly..........................135
21. Medicaid Coverage by 1995.................................144
22. Centralized Case Management Organizations.................149
23. Providers of Hospital Care to the
Indigent Elderly..........................................152


FIGURES
FIGURE
1. Projected Growth of U.S. Elderly
Population Age Groups 1980-2000.......................... 20
2. Health Care Expenses by Age,
United States 1975.........................................41
3. Medicaid Nursing Home Utilization.........................85
4. Medicaid Average Nursing Home
Per Diem Cost..............................................86
5. Escalating Medicaid Nursing Home Costs....................87
6. The Entire U.S. Population is Entitled
to Some Level of Health Service...........................136
7. National Health Insurance in 1995........................138
8. Future Options for Providing Health and
Social Services to the Indigent Elderly.................. 141
9. A Modest Expansion of Medicaid by 1990...................142
10. Employment-Based Health Insurance by 1990................145
11. Charity Care by Providers by 1990...................... 146
12. Cost Sharing by Consumers by 1990........................148
13. Replacement of Medicare by 1995..........................150
14. Need for Skilled Nursing Care
Facilities in 1995........................................154
15. Need for Senior Centers by 1995..........................157
16. Need for Adult Day Care Facilities by 1995...............159
17. Need for Congregate Living by 1995.......................161


XV
18. Need for Personal Care Boarding
Homes by 1995.............................................163
19. Need for home Health Services by 1995......................165
20. Funding for Non-Institutional Services.....................167


CHAPTER I
INTRODUCTION
Overview
American society continues to struggle with the difficulties
involved in providing long-term care to the old, infirm and im-
poverished. Long-term care (L.T.C.) refers to the provision of
health, social and/or personal care services on a recurring or
continuous basis to persons with chronic physical or mental
conditions who live in environments ranging from institutions to
their own homes (American Hospital Association, 1982).
Although all countries express concern about their aging
populations, there is as yet no generally accepted theory of aging
and only a limited coherent body of knowledge about it. The
process of human aging involves physiological and psychological
changes that are sequential, cumulative, and irreversible; but it
is generally agreed that the changes do not occur at the same rate
in any one individual let alone in all people of the same chrono-
logical age. However irreversible the process of aging may be for
all, its onset, its detriments both felt and perceived, and its
characteristics vary both within and among individuals. Even the
onset of symptoms of old age may vary with the biological and
psychological make-up of the individual and with his or her life
history and socioeconomic class (Grundy, 1983).


o
Aging may be defined as a chronological category or as a
physiological degenerative process. It may be defined operation-
ally as that age at which functional limitations occur on physical
mobility (e.g., the inability to climb stairs, walk rapidly). In
an economic context it may be defined as that age at which
retraining for na; skills does not pay the company (in terms of
expected future employment) for the cost of retraining; or the age
at which it is cost-ineffective to hire an older worker because the
expected length of future employment will not compensate adequately
for the cost to the company of extending mandatory pension
benefits. Or, it may be defined socially as that age when one
exits permanently from the labor force and retires (Kamerman &
Kahn, 1976).
This study focused on the aged as a population group, not on
aging as a process. The initial strategy was to employ the
arbitrary chronological definition of "old age" considered standard
for much of the industrialized world. Sixty and over is used to
describe the aged in Metropolitan Denver for the Denver Regional
Council of Government Studies, hereinafter referred to as DRCOG.
One U.N. report uses 45 as initiating aging. In the U.S. ages 45,
55, and 60 are used as criteria for "aging or "older Americans" in
different situations and programs or for different purposes (DRCOG,
1981).
For purposes of social policy, "pensionable age is the most
strategic concept for describing the totality of the aged
population. In industrialized countries in which social insurance


3
is an established program, it is the ages at which individuals are
eligible for old age and retirement pensions that is critical. For
most of the countries described, this is 65 for men and 60 for
women (although in the U.S. it is 62 for the latter) (Moss and
Halamandaus, 1977).
The primary differentiation of needs among the aged is a
reflection of functional impairment more than anything else. Thus,
the aged may be categorized, or dichotomized, between those who are
relatively active and those who are relatively inactive, a
difficult distinction to make but one with obvious implications for
service provision. An alternative typology would categorize the
aged into those who are active, those who are retired but well-
functioning, and those who are retired and incapacitated. Finally,
although as a group they are defined as a population at risk, for
some the risk is greater than for others. Among those representing
the most vulnerable, regardless of whether the risk is poverty,
physical or psychological impairment, or social isolation, or a
combination of all three, are women, the single and widowed, and
the very old (McCullough, 1984).
The needs of the elderly frequently conflict. The policy
options chosen can result in the realization of certain ends, but
at the expense of others. Sometimes, the needs of a particular
segment of the population are defined in terms of the resource
already present; in the case of the elderly, the nursing home in
the United States has been perceived as such a resource.
Therefore, there is a tendency to define its problem primarily in


4
terms of developing more or better nursing homes, or perhaps in
developing and imposing effective quality controls on nursing
homes. Conversely, others might argue that the need is actually
for fewer nursing homes and the development of totally different
approaches for the care of the elderly (Congressional Budget
Office, 1977) Congressional Budget Office of the United States is
hereinafter referred to as CBO.
The policy decisions made will be derived from the
priorities established; these could range from the goal of
maintaining maximal autonomy and self-sufficiency for each
individual to the goal of ensuring care and protection for the very
infirmed. The former suggests the support services are necessary
to help the elderly person within the community, while the latter
suggests the expansion and improvement of institutional
facilities. Meanwhile, as concern mounts about the rising
proportion of the U.S. national budget being expended for the
elderly, a major priority has become that of cost containment.
Well over $20 billion are spent on long-term care problems by
public authorities. Personal out-of-pocket expenditures for long-
term care are difficult to estimate but probably approach $10
billion. The cost of family care has been estimated at $38.2
billion by the Comptroller General (Callahan and Wallack, 1981).
Purpose of the Study
The purpose of this study is to examine what the experts see
as the best future options for providing health and social services


5
to the indigent elderly in Metropolitan Denver, Colorado. Metro-
politan Denver includes: Adams, Arapahoe, Boulder, Clear Creek,
Denver, Douglas, Gilpin, and Jefferson Counties. Problems with
existing programs and the growth in the numbers of indigent elderly
point to the need for better planning and new solutions in long-
term care.
Existing Programs in Long-Term Care
Over the years, various solutions to this nation's long-term
care needs have been proposed and tried as problems have been
identified. At the federal level, major legislation affecting
long-term care for the aged and infirm includes Supplemental
Security Income (Title XVI), Medicare (Title XX of the Social
Security Act), and portions of the Comprehensive Older American's
Act of 1978. These programs provide funding, define regulation and
enforcement, and affect state level programs (U.S. Senate, 1981).
The Supplemental Security Income (S.S.I.) program provides
support for low-income aged, blind and disabled persons,
established by title XVI of the Social Security Act. S.S.I.
replaced state welfare programs for the aged, blind and disabled in
1972. Medicare (Title XVIII) is a nationwide health insurance
program for people aged 65 and over and for persons eligible for
social security disability payments. Health insurance protection
is available to insured persons without regard to income. Monies
from payroll taxes and premiums from beneficiaries are deposited in
special trust funds for use in meeting these expenses incurred by


6
the insured. The program was enacted in 1965 as title XVIII -
Health Insurance for the Aged of the Social Security Act. The
Comprehensive Older Americans Act of 1978 declared that the older
people of our nation are entitled to the full and free enjoyment of
an adequate income in retirement in accordance with the American
standard of living.
Colorado has approximately 2,000 service agencies with
programs for the elderly. There are approximately 143 different
health, medical or in home supportive service programs in the
region which include home health, agencies, nursing homes,
counseling programs, homemaker or chore services, restorative and
rehabilitative programs, and health education and research
centers. Employment or training programs for the elderly are
provided in approximately six programs. There are eight public
income resources and hundreds of income conservation programs in
the eight counties. There are about fifteen legal service programs
and crime programs for the elderly. Sixty-two organizations are
directly involved in providing supplementary service to the elderly
and handicapped in the Denver region. Private housing or repair
services are available through approximately ten organizations.
There are approximately ten organizations in the region with formal
information, assistance and outreach programs. Thirty-one meal
sites are currently operating in Colorado, along with eight home
delivered meal programs, a food stamp program, food commodity
program, and five nutrition education programs. There are thirty-
nine multipurpose senior centers in the region and numerous


7
educational programs through postsecondary education at state
universities, private colleges and community colleges (DRCOG,
1980).
Problems with Existing Programs
The literature states that the present system of long-term
care fails to meet many of the needs of those who require some form
of long-term care, particularly those with needs for
noninstitutional services. The U.S. Department of Health,
Education and Welfare (HEW, 1978) states that 3.6 to 7.8 million
disabled adults receive no formal long-term care services; some of
these persons, however, are receiving informal care through family
or friends. The Congressional Budget Office (CBO) estimated that
in 1976 up to 1.4 million disabled adults who were living alone
received no care, either formal or informal; no estimates were
made, however, of what proportion of these persons did not, in
fact, require any care by others (CBO, 1977a). The CBO does
estimate that
3 to 5 percent of the total noninstitution population (12
to 17 percent of the elderly) have levels of disability so
high that they are bedridden or require assistance in the
most basic functions of daily living ... many of these
persons may, in fact, require some level of institutional
care (CBO, 1977a, p. 20).
The CBO also estimates that in 1976 the number of adults
needing to live in personal care homes, sheltered living
arrangements, and congregate housing exceeded the number actually
residing in such facilities by more than 1.1 million. By 1985,
they estimate that 1.1 to 1.3 million adults will have unmet needs


8
for personal care homes, sheltered living arrangements, and
congregate housing. Similarly, they estimate that in 1976 1.4 to
2.2 million more adults needed home health care or day care than
the number served. By 1985, they estimate that 2.9 to 4.3 million
adults will have unmet needs for home-based services (CBO, 1977a).
Such evidence about need is flawed in several ways: (1) the
criteria are often ambiguous; (2) the basis for government
provision does not distinguish well between government, family, and
local community care now provided; (3) the data do not permit
clear targeting of priority cases if funds are to be very
limited. If funds were to be much increased, the data do not
permit very accurate predictions about how patients would, in fact,
use whatever services are offered or about how they would respond
to expert judgments about what services they should use; (4)
degrees of severity or of suffering are not identified, so that
patient wants are not distinguished from assessed needs nor are
real behavioral choices of patients and families distinguished from
opinions expressed in surveys. The CBO estimates are useful as
rough preliminary guides, not as firmly rooted ones (Morris and
Youket, 1981).
Rapidly Rising Public and Private Expenditures. Major
reforms in the present system of long-term care are also -needed
because of the skyrocketing costs of long-term care. From FY 1965
to FY 1977, national expenditures for nursing home care alone grew
from $1.3 billion to $12.6 billion, an increase of 869%. In


9
relative terms, national expenditures for nursing home care have
grown from 3.3% of all national health expenditures in FY 1965 to
7.8% of all national health expenditures in FY 1977 (Gibson and
Fisher, 1978). The CBO estimated "total national spending for all
long-term care services to have been $18.1 billion in FY 1976; this
would constitute 12.8 to 14.5% of total national health
expenditures in that year (CBO, 1977b, p. 12). These figures do
not clarify whether the increases were unreasonable, or represented
a shift in medical-cost accounting from acute- to long-term care
cost centers, or represented a delayed response to demographic
trends.
This increase in spending for long-term care was partly due
to coverage of long-term care services by public programs,
particularly by Medicaid. Public programs paid 57% of all national
expenditures for nursing home care in FY 1977 and 51 to 57% of
national expenditures for all long-term services in FY 1976.
Medicaid alone paid 51% of all national expenditures for nursing
home care in FY 1977 and 28 to 31% of national expenditures for all
long-term care services in FY 1976 (Gibson and Fisher, 1978). HEW
(1978) estimated total public spending for long-term care to have
been about $12 billion in FY 1977 (HEW, 1978). Medicaid
expenditures for long-term care services have grown 122% from $3.4
billion in FY 1973 to $7.5 billion in FY 1978 (HEW, 1978). HEW
(1978) contended that Medicaid, as an open-ended, federal/state
matching program in which states control eligibility, benefits and
reimbursement under minimum federal equirements, has been chiefly


10
responsible for uncontrolled growth in federal spending for long-
term care.
Federal costs for long-term care are expected to continue to
grow much higher as a result of the aging of the population and the
impact of judicial decisions. The number of persons 65 years of
age and older is expected to grow from 24 million presently to 55
million in the year 2030 (HEW 1978). HEW (1978, p. 5) stated that
"judicial decisions requiring that involuntarily committed mentally
ill and retarded patients to be served in the least restrictive
setting could increase spending by billions of dollars."
The CBO estimated that 5.5 to 7.2 million elderly and
disabled will require some form of long-term care by 1985 (CBO,
1977b). They estimate that spending under present law for long-
term care services will rise from $21.3 to $24.1 billion in FY 1977
to $63.7 to $74.5 billion in FY 1985 (CBO, 1977b).
Any reforms in the present system of long-term care that
seek to improve significantly the quality of care or expand eligi-
bility, benefits, and services under public programs (for example,
to meet unmet needs, to increase the availability and utilization
of noninstitutional care services, to improve equity across the
states, to publicly pay for care now privately paid for or
provided, or to add case management services) are likely to raise
costs. Some reforms may increase the efficient utilization of
long-term care services, but they are also likely .to raise total
costs. Expanded coverage and supply of community care services
would lower demand for institutional care and reduce unnecessary


11
and inappropriate utilization of institutional care services, but
would probably increase the demand for noninstitutional care and
substitute formal care for much informal care. The scale of these
shifts has been estimated in crude terms only (Morris and Youket,
1981).
Fragmentation Among Services and Financing. The present
system of long-term care is highly fragmented, both in terms of
financing and service delivery. A multitude of programs and
agencies at the federal, state, and local levels are involved in
long-term care, but no centralized responsibility exists for long-
term care at any level. HEW (1978) listed twenty-six different
federal programs that provide resources for persons with long-term
care needs. These programs fund similar services as well as
different services, but each has its legislatively mandated
eligibility requirements, benefit coverage, regulations for
provider participation, administrative structures, and service-
delivery mechanisms. They all operate fairly independently at each
level of government. Differences between Medicaid, Title XX, and
SSI are particularly important as they are largely responsible for
the lack of fit between the necessary health, social, and income
components of long-term care under the current system (LaVor,
1977). Programmatic fragmentation has produced a fragmented
service-delivery system for long-term care. There are presently a
wide variety of disconnected types of facilities, services, and
providers that are not tied together in any systematic way. The


12
result is a highly complicated and confused system of long-term
care.
Lack of Case Management Functions. Major reforms are needed
in the present system of long-term care because the current system
lacks important case management functions. Specifically, no
centralized information, referral, and counseling, no centralized
comprehensive needs assessment, no central agent for prescribing
and designing a comprehensive package of services, and no central
agent for pulling together different financial and service
resources exist. There is no central rationing agent for
allocating limited resources for service delivery and financing
among all those with needs for long-term care (particularly for
personal social services in community and in-home settings). There
is no centralized care setting, no centralized coordination of
service-delivery and funding sources, no centralized patient
monitoring and periodic reassessment of needs, and no centralized
advocacy for individual patients (Correia, 1976).
Although professionals argue that case management should be
an integral part of any new program for long-term care, case
management is especially important for the current system of long-
term care. Under the present system, the burden for performing
these functions rests primarily with the patients themselves and
their families, who are ill-equipped to do so. Under the current
system, many programs, services, facilities, providers, and
agencies function independently of one another. Program require-


ments and individual needs are complex. Presently, no one is
available to help individuals and families utilize the available
resources. Professional experts are needed, it is argued, to help
individuals and families deal with the fragmentation and
complexity. Expert assistance should improve the appropriate,
efficient, and cost-effective utilization of the limited resources
available (Eggert, 1977).
Bias Toward Institutional Care. The present system of long-
term care is strongly biased in favor of institutional care and
places little emphasis on care in community settings. The CBO
estimates that over 90% of all public expenditures for long-term
care go for institutional care (CBO 1977a). Medicaid is the
primary source of public funding for long-term care. In fiscal
year (FY) 1978, 38% of total Medicaid expenditures was spent on
institutional long-term care services, while only 0.8% of total
Medicaid expenditures was spent on home health services (HEW,
1978).
With the major portion of public money being expended for
long-term care, patients are unnecessarily or inappropriately
institutionalized so that they can receive the needed public
support for their care. Estimates from empirical studies of the
proportion of nursing home residents inappropriately placed- range
from 6 to 76% (CBO 1977a). The CBO concludes, on the basis on
these studies, that at least 10 to 20% of all skilled nursing
facility (SNF) patients and 20 to 40% of all intermediate care


14
facility (ICF) residents are probably receiving unnecessarily high
levels of care (CBO 1977a). HEW (1978, p. 3) estimates "that
between 14 and 25% of institutionalized patients could be cared for
in less restrictive settings (though not necessarily less
expensively)."
Insufficient supplies of community care services and
restrictions under present programs are the reasons most frequently
cited for the overutilization of institutional care services and
the underutilization of community care services. Personal care
services are necessary in many cases to maintain individuals with
long-term care needs in community settings. Services covered under
Medicaid must be "medically related". States can reimburse
personal care and day care services under Medicaid but few do so.
Most funding for such services is through Title XX. While Medicaid
is an open-ended, federal/state matching program, Title XX is a
close-ended, federal/state matching program. In FY 1980, Medicaid
is estimated to have spent $8.4 billion on long-term care services,
98% of which was used for institutional long-term care services,
while in the same year Title XX is estimated to spend only $574
million on institutional services for the elderly and disabled
(Sims, 1984).
Another factor that works to bias public coverage of long-
term care in favor of institutional care is the way in which
persons become eligible for Medicaid. In states that cover the
"medically needy", expenses for institutional care are often high
enough to make many of those who are institutionalized quickly


15
eligible for Medicaid, while expenses for home health services are
generally not high enough to make many persons with similar needs
eligible for Medicaid. In addition, many restrictions are in force
on coverage of home health services under Medicare and Medicaid,
which have greatly limited the utilization of these services under
these programs (HEW 1978, CBO 1977a). Social, homemaker and
personal care supports may be excluded from home health programs,
although these less medical-type services are seen by consumers as
crucial to maintaining life outside a nursing home (Gurland, 1978).
A desire to balance more equally the provision of
institutional care and noninstitutional care would require
examining the supply and program coverage, but this approach would
probably raise total public costs for long-term care. Public
officials are fearful that the increased demand for noninstitu-
tional care services would outweigh the decreased demand for
institutional care services. The CBO estimates that a federal
social-insurance program fully covering all identified
institutional and noninstitutional long-term care service needs
would expand both the population entitled to public care and the
scope of reimbursed services sufficiently to increase outlays under
federal programs by $32.1 to $55.8 billion over present law by 1985
(CBO 1977b). The argument to rectify an institutional bias thus
encounters a challenge about how to do so without expanding
entitlements, both to a wider eligible population and a broader
range of services.


16
Another source of concern is the quality of care received by
many persons within the present system of long-term care. Public
scandals of poor quality nursing home care have abounded;
widespread instances of poor quality nursing homes have been well
documented by such sources as the Subcommittee on Long-Term Care of
the U.S. Senate Special Committee on Aging, the New York State
Moreland Act Commission, and Mary A. Mendelson in her book, Tender
Loving Greed. In 1973, the Office of Nursing Home Affairs in HEW
found that 59% of all nursing home beds did not meet minimum
federal standards of quality (HEW 1977). According to the 1977
National Nursing Home Survey, 25% of all nursing home facilities
and 11.9% of all nursing home beds are not certified under either
Medicare or Medicaid; 10.6% of all nursing home residents are in
such beds (HEW 1979).
HEW (1978) cited the heavy use of medications, the
administration of drugs by untrained orderlies, the rarity of
physician visits, and high staff turnover as indicators of poor
quality of care in nursing homes. It also stated that anecdotal
evidence exists of appalling instances of low quality care in the
provision of unregulated in-home services under Title XX. It
attributes this low quality to the lack of federal standards for
providers of home-based services under Title XX. It is not known,
however, how widespread these problems are for community- and home-
based care services. Measuring the quality of care provided is
even more difficult in noninstitutional settings than it is in
institutional settings.


17
HEW (1978) argues that many deficiencies of quality
assurance exist for institutional long-term care in the current
system. The current system, it said, is complex, cumbersome,
uncoordinated, and often ineffective. Existing mechanisms tend to
focus on the physical capacity of the facilities and the appro-
priateness of the level of care rendered, not on the quality of
care received. Present review mechanisms do not successfully
assure that long-term care patients receive adequate and
appropriate services to meet their needs. Although we can assess
long-term care patients' conditions to determine their degree of
debilitation, there is no agreement on what constitutes "quality of
care in response to their needs. Outcome measures against which
quality of care can be assessed must include both medical,
functional, and social dimensions, but such measures have not been
fully developed (HEW, 1978).
HEW (1978) goes on to list many specific problems of the
current system for quality assurance of institutional long-term
care. It recommends the development of a single integrated long-
term care quality-assurance system and specifies many regulatory
and legislative changes that should be made in the present system.
Excessive Burdens Placed on Families. The heavy financial
burden that individuals and families must bear under the current
system of long-term care is another leading reason often cited for
the need to change the present system. The costs of long-term care
can be financially catastrophic for individuals and families.


18
"According to a CBO analysis of the incidence and cost of illness,
nursing home care is the principal cause of catastrophic expenses
among the aged." The CBO estimates that the average annual cost of
a nursing home stay in 1975 was $7,300. However, 68% of the
disabled, 73% of the disabled elderly, and 76% of the institu-
tionalized population have household incomes below $7,000 a year
(CBO 1977a).
In FY 1977, 41.4% of all national expenditures for nursing
home care was paid directly by consumers (Gibson and Fisher
1978). In FY 1976, the CBO estimated that 38 to 44% of total
national spending for all long-term care services was paid directly
by consumers (CBO 1977b).
Medicaid pays for 51% of all nursing home care and 28 to 31%
of all long-term care services in this country (Gibson and Fisher,
1978). In order for individuals to become eligible for Medicaid,
however, they must first impoverish themselves. In some states,
individuals whose incomes are above the eligibility for Medicaid
(the medically needy) dispose of all their assets in order to
qualify for public support. According to the CBO, 47.5% of nursing
home patients depleted their resources and qualified as medically
needy (CBO 1977a). In addition, all Medicaid recipients who are
institutionalized must give up all of their income above a personal
allowance (generally $25) in order to help pay for the costs of
their care.
In addition to financial distress, families and individuals
suffer great distress in trying to deal with severe disability


19
without external help. A New York City study found that severe
mental depression was found in 25% of families with disabled elders
(Gurland, 1978).
In brief, long-term care needs have grown and the system has
taken on increased complexity because of the indifference at the
federal level. National debate about health insurance, which
culminated in enactment of Titles XVIII and XIX of the Social
Security Act, focused attention between 1957 and 1965 on acute
illness. Caring in a similar manner for the chronically ill was
not seen as a federal responsibility. Not until the 1970s did
long-term care again become a major object of public policy
attention, for at least two reasons: (1) escalating public
expenditures for health care perturbed the Social Security system,
the basic health-care system, and public officials; and (2) a
confusing proliferation of specialized programs was established to
deal with parts of the long-term care problem, but which introduced
confusion into both health and welfare systems. Thus, the federal
government has been backed into a position of being concerned with
chronic illness, if only to orchestrate the necessary changes
(Scanlon and Feder, 1984).
Growth in Aging Population
Nationally, the U.S. is an aging society. Between 1980 and
2000, the U.S. total population is projected to grow by 17%. In
contrast, the elderly population (over 65) will increase by 28%
over that same period. Thus, in the year 2000 the 32 million


20
elderly will represent 12.2% of the total population, compared with
11.2% in 1980. That growth trend is expected to be 18.3% of the
total population between 1980 and 2000 (Waldo & Lazenky, 1984).
On a national scale the elderly population as a whole is not
only increasing, but it is also aging. Between 1980 and 2000 the
number of persons 75 and older is likely to increase by 45% and the
number 85 and older by 59%. Nationally, those age 85 and older now
number abut 2.3 million persons; by the year 2000 this group will
increase to 3.8 million (Figure 1).
Figure 1
By Age Groups 1980-2000
Source: U.S. Department of Commerce, Bureau of the Census,
Projections of the Total Population by Age and Sex for the United
States:____Selected Years 1980 to 2050. Current Population
Reports. Series P-25, No. 704. Washington, D.C.: U.S. Government
Printing Office, 1977.


21
Projected at the national growth rate shown above, the
elderly population age 65-plus in Colorado is expected to grow by
approximately 19% to 296,000 by 1990. The over-75 age group is
expected to grow by 25% to 123,000 and the over-85 age group is
expected to grow by 22% to slightly over 30,000 persons by that
year (Colorado's Long-Term Care Plan, 1982).
Demographics in Colorado
Colorado's aging population is growing both larger and
older. While the total 65-plus population increased by 31.5%
between 1970 and 1980, the over-85 population increased by 50% over
that same time period. Growth projections for the next 20 years
indicate that the elderly population will grow at an even faster
rate which will increase the need for long-term care services (1980
Census Report, 1981).
Costs for long-term care are increasing even more
dramatically. Based on current utulization rates, nursing home
expenditures are expected to double by 1992. For FY 1979-80, total
public expenditures for long-term care were a quarter of a billion
dollars. Conservative estimates assume an equal number of private
dollars expended on long-term care, meaning that for FY 1979-80
long-term care was a half billion dollar business in Colorado.
Total dollar expenditures are growing annually (Colorado Long-Term
Care Plan, 1982).


22
Final results from the 1980 Census of Population and Housing
show that Colorado's population was 2,889,964 as of April 1,
1980. This figure represents a growth of 30.8%, or 680,368 more
people than were counted in 1970. Colorado's population grew
almost three times faster than the U.S. population as a whole,
which increased by 11.4% during the decade (U.S. Census, 1981).
The 1980 Census shows that the State's population has aged
over the decade, though Colorado's population remains younger than
the nation as a whole. The median age for Colorado (the age at
which half are younger and half are older) increased from 26.2 to
28.6 from 1970 to 1980; the national median age increased from 27.9
to 30.0. Table 1 contrasts Colorado's age distribution with that
of the nation as a whole. The distribution of Colorado's 60-plus
population by age and sex for 1970 and 1980 is shown in Table 2.


Table 1
Population by Age, Colorado and the U.S., 1980
(percent of total)
0-4 5-9 10-14 15-19 20-24 AGE GROUPS 25-29 30-34 35-39 40-44 45-49 60-64 65+
U.S. 7.2 7.4 median age: 8.1 30.0 9.3 9.4 8.6 7.8 6.2 5.2 5.1 4.5 11.3
Colo. 7.5 7.4 median age: 7.8 28.6 9.3 10.5 10.5 9.2 6.7 5.3 4.8 4.3 8.5
Source: U.S. Census, 1981


Table 2
Population Counts by Age and Sex in Colorado, 1970-1980
1980 1970
Age Both Sexes Male Female Both Sexes Male Female
60-64 102,524 48,872 53,652 79,065 37,735 41,332
65-69 84,113 37,858 46,255 62,119 28,192 33,927
70-74 64,501 27,664 36,837 49,398 21,163 28,235
75-79 44,931 17,632 27,299 36,881 15,010 21,871
80-84 29,367 10,052 19.315 23,261 9,096 14,265
85+ 24,349 7,320 17,029 16,254 6,072 10,182
TOTAL 349,785 149,398 200,387 267,078 117,266 259,812
Source; U.S. Census, 1981


25
Two factors have had an important impact on the State's age distri-
bution. Lower birth rates have led to smaller numbers of children.
High levels of in-migration by young adults have swelled the 20-39
age group (this group has also grown as children of the postwar
baby boom passed into adulthood).
Table 3 shows changes in the age distribution of the Colorado
population over the decade. The overall increase for the 20-39 age
group was 70.8%. More moderate gains are shown for the remaining
adult age groups, although the number aged 85 and over increased by
nearly 50%. This reflects recent declines in the mortality rate
for elderly Americans.
Table 3
Changes in Age Distribution of Colorado Population
1970-1980
Age Group 1980 Population Change Number 1970-1980 Percent
Under 19 923,953 61,684 7.2%
20-39 1,065,214 441,733 70.8
40-59 549,882 93,484 20.5
60-84 325,436 74,612 29.7
85+ 24,349 8,095 49.8
Source for above figures: Colorado Department of Local Affairs,
Division of Planning, Colorado Population Reports, 1980 Census
Results: Population Housing, Age, Sex and Ethnicity. 1980 Census
Report Number 2, October, 1981.


26
Categorical Population Estimates in Colorado. Age is not
the only determinant of the need for long-term care. The other
determinants include the physical and mental health status of the
population by categorical classification. Table 4 displays three
categories as they are distributed in the general population.
"In need" does not mean in need of nursing home placement,
nor does it imply the need for long-term care services. "In need"
means that the population requires some level of support services
that could include rehabilitation, maintenance or education
provided either by the community or by an institution.
Table 4
Estimates of Colorado Populations in Need of Some Level of
Support Services by Category
Colorado Population Distribution
Category Percent Total
Mental health population in need includes approximately 1350 1750 in nursing homes1 7.8% 225,400
Developmentally disabled includes 736 in nursing homes''* 1.7% 49,100
Non-institutionalized impaired elderly 0.4% 11,600
Elderly nursing home population* .5% 14,400
Total population in need 10.4% 300,400
Total Colorado population 100% 2,889,964


27
Source of Notes for Table 4:
1. State of Colorado Mental Health Plan, 1980-85. The
estimates were obtained by applying coefficients from the Report of
the President's Commission on Mental Health (1978) to catchment
area populations. The coefficients defining the moderately and
severely psychiatrically disabled are:
Age
0-11
12-17
18-64
65+
Percent in Target Group
6%
10%
7%
13%
The resulting totals were transformed and allocated according to a
social indicators index which included suicide rates, abuse and
neglect rates, divorce rates, percent minority population and
percent unemployment. The data represent modified estimates for
1981.
2. Colorado Developmental Disabilities State Plan 1978,
Table 3-6 pp. 32-33.
3. Population estimates for the impaired elderly were
obtained by applying national coefficients by age for persons who
depend on others for at least one activity of daily living
(bathing, dressing, eating, and going to the toilet) to the
Colorado population age distribution. The coefficients for non-
institutional persons were derived from the 1977 National Health
Interview Survey and published in Long-Term Care; Background and
Future Directions, HCFA, January 1981, p.6. Approximately 2.2% of
those between 65 and 74 years of age and 7.4% of those over 75
years of age would need some outside assistance in order to
maintain themselves.
4. From the December 1980 nursing home census conducted by
the Licensure and Certification Section of the Colorado Department
of Health. This figure represents an actual count of patients in
nursing home beds as reported by each facility. Population totals
from the Developmental Disabilities and Mental Health Studies were
subtracted to determine the number of elderly residents.
Demographics of Metropolitan Denver
From the 1980 census 12.3% or 16,568 of all persons 60 and
over were below the poverty level. Clear Creek County represents
the highest percentage of 60 and over population below the poverty


28
level with 18.8%. However, Clear Creek County only accounted for
0.005% of all persons 60 and over below the poverty level in the
Denver Region. Also, 57.4% or 9,508 of all persons 60 and over
below the poverty level resided in Denver County as shown in Table
5


Table 5
Total Persons and Persons 60 and Over Below Poverty Level
Counties Total persons below poverty level Total persons 60 and over below poverty level % (1) distribution % (2) distribution
Adams 18,472 1,861 10.1 11.3
Arapahoe 13,345 1,359 10.2 8.2
Boulder 18,358 1,387 7.5 8.4
Clear Creek 425 80 18.8 .005
Denver 65,829 9,508 14.4 57.4
Douglas 1,030 182 17.6 1.1
Gilpin 236 18 7.6 .001
Jefferson 16,761 2,173 12.9 13.2
TOTAL 134,456 16,568 12.3 100
(1) represents the percentage of total persons 60 and over below poverty level.
(2) represents a percentage of Denver Region's 60 and over population below the poverty level
Data Source: DROOG Comprehensive Planning Division (U.S. Census STF 3A Tapes for 1980 Data)
N)


30
In 1980, 91.4% or 8,749 of all unrelated individuals 60 and
over below poverty level in the Denver Region were non-family
householders. Denver County alone represents 54.8% or 5,245 of all
non-family householders 65 and over below poverty level. In the
Denver Region, 16.5% or 1,730 of all households 65 and over below
the poverty level were family householders. Denver county
represents 57% or 988 of all family householders 65 or over below
the poverty level in the Denver Region in Table 6 (U.S. Census STF
3A Tapes for 1980 Data).
Table 6
Summary of Unrelated Individuals and Householders
65 and Over Below Poverty Level
Counties Unrelated individuals 65 and over below poverty level Householders 65 and over below poverty level Family Non-family
Adams 847 242 793
Arapahoe 846 115 782
Boulder 841 156 720
Clear Creek 57 4 44
Denver 5,746 988 5,245
Douglas 30 35 30
Gilpin 13 0 13
Jefferson 1,192 190 1,122
TOTAL 9,572 1,730 8,749
Data Source: DRCOG Comprehensive Planning Division (U.S. Census
STF 3A Tapes for 1980 Data)
Table note: As an example to help in reading this table, 93.7% or
793 unrelated individuals 65 and over below poverty level, in Adams
County are householders. The remaining 6.3% or 54 unrelated
individuals live in group quarters, such as non-family households.


I
31
Table 7 provides Census information on total persons in the
Denver Region above and below poverty level according to race, the
total numbers of persons above and below the poverty level will not
equal the total population and total percentage. This is due to
two factors. The first factor is due to suppression of certain
types of data in order to maintain the confidentiality promised
respondents and required by law under the Census Bureau. The
second factor is due to how the data were tabulated for poverty
status. Tabulations of poverty status exclude inmates of
institutions, members of the Armed Forces living in barracks or on
military ships, college students living in dormitories, and
unrelated individuals under 15 years (U.S. Bureau of Census, 1980).
In 1980, 7.8% or 119,378 of all individuals in the Denver
Region were below poverty level status. Blacks represent the
highest percentage of individuals below poverty level status with
20.5%. American Indian, Eskimo and Aleut individuals were close
behind with 19.4% below poverty status. Whites represent the
majority of the population in the Denver Region, but have the
lowest percentage of individuals below poverty status with 7% (U.S.
Bureau of Census STF 3A Tapes for 1980 Data).


I
Table 7
Summary: Total Persons by Race by Poverty Status
Total Number Total number above poverty level Percentage above poverty level Total number below poverty level Percentage below poverty level Others Percentage
Adams County White 219,471 202,234 92.1 14,948 6.9 2,289 1.0
Black 6,216 4,941 79.5 1,057 16.9 224 3.6
American Indian, Eskimo, Aleut 2,095 1,824 87.1 213 10.2 58 2.7
Asian & Pacific Islander 3,686 3,142 85.3 529 14.4 15 0.3
Arapahoe County
White 274,727 260,460 94.8 11,393 4.2 2,874 1.0
Black 8,467 7,174 84.8 937 11.2 356 4.0
American Indian, Eskimo, Aleut 1,474 1,273 86.4 135 0.2 66 4.4
Asian & Pacific Islander 4,580 4,233 92.4 314 6.9 33 0.7
Boulder County
White 179,780 156,022 86.8 16,637 9.3 7,021 3.9
Black 1,766 1,229 69.5 238 13.5 299 7.0
American Indian, Eskimo, Aleut 930 632 68.0 249 26.8 49 5.2
Asian & Pacific Islander 2,451 1,839 75.1 415 16.9 197 8.0
Clear Creek County
White 7*152 6,705 93.8 *412 *5.8 * 35 *0-4
Black (S) (S) IS) (S) (S) (S) (S)
American Indian, Eskimo, Aleut 54 49 90.7 3 5.6 2 3.7
Asian & Pacific Islander 0 0 0 0 0 0 0
* Others are those who are not classified as above or below poverty level because they do not generate any type of income.
Data Source: DRCOG Comprehensive Planning Division (U.S. Census STF 3A Tapes for 1980 Data)
to
to


Table 7 (continued)
Denver County
White 375,628 6,705 93.8 412 5.8 35 0.4
Black 59,095 44,389 75.2 13,462 22.8
American Indian, Eskimo, Aleut 4,318 2,863 66.3 1,259 29.2 197 4.5
Asian & Pacific Islander 8,934 6,658 74.6 2,093 23.5 178 1.9
Douglas County
White 24,741 23,587 95.3 1,001 4.1 153 0.6
Black 88 88 100.0 0 0 0 0
American Indian, Eskimo, Aleut 58 38 65.5 20 34.5 0 0
Asian & Pacific Islander 87 78 89.7 9 10.3 0 0
Gilpin County
White 2,399 2,112 88.0 . 224 9.4 * 63 2.6
Black * 0(S) *(S) *0(S) *(S) *0(3) *(S)
American Indian, Eskimo, Aleut (S) (S) (S) 0(S) * 0(S) (S)
Aslan & Pacific Islander 0 0 0 0 0 0 0
Jefferson County
White 357,611 336,747 94.2 15,605 4.4 5,259 1.4
Black 1,908 1,543 80.9 145 7.6 220
American Indian, Eskimo, Aleut 1,866 1,593 85.4 209 11.2 64 11.5
Asian & Pacific Islander 4,427 3,896 88.0 442 10.0 89 2.0
Region Totals
White 1,441,509 1,316,603 91.4 97,650 6.8 27,256 1.8
Black 77,540 59,364 76.5 15,833 20.5 2,343 3.0
American Indian, Eskimo, Aleut 10,795 8,272 76.6 2,088 19.4 435 4.0
Aslan & Pacific Islander 24,165 19,846 82.1 3,807 15.8 512 2.1
*(S) represents information that is suppressed. Refer to Appendix for the definition of suppression.
Others are those who are not classified as above or below poverty level because they do not generate any type of income.
Data Source: DRCOG Comprehensive Planning Division (U.S. Census STF 3A Tapes for 1980 Data)
LO


34
These statistics are significant for this study because
health and social services to the indigent elderly in Metropolitan
Denver need to be targeted to the minority populations as well as
the whites.
In 1981, an aging services impact and needs assessment was
conducted by the Denver Regional Council of Government's program
for older persons. Of the 600 persons interviewed, 11% reported no
significant problems for which they need or would like to have had
assistance. The remaining 534 older persons described a total of
904 problems they had encountered in their daily living routines.
The content analysis of these 904 problems resulted in 10 general
categories (DRC0G, 1981, Aging Services Impact and Needs
Assessment).
Problems of the Indigent Elderly
The survey found that the most prevalent problems of older
persons were health and financial. Other significant problem areas
were emotional, transportation, housing, safety/crime and
dependency. Less frequent problems were reported in areas of legal
redress, obtaining benefits, and other areas. Some differences
were found in the problems encountered by various demographic
subgroups of the elderly, but a relatively consistent pattern
across all subgroups dominated the findings. The 10 general
categories of problems are described below.
1. Health. Twenty-eight and one tenth percent of the
total problems described by older persons involved health. These


35
problems resulted from specific illnesses which were
incapacitating, severely limiting the ability to care for oneself,
or were very painful. Other health problems included alcoholism,
insufficient health care benefits, and difficulties in obtaining
health care.
2. Financial. Twenty-one and one tenth percent of the
problems reported involved insufficient income. These problems
grew from incomes that were insufficient to meet daily living
expenses or incomes that were fixed while living expenses were
inflating. Expenses of owning and maintaining a home, utility
costs, taxes, increased food costs and rent increases were
frequently described as major problems.
3. Emotional. Ten and three tenths percent of the
problems reported by older persons were descriptions of their own
emotional states. The descriptions involved loneliness or despair,
frequently arising from the loss of a spouse or other family
members. These emotional problems were often described in terms of
isolation from others and a sense of abandonment by family and
society. Some of the problems grew from feeling isolated by
inclement weather conditions. Other problems reflected unhappiness
with the general decline of external conditions, such as the
economy, government, world affairs, etc.
4. Transportation. Ten percent of the total problems
reported by older persons involved transportation. These problems
were associated primarily with the lack of transportation or
complaints about public transportation. The problems usually were


36
connected with the inability to get to shopping facilities, health
care facilities, etc.
5. Dependency. Nine percent of the total problems
reported by older persons involved taking care of other family
members, being forced to live with other family members, or the
loss of ability to care for themselves. As may be seen in the
breakdown of this category, problems associated with taking care of
others were more frequent than problems associated with depending
on others.
6. Housing. Eight percent of the total problems reported
by older persons were associated with their living arrangements or
accommodations. The main problems described in this category were
absence of facilities for cooking, bathing, or other inadequacies,
being forced to move because of rent increases or conversions, and
being unable to find suitable living accommodations.
7. Safety/Crime. Five and six tenths percent of the total
problems described by older persons revolved around fear of harm,
the general increase of crime, actual attacks on their persons,
burglaries and purse-snatching, fear of animals and actual animal
attacks.
8. Benefits. Three percent of the total problems
described by older persons involved benefits. These problems were
often associated with Social Security benefits, and usually
involved problems connected with not receiving Social Security
checks on time or problems in obtaining disability benefits or low-
income housing.


37
9. Legal/Records. Two percent of the total problems
reported by older persons concerned litigation, lawsuits, consumer
ripoffs, difficulties with government agencies, and lack of
satisfactory responses from officials. The majority of these
problems involved lawsuits wherein the elder person was the
complainant and many of the remaining problems were difficulties in
obtaining satisfactory responses from business and repairmen.
10. Others. Three percent of the total problems reported
by older persons were classified as "other" since they did not fit
the above categories. These problems were extremely varied and did
not form a consistent category of sufficient frequency to warrant
classification. The problems ranged from difficulty with newspaper
delivery to problems shoveling snow from the the sidewalk (Denver
Regional Council of Governments, 1981).
Current Service Delivery System
The current service delivery system in the region is
problematic for the following reasons:
1. Services are fragmented to focus narrowly on
isolated needs, rather than focusing on broad based needs.
2. Services are not often coordinated, and service
agencies compete for limited sources of monies.
3. Few service agencies, located in the urban areas,
provide service in the rural or mountainous areas of the
region.


38
4. Federal, state and private funding sources often
dictate unreasonable eligibility criteria for service programs
and limit participation based on geographic boundaries.
5. Programs may change the services provided annually
depending upon funds received.
6. There is no current source of information about all
services available to the elderly in Colorado. Therefore,
elderly persons do not always receive accurate information
from service providers regarding the services for which they
are eligible.
7. Many counties in the region have little to no tax
base, and therefore, have limited funds to disburse to
services for the elderly. There is limited financial support
in many of the other counties in the region for health and
social service programs for the elderly.
8. There is no consistent data base on the elderly
population in all eight counties of the region, therefore it
is difficult to plan for and allocate funds for services
(Colorados Long-Term Care Plan, 1982).
In summary, the following four major problem areas clearly
emerge from consumers and providers of long-term care in Colorado.
1. Insufficient availability of alternatives, with an
emphasis on lack of housing options, and the poor distribution of
services between rural and urban areas.
2. An ineffective and cumbersome regulatory system in
nursing homes that is not sufficiently related to quality.


39
3. Reimbursement policies that do not encourage the
involvement of family and other private dollars, cost effective
program development, or sliding fee scales for services.
4. The lack of a continuum of care concept with case
management on the local level.
In Colorado, the actual development of a comprehensive,
integrated long-term care service delivery system was deemed to be
a local responsibility, with technical assistance from the State
when needed. There was a very strong bias for allowing local
communities to identify their population and service delivery
needs, and to develop mechanisms for maximizing public and private
resources on behalf of all persons in need of long-term care (The
Long-Term Care Planning Group, 1982).
The following service systems will be briefly addressed: 1)
health and medical care: 2) housing; and 3) income.
Health and Medical Care. Health services and systems are
failing to meet the needs of the elderly in two fundamental ways -
rising costs are preventing many elderly persons from obtaining
essential services, and the system is not organized in such a way
as to provide elderly persons with the type of medical and
supportive care that is necessary to maintain their health and
well-being.
The Social Security Bulletin in 1976 reported the rate of
Medicare expenditures from 1966 to 1975 (see Table 8). The nursing
home care expenditures in 1975 were five times the expenditures In


40
1966. The hospital care expenditures were 3.4 times the
expenditures in 1966.
Table 8
Ratio of Medicare Expenditure From 1966 1975
Type of Ratio of Amount Spent in FY 1975
Expenditure to Amount Spent in FY 1966
Total 3.1
Nursing Home Care 5.0
Hospital Care 3.4
Physician's Services 2.4
Dentist's Services 1.8
Drugs amd Drug Sundries 1.9
Other Professional Services 1.7
Eyeglasses and Applicances 1.5
Other Health Services 1.9
Source: Gornick, Marian, Ten Years of Medicare: Impact on the
Covered Population, Social Security Bulletin, July, 1976.
The health care expenditures in 1975 by age are reflected in
Figure 2. An average of $603 was expended on hospital care for
elderly persons 65 and over, compared to $230 for persons ages 19-
64 and $71 for persons under age 19. The average expenditure for
physicians services for the elderly was $218 compared to $100 in
the 19 to 64 age group and $70 in the under 19 age group. The
average expenditure for other health services in 1975 for the
elderly was $539 compared to $142 in the 19 to 64 age group and $70
in the under 19 age group.


41
Figure 2
Per Capita Expenditures
$603
Health Care Expenses by Age
United States 1975
Source: Age Differences in Health Care Spending, Fiscal Year 1975,
by Robert M. Gibson, Social Security Bulletin. June 1976.


42
The Colorado Department of Health and the local health
systems agency collected information on the available certified
home health agencies and range of services provided. Table 9
describes their services. The home health aid services are
contracted for in at least three different organizations in
Denver. Table 10 depicts the utilization and need projection for
home health care in 1984. In 1984, the need for home health visits
for those persons age 65 and over were estimated to increase by
over 29,000 visits. These figures do not include the population
ages 60-64 nor do they include the need for other types of
supportive in-home services such as home-makers, deep house
cleaning, respite care, meal preparation, letter writing, chore
services, etc.
The Colorado Department of Health estimates a target
percentage of 6.5% of the population age 65 and over needing home
health services. The Health Department expects the average person
65 and over needs 20 home health visits per year to maintain their
non-institutionalized status.


Table 9
Availability of Home Health Agencies Services
*
Planning Region Number of Home Health Agencies Skilled Nursing Services Range of Services Provided by Agencies
Speech Therapy Physical Therapy Occupational Therapy Social Worker Home Health Aide
REGION I 1 1 1 1 1 - -
REGION II 2 2 2 2 2 2 2
** REGION III 8 8 8 7 7 - -
REGION V 1 1 - 1 - 3 8

HSA I 12 12 11 11 10 5 10
Data Source: Colorado Department of Health & Central Northeast Colorado HSA
DRCOG Office of Aging Service Area


Table 10
ie
Utilization and Need Projection for Age 65 and Over Hone Health Care
Planning Regions Hone Health Agencies Services 1979 Visiting Nurses Public Health Nurses 1979 Total Patient Care 1979 65 & Over Patient Needs 1979 # of Visits Needed for 65 & Over 1979 65 & Over Patient Needs 1984 // of Visits Needed for 65 & Over 1984
REGION I 96 57 153 525 10,500 599 11,980
REGION II 756 413 1,159 1,396 27,920 1,576 31,520
REGION III** 5,643 1,370 7,013 7,671 140,260 8,466 169,320
REGION V 54 64 118 176 3,520 191 3,820

HSA I 6,539 1,904 8,443 9,768 182,200 10,832 216,640
Utilization and Need Data based on formulae developed by the Colorado Department of Health
DRQ3G Office on Aging Service Area
Source: Central Northeast Colorado Health Systems Agency
-O
-ts


45
Formula derivation for Table 10
(Utilization and Need Projected for Age 65
and Over Home Health Care)
total patients in nursing home beds (10,775)
times
percent of Medicaid/Medicare patients in nursing homes (69%)
times
percent of patients inappropriately placed in nursing homes (20%)
times
percent of reduction due to comprehensive
home health care programs
times
Medicaid nursing home for one patient per year (20%)
times
Annual reimbursement rate for Medicaid patients
equals
Total Medicaid/Medicare nursing home expenditure reduction


46
Elderly persons require availability of services
(supportive, therapeutic, preventative, rehabilitative, and long-
term care) to meet their changing needs. Health and medical
service systems must include preventative care and social support
services. Poverty and isolation greatly affect the health status
of an elderly person. An elderly person with a low income often
cannot afford preventative care services since they are not
reimbursed or covered under Medicare or Medicaid. Adequate income,
housing, and nutrition all contribute to health maintenance.
Finally, elderly persons do not always receive adequate information
about the types of services which are available and to which they
are entitled.
Housing. The largest housing problems in Colorado are the
lack of diverse housing alternatives and the inability of elderly
persons to pay for suitable housing. An expenditure of over one-
fourth of a person's gross income is extreme; however, over 67% of
the elderly renters in 1970 paid more than one-fourth of their
income for rent, and over one-half of the elderly renters paid more
than 35% of their income for rent (Department of Housing and
Community Development, November, 1976, Washington, D.C.).
The Housing Needs Assessment conducted by the Denver
Regional Council of Governments* Comprehensive Planning Division in
1977 showed 35,252 elderly in Adams, Arapahoe, Boulder, Denver and
Jefferson Counties who were below HUD income guidelines and were
inadequately housed. Fifty-two percent of those elderly persons
were in Denver County.


47
Resources exist for purchasing, building, remodeling and
renting housing. The programs are described below in two parts;
namely, (a) major public state-wide housing assistance programs
and (b) private resources.
One of the public programs available is the Housing
Demonstration Grants and Technical Assistance Program. This
program is funded by the State and administered by the Colorado
Division of Housing (DOH) and the Department of Local Affairs. It
is available to public and non-profit private housing sponsors for
the construction, rehabilitation and acquisition of renter and
owner housing for low income households and persons. Generally, an
eligible household is one whose household income does not exceed 80
to 120% (depending on the household size) of the periodically-
determined median income of the county in which the housing unit is
located. The grant funds may not constitute more than 50% of the
total project cost and may not be used for project planning or
administration. In addition to financial participation, the
division can provide technical assistance in matters of
organization, program planning, and policy development, as well as
in all aspects of project execution. The amount of program funds
available is dependent on annual appropriations by the Colorado
General Assembly, ranging from $250,000 in Fiscal Years 1972-73 and
1973-74 to $2,000,000 in Fiscal Year 1974-75.
Other public housing assistance is available through the
Loans-to-Lenders Program. This program is administered by the
Colorado Housing Finance Authority (CHFA) through participating


48
private lending institutions. The program provides mortgage loans
at below market interest rates to eligible borrowers who may
purchase existing or build new single-family homes, condominiums,
or duplexes (if one unit is co-owner occupied). Refinancings are
not eligible. Eligible borrowers must have adjusted family incomes
of less than the median family income of the state or a lesser
amount as established by the CHFA Board of Directors. The amount
of program funds varies with each series of bonds issued by the
CHFA. Since 1975, $1,000,000,000 has been loaned to participating
lenders resulting in approximately 3,500 mortgage loans.
A Rental Assistance Program is also administered by the
FmHA. The program provides funds to borrowers on behalf of
eligible tenants of almost all FmHA rental projects. Tenants
eligible for this assistance are also eligible for interest
credits, i.e., have adjusted household incomes of less than
$10,000. The amount of the rental assistance is the difference
between 25% of the adjusted household income and the gross rent
(shelter rent pays all utility costs except telephone service)
necessary to amortize the mortgage at one percent interest. The
amount of program funds available in Colorado varies each fiscal
year.
Two of the programs under the section 8 Housing Assistance
Payments Program include existing housing and new construction
substantive rehabilitation.
The existing housing program is administered by the U.S.
Department of Housing and Urban Development (HUD) through Public


49
Housing Agencies (PHA's). The program provides funds on behalf of
eligible households so they may shop for and obtain existing rental
housing units which are in standard condition (defined by HUD)
within the PHAs legal jurisdiction. Units presently occupied may
be eligible. Generally, an eligible household is one in which the
household income does not exceed 56 to 100% (depending on the
number of persons in the household) of the HUD-determined median
income applicable to the county in which the housing unit is
located. The amount of the housing assistance is the difference
between the gross rent (shelter rent pays all utility costs except
for telephone service) and usually 25% of the household income.
The gross rent cannot exceed the periodically-established HUD Fair
Market Rent for Existing Housing. The amount of funds available
for this program varies between federal fiscal years and for each
PHA.
The new construction substantial rehabilitation program is
administered by HUD either directly or in cooperation with CHFA or
FmHA. The program provides funds on behalf of eligible households
so that they may reside in newly-constructed or substantially
rehabilitated rental housing units provided by eligible sponsors.
The eligibility criteria for participation is the same as cited in
the preceding paragraph.
A Low-Rent Public Housing Program is also administered
directly by HUD. The program provides capital funds to Local
Housing Authorities (LHA's) for the construction, acquisition, or
rehabilitation of rental housing units. Generally, an eligible


50
household is one in which the adjusted household income does not
exceed 90% of the Section 8 income limits for the county in which
the project is located; the LHA does have the authority to set
lower income limits. Generally, the household pays 25% of its
adjusted income for rent, and the total of the rents collected by
the LHA must equal the project's operating expenses. There are
situations in which HUD pays a portion of the operating expenses.
The amount of program funds available varies between federal fiscal
years and among allocation areas ("Colorado Households Needing and
Qualifying for Housing Assistance, January 1, 1977 to January 1,
1982).
The Aged and Disabled Property Tax Relief Program is
administered through the Colorado Department of Revenue under
Colorado's "Circuit Breaker" law inaugurated July 1, 1971 for 1971
tax returns filed in 1972. Approximately 35% of the total state
population over 65 years old have participated in the program. The
total cost of the state program in 1977 was $11,003,000. The
number of homeowners or renters age 65 and over, or disabled
persons who were beneficiaries in the program, was 58,875. Income
ceiling for participation is $7,300 for a single person and $8,300
for married persons. Relief cannot exceed $410 and is equal to
$410 reduced by 10% of income over $3,300 for individuals and 10%
of income over $4,300 for married couples (20% of rent equals tax
equivalent). Average credit or rebate was $4.20.


51
The Weatherization Program is administered through the U.S.
Department of Energy and the Community Services Administration.
The program is contracted to agencies in each county for the
provision of free storm windows, insulation, weather-stripping, and
other improvements to decrease energy expenses.
As a recipient of the HUD Innovative Award, the City and
County of Denver was recently selected to receive a $640,900 award
to rehabilitate old homes, build new houses and provide rental
units in one of the Spanish-American neighborhoods. HUD has
developed this initiative to aid the low-income inner-city
residents who are adversely affected by urban redevelopment. The
two year project will rehabilitate 255 houses, provide mortgage
assistance to 90 families to buy their own homes, and construct
single family housing to attract middle-income persons into the
area.
Through its Community Development Bloc Grants HUD provides
grants to cities with populations of 25,000 or more to be utilized
for rehabilitation loans or grants. Spending priorities are
determined at the local level, but the law enumerates general
objectives which the bloc grants are designed to fulfill, including
adequate housing, a suitable living environment and expanded
economic opportunities for lower-income groups. The grant monies
can be utilized to purchase land on which they will build housing,
to purchase run-down buildings to renovate, to renovate public
buildings to insure accessibility, to build senior centers; and, in
certain instances, the monies can be used for social services.


52
HUD also grants monies to cities which they loan to
homeowners for rehabilitation. The interest rate to homeowners is
3% at a variable term of up to 20 years. The homeowners must meet
minimum credit standards. The grant monies may also be used for
refinancing homes. Preference is given to low and moderate-income
applicants. The loans may not exceed $27,000 per dwelling unit or
$50,000 for non-residential property.
HUD provides long-term direct low-interest loans to
eligible, private, non-profit organizations to finance rental or
cooperative housing facilities for elderly and handicapped
persons. The amount of available funds vary from year to year.
If public programs dislocate an individual, they have to
abide by the Uniform Relocation Act of 1970 which provides
relocation payments to homeowners who are displaced by public
programs. Homeowners are minimally entitled to fair market value
for their house or land to relocate the family into a decent, safe
and sanitary dwelling unit. At the option of the city, they can
make supplemental relocation grants to homeowners who are not able
to use the above-mentioned options by awarding them another grant
or loan.
Tenants who are dislocated by public programs are minimally
entitled to a cash payment of $2,000 for a down payment on a
house. If they have money in savings, the program may match that
amount up to an additional $2,000 (total contribution not to exceed
$4,000). If the dislocated person does not want to purchase a


53
home, the program can subsidize them $84.50 per month for four
years. This rent subsidy amount is contingent upon income.
Some private resources are also available to assist with
housing needs. Brothers Redevelopment is a voluntary program which
provides major home repair services to low-income homeowners. The
estimated cost of the program in 1978 was $300,000. Residents pay
for materials and the program provides labor at no cost.
There are five local organizations which provide housing to
persons who have no other place to live on a temporary basis.
These organizations include the American Red Cross, Catholic
Resettlement Center, Denver Catholic Community Services, Denver
Indian Center, Lutheran Social Services, Salvation Army, Traveler's
Aid, and Departments of Social Services.
The Neighborhood Action Centers provide housing counseling
on tenant rights, emergency housing, public housing availability
and consumer affairs. The Senior Citizens Law Center at the Legal
Aid Society (funded by Title 111-B funds under the Older Americans
Act) provides legal aid to elderly persons in the region on housing
or landlord-tenant problems. The Denver Commission on Community
Relations, Brothers Redevelopment, Colorado Civil Rights
Commission, Senior Support Services and the Denver Urban Coalition
provide counseling to persons on housing, consumer affairs, budget
counseling, housing discrimination, and relocation.
The Public Service Company has a department with
representatives who work with customers who cannot afford to pay
their utility bills. Public Service Company has also developed a


54
new program to spread utility bills out during the year to lower
the bill during the winter months.
Denver Opportunity disburses crisis-intervention funds to
low income persons for payment of utility bills.
The National Consumer Cooperative Bank provides loans for
non-profit cooperatives at market interest rates. A housing
cooperative is a means by which the occupants of an apartment
building can jointly own the building.
The need for thousands of units in congregates of assisted
housing, along with a variety of alternative housing is critical in
Colorado. The urban elderly do not have access to subsidized or
low-income housing, or they are displaced as a result of
redevelopment in the urban area. The rural elderly do not have
available housing alternatives and risk placement in a nursing home
as a result. Neither the urban nor rural elderly have income
levels which are adequate to incur the costs of home ownership at
today's prevailing interest rates, property values, and
construction costs. There is a lack of housing data on the rural
areas for which there are unique and specialized needs. Sometimes
there are rural portions of primarily urban counties which suffer
because of monies earmarked for urban areas.
Income. Inadequate income in retirement is a problem for
older persons. Expenses for older persons do not decrease at the
rate its income decreases from their years of retirement. In 1969,
the national median income for older persons age 65 and over was


55
$1,857 per year. For older American Indians, the median income was
only $1,408 per year. The Office of Management and Budget is
currently revising its income levels that determine whether a
family is poor. The poverty threshold for a nonfarm family of four
was $3,743 in 1969. The proposed poverty threshold for a nonfarm
family of four in 1979 was $6,700. The Office of Management and
Budget poverty guidelines for 1979 are as follows:
Table 11
Poverty Guidelines for 1979
Family Size Nonf arm Farm
1 $3,400 $2,910
2 4,500 3,840
3 5,600 4,770
4 6,700 5,700
5 7,800 6,630
6 8,900 7,560
Source: "Local Government Funding Report", Government Information
Services, Vol. VII, No. 16, April 16, 1979.


56
In 1969, 21.3% of all elderly persons age 65 and over had
income below the poverty level in the western United States, 31.9%
of all elderly black persons were below the poverty level, and
51.1% of all elderly American Indians in the West age 65 and over
had income below the poverty level (DHEW, Administration on Aging
Statistical Report on Older Americans, June, 1978).
Table 12 reflects the number of elderly persons in the
eight-county region with incomes below poverty level in 1970 and
1978. There was slight increase in the percent of the elderly
population with incomes below poverty level from 1970 to 1978. The
overall percentage change was not as great as the change in each
county.
According to the Department of Commerce, in 1975 the median
annual income levels for persons age 65 and over who had incomes in
Colorado were $5,782 for males and $2,697 for females. ("Money
Income and Poverty Status in 1975 of Families and Persons in the
U.S.", Current Population Reports and Consumer Income, Series P60,
Department of Commerce, Spring, 1976.)
Social Security Administration policies require that older
retired persons earning more than $3,240 ($3,240 for persons under
65; $4,000 for those 65 and older) per year have one dollar
deducted from their Social Security checks for every two dollars
earned


Nearly 90% of the elderly persons age 65 or older receive or
are eligible to receive Social Security benefits. Social Security
benefits are the major source of income for elderly persons age 65
and over (a report on the Senate
Developments in Aging).
Special Committee on Aging


Table 12
Elderly Persons with Income Below Poverty Level
1970 Total Population 1970 65+ 2 of Total Number of Persons Age 65+ with Income Below Poverty Level In 1970 1978 Total Population 1978 65+ 2 of Total Number of Persons Age 65+ with Income Re low Poverty Level In 1978
Total Z of 65+ Total 2 of 65+
Adams 185,808 6,642 3.57 957 14.4 248,938 11,883 4.77 2,229 19.24
Arapahoe 161,012 8,303 5.14 1,333 16.1 259,058 14,600 5.6 2,526 17.54
BouLder 130,002 9,145 6.95 1,710 18.1 191,197 11,542 6.0 1,928 15. bi
Clear Creek 4,819 422 8.76 77 18.2 6,711 364 5.42 41 11.26
Denver 513,995 58,786 11.42 12,607 21.4 525,887 61,257 11.65 13,409 21.83
Douglas 8,406 610 7.25 155 25.4 18,899 1,510 7.99 371 27.99
Gilpin 1,272 143 11.24 84 58.7 2,305 167 7.25 63 37.86
Jefferson 230,995 12,170 5.22 1,831 15.0 370,534 20,443 5.51 3,277 15.83
1,236,309 96,221 7.782 18,754 19.52 1,623,529 121,766 7.52 23,844 19.62
Source: Bureau of Census, DRCnG Comprehensive Planning Division


59
In a needs assessment survey conducted by the DRCOG office
on aging, the respondents were asked to cite their income before
taxes and their sources of income. Tables 13 and 14 below reflect
their responses.
Table 13
Income Before Taxes
% (N = 303)
-0- 1
§1 99 3
$100 124 2
$125 154 2
$155 199 8
$200 299 8
$225 299 12
$300 349 7
$350 399 5
$400 499 7
$500 599 11
$600 699 5
$700 or more 19
Dont know 1
No response 9
Source: "Service Needs of the Elderly: A Five County Urban
Assessment, DRCOG Office on Aging, Denver, CO 1979, page 15.


60
For the purpose of the survey, the respondents were
categorized by their income level into low, medium or high income
status categories. The low-income respondents received a monthly
income of $224 or less. The low-income level was determined by the
Colorado Old Age Pension eligibility requirements at the time the
survey was conducted. The medium-income elderly respondents
receive a monthly income of $225 to $399. The high-income elderly
respondents receive a monthly income of $400 or more per month.
Utilizing these criteria for determining low, medium or high
income, 24% of the respondents were in the low-income level, 31% of
the respondents were in the medium-income level, and 35% of the
respondents were in the high-income level.
The respondents were read a list of possible sources of
income. The respondents were asked to cite which of the select
sources of income they received regularly. Some of the respondents
received income from more than one source.


61
Table 14
Sources of Income
Source
Social Security (N=303)
Personal Savings (N=303)
Dividends and Interest (N=303)
Civilian Retirement Pension (N=303)
Income, Wages, Salary (N=303)
Supplement Security Income (N=303)
Income from Rented Property (N=303)
Armed Services Retirement Benefits (N=303)
Old Age Pension (N=303)
Assistance from Relatives/Friends (N=303)
Food Stamps (N=303)
Income from Insurance (N=303)
Minimal Self-Employment (N=303)
Aid to Blind or Disabled (N=303)
Rent Subsidy (N=303)
General Assistance (N=303)
79
67
55
30
17
11
11
7
6
6
4
4
4
3
2
2
Source: "Service Needs of the Elderly: A Five County Urban
Assessment", DRCOG Office on Aging, Denver, CO 1979, page 16.
*Percent of all respondents who received income from listed source
The Caucasian elderly respondents were more frequently in
the high-income level than either the Black elderly respondents or
the Mexican-American elderly respondents. The Mexican-American


62
elderly respondents were in the low-income level most frequently.
The Black elderly were most frequently in the medium-income
level. The percentages of the low-income elderly persons in the
survey are very similar to the national percentages reported
earlier in this report.
The survey revealed inflation and the high cost of living as
the most frequently cited serious problem of the elderly. The
expenditure patterns of the elderly include items which are common
to all persons; however, low income elderly persons spend a larger
portion of their income on basic items such as medical care, food
and housing.
Seventy eight percent of the retired elderly couples' budget
was expended on medical care, food and housing. Expenditures on
transportation, clothing and other costs were much lower than for
the urban family.
The impact of the elderly persons' concerns about inflation
and the high cost of living is evidenced by looking at the Consumer
Price Index in comparison with the three areas cited above which
incorporate three-fourths of the elderly's expenditures. From
January, 1978 to January, 1979 in Denver, goods and beverages
increased in price by an average of 13.3%. Meat, poultry, fish and
eggs increased in price by 21.3%. Housing expenses increased 16%,
medical care expenses increased 7.5%, and transportation expenses
increased 10%. Table 15 reflects the index.


63
Table 15
Percentage Increase in the Consumer Price Index
in Denver, Colorado
January, 1978 January, 1979
%
ALL ITEMS 12.4
FOOD AND BEVERAGES 13.3
Food 13.4
Food at home 13.0
Cereals & bakery products 11.6
Meats, poultry, fish & eggs 21.3
Dairy products 13.0
Fruits and vegetables 12.8
Other foods at home 5.9
Food away from home 14.8
Alcoholic beverages 11.8
HOUSING 16.2
Rent residential 9.9
Homeownership 21.3
Fuel and other utilities 9.5
Gas (piped) & electricity 16.8
Household furnishings & operation 7.1
APPAREL AND UPKEEP 2.6
Men's & boys apparel 2.3
Women's & girls apparel 5.6
Footwear 2.3
TRANSPORTATION 10.0
Private transportation 10.8
Public transportation 4.8
MEDICAL CARE 7.5
ENTERTAINMENT 9.3
OTHER GOODS & SERVICES 4.9
PERSONAL CARE 5.9
Source: The Consumer Price Index, U.S. Dept, of Labor Statistics,
Kansas City, MO, Feb. 23, 1979.


64
Pensions and Social Security have cost of living increases;
however, the increases have not kept up with costs. The increases
in expenses during the past year in Denver in the areas of food,
housing and medical care alone depict the seriousness of the
problem for elderly persons on fixed incomes.
Income resources are considered in two areas: the resources
or programs which provide cash income, and those resources or
programs that promote income conservation.
Public income resources include pension plans and tax
rebates, among which are the following programs:
1. Social Security benefits are payable for most persons
who reach age 65. The amount of the benefit is determined by past
earnings.
2. Supplemental Security Income program is administered by
the Social Security Administration to meet basic needs and living
expenses of the elderly.
3. Old Age Pension Program is financed by federal and
state funds for the low-income elderly. In the eight county Denver
region, there was a monthly average of 8,111 Old Age Pension
recipients in Fiscal Years 1976-77 (see Table 16).
4. Retirement programs are available for veterans,
railroad employees, military and civil service employees.
5. Real Estate Property Tax Refund and Rent Credit is
available to low-income persons 65 and over for reimbursement of
part of their property tax or for tax relief for renters.


65
Table 16
Public Assistance In Denver Region During 1976-77
County Old Age Pension Caseload (Monthly average) Percent Population on Welfare Percent Population Receiving Food Stamps
Adams 893 8.4 6.1
Arapahoe 603 3.7 2.9
Boulder 643 5.6 3.6
Clear Creek 37 6.4 3.8
Denver 5,103 16.0 10.1
Douglas 44 15.1 1.3
Gilpin 19 12.9 10.1
Jefferson 769 3.4 1.9
Region Total 8,111 8.7 5.9
Colorado 22,761 8.8 5.9
Source: Colorado Department of Health, Health Statistics Section
April 18, 1978.


66
The income conservation programs, or those programs which
offer free or low-cost services, discounts, or subsidies will be
covered in other sections of this report in more detail. They are
itemized in general categories below:
1. Housing Rent subsidies, low-income housing, monthly
average utility bill program, weatherization and minor home repair
programs are available for the elderly.
2. Transportation RTD offers free trips for the elderly
during non-peak hours of the day. Free transportation for
medical/dental care and nutrition is available for the elderly in
all eight counties through county-wide systems, multipurpose senior
centers and private providers.
3. Health Medicare is available to Social Security
recipients. Medicaid is available for low-income elderly
persons. Homemakers/home-health aid service is available in all
eight counties.
4. Nutrition Title III C nutrition sites provide a noon
meal five days per week.
5. Social Services Free/low cost legal service, income
counseling and chore services are available.
6. Recreation Passes are available for the elderly for
free admission to the parks.
7. Other Many restaurants and businesses provide
discounts for the elderly and post a notice in the establishment.


67
Summary of Gaps and Barriers to Service Delivery Systems.
Fixed incomes and physical problems often cause barriers for
participation in activities. Even though many elderly persons are
fairly healthy, independent and mobile, the cost of participation
in or transporting oneself to meaningful activities may be
prohibitive. Availability of elevators, number of steps, location
of parking, accessible restrooms for the handicapped, and grade of
slopes are all variables which elderly persons must consider prior
to participation in a program. A fear of crime may prohibit
elderly persons from participating in evening activities.
National studies have proven that elderly persons tend to
spend their free time in the same ways theyve always spent their
free time. In order to increase utilization of services, elderly
persons should be encouraged to assist in the design of community
programs. Diverse educational, cultural and recreational
activities need to be provided to accommodate the heterogeneous
elderly population, including the minority elderly.
Lack of income and inability to utilize transportation
systems are barriers to elderly participation in recreational
programs. Multipurpose senior centers serve many functions for the
elderly and the community. In addition to providing convenient
settings, they offer a wide range of activities including
recreation. Multipurpose senior centers have the potential for
providing social opportunities for elderly persons.
Title III funds under the Older Americans Act are
insufficient to meet the fiscal requirements of the 39 multipurpose


68
senior centers in Colorado. Financial resources should be
coordinated to insure the development and maintenance of the
community focal points required under the 1978 Amendments to the
Older Americans Act. Lack of coordination exists between
multipurpose senior centers located in close proximity to one
another. Lack of coordination exists between local service
providers and multipurpose senior centers.
A comprehensive summary of all multipurpose senior centers,
along with a list of their services, does not exist. In order to
comply with the 1978 Amendment of the Older Americans Act, training
and guidelines should be established. Criteria and procedures must
be established for the selection and designation of multipurpose
senior centers as focal points in Colorado.
Despite the many public dollars being spent and the number
of organizations available, a litany of long-term care problems has
been identified. Until the present, no consensus has emerged on
how these complex needs should be financed and organized in the
community. This study addresses certain key hypotheses about
experts' opinions regarding the best future options for providing
health and social services to the indigent elderly in Metropolitan
Denver, Colorado. Indigent for the purpose of this study means
those people who are unable to afford needed health and social
services because of poverty or inadequate insurance coverage.


69
Organization of the Study. Chapter I introduces the study
and describes a general basis for addressing the future options for
providing health and social services to the indigent elderly in
Metropolitan Denver, Colorado. The background and need for the
study, which is complemented by the chapter on literature review,
is generally discussed, including the statement of the research
problem. Chapter II, the literature review, provides general
background information on the options to indigent elderly in the
areas of finance, organization, care modalities, and Medicaid
restructuring and the hypotheses to be tested. Chapter III is
devoted to the research methodology and to the specification of the
study areas and the time period selected for the study. This
chapter will identify the study population group, identify the
measurement technique utilized, and describe data collection
procedures. The findings are explained and presented in Chapter
IV. Conclusions and recommendations are included in Chapter V.
i
t


Chapter II
LITERATURE REVIEW
Introduction
Future demographic and social projections imply considerable
increases in the need and demand for long-term care services. The
graying of America the increasing proportion of the population
that is old or very old was discussed in Chapter I. The long-
term care problems of the indigent elderly were also discussed.
These problems included: persistence of unmet needs in the
population, rapidly rising public and private expenditures,
fragmentation among services and financing, lack of case management
functions, bias toward institutional care and excessive burdens
placed on families.
In the following literature review these problems and
prospects for solving these problems are addressed. The approach
of this dissertation is to focus on experts' opinions regarding
possible solutions to the long-term care problems of the indigent
elderly in Metropolitan Denver, Colorado.
The first hypothesis addressed in this dissertation states
that there will be a consensus among experts about the best future
options for providing health and social services to the indigent
elderly in Metropolitan Denver. If one of the objectives of long-


71
term care reform is to eliminate all unmet needs, then eligibility
and benefits under public programs providing resources for long-
term care, as well as the actual supply of noninstitutional long-
term care services, would have to be greatly expanded. This could
be done under existing programs, but doing so would raise public
costs for long-term care substantially. This expansion would also
substitute formal care for informal care and public payment for
these services as opposed to private payment for these services.
Options for Financing Long-Term Care
The purpose of this portion of the literature review is to
present a synthesis of what the experts perceived as the major
reform options for financing long-term care. Seven analyses are
identified: Congressional Budget Office (CBO, 1977); Correia
(1976); Joe and Meltzer (1976); Poliak (1974); and U.S. Department
of Health, Education and Welfare (HEW, 1974,1976,1978).
Rather than describe each paper separately, the contribution
from each author is discussed according to the financing
characteristics of the option analyzed. These financing options
include: cash payments, voucher/disability allowance, national
health insurance, and mixed financing systems (specialization
program funding for long-term care setting: need or cost).


72
Osh payments. This option was considered by Poliak (1974)
and Correia (1976). According to Poliak, cash grants would be
given to eligible clients in proportion to their assessed level of
need. Clients would then be able to purchase whatever services
from whatever providers they wished (Correia does not define this
option).
Correia and Poliak agree that such a program would maximize
the flexibility of clients in meeting their long-term care needs
and in matching services to their particular circumstances but that
the cost of such a program would be very high.
Poliak and Correia disagree explicitly about the
administrative difficulty and complexity of this option. Poliak
believes that a cash-payment program would present fewer
administrative difficulties than a vendor payment program. Correia
states that a cash-payment program would be the most difficult
system to administer because clients would have a strong incentive
to exaggerate their disabilities. He concludes that such an
approach is unworkable because of its high cost and administrative
difficulties.
Vouchers. Poliak (1974) and others consider vouchers for
long-term care because in their opinion vouchers are a form of
program benefits and a way of organizing the supply of services.
As with cash payments, not all clients with needs for long-term
care may be capable of making effective consumer choices in the
marketplace.


73
National Health Insurance. This option was discussed
briefly by Joe and Meltzer (1976) who concluded that long-term care
should not be part of a National Health Insurance program unless no
alternative program is available. Since all proposals consider
only institutional long-term care, it would maintain arbitrary
classifications of institutions. These arbitrary divisions between
health and non-health long-term care services, under National
Health Insurance would be extremely expensive and would tend to
confine long-term care to a medical model.
Mixed Financing Systems. Among the mixed financing systems,
separate social insurance programs, specialized program funding by
type of care setting, and specialization of program funding by need
or cost, were dicussed.
Separate Social Insurance Program. This insurance option
has been looked at by the CBO (1977), Correia (1976), HEW (1974)
and Poliak (1974). This would be a federally administered,
individual entitlement program. Federal financing would be open-
ended and draw from general revenues. There would be no premium
payments or enrollment, but client cost sharing would be
required. Such a program could provide nationally uniform and more
equitable coverage of populations and benefits. The costs of such
a program are difficult to predict but are likely to be very
high. Federal regulation and intervention are likely to be
extensive and may not be adequately responsive to long-term
circumstances.


74
Specialization of Program Funding for Long-Term Care by Type
of Care Setting. HEW (1974), Correia (1976) and HEW (1978) discuss
this kind of option. HEW (1974) and Correia propose an open-ended,
individual entitlement (insurance) program for institutional long-
term care services and a separate program of closed-ended grants to
states for noninstitutional long-term care services. Such a system
of structuring program funding for long-term care would guarantee
access to institutional care for those who need it, while expanding
the availability and coverage of noninstitutional care.
Another variation of this option considered by HEW (1978)
would provide federal matching rates for institutional long-term
care services under Medicaid and would simply be reduced (instead
of being capped). The matching rates for noninstitutional long-
term care services under Medicaid would be raised. States would
likely support any increase in federal matching rates for
community-based services but would oppose any reduction in matching
rates for institutional services.
Specialization of Program Funding for Long-Term Care by Type
of Need or Cost. Although their proposals were very similar, HEW
(1974) and Joe and Meltzer (1976) each make a different set of
points about such a method of structuring program funding for long-
term care. HEW (1974) says that such an approach "relies upon
individual enlistment but allows state flexibility for social
services" (p. 53). Joe and Meltzer (1976) state that separating
out room and board from service costs enable a much simpler, more


75
effective way of setting room and board rates that are
realistically related to local conditions, zoning requirements, and
cost of housing.
Three innovative options for financing long-term care are
now discussed including the bloc grant, a national compulsory long-
term care insurance program, and a federal disability allowance
voucher program. All of these proposals are concerned with ways of
meeting long-term care needs, yet also with assuring efficient ex-
penditures of funds.
Bloc Grant Program. Hudson (1981) examined the concept of a
bloc grant and reviewed recent experience with some bloc grant
programs. He applies lessons learned to what might occur under a
bloc grant for long-term care. In Hudson's assessment, the bloc
grant might be a successful mechanism for limiting the expenditure
of funds in long-term care, but its impact on meeting human needs
may be less than positive. Hudson's main point seems to be that
the state-level political process engendered by the need to
allocate limited and fixed resources to a variety of long-term care
purposes could reduce alternatives and constrain the development of
new services. Success of any bloc grant approach would be highly
dependent on continued federal involvement in enforcing legislative
and regulatory provisions of the bloc grant legislation. He noted
that perhaps the only financial "carrot" large enough to induce
states to accept a bloc grant would be a national health insurance
program that relieved the states of Medicaid.


76
National Compulsory Insurance Program. Bishop (1981)
presented a convincing case that the private insurance industry
cannot offer comprehensive policies insuring against the risk of
long-term care disabilities. Bishop pointed out the significance
of the insurance problems of adverse selection and moral hazard for
long-term care and identified some unique problem factors resulting
from the nature of long-term care needs and the services required
to meet them. Among these factors are definitions of benefits and
the relationship of non-compensated family services to the benefit
structure. Bishop concluded that the only way to overcome these
problems is through a national compulsory program where individuals
insure themselves early in life for the increasing probability of
becoming disabled as they grow older. Bishop proposed that
efficiency in allocating resources be built on the elements of
consumer choice and co-payment. She described how this approach
would be as adaptable to the poor as to the rich. Despite the
strong tilt toward consumer control, a large federal role is
maintained, not only in the financing of the system but also in
personal needs assessment, rate regulation, and quality control.
Federal Disability Allowance Program. Gruenberg and
Pillemer (1981) focused their analysis on a disability allowance
approach. While this approach has some of the features of' the
insurance option in that it prescribes the covered benefits, it is
structured so as to be close to a cash-based system. To avoid some
of the economic and political problems usually associated with


77
assistance-type programs, the authors described a program that is
capable of differentiating individuals by degree of need, family
status, and income. While constraining the eligibility and
payment level, considerable consumer sovereignty remains. In this
discussion they briefly alluded to the preponderance of cash
programs in Western European countries. These countries have been
able to overcome the reluctance of public officials to provide
cash. By not including an income and assets test in their
proposals, Gruenberg and Pillemer may have developed a politically
acceptable compromise.
In summary all three of these options maintain a large role
for the federal government in financing these programs and insuring
that they are effective and efficient in meeting human needs.
There appears to be no way to release the federal government from
its responsibility in financing long-term care problems.
Range of Care Options
The second hypothesis addressed in this dissertation states
that there will be diverse opinions among experts about how to
implement future options for the care of the indigent elderly in
Metropolitan Denver.
If the objectives of LTC include helping individuals cope
with their disabilities, reducing their dependencies on others, and
narrowing the gap between their actual and potential functional
capabilities, then it is clear that the nursing home is not the
only appropriate site of care, (U.S. Comptroller General, 1979).


78
U.S. Comptroller General is hereafter referred to as GAO. LTC
services (health, social and income support) can be provided in the
home, adult day care centers, outpatient ambulatory care
facilities, and, in some cases of great disability and/or lack of
major social supports, the nursing home or the acute care hospital.
Long-Term Care. LTC sites differ in the type of care they
provide, or they may differ not in the type of care but in the way
the services are packaged. For example, physical therapy (PT) can
be offered in the home by visiting professionals or can be provided
in a hospital or day hospital setting. Clearly, the sites of care
and the services they offer can operate as substitutes or
complements in a static sense. In a dynamic sense, they can serve
as steps or sequences in a continuum of care which may begin with
the home, involve all episodes of hospitalization, find the patient
in some sort of extended care facility, and end with the patient
back at home and with many movements back and forth (Rice and
Taylor, 1984).
Local Long-Term Care Organizations. The use of local long-
term care organizations is discussed by Correia (1976), HEW (1976)
and HEW (1978). Such organizations would receive federal/state
grants to provide long-term care services in their local area.
Their functions would include individual needs assessment, referral
to and coordination of appropriate services, case management
planning; a comprehensive, local service delivery system for long-
term care (if public); quality assurance; and advocacy. Many
possible variants of such an agency exist.


79
The use of local long-term care organizations would allow
much greater flexibility in allocating resources, both among
individuals and among various types of services (institutional and
non-institutional, health and social) in meeting individual needs
for care in responding to local needs, circumstances, preferences,
and priorities, and in controlling expenditures. Fewer externally
imposed constraints and control mechanisms would be needed, such as
those involving restrictions on benefit coverage, eligibility
criteria, reimbursement methods and rates, and various means of
controlling the utilization of services. The quality of care
provided would be better controlled. Individual needs assessment
would provide a better basis for planning community long-term care
delivery systems (Youket, 1981).
Other options considered for organizing the delivery of
long-term care services were discussed, including the case
management concept, the single agency model, and the social health
maintenance organization (S/HMO). In a period of fiscal
constraint, organizational structural change may be feasible as it
adopts a new approach to an already existing network.
Case Management System. Beatrice (1981) presented a
detailed analysis of the case management concept and showed how
case management might be the most immediate device available for
improving the life of persons with long-term care needs. Beatrice
defined and discussed identifiable case management functions
ranging from data collection to assessment to follow-up. Beatrice


80
saw the variables of authority, location, and assessment style as
issues to be resolved prior to the establishment of any case
management system. Beatrice believed that local environments are
critical in shaping the case management process.
Single Agency Model. James Callahan (1981) in his
discussion of a single agency model recommended incrementalism.
Callahan reviewed a number of single agency efforts of some other
demonstrations. Drawing upon system concepts, he identified
compatible and incompatible functions and suggested a model that
builds on mutually reinforcing functions. Callahan called for the
separation of financing, planning, and advocacy from service
delivery.
Social and Health Maintenance Organization. Diamond and
Berman (1981) presented the concept of a new entity (S/HMO) as a
way of bridging the financing and delivery of long-term care
services. They called for a prepaid, capitated organization that
offers a full range of medical and social services to an enrolled
population over age sixty-five. Having to operate within a fixed
per capita budget was presented as a means to shift care from high-
cost institutional services to lower-cost, ambulatory community and
personal care services. While the S/HMO was presented as an
exciting innovation, the authors candidly reviewed the problems of
enrollment, risk sharing, cost cutting and quality of care.
In summary, case management, a single agency, and a social
health maintenance organization are three particular ways of
organizing long-term care functions.


81
Long-Term Care Institutions
Turning now to a discussion of long-term care institutions,
the number of patients filling these institutions is staggering.
Today 1.4 million individuals reside in approximately 23,000
nursing homes. By the year 2000 this number could jump to 2.6
million, almost doubling in 20 years. However, the numbers do not
reflect the -real picture; one must look at the composition of the
patient mix. This increase in the aged population especially in
the 85 age group with a far healthier "young aged population will
result in a long-term care facility different from today's skilled
nursing facility (Vladeck, 1980).
The third hypothesis addressed in this dissertation states
that there will be a consensus among experts that skilled nursing
home care will increase to accommodate the increased numbers of
frail indigent elderly. One change that nursing homes will either
face or instigate will be in the treatment area. During the years
1970 to 1980, the emphasis in nursing homes was on psycho-social
care with an accompanying reduction in emphasis on the acute care
model. By the year 2000 this situation will change. Patients will
be entering nursing homes in greater numbers and a far different
patient mix will exist. Medical advances that allow individuals to
stay healthy well into their eighth decade will create a very old
and very sick nursing home population. Patients will enter
facilities in their 80's and require round-the-clock nursing and
physician care with less use made of the allied health and social
services professions (Willging, Kreshner and Peres, 1984).


82
Colorado's Nursing Home Population. The nursing home
population of Colorado for 1980 was 16,375 or 0.55% of the state's
total population. A 1980 survey conducted by the State Mental
Health Division as a part of the long-term care systems development
grant activities estimated that between eight and eleven percent
(1,350 to 1,750 persons) of the nursing home population are
chronically mentally ill. Between 550 and 650 of these individuals
could be appropriately served in mental health facilities (400-450
on a residential basis and 150-200 in a community-based setting).
With effective mental health assistance for a period of time, a
significant percentage of the 400-450 transferred to mental health
residential care could be moved to a more appropriate and
desirable, and perhaps less costly, community-based setting
(Colorado State Health Plan, 1980).
A census by the Division for Developmental Disabilities
determined that in 1980 there were 736 developmentally disabled
(DD) persons residing in nursing homes across the state. Of this
total, 556 are under age 65 and 180 are aged 65 or older. The
second phase of the study will make recommendations on the
availability and development of appropriate alternatives.
In addition to the above totals, eight percent (1,090
individuals) of the elderly nursing home population could be
adequately supported outside the nursing home if appropriate
service-based settings were available. It is not possible to
determine what additional percentage of the nursing home population
would have maintained a higher level of functioning if community-


83
based services had been available when nursing home placement had
been initiated (Sims, 1984).
Clearly, these data are important in estimating and planning
long-term care requirements such as nursing home bed supply and
costs of home care alternatives. However, calculating long-term
care needs requires a more thorough understanding of the life
styles of the elderly. Ninety-five percent of the elderly are not
residents of nursing homes. Colorado's utilization of nursing
homes approximates the national average. Those in nursing homes
are not typical of the elderly population. More than 80% of the
nursing home population is 75 years of age and older. Less than
one percent of the population from 64-74 is in a nursing home.
More than 21% of the population 85 years and older are in a nursing
home (U.S. Bureau of the Census, 1978b).
A representative nursing home resident is an 80-year-old
white female, who is a widow or spinster of limited means, with
three or four chronic ailments (U.S. Senate, 1974). Many very old,
chronically ill people are cared for at home through a network of
informal supports. Estimates indicate that as much as 80% of all
required long-term care is being provided through informal
systems. Most of these care-givers are women. It is not known to
what degree these people may require additional assistance. In the
absence of a clear understanding of who requires assistance, it is
extremely difficult to project needed services or costs.
Population trends are indicative of what may be expected, but more
refined models and calculations are required for determining what
actions to take (Colorado Foundation for Medical Care, 1979).


84
Medicaid Nursing Home Utilization and Costs. The level of
Medicaid nursing home utilization in Colorado over the last five
years (state fiscal year 1976-77 to fiscal year 1980-81) has shown
a steady increase. The state accounting system records the total
number of Medicaid nursing home days per year but does not show the
number of days per client. The state does not have historical data
on the average length of stay per nursing home resident. Initial
data gathering indicates that, effective with 1980 data, the number
of new nursing home admissions is decreasing while the length of
stay is increasing. The graph in Figure 3 plots the days of
Medicaid nursing home utilization. Figure 4 plots the increase in
the Medicaid per diem cost for that same time period. The Medicaid
per diem cost considers only those dollars actually paid to nursing
homes by Medicaid. Patient per diem expenses are higher. Part of
the difference is paid by the patient's income resources such as
private or public retirement benefits. The remaining difference
either is compensated for by higher rates to private patients or is
not recovered by the nursing home. A 1981 study by the Colorado
Office of State Planning and Budgeting (OSPB) determined that daily
nursing home rates in Colorado including Medicaid and private
payments for mid-1981 were $30.97 for skilled nursing care and
$29.69 for intermediate nursing care.
Trend analysis using linear regression allows the analyst to
project expenditures of Medicaid dollars and utilization rates
based on a constant growth rate. Figure 5 displays the projected
total Medicaid financial burden to the state based upon the
anticipated increases in days of utilization and per diem expenses.


85
Figure 3
Average Daily
Medicaid Nursing
Home Population
(in thousands)
Medicaid Nursing Home Utilization
o = actual data
x = projected value from linear regression
Year
Source: Colorado Office of State Planning and Budgeting (1981)


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