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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 : ill. ; 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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Thesis:
Thesis (Ph. D.)--University of Colorado at Denver, 1985.
Bibliography:
Includes bibliographical references (leaves 184-191).
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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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
1985


This thesis for the Doctor of Public Administration
degree by
Hilda Kasoff Grey
has been approved for the
Graduate School
of Public Affairs
by
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
commend
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 Horae 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 American's 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


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-


13

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
Both Both
Age Sexes Male Female 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 population4 .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
Total persons below Total persons 60 and
Counties poverty level 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).


---------1--------
I
Table 7
Summary: Total Persons by Race by Poverty Status
Total Number Total number above poverty level Percentage above poverty level Total number be Lou 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
Aslan & 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) * v (8) (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)
LO
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
Aslan & 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 t(S> Q(S) *(S) *0(S) *(S) *0(S) *(S)
American Indian, Eskimo, Aleut (S) (S) (S) 0(S) * 0(S) (S)
Asian & 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 I.
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)


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 Governments 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.
!
I
i
I
I
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.
i
t
i
i
i
i
j
i
i
i
\
<
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
f
I
Figure 2
Per Capita Expenditures
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
ft* REGION III 8 8 8 7 7 - -
REGION V 1 1 - 1 - 3 8

HSA I 12 12 11 11 10 5 10
ft 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 # aE 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
DROOG Office on Aging Service Area
Source: Central Northeast Colorado Health Systems Agency
-O


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 Special Committee on Aging,
Developments in Aging).


Table 12
Elderly Persons with Income Below Poverty Level
1970 Total Population 1970 651 Z of Total Number of Persons Age 65+ with Income Below Poverty Level In 1970 1978 Total Population 1978 65+ Z of Total Number of Persons Age 65+ with Income Re low Poverty Level In 1978
Total Z of 65+ Total Z 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. b3
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 7.78Z IB,754 19.5Z 1,623,529 121,766 7.5Z 23,844 19.6Z
Source: Bureau of Census, DRCOG 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
Don1t 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)


Full Text

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I 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 1985

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I I i r l I I i i I I I I I I i I I I. l I I This thesis for the Doctor of Public Administration degree by Hilda Kasoff Grey has been approved for the Graduate School of Public Affairs by Eileen Orleans Date -hc I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i 'I by Hilda Kasoff Grey 1985 All Rights Reserved

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i i i I I I I I I I I' 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The form and content of its publication. v commend

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 Hellman for their cooperation and scholarly guidance. advice were invaluable to this study. Their suggestions and 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 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i i I i I I I i I l i I l l I I I i l i 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, encouragement and love. Hilda Kasoff Grey Denver, Colorado June 1985 Howard, for his understanding,

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i ; I i CONTENTS CHAPTER I INTRODUCTION Overview 1 Purpose of the studY Existing programs in long-term care S Problems with existing programs ? Rapidly rising public and private expenditures Fragmentation among services and financing ll Lack of case management functions 12 Bias toward institutional care 13 Excessive burdens placed on families 17 Growth in aging population Demographics in Colorado 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 Housing Income ss

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. j' 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 Vouchers 72 National health insurance Mixed financing insurance73 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 National Compulsory Insurance Program 76 Federal Disability Program 76 Range of care options Long-term care Local long-term care organizations 78 Case management system Single agency model ao Social and health maintenance organization BO Long-term care institutions Bl Colorado's nursing home population 82 i! 1

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ll X Medicaid nursing home utilization and costs Family support services 94 Alternative services Funding under MedicarelOO Funding under MedicaidlOl Funding under Social Security Act l02 Funding under Older Americans Act l03 State Center Grants Program l03 Housing and Urban Development Programs l03 Problems with fundingl04 Problems of quality assurance l08 Restructuring Medicaid llO Summary 111 CHAPTER III RESEARCH METHODOLOGY Introduction ll3 Key characteristics of Delphi 1 Steps in Delphill5 Results in Delphi ll8 History and previous applications of Delphi ll9 Strengths and limitations of Delphi l22 Objectives l24 Formulation of the problem regarding indigent elderlYl24 Test and interpretation regarding indigent elderlYl27

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :: i i I I f ': I i l I 1 I I l I i I I i I I I I I I I j I I I I I I i I I I I \ il i I: xi Limitations .. 131 Summary CHAPTER IV FINDINGS Introduction l33 Problems of the indigent elderly l34 Hypothesis 1 135 Hypothesis 2 Hypothesis 3 Hypothesis 4 Hypothesis 5 Summary 16 7 CHAPTER V CONCLUSIONS AND RECOMMENDATIONS Conclusions I69 Recommendations l80 REFERENCES . 184 APPENDICES A. Round one questionnaire and cover letter l92 B. Round two questionnaire and cover letter l95 c. Round three questionnaire and cover letter 209 D. Round three results

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. : j 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 6. Summary of Unrelated Individuals and Householders 65 and Over Below Poverty Status 30 7. Summary: Total Persons by Race by Poverty Status 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 14. Sources of Income 61 15. Percentage Increase in the Consumer Price Index 63 16. Public Assistance in Denver Region During 1976-77 65

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 l52

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :! i l I I l I i ! i i II 1 I 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 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 l41 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 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i i I i l I I I I I i i l j l I : j 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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, l9ti2). 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 chronological 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).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. j: 2 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 nev; 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, 19 7 6) 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 JOOst 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 I I I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 soci-al 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 I j special trust funds for use in meeting these expenses incurred by I I II i I i I :

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. .I 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 American's 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 thirtynine multipurpose senior centers in the region and numerous

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I I l I I I l I I j l I l I I I l I I I I l l i I 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. l I i i i i l I I 1 j I I I l I i l i i I I 1 I I I I l ! i !J :I 'j 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 car2 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I i i 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 (19 78) 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. \j 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I i I I I I I i l I l I I I I l l i I I I I I l \! !f j! I 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-tem 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-tem 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. l i I 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 deli very 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-

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 'I 13 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 longterm 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, institutionalized patients so that are unnecessarily they can receive or inappropriately 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; I 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 longterm 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. t i I j I i l ( I l I I i I I : I i I 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-tiona! 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 'i I I 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 institutionalized 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 C.BO 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 'I II II '' I 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). Percent of 1980 Level 160 150 140 130 120 110 100 Figure 1 >85 >65 all 1990 2000 Year Projected Growth of u.s. Elderly Population 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :: .-.::._"_-- __ ... _..,., __ ___ ___ .. __ _....a.-.--,,......----.----------.-----------__ ,__.. _., - --... --...-.-------...--... ..... ..--u Table 1 Population by Age, Colorado and the U.S., 1980 (percent of total) AGE GROUPS 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 60-64 65+ u.s. 7.2 7.4 8.1 9.3 9.4 8.6 7.8 6.2 5.2 5.1 4.5 11.3 median age: 30.0 Colo. 7.5 7.4 7.8 9.3 10.5 10.5 9.2 6.7 5.3 4.8 4.3 8.5 median age: 28.6 Source: u.s. Census, 1981 N w

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. --------4 __ ... ___ -----.. ---------------.... --. Age 60-64 65-69 70-74 75-79 80-84 85+ TOTAL Source: Table 2 Population Counts by Age and Sex in Colorado, 1970-1980 1980 1970 Both Both Sexes Male Female Sexes Male 102,524 48,872 53,652 79,065 37,735 84' 113 37,858 46,255 62,119 28,192 64,501 27,664 36,837 49,398 21,163 44,931 17,632 27 '299 36,881 15,010 29,367 10,052 19.315 23,261 9,096 24,349 7,320 17,029 16,254 6,U72 349,785 149,398 200,387 267,078 117 '266 u.s. Census, 1981 Female 41,332 33,927 28,235 21,871 14,265 10, 182 259,812 N

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I I i l l i i I I I I I I I l I I I I I I I i l I i I il ! 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 70.81.. 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. Age Group Under 19 20-39 40-59 60-84 85+ Table 3 Changes in Age Distribution of Colorado Population 1970-1980 1980 Change 1970-1980 Population Number Percent 923,953 61,684 7.2% 1,065,214 441,733 70.8 549,882 93,484 20.5 325,436 74,612 29.7 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :l 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 Category Mental health population in need includes approximately 1 1350 1750 in nursing homes Developmentally disabled includes 736 in nursing homes 2 impaired elderly Elderly home population Total population in need Total Colorado population Colorado Population Distribution Percent Total 7.8% 225,400 1.7% 49,100 0.4% 11,600 .5% 14,400 10.4% 300,400 100% 2,889,964

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I i I i i I I I i I I I I I I I I i ) i i ( i I I I I l I I I I I i i i I 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 Percent in Target Group 0-11 6% 12-17 10% 18-64 7% 65+ 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 unemplo)rment. 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 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. : i 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 s.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. "- -------------------.. --_ ..... --... .. ..,,_ ....... ...... ... ,_,. ___ A_O ...... ------.-... _.. .... _,..._. ______ ...... ,.-.,. ........ _._..,.,_ ..... .. Table 5 Total Persors and Persons 60 and 0\t!r Poverty Level Total persors Total persons 60 am Ca.mties poverty level over poverty level % (1) distribution % (2) distribution AdaJs 18,472 1,861 10.1 ll. 3 Arapahoe 13,345 1,359 10.2 8.2 Boulder 18,358 1,387 7.5 8.4 Clear Creek 425 00 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 .verty level. (2) represents a percent8,!J! oc Denver Regim' s 60 and over population belcw the )Xlverty level N Data Soorce: Ilm Canprehersive Planning Division (U.S. Census SfF 3A Tapes for 1980 Data) \0

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 Data). Table 6 Summary of Unrelated Individuals and Householders 65 and Over Below Poverty Level Unrelated individuals Householders 65 and over 65 and over Counties below poverty level below :2overtx: 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 i individuals live in group quarters, such as non-family households. I I I I [I ; t

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 I I I I i

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Adams County White Black American Indian, Eskimo, Aleut Asian & Pacific Islander Arapahoe County White Black American Indian, Eskimo, Aleut Asian & Pacific Islander Boulder County White Black American Indian, Eskimo, Aleut Asian & Pacific Islander Clear Creek County White American Indian, Eskimo, Aleut Asian & Pacific Islander --l--Table 7 Summary: Total Persons by Race by Poverty Status Total Number 2l9 ,471 6,21& 2,095 3,68& 274,727 8,/&7 1,474 4, ;so 179,780 1,766 930. 2,451 7 152 " 54 0 Total number above poverty level 202,234 4,941 1,824 3,142 260,460 7,174 1,273 4,233 156,022 1,229 &32 1,839 &.l705 (S) 49 0 Percentage above poverty level 7').5 87.1 85.3 94,8 84.8 8&.4 92.4 86.8 69.5 68.0 75.1 p.8 (:i) 90.7 0 Total nurnher below poverty level 14. 9!!.!! 1,057 213 529 11,393 937 135 314 1&,&37 238 249 415 41Z *cs> 3 0 Percentage below poverty level &.9 1&.9 10.2 14.4 4.2 11.2 0.2 &.9 9.3 13.5 26.8 16.9 5,8 *cs> 5.6 0 *(s) represents infor:nation that is suppressed. Refer to Appendix for the definition of suppressivn. Others Z,Zil9 224 58 15 2,874 356 && 33 7,021 299 4'1 197 35 * 2 0 Others are those who are not classified as above or below poverty lete1 because they do not generate any type of income. Data Source: DRCOG Comprehensive Planning Division (U.S. Census STF 3A Tapes for 1980 !Jata) Percentage 1.0 3.6 2.7 0.3 1.0 4,0 4.4 0.7 3.9 7.0 5.2 8.1) .o.4 (S) 3.7 0 w N

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ...... ----------------.. ... ...... ... ----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 23.5 178 1.9 Douglas County White 24.741 23,587 95.3 1,001 4.1 153 0.6 Black 81:1 81:1 100.0 0 0 0 0 American Indian, Eskimo, Aleut 51:1 31:1 65.5 20 34.5 0 0 Asian & Pacific Islander 1:17 78 89.7 9 10.3 0 0 Gilpin County White tfl2 224 9.4 63 *2.& Black (S) 2(S) . :o * :o(S) . American Indian, Eskimo, Aleut * (S) (S) O(S) * O(S) (S) Asian & Pacific Islander 0 0 0 0 0 0 0 Jefferson County White 357,611 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 ll.2 64 ll. 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 Asian & Pacific Islander 24,165 19,846 82.1 3,807 15.8 512 2.1 * 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 JA Tapes for 1980 Data) w w

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. j I i l I I I I I I I I I i I I I J I I I 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 (DR COG, 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I l I I I i I I j I i i I I I 'I 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I ; i 36 connected with the inability to get to shopping facilities, health care facilities, etc. s. Dependency. Nine percent of the reported by older persons involved taking care total problems 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 lowincome housing.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i i I i I I I I i I i, il ;i i I ; I 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 (Colorado's 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I l I j l 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 1n

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i i I I I I I I II I 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 Expenditure Total Nursing Home Care Hospital Care Physician's Services Dentist's Services Drugs amd Drug Sundries Other Professional Services Eyeglasses and Applicances Other Health Services Ratio of Amount Spent in FY 1975 to Amount Spent in FY 1966 3.1 5.0 3.4 2.4 1.8 1.9 1.7 1.5 1.9 Source: 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 physician's 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I [ I I i I I i i i i i I I I I i i I I I I I i I I l I I I II I' ,I II $71 D $603 Hospital care Under 19 Years Figure 2 Per Capita Expenditures ... $70 $218 Physician's Services 19-64 Years Health Care Expenses by Age United States 1975 $539 $70 Other Health Services 65 Years and Over 41 Source: Age Differences in Health Care Spending, Fiscal Year 1975, by Robert M. Gibson, Social Security Bulletin, June 1976.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i 'I 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. _,.. -,..__ .. -. -. ----Table 9 Availability of Home Health Agencies Services Range of Services Provided hi Agencies Number of Skilled Home Planning Home Health Nursing Speech Physical Occupational Social Health Region Agencies Services Therapy Therapy Therapy Worker 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 Sourc.e: Colorado Department of Health & Central Northeast Colorado HSA ** DRCOG Office of Aging Service Area .p. w

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :.::::-.::.:::=-.: ---. --" ...... -... ------Table 10 Utillzatioo ani Need Projection for As!ft. 55 ani OVer Hone Health Care Hone Visitirg /!of Health Public Total 65 & OVer Visits 65 & Over Agencies Health Patient Patient Needed for Patient Planning Servires NJ.rses Care Needs 65 & Over Needs Regions 1979 1979 1979 1979 1979 1984 I 96 57 153 525 1o,m 599 II 7'XJ 413 1,159 1,396 27,920 1,576 REI;IOO nr** 5,643 1,370 7,013 7,671 140,260 8,466 REGIOO V 54 64 118 176 3,520 191 HSA I 6,539 1,904 8,443 9,768 182,200 10,832 Utilization al1 Need Data l:ssed on fornulae developed by the Colorado DepartiiBlt of Health ** Ltm Office Service Area Source: U!ntral Northeast Colorado H:!alth Systerrs Age'CK"'f II of Visits Needed for 65 & Over 1984 11,980 31,520 169,320 3,820 216,640 ""' ""'

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I i I I I I 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 Regi.onaf 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I d I 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 PHA's 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 BUD-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 i

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. j I 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I' ; i I i I I I I I I I I I I l i I I I I l I ! I I ,, ll I! :' i I 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I ; I II I i :I I. I I ; I 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. '; :I 'I i I i ; ! i t t I i I I I I l I I I I { : i i I I I I I i I I I I I I I I; I! 11 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; ; I 'I 55 $1,857 per year. For older American Indians, the median income was only $1,408 per year. The Office of "ianagement 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 Nonfarm 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I l II 'I II i l li I' ; 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 57 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 Special Committee on Aging, Developments in Aging).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. .. .... ._ .......... _., .._ ............. __ ... ___ ....... ----.. Table 12 Elderly Persons with Below Poverty Level Number of PerannR Age 65+ with lmnme Relnw Poverty l,r>wl in 1970 1970 1978 Total 1970 % of % of Tot Ill Population 65+ Totlll Total 65+ Population Adams 6,642 957 14.4 248,938 Arapahoe 161,012 8,303 1,333 16.1 259,058 Boulder 130,002 9,145 6.95 I ,710 18.1 191 '197 Clear Creek 4,819 422 8.76 77 111.2 6,711 Denver 513,995 58,786 11.42 12,607 21.4 525,887 Douglas 8,406 610 7.25 155 25.4 18,899 Gilpin 1,272 143 11.24 84 58.7 2,305 Jefferson 230,995 12,170 5.22 1,831 15.0 370,534 I ,236,309 96,221 7.78% 18,754 19.5% 1,623,529 Bureau of Census, DRCOG Comprehensive Planning Division 1978 % of Total II ,883 4.77 14,600 II, 542 6.0 364 5.42 61 ,257 11.&5 7.99 167 7,25 20,443 5.51 121 '766 7.5% Number of Persons AP,e with lnrome Rr I ow Poverty Leve I In 1978 % of Total 6H 2,229 19,24 2,526 17.54 1,9211 41 11.26 13,409 2l.IB 371 27.99 63 37.86 3,277 15.83 23,844 19.6% VI co

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; l I i l i! I, i! 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) -01 $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 Don't 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. \ i 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 14 Sources of Income %* Source Social Security (N=303) 79 Personal Savings (N=303) 67 Dividends and Interest (N=303) 55 Civilian Retirement Pension (N=303) 30 Income, Wages, Salary (N=303) 17 Supplement Security Income (N=303) 11 Income from Rented Property (N=303) 11 Armed Services Retirement Benefits (N=303) 7 Old Age Pension (N=303) 6 Assistance from Relatives/Friends (N=303) 6 Food Stamps (N=303) 4 Income from Insurance (N=303) 4 Minimal Self-Employment (N=303) 4 Aid to Blind or Disabled (N=303) 3 Rent Subsidy (N=303) 2 General Assistance (N=303) 2 61 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. \I [I l; ; I ; l 62 elderly respondents were in the low-income level most frequently. The Black elderly were most frequently in the mediumrincome 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. il I I i l I I I l I I i i I I i I i l I I I I Table 15 Percentage Increase in the Consumer Price Index in Denver, Colorado ALL ITEMS FOOD AND BEVERAGES Food Food at home January, 1978 -January, 1979 Cereals & bakery products Meats, poultry, fish & eggs Dairy products Fruits and vegetables Other foods at home Food away from home Alcoholic beverages HOUSING Rent residential Homeowners hip Fuel and other utilities Gas (piped) & electricity Household furnishings & operation APPAREL AND UPKEEP Men's & boys apparel Women's & girls apparel Footwear TRANSPORTATION Private transportation Public transportation MEDICAL CARE ENTERTAINMENT OTHER GOODS & SERVICES PERSONAL CARE % 12.4 13.3 13.4 13.0 11.6 21.3 13.0 12.8 5.9 14.8 11.8 16.2 9.9 21.3 9.5 16.8 7.1 2.6 2.3 5.6 2.3 10.0 10.8 4.8 7.5 9.3 4.9 5.9 63 Source: The Consumer Price Index, u.s. Dept. of Labor Statistics, Kansas City, MO, Feb. 23, 1979.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I i I ll 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 16 Public Assistance In Denver Region During 1976-77 County Adams Arapahoe Boulder Clear Creek Denver Douglas Gilpin Jefferson Region Total Colorado Old Age Pension Caseload (Monthly average) 893 603 643 37 5,103 44 19 769 8,111 22,761 Percent Population on Welfare 8.4 3.7 5.6 6.4 16.0 15.1 12.9 3.4 8.7 8.8 Percent Population Receiving Food Stamps 6.1 2.9 3.6 3.8 10.1 1.3 10.1 1.9 5.9 5.9 65 Source: Colorado Department of Health, Health Statistics Section, April 18, 1978.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; .I I I 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 they've 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 longterm 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-

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. l I i l i' 'I :I I. j i ;, i 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); Pollak (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).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I i 72 payments. This option was considered by Pollak (1974) and Correia (1976). According to Pollak, 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 Pollak 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. Pollak and Correia disagree explicitly about the administrative difficulty and complexity of this option. Pollak 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. Pollak (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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i 'I i I il I 'I :! 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 Pollak (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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; i l! 'l J 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 longterm 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 75 effective way of setting room and board rates that are realistically related to local conditions, zoning requirements, and cost of housi-qg. Three innovative options for financing long-term care are now discussed including the bloc grant, a national compulsory longterm 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 expenditures 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ,i 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).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I ij q '' '; l j 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

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 highcost 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 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).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 82 Colorado's Nursing Home Population. I 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:I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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 in ormal 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).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 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.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I i i i i l i i I I I I, ll ., I l i :! Average Daily Medicaid Nursing Home Population (in thousands) Figure 3 140 130 120 110 100 90 76 77 '78 79 80 81 82 83 84 85 Year Medicaid Nursing Home Utilization o = actual data x = projected value from linear regression Source: Colorado Office of State Planning and Budgeting (1981). 85

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 86 Figure 4 32 30 28 26 Per Diem 24 Cost 't:r 22 20 18 16 14 0 76 77 78 79 80 81 82 83 84 85 Year Medicaid Average Nursing Home Per Diem Cost o = actual data x = projected value from linear regression Source: Colorado Office of State Planning and Budgeting (1981).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :i I :I :I Dollars (in millions) 200 175 150 125 100 75 50 25 87 Figure 5 1976 1980 1984 1988 Year Escalating Medicaid Nursing Home Costs Source: Colorado Department of Social Services, Accounting Office (1981 ).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 88 The following cost and utilization figures in Table 17 are taken from the Medicaid records of the Colorado Department of Social Services, Accounting Office. Fiscal Year 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 Table 17 Medicaid Nursing Home Population and Cost Per Diem Cost Actual $13.74 15.47 17.27 19.10 21.15 Estimated 22.88 24.73 26.57 28.42 30.26 32.11 33.95 35.80 Daily Medicaid Population 9,461 9,859 10,018 10,852 11,203 11,622 12,069 12,517 12,965 13,413 13,860 14,308 14,756 Annualized Medicaid Dollars (in millions) $47.5 55.7 63.2 75.7 86.5 97.1 108.9 121.4 134.5 148.1 162.4 177.3 192.8 Source: Colorado Department of Social Services, Accounting Office, 1981 If expenses climb at a constant rate, the per diem Medicaid nursing home rate should double by 1992 while total Medicaid nurs1ng home annual residency days will not double until 2005, over a decade later. By 2005 Medicaid per diem charges will have tripled. When anticipated increases in the Medicaid per diem rate are considered along with the increasing rate of utilization

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 89 (caused primarily by longer lengths of stay) the total Medicaid nursing home expense increases at a dramatic rate, doubling by year 1988 (Colorado Department of Social Services, 1981). Long-term care in Colorado is expensive. For FY 79-80, public expenditures were approximately 228 million dollars which included about $93 million of state funds. Of that 93 million dollars, $47 million was paid to nursing homes, $21 million for income support payments, and $11 million for other medical expenses. The remaining $14 million was divided among other services including food programs, mental health services, and homehealth/homemaker care. These dollars were spent on the impaired elderly and institutionalized developmentally disabled clients. Only disability pension dollars for persons aged 60-64 are included (Colorado Long-Term Plan, 1982). With current data collection methods, it is not possible to count the number of people served by these dollars without duplication; thus, it is difficult to calculate a reliable per capita cost. The nursing home population in 1979 was approximately 16,000. Long-term care utilization studies indicate that an equal number of persons received long-term care community services. Therefore, 32,000 elderly persons (or approximately 20% of the 65-plus population) utilized the long-term care system in FY 79-80. This would give a state capita cost of $2,900. When federal dollars are considered, the per capita cost increases to $7,100 (Colorado Long-Term Plan, 1982).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 90 The University of Colorado Health Sciences Center estimates that private long-term care costs are approximately equal to public expenditures, bringing total estimated long-term care dollars for FY 79-80 to a half billion dollars. When the rate of increase in health care costs is considered, the future financial impact on the state becomes frightening. Long-term care in Colorado is becoming increasingly expensive and will be more difficult to finance in view of budget constraints (Colorado State Health Plan, 1980). Anywhere from ten to forty percent of the elderly people now in nursing homes could equally well be cared for in a noninstitutional environment, according to the findings of both state and national research. Non-institutional care would in many cases cost less per capita than residence in a nursing home. The majority of elderly people prefer receiving assistance that would permit them to remain in their own homes or in a similar residential setting to entering a nursing home and giving up their possessions and community ties. Why then does the problem of inappropriate institutionalization exist (Grimaldi, 1984)? There is general agreement that a major cause of the problem is that most private insurance policies and public programs will pay for services provided in a nursing home but do not allow for many similar services delivered in the home. The services for which costs are reimbursed, and the nature of the restrictions upon their eligibility for reimbursement, vary according to the payment source. Medicare, for example, will not pay for any home care unless an elderly person has recently been hospitalized (McCaffree, 1977).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I I l I l I I I I \I I I :I 91 National research has shown that elderly people who might otherwise remain at home are constrained to enter nursing homes most frequently for lack of a variety of support services at home, such as personal care services (assistance with bathing, dressing, meal preparation); homemaker services (cleaning, laundry, shopping); home repair services; transportation services; and financial management services (Colorado State Health Plan, 1980). In Colorado, as in many other states, attention has in recent years been focused on the issue of whether long-term care institutions provide care appropriate to the needs of their elderly residents. Rising public expenditures for nursing home care have led state and federal governments to seek less expensive alternatives. Older persons and their families also are interested in seeing alternatives to institutional care developed, not because the alternatives are necessarily cheaper, but because they are more attractive than institutionalization. Providers of alternative services, notably home health agencies, are also anxious to gain government support for the development of their services (Griffith, 1984). Thus, alternatives to long-term care have been espoused for financial and humanitarian reasons, but information on the costs, and need for specific services, with the possible exception of home health, is not abundant. Moreover, a move to decentralized care may create problems of its own -rising costs and difficulties in assuring quality of care (Hammond, 1979).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 92 Long-term care -the delivery of health, support, and social services to persons recovering from acute conditions or having chronic medical conditions or functional disabilities -has three goals: prevention of functional ability loss, minimization of the impact of such loss when it occurs, and rehabilitation to the greatest extent possible. Until recently, both the American government and the public have viewed institutionalization as the major component of the long-term care system (Colorado Long-Term Care Plan, 1982). The rate of inappropriate institutionalization has been much studied. Unfortunately, the studies are not entirely comparable because they use neither the same methodology nor the same definition of inappropriate institutionalization. In general, the studies have concerned themselves with estimating the number of people now in instutions who could be maintained in the community if the appropriate support services were available. Two other kinds of inappropriate institutionalization are often overlooked: placement in the wrong type of care (e.g., when mentally retarded patients are placed in nursing homes) and placement in too low a level of care (e.g., when people needing skilled care are placed in intermediate care facilities) (GAO, 1977). This last kind of inappropriate institutionalization is especially important for planners to bear in mind. If planners base their recommendations on estimates of inappropriate institutionalization which do not take into account the capacity of

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I II I I 93 the current system to provide alternative care, they may deinstitutionalize too quickly, leaving people in the community without the necessary support services (Jazwiecki, 1984). In studies where a distinction was drawn between people who could be maintained at home, based on disability rating alone, and those who could be maintained at home given the existing service system, there was a considerable discrepancy between the size of the two groups. In Minnesota, 18% of nursing home residents were found to be inappropriately placed. However, only 9% of these people could be maintained outside the institution with the current support system. A Massachusetts Public Health Department study of nursing home residents found that 64% of present nursing home patients did not need skilled nursing care, but only 15% of the patients could be adequately maintained outside of the institution. Three studies of inappropriate institutionalization have been conducted in Colorado and the results varied widely. In November, 1975, the PSRO surveyed 158 patients in 20 Denver metropolitan area nursing homes. It that 44% of the patients surveyed were receiving a more intense level of care than they needed. A second PSRO study, conducted in October, 1978, indicated that between 5% and 20% of nursing home patients could be placed in residential settings based on disability alone, but when availability of alternatives in the community were taken into account, only 4% to 10% of the patients were recommended for deinstitutionalization. Preliminary data on inappropriate institutionalization collected in late 1979 by the PSRO under P.L.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ., :I I 94 95-147 indicated that only one percent of Medicaid referrals for nursing home care were inappropriate. More recent data indicate that between March 1979 and March 1980, 18% of the Medicaid patients admitted to nursing homes were identified by the PSRO as potential clients for alternatives to the nursing home. In the vast majority of cases, however, alternatives were not available (Colorado State Health Plan, 1980). Family Support Services The fourth hypothesis addressed in this dissertation discusses the consensus among experts that there will be less family direct support to care for the indigent elderly in Metropolitan Denver. Surveys indicate that most of the long-term care received by impaired persons living outside nursing homes is delivered by family and friends. Among impaired elderly, less than 10% of care recipients got their care from formal or hired providers (Saldo, 1983). Despite the importance of families as providers of long-term care, information is lacking to assess properly the burden that providing this care imposes. The circumstances that enable or lead people to rely on their families and the resources or social costs family-provided care involves is clear. The availability of informal care in the home may decline with the increasing participation and attachment of women to the labor force. Daughters and daughters-in-law have traditionally been the second most important source of informal care, following the patient's own spouse. As the proportion of women who are

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 95 firmly established in careers increases, their ability and willingness to provide such care presumably declines (Newsweek, 1985 ). A larger share of dependent persons than in the past may, therefore, have to seek services from formal providers (Scanlon and Feder, 1984). Unfortunately, the debate today regarding home care and its role in the long-term care continuum has focused enormously and almost exclusively on home care as a fiscal solution to the impending fiscal crisis facing long-term care. It has been argued that, if only the institution providing long-term care could be depopulated and the patients placed in the home setting, the financial savings to federal and state government could be substantial (Willging and Neuschler, 1982). Alternative Services The fifth hypothesis addressed by the experts in this dissertation is concerned with the issues relating to the increased utilization of home services by the indigent elderly in Metropolitan Denver. Home care is clearly a desirable alternative to many long-term care patients in terms of their health care needs and their personal preferences. For the critically ill patient, a replication in the home of the services provided in an institutional setting would be very costly. Recent data suggest that the cost of caring for a homebound patient is now on a par with that of caring for an institutionalized patient with equivalent needs. Within the Medicaid program the problem is even

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 96 worse. Once moved from the institution to the home setting, the Medicaid patient has continued entitlements to the welfare grant in addition to the cost of home health. Consequently, the total cost to the public funding sources can be dramatically higher in the home care setting than in the institutional setting (Willging .!:!_ al. 1984 ) Since alternatives to long-term care can include any service which allows an individual to remain out of a nursing home, a wide variety of services can justifiably be termed "alternatives". Needed services range from the unskilled and basic to the skilled and medically-oriented. The Congressional Budget Office (1977) issue paper, Long-Term Care for the Elderly and Disabled, divided these services into three categories. follows: Basic services are as Homemaker services: laundry, home management. cooking, shopping, housekeeping, Chore services : maintenance, lawn care. Social services: less frequent tasks related to home guidance in social or emotional problems, advice in financial and legal matters, friendly visiting, transportation. The Health related services are: Nutrition and health education. Personal care services: bathing, toileting, feeding, assistance in walking, exercise, medication.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 97 Occupational therapy: medically-directed activities to promote the restoration of useful function. The skilled services are: Physical and speech therapy: use of physical or chemical agents and devices to relieve pain, restore function and prevent loss of use of a part of the body or of speech and writing. Skilled nursing: administration of medicine, changing of catheter and dressings, evaluation of condition. These services may be provided in any of several settings; indeed, alternatives are sometimes classified or even defined according to where the care is rendered. For example, day care centers and day hospitals provide health-related and skilled care in centralized settings during the day only. Domiciliary care facilities, in addition to providing shelter, may arrange for basic and health-related services. Home care delivers services of all three categories (basic, health-related, and skilled) in the client's own home. There is very little information on the need of Coloradans for particular kinds of alternative services. Although several needs assessments have been performed on subsets of Colorado's elderly, all such assessments have surveyed the noninstitutionalized elderly. To assume that the results of these assessments accurately represent the needs of those who are now or would in the future be inappropriately placed in nursing homes would be erroneous (Capitol Hill Area Planning Council, 1977).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 98 If information on the need for alternative services is scanty, information on providers of alternative services -with the exception of home health agencies -is nearly non-existent. The Congressional Budget Office Study found that most long-term care is provided by family and friends, with little assistance from public programs. These providers, of course, will be nearly impossible to count. Even obtaining a comprehensive list of organizations whose business it is to provide alternatives is difficult (CBO, 1977). As was noted above, alternatives to long-term care encompass a wide variety of services. Consequently, there is no umbrella industry organization which keeps information on all providers of alternatives. Moreover, government support for alternative services is now authorized under several programs, discussed in the next section. Each government program has its own definitions, eligibility requirements, and data collection policies. Medicare, for example, counts the number of claims processed, not the number of individuals served. Title XX does not count number of clients either, but "episodes" or "visits". As a result, although agencies inventory the providers under their jurisdiction, no single government agency keeps an inventory of all providers of alternative services, and what data does exist cannot be compared across agencies. Finally, some providers of alternative services are funded exclusively by private payments and charitable donations, and so have no affiliation with any government agency.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I i I I I I I I I I I i I I I j I i i I :I 99 Thus, although certain communities have developed lists of available services and their providers, such inventories are unusual because they are arduous to compile. In Denver alone, where an inventory is being developed by the Senior Resources Group of the Denver Commission on Community Relations, there are over 240 providers of services to the elderly in 13 different categories of services (DRCOG, 1981). Home health agencies are the one form of alternative service for which information is relatively abundant. As of June, 1979, 36 certified home health agencies were serving 56 of Colorado's 63 counties and 98% of its population. Most agencies in the non-metropolitan areas, however, do not offer much in the way of alternative services; they are often minimally staffed and have only one or two services besides nursing care (Hammond, 1979). Clearly, information on the providers of alternative services is as crucial as information on the need for alternative services. Until a more complete picture of the current providers of service is available, we will not know whether, for instance, to expand the number of providers of alternative services, to publicize existing providers, or to provide transportation to those providers. At a minimum, a comprehensive inventory of providers must be developed from the existing partial lists; ideally, a uniform method of recording the utilization and costs of alternative services will be developed and implemented (Ting, 1984).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 100 The major sources of public support for alternative services come from the federal government through Titles XVIII, XIX and XX of the Social Security Act; Title III of the Older Americans Act; and Section 8 of the Department of Housing and Urban Development. State and local governments contribute to several of these programs -Title III of the older Americans Act and Titles XIX (state only) and XX of the Social Security Act. In addition, the State Center Grants Program offers state funds to local agencies for services for the elderly not covered under other programs. Each of the government programs has different conditions for reimbursement and covers different services. These are described below. Funding Under Medicare. Medicare is a federal program for people over age 65 and for those who have been disabled for at least 24 months. It is divided into two parts. Part A is hospital insurance, but will pay for physician ordered home care if the patient: 1) has been in a participating hospital or skilled nursing facility for three consecutive days; 2) is certified by a physician to be confined to the home; and 3) is in need of parttime skilled nursing care, or physical or occupational therapy (HEW, 1979). The Medicare home health benefit is intended for further treatment of a condition treated in the hospital or skilled nursing facility. The agency providing the services must be certified by Medicare, and a physician must determine the patients' needs and set up a home health plan within 14 days of discharge from a

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. hospital or skilled nursing facility. 101 Part A will pay for a maximum of 100 home health visits per spell of illness. Medicare Part B covers physician services and outpatient medical, physical therapy, and speech pathology services. It, too, will pay for home health services ordered by a physician. The requirements for eligibility under Part B are similar to Part A, except that the patient need not have been institutionalized. Medicare was not designed to provide long-term care; it is oriented toward treatment and consequently spends only a small portion of its budget on in-home services. "alternative" paid for by Medicare. Home health care is the only Funding Under Medicaid. Medicaid is joint federal/state medical insurance program for low-income people. Medicaid eligibility for home health services In Colorado, is limited to recipients of Supplemental Security Income (SSI) and to persons in the categorically needy programs: Aid to Families with Dependent Children (AFDC), Aid to the Needy Disabled (AND), Aid to the Blind (AB), and Old Age Pension ( OAP). Medicaid home health benefits cover up to 150 visits per year for nursing services, aide services, medical supplies, and medical appliances. In 1979 and again in 1980, .a bill was introduced in the Colorado Legislature which would add physical, occupational-, and speech therapy, case management, Medicaid home health benefits. services must be provided by and personal care services as To be reimbursable, home health or under the supervision of a

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I I I I l I l i I i I I ; 102 participating home health agency (i.e., one which is certified for Medicare payment and has a written agreement with the Colorado Department of Social Services). Senate Bill 38 was passed in 1980 which affects these changes in Medicaid reimbursement. In fiscal year 1978-79, approximately 545,000 Medicaid dollars were spent on home health care. Home health care is the only alternative service paid for under the federal Medicaid program. Funding Under Social Security Act. Title XX is a 75-25 federal/state matching program to provide social services to low-income people including AFDC and SSI recipients. Alternatives to institutionalization which may be funded under this program include homemaker, chore, and home aid services, day care, foster care, transportation to health services, counseling, and information and referral. Priorities for service are determined by the county Department of Social Services, which, since passage of the Child Protection Laws, have had to curtail their services to adults in order to meet federal and state requirements for child protection. Although Title XX expenditures are not categorized by the age of the client, it is possible to estimate support for alternative services for the elderly from the 1980 State Department of Social Services Plan. According to the Plan, Program Area 1, which promotes self-sufficiency among aged and disabled adults, spent an estimated $1,267,000 on services for persons over age 60.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; I il 'I I :I 103 Funding Under the Older Americans Act. Title III of the Older Americans Act funds basic services (III B) and nutrition programs (III C) for the elderly, whatever their income. Basic services include physician-ordered services, chore services, and transportation, among others. Both home-delivered and congregate meals are provided by the nutrition program. Funds are distributed through 13 Area Agencies on Aging, which determine local service priorities and contract with providers. In fiscal year 1979, $1,405,000 were spent on basic services and $2,667,000 on nutrition programs. State Center Grants Program. Since 1967, the state of Colorado has granted funds to local agencies to provide services to the elderly. The nature of the services to be funded varies from year to year, the focus being determined by the Colorado Commission on Aging. In 1979, for example, the program funded hospices, homemaker, and home health care. In 1980, the focus will be chore and handyman service. The State Center Grants Program was appropriated $110,000 in fiscal year 1979. Housing and Urban Development Programs. Section 8 federal funds are available for subsidized housing and for congregate housing for the disabled. Although limited, some funds have been and continue to be used to construct high and low-rise housing for the elderly. In many of these projects, residents can obtain at least one meal per day either from "Meals on Wheels" or from the management of the project. In addition, Section 202 funds are

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 104 available in some cases for mortgage-subsidy for elderly and handicapped housing projects. Problems with Funding for Alternative Services. The frag-mentation of funding for alternatives to long-term care, evident from the preceding description, creates obstacles for elderly people trying to obtain appropriate care. Their problem is not merely the complexity of the benefit packages and eligibility requirements, it is a problem inherent in long-term care. Chronic conditions require a package of services which can vary over time. A fragmented system of funding makes this flexibility and continuity of care extremely difficult to achieve (GAO, 1977). In addition to this global criticism of the funding system, there are specific perverse incentives in the system as it now exists. Perhaps the most infamous of these is the Medicare requirement of a three-day institutionalization prior to home health care. This discussion will not dwell on Medicare eligibility requirements, however, because they are determined by the federal government. Instead it will concentrate on the Medicaid program, the funding source most amenable to influence by the state. In contrast to Medicare, Medicaid's eligibility requirements and benefit packages are under partial control of the state. Unlike Title XX, it is an entitlement program and therefore can tap unlimited federal matching funds. Moreover, as primary source of j i funding for nursing home care (Medicaid pays for approximately 70% i I l i I I :! i;

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I 105 of nursing home admissions), it is the source most likely to experience savings by reduced utilization of nursing homes. Income eligibility for Medicaid varies according to whether a person is institutionalized. An individual whose income is less than three times the SSI allowance can obtain institutional care under Medicaid, but the same services outside an institution cannot be reimbursed unless his income is within SSI limits. In other words, people whose monthly income is greater than $208 but less than $624 may be forced into institutions in order to obtain services which might more cost-effectively be provided to them outside the institution. A great many individuals need only a few minutes of nursing care per day, but need the care every day. In a congregate setting, this kind of service could easily be provided, but under the current regulations, every visit, no matter how short,. would be counted as a full visit. Thus, patients would soon reach the limit of the number of annual visits which could be reimbursed by Medicaid. If a system of fractional .visits were instituted, this problem could be avoided. Medicaid will reimburse visits to a nearby hospital for physical and speech therapy (including transportation to and from the hospital), and with the passage of SB 38 in 1980, Medicaid now reimburses for such services in the home. Since Medicare, rather than Medicaid, is the major consumer of home health services, home health agencies tend to limit their services to the minimum required for Medicare certification:

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I 106 skilled nursing plus home health aides, physical therapy, occupational therapy, or speech therapy. Consequently, only a portion of the professional, technical, and health related services that can be provided to patients in their homes and that are necessary to meet the medical needs of those patients adequately are available to them through home health agencies. Medicaid cannot require home health agencies to meet more stringent requirements unless there is a home health licensing law in the state (Colorado Long-Term Care Plan, 1982). Studies of the cost-effectiveness of home care services, particularly home health services, have been inconclusive. One factor affecting the cost-effectiveness of home health is the disability level of the client. The General Acounting Office of Congress completed a major study in December 1977 in which costs of care were calculated for individuals grouped into seven levels of disability. For only a fraction of those at the most disabled level was a community-based care more expensive than nursing home care. Of nursing home residents studied, 24% were assessed to be at less than the most disabled level. In Colorado, this would represent approximately 3,120 individuals (GAO, 1977). Whether home health is deemed cost-effective also depends on its basis of comparison. A 1978 literature review revealed that the vast majority of studies demonstrating cost-effectiveness of home health services compared home health with hospital, rather than nursing home care.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I 107 Another literature review, completed in 1979, concluded that the preponderance of evidence from the studies reviewed suggests that from the standpoint of third-party underwriters, home health care is indeed less expensive than extended hospitalization. Available information indicates that the costs of home health services for patients requiring the same level of care are roughly equivalent to the costs of nursing home care. Other studies comparing home health to nursing home care have reported savings ranging from $263 to $1,716 per patient per year (Perry, 1979). There is practically no evidence regarding the impact of the various approaches to alternative long-term care on the rate of institutionalization in nursing homes. At best, the literature demonstrates that home health services reduce the length of hospitalizations. Preliminary results from a study sponsored by the National Center for Health Services Research suggested that institutionalization was reduced by day care but not by homemaker services. These results, which are based on Medicare data, may not reflect how day care or home care services would affect the bulk of institutionalization, paid for by Medicaid (Kurowski, 1980). It has been widely surmised that a significant number of the functionally disabled elderly who are not in institutions are receiving inadequate support services and could increase their capacity for independence by use of alternative long-term care. Substantial use of services by this group could increase the total program costs dramatically; an estimated 11.8% to 16.8% of the elderly are functionally disabled.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 108 Considering that only five percent of the United States elderly population resides in nursing homes and that only some fraction of these are inappropriately institutionalized, it is clear that the uninstitutionalized elderly disabled could well "flood" an alternative system. Both experience and conjecture support the view that addition of alternatives will raise total costs, especially if prior institutionalization is not a prerequisite for care. In 1966, when Kaiser Health Plan of Portland, Oregon, added extended care and home health care to its benefits package, total expenditures increased. Pollak (1974) concluded that although home health and homemaker services would reduce institutionalization, the potential demand for those services would more than offset any cost saving. Taking together the inconclusive findings of cost-effectiveness studies, the lack of evidence of decreased utilization of nursing homes, and the suggestions that there is a large potential demand for alternatives, it is clear that alternative long-term care services should not be regarded as a way to decrease total health care expenditures. Problems of Quality Assurance. In addition to potentially increasing cost, an alternative long-tenn care program may create problems of quality assurance. As care is decentralized, it becomes harder to audit. There are, furthermore, no established standards of care for many alternative services and, at least at I ; I '' I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I I I I I I I I I I I i i I I 'i ; I I 109 present, no agencies responsible for their oversight (Kurowski and Shanghnessy, 1981). Two approaches to quality assurance should be considered: licensure and utilization review. As was ment1oned above, licensure of home health agencies would allow the state to add requirements beyond the federal conditions for Medicare certification. Licensure could be used to increase the comprehensiveness of services and the flexibility of their provision, as well as to examine at regular intervals the quality of the providers. A licensure law would insure that certain structural requirements (e.g., staffing, equipment, etc.) were met. A more process-oriented approach to quality assurance is utilization review. The most efficient way of implementing utilization review is within the context of case management. Many people have suggested that the only way to insure a flexible, tailored service program in an essentially fragmented funding system is to have a case manager who guides the client through that system (Beatrice, 1981). The costs of a case management system may be substantial. Nevertheless, if such a system is developed, utilization review might become one of the responsibilities of the case manager. As with any auditor, careful consideration must be given to how the role of case manager would influence the incentive to be an effective auditor. Another serious obstacle to the implementation of utilization review is the lack of standards of care for many alternative services. Utilization review of alternatives is, thus, not a feasible program in the short run (Grimaldi, 1984).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ! I I I i I, i I 110 In addition to the two approaches just described, a management information system should be designed and installed at the state and local levels so that resource utilization can be traced by planners and auditors (State Health Plan, 1980). Of the $27.2 billion in nursing home expenditures in 1982, Medicaid paid for approximately 49% (over $13.2 billion) while Medicare paid only $1.7, the rest came from personal resources. Extrapolating at a conservative growth rate commensurate with increases in the population needing such care, the cost by the year 1990 could approach $90 billion (Willging et al., 1984). Restructuring Medicaid. In the summary report of the National Study Group on State Medicaid Strategies (1983), the following recommendations for restructuring Medicaid into two separate systems of care included: 1. A federally financed and administered National Primary Health Care Program. This program would provide basic health care benefits (ambulatory and short term institutional) for all low income individuals and families without eligibility ties to categorical cost assistance programs. Benefits would be provided through capitated financing and delivery systems. 2. A state administered continuing care system. This system would provide a full range of health and social long-term care services to dependent individuals with demonstrated functional impairments. Federal funds for states through an indexed capitation payment to provide needed services within broad federal criteria and guidelines. The term "continuing care system" replaces "long-term care" and includes a broader range of inhome and community support services as well as longterm institutional care in a nursing home or other health-related or domiciliary facility (page 3).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 111 Looking toward the future, despite increases in average resources and changes in living environments, many elderly will remain unable to afford long-term care. Future income improvements will be uneven. By the year 2000, at least 20% will have no private pensions and many pensions will receive very limited benefits. Women, in particular, will remain disadvantaged, since most pensions do not extend to survivors. Some elderly will enter retirement with limited savings and Social Security benefits reflecting a lifetime of moderate to low income. Moreover, having more resources at retirement age may not mean much when one needs formal long-term care. The typical formal long-term care user, a widow of 80, will first need care 15-20 years after her spouse's retirement. By that time, the incremental resources available at retirement may have been exhausted (Scanlan and Feder, 1984). An important public sector role will be the continued subsidizing of people unable to afford services. The nature and extent of the public role cannot be easily foreseen. Even with private resources meeting the needs. of a larger share of the dependent population, the total projected increase in that population likely implies a greater demand for public subsidies. Pressure to resolve these inadequacies will rise with the growth in the elderly population and public policymakers will be forced to respond.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I 112 Summary In summary, the purpose of this study was to address experts' opinions and future options regarding health and social services to the indigent elderly in Metropolitan Denver. The hypotheses I addressed include: 1. There will be a consensus among experts about the best future options for providing health and social services to the indigent elderly. 2. There will be diverse opinions among the experts about how to implement future options for the care of the indigent elderly. 3. There will be a consensus among the experts that skilled nursing home care will increase to accommodate the increased numbers of frail indigent elderly. 4. There will be a consensus among the experts that there will be less family direct support to the care of the indigent elderly. 5. There will be a consensus among the experts that home services will be more widely utilized by the indigent elderly. Chapter III is devoted to the research methodology and to the specification of the study area and the time period selected for this study.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I II i I CHAPTER III RESEARCH METHODOLOGY Introduction In order to test the hypotheses regarding the indigent elderly in Metropolitan Denver, the Delphi technique was used. This technique is a method of soliciting and combining the opinion of a group of experts. It involves the use of a series of questionnaires designed to produce group consensus and eliminate face-to-face conformation as experienced on panels or committees. It also attempts, in a rapid and relatively efficient manner, to combine the knowledge and abilities of a diverse group of experts in quantifying the variables that are either intangible or vague (Dalkey, Rourke, Lewis, and Snyder, 1972). Key Characteristics of Delphi Key characteristics of the Delphi approach are (1) anonymity of survey panel members, (2) anonymity of responses, (3) multiple iterations, (4) statistical analyses of panel responses, and (5) controlled feedback of responses to panel members. The Delphi Technique prevents any one member of the panel from unduly influencing the responses of other panel members. Through the statistical summaries and minority report, panel members

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 114 communicate with each other, but only in a limited goal-centered manner. The systematic control lends an air of objectivity to the outcome, which provides a sharing of responsibility that is reassuring, and releases the participants from group inhibition (Helmer, 1963). Conventional Delphi is primarily concerned with experts, but may also use other subject groups who may be informed to a greater or lesser extent in the target area of inquiry, but who do not qualify as experts. Conventional Delphi as used by Sackman, 1975, exhibits the following characteristics: 1. The format is typically, but not always, a paper and pencil questionnaire; it may be administered by mail, in a personal interview, or at an interactive, online computer console. The basic data-presentation and data-collection technique is the structured, formal questionnaire in each case. 2. The questionnaire consists of a series of items using similar or different scales, quantitative or qualitative, concerned with study objectives. 3. The questionnaire items may be generated by the director, participants, or both. 4. The questionnaire is accompanied by some set of instructions, guidelines, and ground rules. 5. The questionnaire is administered to the participants for two or more rounds; participants respond to scaled objective items; they may or may not respond to open-end verbal requests. 6. Each iteration is accompanied by some form of statistical feedback, which usually involves a measure of central tendency, some measure of dispersion, or perhaps the entire frequency distribution of responses for each item. 7. Each iteration may or may not be accompanied by selected verbal feedback from some participants, with the types and amounts of feedback determined by the director.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; I i ll I I' i I 8. Individual responses to items are kept anonymous for all iterations. However, the director may list participants by name and affiliations as part of the study. 9. Outliers (upper and lower quartile responses) may be asked by the director to provide written justification for their responses. 10. Iteration with the above types of feedback is continued until convergence of opinion, or consensus, reaches some point of diminishing returns, as determined by the director. 11. Participants do not meet or discuss issues face to face and may be geographically remote from one another. (Sackman, 1975, pp. 9-10). 115 Steps in Delphi Procedure The chronological framework for a Delphi study follows a problem-solving sequence: establishment of objectives, formulation of the problem, solution testing, and the write-up and dissemination of results. In the Delphi context, objectives include needs, goals, basic value assumptions, and expected payoffs. Formulation of the problem is accomplished through the design of the questionnaire and its experimental implementation. Solution testing includes iterative field administration and scoring of responses to the questionnaire. The last stage involves the interpretation of results by the Delphi director in communicating findings to others. Each stage is briefly examined to provide a chronological chain of methodological issues as a framework for discussing Delphi methodology (Dalkey, 1975). After establishing the objectives, the next step in a Delphi study is the formulation of the problem, the design of the

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 116 questionnaire, and its application. How effectively is the area of inquiry defined and delimited by the Delphi investigator? Is there an effort to make the questionnaire bias free? Are his assumptions spelled out? Are there explicit hypotheses, and are they operationally defined? Has the relevant literature been reviewed and systematically evaluated? Have baseline statistic and qualitative characteristics of the area of inquiry been documented and spelled out so that respondents derive their forecasts and opinions from a common specification of the current state of the art? (Sackman, 1975). In developing the questionnaire, many technical considerations arise. Is the questionnaire an informal, ad hoc collection of items? Or is it systematically designed as a standardized instrument to be administered under rigorously controlled conditions? How are the items constructed? How large was the original pool of items, how were they derived, and what pilot procedures were used for item analysis to prune them down to the final set used for the study? What psychometric scaling approach was selected (e.g., Thurstone, Likert, or Guttman psychometric scales, or econometric scales) and what factors determine the selection? (Pill, 1971). Then there are problems ('Oncerning the panelist sample to which the questionnaire is applied. What is an "expert" in the target application field, and how are such experts operationally defined? How many panelists are used? What are the expected levels of statistical precision of the results relative to planned

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 117 sample size for the dispersion of responses anticipated? Can the selected panelist sample be systematically related to an objectively defined population with measurable sampling parameters? Is the choice of experts random or is it selective? Are sampling procedures rigorously defined relative to hypothesis testing for opinion polling? (Cochran, 1963) In administering the questionnaire, many problematic issues arise. How are dropouts handled in the results? Which items should be dropped, modified, or retained in their original form in successive Delphi rounds? What kind of feedback, how much feedback, and in what form should it be presented to panelists? When is the point of diminishing returns reached in successive iterations? How long should the intervals be between success! ve rounds, and how can participants be encouraged to respond promptly to expedite turnaround time? What is the tradeoff between more items and a longer form versus fewer items with less data in relation to study objectives? Does the director reinforce and encourage conformist or dissenting behavior in successive rounds? In working with distributed Delphi by mailed questionnaires and iterative polling, what opportunities exist for misusing the technique? (Sackman, 1975). In the final stage of writeup and dissemination of results, the main problems center around the analysis and interpretation of findings. Should only descriptive results be presented, or should all statistics be accompanied by standard errors of estimate, clearly indicating the empirical level of precision? Is it

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ll8 misleading to present only interquartile ranges in graphic portrayal of Delphi results, or should the full range and true dispersion of results also be presented? Should first-round results be presented showing the full dispersions of expert opinion? How strongly should the expert halo effect be exploited, or should it be controlled in evaluating results? Should the procedure and the interpretation give weight to adversary or consensus positions? (Sackman, 1975). Results in Delphi Procedure The application objective of conventional Delphi may be the forecasting of specified events, long-term or short-term; it may be the generation of quantitative estimates (cost, market demand, number of users, etc.) from a set of participants; or it may be aimed at qualitative evaluations (qualitative scales of agreement, disagreement, preference among alternatives). The range of application objectives thus includes any type of quantitative or qualitative rating scale, and as such is coextensive with questionnaires broadly considered (Dalkey, 1969). Other key objectives for conventional Delphi may be singled out, including consensus of participants and heuristic goals. The consensus intent of Delphi is typically oriented toward controlled and rational exchange of iterated opinion leading toward optimal convergence of opinion achievable within the framework of the technique. The heuristic objective views Delphi as an educational technique to help participants, the director, and users to explore

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I \ ! ; I :I 119 a problem area more thoroughly, leading to greater insight on the target problem (Sackman, 1975). The payoff of a Delphi study is typically a presentation of observed expert concurrence in a given application area where none existed previously. This assumes that participating panelists are experts in the subject area, and that the reported consensus was obtained through reliable and valid procedures. Proponents of Delphi stress three quintessential attributes that contribute to authentic consensus and valid results: anonymity of panelists, statistical response, and iterative polling with feedback (Dalkey, 1969). History and Previous Applications of Delphi The Delphi technique originated at RAND Corporation with related studies starting in 1948. Fourteen documents were produced at RAND between 1948 and 1963 dealing with the rudiments of the Delphi Technique. The names of Dalkey, Gordon and Helmer were prominent in this formative period. Since 1963, many hundreds of Delphi studies have been published under corporate government, and academic sponsorship, over a vast range of topics, in the United States and abroad including Europe, the Soviet Union, and Japan (Quade 19 7 5 ) The Delphi Technique was first developed as a forecasting tool at the RAND Corporation. Dr. Olaf Helmer, a mathematician-philosopher and one of the founders of the Institute for the Future, developed the technique as an attempt to deal with very

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 120 distant futures by making systematic use of the "intuitive guesstimate" of large numbers of experts. The RAND Corporation continued to refine the Delphi procedure, and around 1950 the technique was used on problems of group information utilization. Specifically, RAND was concerned with the possibility of utilizing expert opinions and predictions in policy making (Dalkey, 1969). The testing of their predictions spanned a period of less than a year and was very narrow in scope. The reliability. results, however, produced great accuracy and Although the predictions of the Delphi Technique were short-term and limited, the results tended to produce significantly better predictions than individual responses such as round-table discussions and other interpersonal interactions. The Delphi development was an advance in analysis in that it provided equally good results by statistically combining individual responses. Group interaction was not the sole contributor leading to the improvement of the total group's ability to predict end results. The 1950 RAND group found that the procedure was reliable in shortrange predictions and to some extent in examining the character of the justification given the predictions (Lindeman, 1981 ). RAND Corporation studies and psychological analyses have demonstrated the inherent dangers of opinions derived from a group with members working on a face-to-face basis. The Delphi Technique has been applied to numerous fields since its development in the 1940's. In the past few years, there have been many applications of the technique in such areas as

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 121 industry (Campbell, R.M., 1966), social planning at the community level (Reisman, A., Mantel, S.J., Dean, B.V. and N. Eisenberg, 1969), evaluation of research projects (Dean and Mathis, 1969), education innovation (Adelson, Alkin, Carey and Helmer, 1967), and forecasting physician supply and requirements (U.S., Graduate Medical Education, 1981). One of the most extensive uses of the method has been in higher education as focusing on costeffectiveness, cost/benefit analysis, university-wide and statewide educational goals and objectives and consensus on rating scales/values, and generalized educational goals and objectives for the future (Judd, 1972). Early Delphi studies at Rand were primarily concerned with scientific and technological forecasting. They were viewed as experiments with what was thought to be an interesting, and possibly useful, new technique. From these humble beginnings, Delphi has spread rapidly, with hundreds of studies appearing in the United States, accompanied by growing use in other countries, including extensive use in the United Kingdom (Curril, 1972) and use in the Soviet Union (Martino, 1973) and in Japan. Delphi applications have grown in all directions to include forecasting of many social phenomena, including human attitudes and values (Reisman .et al., 1969), and even the "quality of life" (Dalkey, Rourke, Lewis and Snyder, 1972). A large and growing roster of major firms have used Delphi for diverse purposes. Applications have expanded until, broadly considered, they are virtually indistinguishable from the questionnaire technique. Advocates,

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 122 such as Turoff (1971), have expanded the scope of Delphi as a general-purpose vehicle for distributed human communication and consensus, and for group problem solving. Delphi has been propelled at an increasingly accelerated rate into the general field of questionnaire design and development not only for "experts," but for nonexperts as well. The core question arises: How does Delphi rate in comparison with competing approaches in the well-established fields of questionnaire design and application in the social sciences? (Dror, 1977). Strengths and Limitations of Delphi Advantages of Delphi are primarily low cost, versatile application to virtually any area where "experts" can be found, ease of administration, minimal time and effort on the part of the director and panelists, and the simplicity, popularity, and directness of the method (Sackman, 1975). The Delphi procedure promises to become a highly effective means for group information processing according to Quade, (1975). The anonymous debate among experts as conducted by Delphi procedures, in many instances where a valid comparison can be made, has proven to be superior to the same experts engaging in a face-to-face discussion in arriving at a group position on a given question (Dalkey, 1972). Whereas a true consensus is not always achieved, a convergence toward a CQnsensus almost always takes place. An underlying premise of any Delphi procedure is that, by and large, a respondent is better equipped to answer a question the

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 123 more information he has about it, including how other individuals have answered the same question. This is provided through feedback. Feedback may be either verbal or numerical. Unless the number of participants is small, designing verbal feedback presents a problem. In view of the accelerating use of Delphi procedures by a wide spectrum of public and private institutions, two uses are of immediate practical concern; namely, for forecasting technological and social events and for value judgements. The purpose of a Delphi exercise is not to furnish the investigator with data about the respondents. It is to estimate the answer to an uncertain question for which there is no welldefined way to find a definitive answer at the time of the exercise. Imperfect as it is, the Delphi process appears to promise a way to investigate many problems with a high social and political content. Delphi offers a hope of introducing a systems approach into a range of problems where such models cannot be formulated (Quade, p. 196). Delphi is not without criticism, for example, as shown in the comments of Pill (1971) and Sackman (1974). Much of this criticism is justified for the procedures have often been inappropriately used. Delphi is not an opinion-polling technique. In general, a pollster is not interested in the correctness or incorrectness of the responses he gets from the sample. The responses are treated as data, not assertions, that allow the pollster to draw conclusions about the respondents, and

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I i I :I 'i 124 thus, if his sampling procedures are correct, about the population from which they come (Quade, 1975). Objectives for the Study Regarding Indigent Elderly Following the chronological framework for a Delphi study a problem solving sequence was used regarding expert's opinions of future options of the indigent elderly in Metropolitan Denver, Colorado. The following five hypotheses were tested: 1. There will be a consensus among experts about the best future options for providing health and social services to the indigent elderly. 2. There will be diverse opinions among the experts about how to implement future options for the care of the indigent elderly. 3. There will be a consensus among the experts that skilled nursing home care will increase to accommodate the increased numbers of frail indigent elderly. 4. There will be a consensus among the experts that there will be less family direct support to the care of the indigent elderly. 5. There will be a consensus among the experts that home services will be more widely utilized by the indigent elderly. Formulation of the Problem Initially, twenty experts agreed by telephone to participate in this Delphi Survey. These experts included: five administrators, five clinicians, five consumers and five policy

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 125 makers from the Denver Metropolitan Region. Experts were selected based on their knowledge and experience regarding the indigent elderly in Metropolitan Denver. Among the administrators, a large public hospital, extended care facilities and home health agencies were represented. The clinicians included physicians, geriatric nurse practitioners and a clinical psychologist. Consumers were represented by elderly members of various public interest group working with the elderly in Metropolitan Denver. Policy makers included public and private organization officials providing services to the indigent elderly in Metropolitan Denver. Of the total twenty experts, seven were males and thirteen were females. One panelist was black and one was Mexican American. Panel members were asked to complete a question about the role with which they identified themselves; i.e., administration, clinician, consumer, or policy maker. In the Age information was not collected. instructions to the three rounds of the questionnaires, confidentiality was discussed, stating that their (the panelists') answers would be kept strictly confidential and would not be identified with them in anyway. The Delphi procedure used in this study consisted of three survey rounds: Round 1: Round 2: Identification of issues. Response to a 55 item questionnaire developed from the responses to Round 1.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I f I I I I l ( I t l I I I I I I i I : j 126 Round 3: Response to the same 55 item questionnaire showing a statistical summary of Round 2 responses. Panelists were asked to give their rationale for any response outside :i:: one standard deviation of the mean. The results of Round 1 were used to develop a 55 item questionnaire used for Rounds 2 and 3. This researcher categorized individual responses, tabulated the frequency of items, and clustered similar items. The most frequently mentioned categories of items were used as the bases for the questionnaire for Round 2. The researcher then conducted a further review of the literature and, using that review as a frame of reference, added, subtracted, and modified the proposed items. The researcher's dissertation committee reviewed the proposed questionnaire items to determine content validity. Also, pretesting of the questionnaire by five other experts was carried out. In July, 1984, the Round 1 instruments were sent to the 20 experts who had responded positively to the request that they participate in this study. A cover letter described the specific nature of the Delphi process and the procedure for preserving anonymity accompanied the instrument (see Appendix A). These provided the bases for the 55 item questionnaire used for Round 2. In February, 1985, 20 second round instruments were sent with a cover letter encouraging continuance in the Delphi

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 127 process. Round 2 results were summarized using the following measures: Mean: Arithmetic average Mode: Most frequent response. Percentage Distribution: In many instances the entire distribution of responses to a question was reported. Answers to Round 2 which implied consensus (a single answer comprising either 40% or more of the total responses or two adjacent responses totaling 70% or more of the total responses) were enclosed in a box for ease in reviewing the Round 2 results. Three weeks later, 20 instruments were sent with a cover letter expressing gratitude for thoughtful responses of the participants, closure of the Delphi process, and reiteration of the promise to send a summary of the findings and participant comments to each subject. The participants were encouraged to use the supplied feedback from the second round to facilitate reiterative judgement during the third round. Individual written responses were recorded and panelists were asked to give their rationale for any response outside the 80% range or if they disagree with the Round 2 results. Test' and Interpretation The first round questionnaire used to obtain information regarding the future options of the indigent elderly in I Metropolitan Denver is included as Appendix A. This questionnaire I I I' I i ; I :!

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 128 was answered by 18 experts out of 20 or 90%. These answers have been outlined in Tables 18 and 19. Each topic is followed by a figure representing the number of times (frequency) that subject or one very similar to it was indicated by a respondent. The first round elicited experts' opinions regarding characteristics and solutions to the problems of the indigent elderly in Metropolitan Denver. "Isolation" was the most frequently mentioned patient characteristic of the indigent elderly with twelve experts including isolation in their list. "Lack of money" was reported by ten of the experts and lack of adequate housing ranked third with seven experts believing it to be a salient characteristic of the indigent elderly in Metropolitan Denver. Solutions to the problems of the indigent elderly ranked in order of the frequency of response were: Adult day care facilities with eight experts reporting, increase of Medicaid coverage and more senior centers with seven experts reporting, and the need for centralized case management system with six experts reporting.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 129 Table 18 Characteristics of Indigent Elderly Characteristics Freguenc;x: 1. Lack of money 10 2. Isolation 12 3. Lack of family support 4 4. Low self image 4 5. Lack of community support 5 6. Fear of illness 4 7. Lack of adequate housing 7 Table 19 Solutions for Indigent Elderly Solutions Freguenc;x: 1. Increase Medicaid coverage 7 2. More senior centers 7 3. Use of congregate housing 5 4. Adult day care facilities 8 5. Personal care boarding homes 3 6. Improved skilled nursing facilities (SNF) 2 7. Use of geriatric nurse practitioners 2 8. Communication effort via free media 3 9. Tax credit for providers of transportation 2 10. Centralized case management system 6 I I 1! lj

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 130 The results of Round 1 were used to develop the 55 item questionaire used for Rounds 2 and 3. The author categorized individual responses, tabulated the frequency of items, and clustered similar items. The most frequently mentioned categories of items were used as the bases for the questionnaire used in Rounds 2 and 3. The author conducted two on-line computer searches of the literature using the Medline data base and the PAIS data base. Using these searches as a frame of reference, the author added, subtracted and modified the prepared items. author sent the proposed questionnaire to her committee members to determine content validity. Then this dissertation With minor alterations, the proposed questionnaire was judged valid. Lastly, the author pretested the proposed questionnaire with 5 other experts. These experts reviewed the proposed items and their suggestions were incorporated. The 55 item questionnaire that resulted from this process is presented as Appendix B. The Round 2 questionnaire was answered by 12 people out of 20, or 60%. These answers were summarized using the following measures: mean, mode, and percentage distribution. The entire distribution of responses to a question were reported in the Round 3 questionnaire. A single answer comprising either 40% or more of the total responses or two adjacent responses totaling 70% or more of the total responses were enclosed in a box for ease in reviewing Round 2 results. These results formulated the basis for the Round 3 Questionnaire (see Appendix C).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 131 The Round 3 questionnaire was responded to by 19 people out of 20 or 95%. These responses were again summarized using the following measures: mean, mode, and percentage distribution. Each questionnaire was coded by panelist. The data gathering phase of the study took place over a period of eleven months. Limitations There were a few limitations in this research which need to be made explicit so that subsequent inferences and conclusions drawn can be tempered appropriately. The study was limited to include 20 expert panelists in Metropolitan Denver. These experts are not a cross section nor typical of all experts, but rather a select group. It was not intended that the analysis of these experts would be representative of all experts in this country. This would be an area for further research. Another limitation of this study is that the use of experts can lead to a serious technical limitation, in this case the "expert halo effect". Sackman (1975), an ardent critic of Delphi procedures, argues that there is the tendency of respondents to be unduly influenced by any favorable or unfavorable characteristic of the questionnaire which colors and contaminates the judgement of the experts. Despite these limitations, the Delphi procedure was used in this study because of its advantages; namely, that the method is primarily low cost, has versatile application of virtually any area where "experts" can be found, is easy to administer and requires minimal time and effort on the part of the panelists.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :! 1 J : \ I I i j I l I I I I I i j I I; I ;I 132 SUIIIIIlary In summary, the Delphi Procedure was used in this study in order to deal with options of the indigent elderly in Metropolitan Denver. This procedure involved the use of a series of three survey questionnaires designed to produce group consensus and eliminate face to face confrontation as experienced on other types of expert panels. This study was limited to include twenty experts; five administrators, five clinicians, five consumers, and five policy makers in Metropolitan Denver, Colorado. Chapter IV deals with the findings regarding the future options of the indigent elderly in Metropolitan Denver, Colorado.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I '! CHAPTER IV FINDINGS Introduction This study was designed to examine experts' opinions regarding future options for providing health and social services to the indigent elderly in Metropolitan Denver, Colorado. Twenty expert panelists were surveyed in three rounds of questionnaires including: five administrators, five clinicians, five consumers, and five policymakers. Round 1 questionnaires were answered by 18 of the 20 panelists with a 90% response rate. Round 2 response rate was 60% with 12 panelists out of 20 reporting. Upon telephone inquiry it was learned that six of the panelists were on vacation. Rather than delay or revise the research plan regarding the scheduling of the Round 3 mailing, the decision was made to proceed with the data available from Round 2. The data were reported in the Round 3 questionnaire to which 19 panelists out of 20 or 95% responded. References were made to these twenty panelists throughout these findings. The findings reported in this section were summarized from Round 3 questionnaires. Survey results were reported in five broad categories based on the five hypotheses developed for this study. These five hypotheses and their results provided the framework for this chapter. The data

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I I I I II 'I II I 134 thus obtained from the expert panelists are presented here together with an analysis of the results which may serve as a guide to policymakers and practioners of the future. Problems of the Indigent Elderly Before options for providing health and social services to the indigent elderly, can be discussed, the significant problems of these people as reported by the panelists must be identified. Table 20 indicates the average responses regarding the problems of the indigent elderly. The five problems receiving the highest rankings from the panelists include: lack of money, isolation, lack of community support, lack of family support, and lack of adequate housing. "Lack of money" was mentioned most frequently and by quite a margin over "isolation". Further, while "isolation" was listed second, "lack of transportation" did not make the top five problems. Apparently these experts were not thinking strictly of geographical isolation. These findings are comparable to a survey done by the Denver Regional Council of Governments (DRCOG) program (1981) where the most prevalent problems of older persons were health and financial as reported by the elderly themselves. Other significant problem areas from the DRCOG study included emotional, transportation, housing, safety/crime and dependency problems.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I i 'j :I Table 20 Problems of the Indigent Elderly Problems of the Panel Round Indigent Elderly 3 Ranking 1. Lack of money Ill 2. Isolation 112 3. Lack of community support 113 4. Lack of family support //4 s. Lack of adequate housing liS Hypothesis 1 135 Average Round 3 Respones 1.421 3.368 3.947 4.315 4.789 There will be a consensus among experts regarding the best future options for providing health and social services to the indigent elderly in Metropolitan Denver. Options for the purpose of discussing these findings means the power or the right to choose. Figure 6 shows the results of round 3 responses regarding social issues in health care. Ninety five percent of the panelists believe that the indigent elderly in Metropolitan Denver deserve the same level of health services as everyone else in the United States. These findings support hypothesis I which states that there will be a consensus among the experts about the best future options for providing health and social services to the indigent elderly in Metropolitan Denver. Consensus for the purpose of these findings means a single response of 40% or more of the total responses to a question or two "adjacent responses" totaling 70% or more of the total responses.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 6 5% Disagree 95% Agree The Entire U.S. Population is Entitled to the Same Level of Health Services In the study "Health Care in the 1990's: 136 Trends and Strategies" conducted by the American College of Hospital Administrators and Arthur Andersen Co. ( 1984), only 12% of their panelist thought everyone was entitled to the same level of health services. Forty five percent of panelists strongly disagreed that the entire U.S population was entitled to the same level of health services. The American College/Arthur Andersen study (1984) was composed of six panels of experts including hospital leaders, physicians, other providers, legislators/regulators, suppliers and payors. One thousand experts were surveyed in this study and the results of this study present, for the first time, a comprehensive assessment of trends and strategies reshaping health care in America today. Results from this study will be referred to throughout these findings where they are applicable.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I i I i I i 'I I li i I II 137 One way health services to the indigent elderly can be provided is through National Health Insurance. Figure 7 reveals that 53% of the experts slightly agree that the u.s. will adopt some form of National Health Insurance by 1995. The American College study ( 1984) cited earlier revealed that 33% of their panelists slightly agree that the U.S. will adopt some form of National Health Insurance in the future. In the American College study, the expectation that NHI will occur is particularly strong among provider panelists and it is weakest among the payor panelists.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I j I I 1 i I I I I j I I I I i I ,, I \ 53% .. Agree Slightly Agree Figure 7 5% 16% j:<;.,,,:;:] Slightly Disagree Strongly Disagree -Neither Agree or Disagree National Health Insurance in 1995 138 The largest consensus among the experts is shown in regards to the need for specialty facilities for providing health and social services to the indigent elderly in Metropolitan Denver by 1995. Figure 8 dramatically points out a consensus among the experts as none of them reported a slightly lesser or significantly lesser need for specialty facilities in the future. The need for skilled nursing facilities (SNF's) by 1995 will be significantly greater as reported by 53% of the experts and

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :j I I I I I I I 'I i I 'I 'I I 139 slightly greater by 47% of these panelists. Only 8% of the panelists reported no change. These issues will be discussed in depth later under hypothesis 3 which states that there will be a consensus among the experts that skilled nursing home care will increase to accommodate the increased numbers of frail indigent elderly. Congregate living housing is viewed by 63% of the panelists as having a significantly greater need by 1995 and 39% of the panelists as having a slightly greater need. This issue will be discussed further under hypothesis 4 which states that there will be a consensus among the experts that there will be less direct family support to the care of the indigent elderly. Eighty-four percent of the panelists believe that there will be a significantly greater need for adult day care facilities by 1995 while 16% believe that there will be a slightly greater need for these facilities. This issue will also be discussed further under hypothesis 4. Personal care boarding homes report the same percentage of increasing need by 1995 as adult day care facilities reported above. The need for hospices in 1995 will significantly increase according to 79% of the experts. Sixteen percent of the experts report a slightly greater need, and 5% of the experts report no change by 1995. Sixty-three percent of the experts report a significantly greater need for rehabilitation facilities while 32% indicated a slightly greater need for these facilities by 1995.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. '' l I i l II !! :I 140 The need for community recreation centers will be significantly greater as reported by 58% of the experts. Thirty two percent thought that there would be slightly greater need and 5% of the experts think there will be no change in need by 1995. The significantly greater need for community recreation centers, congregate living housing and adult day care facilities by 1995 will offset the decreased direct family support to care for the indigent elderly and will be discussed under hypothesis 4. Hypothesis number one predicted that there would be a consensus among experts about the best future options for providing health and social services to the indigent elderly. As shown in Figure 8, there was unanimity among respondents that the need for skilled nursing care facilities, congregate living housing, adult day care facilities and personal care boarding homes would increase by 1995. Ninety five percent of the panelists agreed that there would be increased need for home health agencies, hospices and rehabilitation services. Ninety percent believed there would be an increased need for community recreation centers.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :; Lesser D Strongly Agree Slightly Agree Disagree Figure 8 Desree of Need I Skilled '"'""' Adult Day Carp Fnc ilities Personal Cnre Bnardtnr. Homes Home Health Agenc.-les Rehabll!tation '"5% wl!re neglected in certain areas due to No Change figures. Greo'ltcr 637. 84:: 847. 79:t 79:t 63? Future Options for Providing Health and Social Services to the Indigent Elderly 141

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 142 Hypothesis 2 There will be diverse opinions among the experts regarding how to implement future options for the care of the indigent elderly in Metropolitan Denver. In particular, diversity is expected regarding options for financing long-term care and options for a case management system. The Colorado Task Force on the Medically Indigent (1984) has recommended a certain combination of public and private initiatives. Figure 9 reflects the results of the panelists regarding a modest expansion of Medicaid. Forty two percent strongly agree to this initiative while 53% slightly agree to a modest expansion of Medicaid by 1990. Figure 9 ': .. .: Strongly Disagree r:::: :I Slightly Agree 42% 53% Strongly Agree A Modest Expansion of Medicaid by 1990

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I 143 However, Table 21 reflects what the panelists believe will occur to the expansion of Medicaid by 1995. A considerable diversity or lack of consensus is revealed in these figures. The conclusions regarding experts' expectations that may be drawn from these figures include: inpatient hospital care will experience a limited Medicaid coverage by 1995, based services including outpatient care, home health care, hospice care and rehabilitation services will slightly expand under Medicaid coverage by 1995. Sixty three percent of respondents believe that Medicaid will slightly limit its coverage of inpatient hospital care to indigent elderly by 1995. Fifty three percent of the experts believe that Medicaid will slightly expand its coverage for outpatient hospital care by 1995. There was no consensus among the experts regarding Medicaid coverage for skilled nursing care to the indigent elderly but the range was from 32% who believe ;Medicaid will slightly expand its coverage to 32% who believe Medicaid will slightly limit its coverage to indige.nt elderly by 1995. Physician services under Medicaid coverage range from no change (37%) to slightly limit coverage (32%). Sixty three percent of expert panelists believe that Medicaid will slightly expand coverage for home health care by 1995. Also 63% of the panelists feel that Medicaid will slightly expand its coverage of hospice care by 1995. Forty seven percent of the panelists believe. that Medicaid will slightly expand its coverage of rehabilitation services to the indigent elderly by 1995.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 144 Table 21 Medicaid Coverage 1995 Significantly Slightly No Slightly Significantly El!paD:l Expani Liml.t Limit Inpatient 5% 0 5% 63% 26% rospital care
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 145 Figure 10 32% 32% Strongly Agree D Slightly Agree i 11% -Neither Slightly Disagree -Strongly Disagree D Not Useable Response Employment-Based Health Insurance by 1990 Figure 11 addresses the initiative regarding charity care by providers in 1990. Fifty eight percent of the expert panelists strongly agree that health care providers should provide a basic level of charity care. In the Colorado Task Force study (1984), it was recommended that health care providers should be required to contribute charity care, consumers should pay a share of the cost of their care on a sliding scale based on income and family size. At present, many Colorado hospitals and physicians provide charity care to the poor, but this burden is borne unequally. As long as the state does not completely fund all needed charity care a majority of the Colorado Task Force members recommended that all providers continue to provide some charity care. Physicians were

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. j. j \ I I i I ! ; i I I f i I I I 146 encouraged to continue to serve some patients free or at a discount. Another approach to this problem of charity care by hospitals is now used by some eastern states to tax all hospitals and redistrubute these funds to institutions caring for the poor. The Colorado Task Force recognized that ultimately the cost of this charity care is borne by other paying patients, philanthropy, or non-patient revenues, but felt that this contribution is appropriate because of the tax and licensure benefits given to hospitals. Figure 11 58% . . . 26% 11% IT] Strongly Agree D Slightly Agree Neither Slightly Disagree Charity Care by Providers in 1990 Figure 12 considers cost sharing by consumers. Thirty seven percent of the panelists slightly agree with cost sharing by consumers while 21% strongly agree with cost sharing by

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I :I 'I i 147 consumers. However, 26% of the panelists neither agree nor disagree. The Colorado Task Force believed that medically indigent program patients should be required to share the cost of their care by paying a co payment for services rendered. Copayments should be determined according to the patient's ability to pay, considering income and family size. Total out-of-pocket expenses should be limited to a percentage of the family's income so that the copayments do not constitute a catastrophic health care cost. For lowest income groups cost sharing must be minimal in order not to deter people from seeking needed care. The cost sharing requirements should be set at a level that encourages insured persons to maintain private health insurance and not to feel that it is less expensive to rely on the state medically indigent program.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 12 26% 37% CI1 D rm D Strongly Agree Slightly Agree Neither Slightly Disagree Not Useable Response Cost sharing by Consumers by 1990 148 As stated in the beginning of hypothesis 2, most of the diversity among the experts regarding how to implement uture options for providing health and social services to the indigent elderly in Metropolitan Denver is likely to be due to options for financing long-term care and options for a case management system. Table 22 addresses the options for a case management system. The panelists were divided almost evenly on which agency is best qualified to implement an appropriate, efficient, and cost-effect-ive utilization of the limited resources available to the indigent elderly in Metropolitan Denver. Forty seven percent favored a supraboard newly created for this purpose while 42% favored the Department of Social Services.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I 149 As stated various times in this study government health programs for the indigent elderly are fragmented. The Colorado Task Force recommends as a long-term objective that all public programs funding care to low income persons be coordinated and integrated into an efficient system of health care that can be more effectively used and understood by the poor. Coordination of existing programs could save administrative costs and eliminate duplication and gaps as well as making the system more useable for its intended beneficiaries. The Colorado Task Force recommends that the fiscal and coordinating agency should be the Department of Social Services, which would be responsible for establishing eligibility standards and distributing funds. Table 22 Centralized Case Management Organizations Centralized Case Management Functions 1. Community N.F.P. Hospitals 2. Department of Social Services 3. Supraboard newly created for this purpose 4. Other (Specify Not Useable) Round #3 Response 5% 42% 47% 5% Figure 13 reflects the opinions of the experts regarding the replacement of the Medicare system by state and local agencies by the year 1995. Fifty-eight percent of the panelist strongly disagree with this statement. Twenty one percent slightly agree with this statement. Similarly on the American College Study

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 150 (1984) 25% of the panelists strongly disagree with the statement and another 44% slightly disagree that by 1995, state payment systems agencies will replace the Medicare payment system. Figure 13 -..l.! Strongly Agree .. fj-};/j Slightly Agree 11% Slightly Disagree Strongly Disagree -Neither Agree or Disagree Replacement of Medicare

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 151 Table 23 displays providers of health care for the indigent elderly by 1995. Sixty-eight percent believe that the state and local governmental hospitals will increase health care to the indigent elderly. Seventy four percent of respondents predicted that HMO's would increase health care to indigent elderly and five percent thought this provider would decrease services in the future. Less than half the experts predicted an increase in hospital care among religious providers and 10% predicted a decrease. A slight majority (52%) felt there would be an increase in services among other not-for-prof it providers while 27% anticipate a decrease. Only 26% thought there would be an increase in hospital services among investor-owned providers compared with 42% indicating a decrease of hospital services to indigent elderly (see Table 23).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. !I il j I ; 152 Table 23 Providers of Hospital Care to the Indigent Elderly 1995 Not Significantly Slightly No Slightly Significantly Useable Increase Increase Change Decrease I.lecrea;e ResJXlOSe Goveitllll:mt 5Y. 16% 37% 32% 11% federal Govemnent5% 63% 8% 26% state & local Rel:igious 11% 37% 37% 5% 5% 5% Other not-for-5% 47% 16% 16% 11% 5% profit Investor-owned 5% 21% 26% 8% 42% 5% H.M.O. 's 16% 58% 21% 5% In summary, there was total agreement among the experts that the need for specialty facilities will increase; however, as predicted in Hypothesis two, there was little agreement about how to implement future options for the care of the indigent elderly. The measurement of the panelists' agreement or disagreement on how to implement future options for the care of the indigent elderly was obtained from panel responses to (a) types of providers of hospital care to the indigent elderly in the future, (b) changes in future regulations pertaining to health matters, (c) areas of expansion and/or limitation in Medicaid program coverage, and (d) government funding for non-institutional services. As identified earlier in these findings, the number one ranked problem of the

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 153 indigent elderly, i.e., lack of money, permeates any selected options for implementation (see Table 20). Hypothesis 3 There will be a consensus among the experts that skilled nursing home care will increase to accommodate the increased numbers of frail indigent elderly. In the 1977 National Nursing Home Survey (NNHS), the National Center for Health Statistics defines nursing home as a facility offering living accommodations, personal care, and in most instances, some degree of health care to the elderly and disabled (Lloyd and Greenspan, 1980). The number of patients filling these institutions is staggering. The nursing home population ofcolorado for 1980 was 16,375 or 0.55% of the state's total population. Ninety-five percent of the elderly are not residents of nursing homes, which is consistent with the national average. More than 21% of the population 85 years and older are in nursing homes. 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. Figure 14 shows experts' opinions regarding the need for skilled nursing facilities (SNF) by 1995. One hundred percent of the experts felt that there would be a greater need for skilled nursing facilities by 1995. Long-term care in Colorado is becoming increasingly more expensive and will be more difficult to finance in view of budget constraints, a University of Colorado Health

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Science Center report revealed in 1980. 154 This Center study estimated that private long-term care costs are approximately equal to public expenditure bringing the total estimated long-term care dollars for FY 79-80 to a half billion dollars. When the rate of increase in long-term care costs is considered, the future financial impact on Metropolitan Denver becomes frightening. Figure 14 53% Slightly Greater Need Significantly Greater Need Need for Skilled Nursing Care Facilities in 1995 In summary, to test the hypothesis that there will be a consensus among the experts that skilled nursing home care will increase to accommodate the increased numbers of frail indigent elderly, the panelists' attitudes regarding specialty facility

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ,I 155 needs and utilization of more aggressive social services involvement in SNF were examined. Figure 14 shows that 100% of respondents believed the need for SNF would increase by the year 1995. Seventy-four percent agreed that the routine day-to-day living for the indigent elderly would improve if more aggressive social services were employed in skilled nursing facilities (see item 42 in Appendix D). Hypothesis 4 There will be a consensus among the experts that there will be less direct family support to the care of the indigent elderly in Metropolitan Denver. Surveys indicate that most of the longterm care received by indigent elderly persons living outside of nursing homes is delivered by the family and friends. Despite the importance of families as providers of long-term care, information is lacking to properly assess the burden that providing this care imposes. The availability of informal care in the home will decline with the increasing participation of women in the labor force. Daughters and daughters-in-law have traditionally been the second most important source of informal care following the patient's own spouse. Information regarding this hypothesis was gathered indirectly by looking at the increased need for senior centers, adult day care facilities, congregate living, and personal care boarding homes. Figure IS shows the expected need for senior centers by 1995. Ninety four percent of the panelists agree to the

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I I I II il 156 need for senior centers throughout the community regardless of the neighborhood income levels. Further, ninety five percent of the panelists agree that the government should provide senior centers throughout the community (see item 44 of Appendix D). In order to maintain independence and self-sufficiency, elderly persons require a wide range of activities (recreational, nutritional, social, health, etc.). Multipurpose senior centers serve many functions for the elderly and the community. They provide a local, more convenient setting, they reduce service fragmentation, they have the capacity to provide more "direct services to the elderly in a centralized location, they can reduce administrative costs and avoid duplication, they provide a mechanism to serve more elderly in a shorter period of time, and they are able to assess some of the elderly's needs and provide information and assistance as well. Multipurpose senior centers can serve as a referral source to other local and regional agencies for elderly persons needing services and not knowing how to obtain them. Multipurpose senior centers provide opportunities for social interaction, thus combating isolation and loneliness for many elderly persons. The centers can provide volunteer opportunities and paid employment at the center. Most of the respondents in the Denver Regional Council of Government Office on Aging needs assessment study (1980) participated in activities. These activities ranged from activities to meet basic needs to recreational activities with someone else. Multipurpose senior centers could provide social

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ' I I I I I l I I i I I I I !l I. j i 1 I i' 157 opportunities for lonely elderly persons. There is a need to continue to provide services for low-income elderly persons who cannot purchase needed services elsewhere. Figure 15 26% 5% 5] Strongly Agree CJ Slightly Agree c===J Not Useable Response Need for Senior Centers by 1995 Figure 16 describes the need for adult day care facilities by 1995. Eighty-four percent of the panelists feel that there will be a significantly greater need for adult day care facilities by 1995. Another 16% felt that there would be a slightly greater need by 1995. Among the most commonly proposed long-term care alternatives to nursing homes are those gathered under the umbrella of adult day care (ADC). Actually, adult day care is not an "alternative" but usually part of a spectrum of care. It is not a simply defined category of provision, nor is it simply a substitute for other components of health care (Palmer, 1980).

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. .i 158 Brahna Trager's report (1979) on the 1977 and 1978 conferences on adult day care provided a useful summary. She observed that a number of characteristics and requirements are common to all adult day care programs. All must be carefully planned, yet amenable to criticism and change. All should have clear goals and objectives for their services, most particularily those which see adult day care as part of a spectrum of care rather than an answer in itself. Care setting requirements and availability must be previously determined, as must staff training and administrative and organizational procedures. Coordination with other care modes must be emphasized, as must the involvement of clients and families in the design and delivery of services. This last point is important because patient's needs must be clearly understood, because family support may be crucial to the success of an adult day care program and because family assumption of responsibility may be highly influential in determining outcomes for indigent elderly family members. il :! ij I I i I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I I II 159 Figure 16 Significantly Greater Need Slightly Greater Need Need for Adult Day Care Facilities by 1995 Figure 17 indicates the expected need for congregate living by 1995. Sixty three percent of the panelists agree that the need for congregate living housing will be significantly greater in 1995. Another 37% agree that the need for congregate living will be slightly greater by 1995. Housing conditions and services can have a dramatic impact on-the older person's ability to cope with a chronic illness or disability. The most common housing problems experienced by a chronically disabled, elderly person are the results of an inadequate or inappropriate home setting. Whether the setting is a

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. l i i l I l i l l I I i i i I 160 private home, boarding home, congregate living home, etc. the crucial factor is whether the nature of the dwelling and the services offered (if any) are appropriate for the level of care required by a dependent elderly person. Every functionally limited, older person needs a certain combination of housing and services. The difficult policy and program task is to provide appropriate levels of housing and/or services to match the diverse needs of a dependent population. At the 1971 White House Conference on Aging, delegates called for a national statement of goals on the provision of a spectrum of housing for the elderly. Included in this spectrum were: 1-long-term care facilities for the sick, 2-facilities with limited medical care and food and homemaker services for those who needed continual supervision and assistance, 3-congregate housing with food and personal services for those who require some assistance but who only need routine medical care, and 4-housing for independent living with recreational and program activities provided" (Thomas, S.G., 1980, p. 395-396). The Congregate Housing Services Program, Title IV of the 1978 Housing Act is designed to encourage the development of a housing continuum which relates directly to the realities of the aging process. Under this act, public housing agencies and borrowers may receive funds to provide meals and other supportive services to eligible project residents. These services are meant to help elderly occupants living independently, preventing their

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 161 premature or unnecessary institutionalization. Overall, the program ties support services to housing to guarantee a long-term funding source, provide an incentive for the construction of congregate facilities, and fill the gap where direct family support is not available. 63% Figure 17 Significantly Greater Need Slightly Greater Need Need for Congregate Living by 1995 Figure 18 shows the need for personal care boarding homes by 1995. Sixty eight percent of the panelists strongly agree that personal care boarding homes would significantly improve the quality of living for some indigent elderly. Twenty one percent slightly agree with this statement.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 162 Personal care boarding homes are considered under domiciliary care. More complicated and diverse than home care, it lacks even the general focus on nursing care characterizing nursing homes. complex. The purposes and intentions of domiciliary care are To some analysts and policymakers, domiciliary care facilities are halfway houses for deinstutionalized elderly; to others they resemble community-based old peoples homes of a noninstitutional type; to still others, they may be sheltered homes for the frail. Perhaps it is safest to say the domiciliary care facilities are all of these and more. At present, domiciliary care facilities seem to constitute a set of flexible, reasonably safe, community based facilities providing low-intensity, noninstitutional care, supervision, meals, and rooms to groups of vulnerable people who literally may have no place to go and would find living on their own in the community extremely difficult (Palmer, 1980). Diversity among clients is mirrored by a variety among providers. Some facilities, usually private pay, resemble high quality hotels offering some supervision in a sheltered environment together with good quality food and accommodations. Others are dirty, dark and overcrowded, providing little more than "three hots and a cot'". Most probably lie in between, providing adequate food and lodging in a supervised, reasonably clean environment.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 18 :11% 163 Strongly Agree c===J Slightly Agree c===JNot Useable Response Need for Personal Care Boarding Homes by 1995 In summary, hypothesis four stated there will be a consensus among the experts that there will be less direct family support to the care of the indigent elderly. Indirect measurement of this element was indicated by the need for home health agencies, and senior centers, adult day care facilities, personal care boarding homes, and congregate living housing. Data recorded in Figure 17 indicates that one hundred percent of respondents believed there would be a greater need for congregate living housing in 1995 and ninety-five percent believed there would be a greater need for home health agencies. Hypothesis 5 There will be a consensus among the. experts that home services will be more widely utilized by the indigent elderly in Metropolitan Denver. Figure 19 reflects the need for home health services by 1995. Seventy-nine percent of the panelist agree that

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 164 there will be a significantly greater need for home health services by 1995. Sixteen percent of the panelists agree that there will be a slightly greater need for home health services by 1995. Home care is clearly a desirable alternative to many long-term care patients in terms of their health care needs and their personal preferences. The Congressional Budget Office divided home health services into three categories: 1) basic services, 2) health related services and 3) skilled services. These services are provided in any of several settings including: day care centers, domiciliary care facilities, or in the client's own home.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 19 5% Significantly Greater Need Slightly Greater Need -No Change Need for Home Health Services by 1995 165 The major sources of public support for alternative services comes from the federal government through Titles XVIII, XIX and XX of the Social Security Act, Title III of the Older American's Act and section 8 of the Department of Housing and Urban Development. State and local governments contribute to several of these programs. Each of the government programs has different conditions for reimbursement and covers different services.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 166 The fragmentation of funding for alternatives to long-term care evident from the preceding paragraph creates obstacles for elderly people trying to obtain appropriate care. Studies of the cost-effectiveness of home care services, particularly home health services have been inconclusive. Whether home health is deemed cost-effective also depends on with what it is being compared. A 1978 literature review revealed that the vast majority of studies demonstrating cost-effectiveness of home health services compared home health with hospital rather than nursing home care (Colorado State Health Plan, 1982). Taken together the inconclusive findings of cost effectiveness studies, the lack of evidence regarding utilization of nursing homes, and the suggestions that there is a large potential demand for alternatives, it is clear that alternative long-term care services should not be regarded as a way to decrease total health care expenditures. This information is reflected in Figure 20 where funding for non-institutional services is displayed. Fifty three percent of. the panelists slightly agree that expanded governmental funding of non-institutional services would increase, not decrease, total government long-term care expenditures.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 'i I i I I I I lj I i I :;,>:'.:)Strongly [;/;/(]Slightly .. Agree Agree Agree or Disagree Figure 20 J;;::::i:'=:=:J Slightly Disagree Strongly Disagree Not Useable Response Funding for Non Institutional Services 167 The fifth hypothesis predicted that there would be a consensus among the experts that home services will be more widely utilized by the indigent elderly. Indicators of this factor were the responses pertaining to limitation of Medicaid program coverage for home health care and the identification of greater need for home health agencies by 1995. Summary In summary, future demographic and social projections imply considerable increases in the need and demand for long-term care

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. t i l I I I I I i i ; I '' l i 168 services . The long-term care problems of the indigent elderly include: 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. The preceding findings reviewed the prospects for solving these problems by examining experts' opinions regarding future options for providing health and social services to the indigent elderly in Metropolitan Denver. The findings of twenty expert panelists were analyzed based on five hypotheses developed for this study. In the next chapter these findings will be summarized and their implications discussed.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i 1 I I I I i I I !I I Chapter V CONCLUSIONS AND RECOMMENDATIONS Conclusions This study emerged out of a concern that there exist many problems with long-term care programs in the United States. Long-term care 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. 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. Colorado has approximately 2000 service agencies with programs for the elderly. They include: 143 different health, medical or in home supportive service programs; 6 employment or training programs; 8 public income resources and hundreds of income conservation programs; 15 legal service programs to name just a partial list. Still 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. Major reforms in the present system of long-term care are needed because

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 170 of the skyrocketing cost of long-term care. This increase in spending for long-term care is due in part to coverage of long-term care services by public programs particularly by Medicaid. Federal costs for long-term care are expected to continue to grow much higher as a result of the aging of the population. Problems with the existing programs in long-term care as discussed include: 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. These problems will only grow because of the growth in the number of needy elderly. Nationally the United States 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. In the year 2000, the 32 million elderly will represent 12.2% of the total population compared with 11.2% in 1980. Also, 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%. Colorado's aging population is growing both larger and older. Growth projections for the next twenty years indicate that the elderly population will grow at an even faster rate which will increase the need for long-term care services. Age is not the only determinant of the need for long-term care. Other determinants

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. l I I I I i l ; I i I I I 171 include the physical and mental health status of the elderly population. The primary differentiation of needs among the elderly is a reflection of functional impairment more than anything else. From the 1980 census, 12.3% or 16,568 of all persons 60 and over were below the poverty level in Metropolitan Denver. Blacks represented 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%. These statistics were significant for this study because health and social services to the indigent elderly in Metropolitan Denver need to be targeted to these minority populations as well as the whites. The current service delivery system in the Denver 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. 4. Federal, state and private funding sources often dictate unreasonable eligibility criteria for service programs and limit participation based on geographic boundaries.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; I I i I I i I I I I I I I I lj I I' :1 'I '' 172 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 services to 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 (Denver Regional Council of Governments, 1980). The following service systems were discussed in Chapter I: 1) health and medical care, 2) housing and 3) income. 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. Elderly persons require availability of services (supportive, therapeutic, preventative, rehabilitative, and long-term care) to meet their changing needs. Health and medical

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 173 services systems must include preventative care and social support services. Poverty and isolation greatly affect the health status of an elderly person. Adequate income, housing and nutrition all contribute to health maintenance. Finally, elderly persons do not always receive adequate information about the types of health and medical services which are available and to which they are entitled. The second service problem is 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. The need for thousands of units in congregates of assisted housing, along with a variety of alternative housing is critical in Metropolitan Denver. 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. Inadequate income in retirement is a third problem for older persons. Expenses for older persons do not decrease at the rate their income incomes and decreases physical for their years problems often of retirement. Fixed 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. National studies have proven that elderly persons tend to spend their free time in the same ways they've always spent their free time. In order to increase utilization of services, elderly

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 174 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. Despite the many public dollars being spent and the number of organizations available, a litany of long-term care problems exist. Until the present, little consensus has emerged on how these complex needs should be financed and administered in Metropolitan Denver. This study addressed certain key hypotheses regarding experts'' opinions concerning future options for providing health and social services to the indigent elderly in Metropolitan Denver, Colorado including: 1. There will be a consensus among experts about the best future options for providing health and social services to the indigent elderly. 2. There will be diverse opinions among the experts about how to implement future options for the care of the indigent elderly. 3. There will be a consensus among the experts that skilled nursing home care will increase to accommodate the increased number of frail indigent elderly. 4. There will be a consensus among the experts that there will be less direct family support to the care of the indigent elderly. 5. There will be a consensus among the experts that home services will be more widely utilized in the future by the indigent elderly.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I l I i I I I l l j I ) I I j L ll :I :1 175 In the literature review (Chapter II) the problems and prospects for solving these problems of the indigent elderly in Metropolitan Denver were addressed. Among the matters considered were options for financing long-term care, range of care options, long-term care institutions, family support services, and home services. The financial options included: cash payments, voucher/disability allowance, national health insurance, and mixed financing systems. The range of care options included: the case management concept, the single agency model and the social health maintenance organization. Long-term care institutions were discussed including inappropriate institutionalization in Colorado. Family support services were summarized including the fact that a larger share of dependent indigent elderly will have to seek services from formal providers in the future. In discussing home health services, it was found that the fragmentation of funding for alternatives to long-term care may create obstacles for indigent elderly people trying to obtain appropriate care. In order to deal with options .of the indigent elderly in Metropolitan Denver, the Delphi procedure was used. This procedure involved the use of a series of three survey questionnaires designed to produce group consensus and eliminate face to face confrontation as experienced on other types of expert panels. This study was limited to include twenty experts: five adminstrators, five clinicians, five consumers and five policy makers in Metropolitan Denver, Colorado.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 176 Following the chronological framework for a Delphi study, a problem solving sequence was used regarding experts' opinions of future options of the indigent elderly in Metropolitan Denver. Survey results were reported in five broad categories based on the five hypotheses developed for this study. consisted of three survey rounds: Round 1: Identification of issues. The Delphi procedure Round 2: Response to a 55 item questionnaire developed from the responses to Round 1. Round 3: Response to the same 55 item questionnaire showing a statistical summary of Round 2 responses. The significance of the findings of this study are many. Concern about th12 epidemic of the indigent elderly stems primarily from two factors: numbers and dollars. We hear a great deal of talk about the incipient demise of Social Security, the bankrupt status of Medicare, the death of the family, and dire predictions of demographic cataclysms. There is indeed cause for concern, but not necessarily for alarm. The message is clear; we cannot go on as we have. New approaches are needed. The shape of those approaches to meeting the needs of growing numbers of elderly persons in the society will reflect societal values. The panel of experts in this study perceive that the indigent elderly are entitled to the same level of services as the entire u.s. population. However, access to these services will become more of a problem for Medicaid beneficiaries in the future, most respondents agree.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 177 The experts in this study slightly agree that the U.S will adopt some form of national health insurance by 1995. Experts in the health care field believe we are going to experience reregulation in the 1990's as compared to deregulation of the 1980's. At the same time, the concept of competition will be furthered in the 1990's. The rules of the game are constantly changing, often in opposing directions, as legislators and regulators try to balance social needs and demands with economic realities. In the future, the experts in this study believed that funding for non-institutional services by the government would increase the total long-term care expenditures. There have been few attempts to make a comprehensive assessment of the well being of representative groups of elderly people as a basis for policy decisions concerning the provisions of appropriate services. Rather than considering the indigent elderly person as an integral human being, the tendency of care givers and research workers alike has been to measure single dimensions of well being, such as mental function, social support, economic status, physical morbidity or capacity for self care. However, indigent elderly people are subject to multiple disadvantages, and their physical, mental, social and economic well being are closely interrelated more so than at younger ages -so that combined assessment of the various dimensions of well-being is necessary. The federal government has determined that it can no longer afford the escalating costs of the Medicare and Medicaid :' I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 178 programs. The dramatic changes made in the financial payment structure in the last few years will be expanded as the indigent aging of the nation's population places increased demands on the financially strained resources. The experts in this study could not reach a consensus on a combination of public and private initiatives for the indigent elderly. Fifty three percent of them slightly agreed that in 1990 there will be a modest expansion of the Medicaid program. Fifty eight percent of the panelists strongly agree with a basic level of charity care by providers. However, an employment-based health insurance did not receive a consensus as an initiative for the indigent elderly. Also, there was no consensus regarding cost sharing by consumers in 1990. In Chapter II of this study the following financing options were discussed: Cash payments, voucher/disability allowance, national health insurance, and a mixed financing system. The experts in this study reached a high consensus that all of these financing options require a large role for the federal government in financing programs for the indigent elderly 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 responsibilities in financing long-term care solutions. In addition, the American College of Hospital Administrators Report (1984) predicted that with changes in payment incentives, ambulatory services including home care, hospice and outpatient surgery as well as extended care, physical therapy and rehabilitation will become more expanded by health care providers

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 179 by 1990. They further predict that Medicare will change its coverage based strictly on financial need rather than to all elderly citizens. By the year 2030, an estimated 21% of all Americans will be over the age of 65, and nearly one-seventh of these senior citizens will be over 85. In light of the complicated financial and emotional burdens inherent in caring for parents, experts on aging are troubled by the prospect of a society in which the old will be looking after the very old. Regarding that agency which is best qualified to implement an appropriate, efficient, and cost effective utilization of the limited resources available to the indigent elderly in Metropolitan Denver, the eKperts were almost evenly split between a supra board newly created for this purpose and the Department of Social Services. One panelist would only add another fragmented system. connnented that the supraboard solution level of bureaucracy to an already The experts felt that need for skilled nursing facilities would be significantly greater in 1995.. The need for nursing homes is not simply because of the presence of disease or even functional disabilities. It is also a result of a lack of social support. Often the family becomes exhausted after caring for an elderly patient for a long time. Family fatigue is especially a problem when the patient has symptoms that are very disruptive. These results are strongly supported in the literature where the use of local long-term care organizations are discussed. For example, in Chapter II it was reported that the use of local long-term care

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 180 organizations would allow much greater flexibility in allocating resources at the local level. All of the experts agree that individual needs assessment would provide a better basis for planning community long-term care delivery systems. In summary, a high level of consensus existed among experts concerning where the trends are headed and what the operational strategies regarding the future options of the indigent elderly in Metropolitan Denver should be. All five of the following hypotheses were supported by this study: 1) there was a consensus among the experts regarding the best future options for providing health and social services to the indigent elderly. 2) there were diverse opinions among the experts regarding how to implement future options for the care of the indigent elderly. 3) there was a consensus among the experts stating that skilled nursing home care will increase to accommodate the increased numbers of frail indigent elderly. 4) there was a consensus among the experts that there will be less direct family support to the care of the indigent elderly in the future. 5) there was a consensus among the experts that home services will be more widely utilized by the indigent elderly in the future. None of the five hypotheses were not supported. Recommendations This section suggests appropriate actions which might be taken in the near future at the community level to develop a systematic and comprehensive long-term care community program. The

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 181 results of this study discussed previously and the strengths and weaknesses of current efforts were used to develop this list of actions. Many of the conclusions and recommendations discussed below are supported by Colorado's Long-Term Care Plan (1982). First, as revealed in this study, community decision-makers should create a supraboard for the purpose of implementing an appropriate, efficient and cost-effective utilization of the limited resources available to the indigent elderly in Metropolitan Denver. This recommendation deals with the need to have a single agency with the primary responsibility for planning, coordinating, delivering and evaluating long-term care services at the community level. As the lead agency, the supraboard would be responsible for coordinating long-term care planning efforts with the Departments of Social Services, Health, Institutions, Local Affairs, Highway, and Education. Once the supraboard is authorized, annual or multi-year appropriations should be sought. The program authorization should include a specific dollar amount (e.g., $20 to 30 million) over the next 10 years. Second, organize the supraboard to include key programs and functions. This effort to organize is in response to the fragmentation that presently exists in the service delivery system. The creation of this supraboard should be to focus on long-term care and its relationship to the local community. It should be stipulated that at least four program service elements must be in place: information and referral, case management, a

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 182 spectrum of appropriate services, and supports for the informal support systems. These program elements are necessary components of a comprehensive long-term care system at the local level. Specific recommendations in the area of information and referral include the development of a comprehensive data system on providers, eligibility requirements, and service capacity at the local level. Specific recommendations in the area of case management include the designation of case management functions, establishing the responsibility and authority of the case manager, and providing training for the designated case managers. Access to an appropriate spectrum of long-term care services is contingent upon the availability of high quality services which are affordable, accessible, and acceptable to the clients in need. The informal support system must be built at the local level as well as at the state level. Third, make reimbursement and financing of the current longterm care system more efficient and increase local appropriations based on needs identified through. the local long-term care systems. Currently, appropriated public dollars should be used more efficiently by consolidating funding sources, developing local plans, targeting those most in need, developing a sliding scale for services, developing cost-effective alternatives to long-term care, and maximizing third-party, family and community resources in the payment of long-term care. Finally, deliver services which are of high quality at the local level including housing alternatives to provide options

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 183 between living in a nursing home and living in the community. The data from this study revealed that the largest consensus among the experts was shown in regards to the need for speciality facilities for providing health and social services to the indigent elderly in Metropolitan Denver by 1995. These facilities include the increasing need for skilled nursing facilities, congregate living housing, and personal care boarding homes by 1995. The experts also believe that there will be an increasing need for adult day care facilities and multipurpose senior centers by 1995. In conclusion, Metropolitan Denver's long-term care system is expensive and growing more expensive every year. Despite these large expenditures, Metropolitan Denver's long-term care system does not meet the needs of many individuals in need of long-term care. Future demographic and social projections imply considerable increases in need for long-term care services. This study revealed several prospects for solving these problems by examining experts' opinions regarding future options for providing health and social services to the indigent elderly in Metropolitan Denver, Colorado. It is believed that a well designed and properly coordinated program incorporating the information from this study could save citizens many billions of dollars and simultaneously result in better long-term care.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I 1 l I i l l I i! REFERENCES Adelson, M., Alkin, M., Carey, C. and Helmer, 0. (1967). The Education Innovation Study. American Behavioral Scientist, 8-12 & 21-27. American College of Hospital Administrators and Arthur Andersen & Co. (1984). Health care in the 1990's: Trends and Strategies. A report. Chicago: Arthur Andersen & Co./American College of Hospital Administrators. American Hospital Association. (1982). Hospital Administration Terminology. Chicago: Author. Beatrice, D.F. (1981). Case Management: A policy option for long term care. In J.J. Callahan & S. Wallack (Eds.), Reforming the long term care system (pp. 121-162). Lexington, MA: D.C. Heath. Bishop, C. (1981). A compulsory national long-term care insurance program. In J.J. Callahan & s. Wallack (Eds.), Reforming the long term care system (pp. 61-68). Lexington, MA: D.C. Heath. Callahan, J. J. & Wallack, S. (Eds. ) (1981). Reforming the, long term care system. Lexington, MA: D.C. Heath. Campbell, R.M. (1966). A methodical study of the utilization of experts in business forecasting. Unpublished Ph.D. Dissertation, University of California, Los Angeles. Capitol Hill Area Planning Council for Health Support Services for Seniors. (1977). Health needs assessment of Capitol Hill elderly. Denver, CO: Author. Cochran, W.G. (1963). Sampling Techniques. New York: Wiley. Colorado Foundation for Medical Care. (1979). Status report of the referral process for alternative services for Medicaid recipients. Denver, CO: Author. Colorado population reports, 1980 census results: Population, housing, age, sex and ethnicity. 1980 Census Report Number 2. Denver: Colorado Department of Local Affairs, Division of Planning. Colorado State Health Plan. (1980). Home health care (pp. 1-46). Denver, CO: Colorado Department of Health.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 185 Colorado Task Force on the Medically Indigent. (1984). Colorado's sick and uninsured: We can do better. (Vols. 1-3). Denver: Piton Foundation. Congressional Budget Office (CBO). (1977a). Long-term care for the elderly and disabled. February: 16-17. Congressional Budget Office (CBO). (1977b). Long-term care: Actuarial cost estimates. (August: table 7, p. 27). Correia, E. (1976, August). National health insurance, welfare reform, and the disabled: Issues in program reform. Prepared for Office of the Assistant Secretry for Planning and Evaluation, U.S Department of Health, Education and Welfare, Washington, D.C. Currill, D.L. (1972, March). Technological forecasting in six major U.K. companies. Long Rang Planning (pp. 86-98). The Delphi Method: An Experimental Study of Memorandum RM 5888 PR. Santa Monica, CA: Dalkey, N.C. (1969) Group Opinon. Rand Corporation. Dalkey, N.C., Rourke, D.L., Lewis, Studies in the Quality of Life. R. & Snyder, Lexington, MA: D. (1972). D.C. Heath. Dean, B. V. & Mathis, S. Development Project Memorandum No. 165. Research, School of University. ( 1969). Analysis of the Exploratory Evaluation Experiment. Technical Cleveland: Department of Operations Management, Case Western Reserve Denver Regional Council of Governments (DRCOG). (1980). Area plan on aging services. Denver, CO: DRCOG Office on Aging for Colorado Denver Regional Council of Governments (DRCOG). (1981). services impact and needs assessment. Denver, CO: Office on Aging for Colorado. Aging DR COG Diamond, L.M. & Berman, D.E. (1981). The social/health maintenance organization: A single entry, prepaid, longterm care deli very system. In J .J. Callahan & s. Wallack (Eds.), Reforming the long-term care system (pp. 163200). Lexington, MA: D.C. Heath. Dror, Y. (1971). Ventures in policy sciences. New York: American Elsevier. [Chapter 8]. Eggert, G., et al. disability. (1977). Caring for the patient with long-term Geriatrics, [October], 3-20.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I ! I I I II i 186 Fillenbaum, G.G. ( 1984). The well being of the elderly: Approaches to multidimensional assessment. Geneva, Switzerland: World Health Organization. Gelman, D. (1985, May 6). Who's taking care of our parents? Newsweek, pp. 61-68. Gibson, R.M. & Fisher, C.R. (1976, June). National health expenditures, Fiscal Year 1975. Social Securiti Bulletin, P 61. Gibson, R.M. & Fisher, C.R. (1978' July). National health expenditures, Fiscal Year 1977. Social Securiti Bulletin, 3-20. Griffith, J.R. (1984, November). Meeting the community hospital's responsibility to the aging. Frontiers of Health Services Management, _!_( 2), 13-28. Grimaldi, P. (1984, September). How major regulations strive to ensure quality care in nursing homes. Healthcare Financial Management, 50-72. Gruenberg, L. & Pillemer, K. (1981). Disability allowance for long-term care. In J .J. Callahan & S. Wallack (Eds.). Reforming the long-term care system (pp.69-72). Lexington, MA: D.C. Heath. Grundy, E. (1983). Demography and the old age. Journal of. the American Geriatrics Societ:r, 1!_(6), 325-332. Gurland, B. (1978). Dependency among the elderl:r in New York. New York Community Council of Greater New York. Hammond, J. (1979). Home health care cost effectiveness: An overview of the literature. Public Health Reports, 44, 305-312. Helmer, 0. (1963). The systematic use of expert judgment in Operations Research. P-2795. Santa Monica, CA: Rand Corporation. Hudson, -R. (1981). Restructuring federal/ state relations in long term care: The bloc gran alternative. In J.J. Callahan & S. Wallack (Eds.), Reforming the long term care s:rstem (pp. 72-78). Lexington, MA: D.C. Heath. Jazwilcki, T. (1984, April). facility services under Management, 76-80. How states pay for long-term care Medicaid. Healthcare Financial

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Joe, T. & Meltzer, J. (1976, May 14). for long-term care. San Francisco: University of California. 187 Policies and strategies Health Policy Program, Judd, R.C. (1972, July). Forecasting for consensus gathering, Delphi grows up to college needs. College and University Business, 35-38 & 43. Kamerman, S.J. and Kahn, A.J. (1976). Social services in the United States: Policies and programs. Philadelphia: Temple University Press. Kane, R.L., Ouslander, J.G. & Abrass, Clinical Geriatrics. New York: I. (1984). McGraw Hill. Essentials of Kurowski, B. (1980). A cost-effectiveness analysis of home health Implications of public policy and future research. Doctoral dissertation, University of Colorado Graduate School of Public Affairs. Kurowski, B. and Shaughnessy, P.U. (1983). The measurement and assurance of quality. (1983). In R.J. Vogel & H.C. Palmer (Eds.), Long term care: Perspectives from research and demonstrations (pp. 103-133). U.S. Department of Health and Human Services, Health Care Financing Administration. LaVor, J. (1977). Long-term care: A challenge to service systems. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health, Education and Welfare. Washington, D.C. [April]. Lindeman, C.A. (1981). Priorities within the health care system: A Delphi survey. Kansas City, MO: American Nurses Association. Lloyd, S. & Greenspan, N. (1980). Nursing homes, home health services and adult day care. In R.J. Vogel & H.C. Palmer (Eds. ). Long-term care: Perspectives from research and demonstrations (pp. 133-166). U.S. Department of Health and Human Services, Health Care Financing Administration. Martino, J.P. (1973, February). How the Soviets forecast technology. The Futurist, 1. McCaffree, K. (1977). Cost data reporting system for nursing home ..;;;c;.;;;a;.;;;r-="e .... : ...... t. (Publication No. HRA 7 7-3169). Rockville, MD: National Center for Health Services Research, DHEW.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i 188 McCullough, L. (1984, February). Medical care for elderly patients with diminished competence: an ethical analysis. Journal of the American Geriatrics Society, 150-153. Mendelson, M. (1984). Tender Loving Greed. New York: Alfred A. Knopf. Moreland Act Commission on Nursing Homes and Residential Facilities. (1976). New York: Moreland Act Commission on Nursing Homes and Residential Facilities. Moss, F .E. bad: & Halamandrais, V .J. (1977). Too old. too sick, too Nursing homes in America. Aspen Systems Corporation. Palmer, H. (1983). The system of provision. In R.J. Vogel & H.C. Palmer (Eds.). Long term care: Perspectives from research and demonstrations (pp. 1-62). Health Care Financing Administration, U.S. Department of Health and Human Services. Pill, J. (1971). The Delphi Method: Substance, contexts, a critique and an annotated bibliography. Socio-economic Planning Sciences. 2. Pollak, w. (1974). Federal long-term care strategy: Options and analyses. Washington, D.C.: The Urban Institute. [ 17 October 1973 --Revised 25 February 1974]. Quade, E.S. (1975). Analyses for public decisions. York: Elsevier. Reisman, A. (1969). Evaluation and budgeting for a system of social agencies. Technical Memorandum No. 167. Cleveland: Operations Research Department, School of Management, Case Western Reserve. Reisman, A., Mantel, S.J., Jr., Dean, B.V. & Eisenberg, H. (1969). Evaluation and budgeting for a system of social agencies. Technical Memorandum No. 167. Cleveland: Operations Research Department, School of Management, Case Western Reserve University. Rice, J & Taylor, S. (1984, February). Assessing the market for long-term care services. Healthcare Financial Management, PP 32-46. Sackman, H. (1975). Delphi critique. Lexington, MA: D.C. Heath. Scanlon, W. & Feder, J. (1984, January). The long term care marketplace: An overview. Healthcare Financial Management, PP 18-19, 24-36.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i ; I I I I J I 189 Thomas, S.G. (1980). The significance of housing as a resource. In R.V. Vogel & H.C. Palmer (Eds.). Long term care: Perspectives from research and demonstrations (pp. 391-414). Health Care Financing Administration, u.s. Department of Health and Human Services. Ting, H. (1984, May). New Directions in nursing home and home healthcare marketing. Healthcare Financial Management, pp. 62-72. Trager, B. (1979, May). Adult day health care -A conference report. Arlington, VA (1977, September) and Tucson, AZ (1978, September) under Grant No. 1 Rl3HS 10580-01, National Center for Health Services Research, OASH. Turoff, M. (1971). Delphi and its potential impact on information systems. AFIPS Conference Proceedings, 39. Montvale, NJ: AFIPS Press. u.s. Comptroller General, General Accounting Office. (1979, November). Entering a nursing home: Costly implications for Medicaid and the Elderly. u.s. Comptroller General, General Accounting Office. (1977). Home health: The need for a national policy to better provide for the elderly. (Publication No. HRD 78-19). Washington, DC: Government Printing Office. u.s. Congress. House. Staff of the subcommittee on Health and Environment of the Committee on Interstate and Foreign Commerce. A discursive dictionary of health care. Washington, DC: Government Printing Office, 1976. u.s. Congress. House. Older Americans Act of 1965, Public Law 89-73, 89th Congress, 2nd Session, H.R. 3708, 1965. U.S. Congress. House. Select Committee on Aging. fragmentation of services for the elderly. Publication No. 95-93, 4 April 1977), p. 106. Hearings on (Committee U.S. 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. U.S. Census Report for 1980: Bureau of the Census. Census, 1980. Summary Tape File 3A prepared by the Washington, D.C.: U.S. Bureau of the

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 190 U.S. Department of Health and Human Services. (1982). Colorado's long term care plan, 1982. Funded by a grant from the Administration of Aging. u.s. Department of Health, Education and Welfare (HEW), Office of the Secretary. (1974). Program design choices for long term care legislative initiative --Decision Memorandum. Washington, D.C., August. U.S. Department of Health, Education and Welfare (HEW), Office of the Secretary. (1976). Long term care services legislative proposal. Washington, D.C., October 19. U.S. Department of Health, Education and Welfare (HEW), Office of the Secretary. (1978). Memorandum for July 14, 1978, Briefing, Major Initiative: Long-term care/community services. Washington, D.C., p. 3 and appendix 10, table 1. U.S. Department of Health, Education and Welfare. (HEW). National Center for Health Statistics. (1979). The national nursing home survey: 1977 summary for the United States, Washington, DC, July. U.S. Department of Health, Education and Welfare (HEW). (1979). Home health services under Titles XVIII, XIX, and XX in U.S. Congress, Senate, Special Committee on Aging. Home care services for older Americans: Planning for the future. (96th Congress, 1st session, 7 May 1979). Washington, DC: Government Printing Office. U.S. Department of Health, Education and Welfare (HEW), Office of the Secretary. (1978). Memorandum for July 14, 1978, Briefing, Major Initative: Long term care/community service. Washington, D.C. U.S. Graduate Medical Education. (1981). National Advisory Committee, Report to the Secretary. Vol. 2. Modeling, Research and Data Technical Panel. Hyattsville, MD: U.S. Health Resources Administration, Office of Graduate Medical Education. Vladeck, B. (1980). Unloving care: The nursing home tragedy. New York: Basic Books. Waldo, D.R. & Lazenky, H. Demographic characteristics and health care use and expenditures by the aged in the United States. (1977-1984). Health Care Financing Review. Fall 1984, Vol. 6, No. 1, pp. 1-29. Willging, P., Kerschner, P. & Peres, J. (1984, December). Longterm care: The Malthusian Dilemma. Healthcare Financial Management, pp. 48-54.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Willging, P. & Neuschler, E. (1982). continues on future of federal care. Hospitals, 61-65. 191 Long term care: Debate financing of long term Youket, P. (1981). Appendix A: Previous analyses of major reform options for long term care. In J. J. Callahan & S. Wallack (Eds.), Reforming the long term care system (pp. 183-201). Lexington, MA: D.C. Heath.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDICES

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX A Cover Letter Round 1 Questionnaire

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 'I Dear Panelist: Hilda Grey, R.N., M.H.A. 231 Adams Street Denver, CO 80206 July 31, 1985 194 Thank you for consenting to participate in this Delphi Survey regarding the indigent elderly in Metropolitan Denver. Administrators, clinicians, consumers and policymakers have studied extensively the physical, emotional and social problems of the aging in Denver, usually concluding that the vast majority of the indigent elderly population requires special assistance in meeting their essential needs. The purpose of this study is to identify and discuss the best future options for providing health and social services to the indigent elderly in Metropolitan Denver. In order to address these problems regarding the indigent elderly in Metropolitan Denver, a Delphi Technique will be used. The Delphi Technique is a method of soliciting and combining the opinions of a group of experiments. It involves the use of a series of questionnaires designed to produce group consensus and eliminate face-to-face confrontation as experienced on other panels. It also attempts to combine the knowledge and abilities of a diverse group of experiments, such as yourself, in quantifying difficult questions. The Delphi procedure to be used in this study will consist of three rounds. Round I is the identification of the issues regarding indigent elderly in Denver. The results of Round I will be used to develop a questionnaire by August 10, 1984 so that the tabulations for Round II can be sent to you. Following the completion of Round II you will receive a complete copy of the results of this survey. Thank you again for participating in this survey. Sincerely, Hilda Grey, R.N., M.H.A. HG:kjb

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Instructions: questions. Questions 1. 195 Questionnaire for Round I Please use this form to respond to the following Please list what you believe to be the salient characteristics of the indigent elderly in Metropolitan Denver. Question 2. What do you see as the best future options for providing health and social services to the indigent elderly in Metropolitan Denver? Please do not focus on problems but list constructive approaches. Please use as much space as you desire; feel free to attach additional pages. Question 3. Which professional role listed below best described yourself regarding the indigent elderly in Metropolitan Denver? Administrator Clinician Consumer Policy Maker Thank you

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 I I I II I i II APPENDIX B Cover Letter Round 2 Questionnaire

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i i i l ! i l 1 i i I I f I t \ i February 27, 1985 Dear Panelist: 197 Hilda Grey, R.N., M.H.A. 231 Adams Street Denver, CO 80206 Thank you for participating in Round II of this Delphi Survey regarding the indigent elderly in Metropolitan Denver. Administrators, clinicians, consumers and policymakers have studied extensively the physical, emotional and social problems of the aging in Denver, usually concluding that the vast majority of the indigent elderly population requires special assistance in meeting their essential needs. The purpose of this study is to identify and discuss the best future options for providing health and social services to the indigent elderly in Metropolitan Denver. In order to address these problems regarding the indigent elderly in Metropolitan Denver, a Delphi Technique is being used. The Delphi Technique is a method of soliciting and combining the opinions of a group of experiments. It involves the use of a series of questionnaires designed to produce group consensus and eliminate face-to-face confrontation as experienced on other panels. It also attempts to combine the knowledge and abilities of a diverse group of experts, such as yourself, in quantifying difficult questions. Round I was the identification of the issues regarding indigent elderly in Denver. The results of Round I have been used to develop this questionnaire for Round II. Please return your results by March 15 so that the tabulations for Round III can be sent to you. Following the completion of Round III, you will receive a complete copy of the results of this survey. Thank you again for participating in this survey. Sincerely, Hilda Grey, R.N., M.H.A. HG/kjb

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 198 Instructions: 1. Please answer each question. If you are unable to answer any question, leave the answer space blank. 2. This questionnaire should only take a few minutes of your time to complete. The questions solicit opinions and should be answered quickly, without discussion with others or any research. Of course, your answers will be kept strictly confidential and will not be identified with you in any way. 3. Please use the "other" category freely and provide additional comments. The last question provides space for comments about any additional issues not covered in the body of the questionnaire. 4. Please reply by Karch 15, 1985 to help complete the survey process in a timely fashion. 5. A comprehensive copy of the final report will be sent to you upon completion of the third round questionnaire. 6. Please return the questionnaire in the enclosed postage paid envelope to: Hilda Grey 231 Adams Street Denver, CO 80206

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. QUESTIONNAIRE TO DETERMINE FUTURE OPTIONS FOR PROVIDING HEALTH AND SOCIAL SERVICES TO THE INDIGENT ELDERLY IN METROPOLITAN DENVER, COLORADO Problems of the Indigent Elderly 199 From the list provided below, please rank the top five problems of the indigent elderly in Metropolitan Denver with "1" as the most important problem, "2" as the second most important problem, etc. Problem Your ranking 1. Lack of money 2. Isolation 3. Lack of family support 4. Low self image 5. Lack of community support 6. Fear of illness 7. Lack of adequate housing 8. Other (specify---------') Community Attitudes Toward Indigent Elderly Neither Strongly Slightly Believe nor Slightly Strongly Believe Believe Disbelieve Disbelieve Disbelieve To what extent, 1. 2. 3. 4. s. do you believe that the responsibility for the elderly, in general, should be confined to themselves instead of the community? In your opinion, 1. 2. 3. 4. s. should physicians have the full responsibility for the health programs of the elderly in the community?

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 200 Social Issues in Health Care Please indicate your agreement or disagreement with the following statements by circling the applicable number on each line below. Strongly Agree Compared with the entire U.S. population the indigent elderly in Metro. Denver deserve a minimum level of health care. The indigent elderly patient in Metro Denver should have the right to refuse treatment or medication which may prolong life in the event of terminal illness. The indigent elderly in Metro. Denver deserve the same level of health services as everyone else in the u.s. In the future, the Medicare program should limit the dollar amount to be used for the extension of life for the indigent, chronically ill aged. 1. 1. 1. 1. Neither Slightly Agree nor Agree Disagree 2. 3. 2. 3. 2. 3. 2. 3. Slightly Disagree 4. 4. 4. 4. Strongly Disagree s. s. s. s.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 201 Providers of Hospital Care to the Indigent Elderly By 1995, which of the providers of hospital care listed below do you believe will increase health care to the indigent elderly? Government -federal Government -state & local Religious Other not-forprofit Investor-owned H.M.O.'s Significantly Increase 1. 1. 1. 1. 1. 1. Medicaid Program Coverage 1995 Slightly No Increase Change 2. 3. 2. 3. 2. 3. 2. 3. 2. 3. 2. 3. Slightly Significantly Decrease Decrease 4. 5. 4. 5. 4. 5. 4. 5. 4. 5. 4. 5. By the year 1995, do you believe that Medicaid will expand or limit cove. <1ge for the services to the indigent elderly that are listed below: Significantly Expand Inpatient hospital care Out patient hospital care Skilled nursing care PhysiCian services Home health care Hospice care Rehabilitation services 1. 1. 1. 1. 1. 1. 1. 1995 Slightly No Expand Change 2. 3. 2. 3. 2. 3. 2. 3. 2. 3. 2. 3. 2. 3. Slightly Significantly Limit Limit 4. 5. 4. 5. 4. 5. 4. 5. 4. 5. 4. 5. 4. 5.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 202 Regulation Please indicate your agreement or disagreement with the following statements regarding regulatory changes that may occur between now and 1995. That the U.s. will adopt some form of national health insurance State and local payment systems agencies will replace the Medicare payment system The criteria for life and death will be refined to allow withdrawal of life support systems in cases of terminal illnesses The Medicare program will place a dollar ceiling for the extension of life for the chronically ill aged Strongly Agree 1. 1. 1. l. 1995 Neither Slightly Agree nor Agree Disagree 2. 3. 2. 3. 2. 3. 2. 3. Funding for Non-institutional Services To what extent do you agree or disagree that expanded government funding of noninstitutional services would increase, not decrease, total government long-Strongly Agree 1. term care expenditures? Neither Slightly Agree nor Agree Disagree 2. 3. Slightly Disagree 4. 4. 4. 4. Slightly Disagree 4. Strongly Disagree 5. 5. 5. 5. Strongly Disagree 5

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 203 Specialty Facility Needs By the year 1995, what do you believe to be the need for specialty facilities for indigent elderly? 1995 Significantly Slightly Slightly Significantly Greater Greater No Lesser Lesser Need Need Change Need Need Skilled nursing 1. 2. 3. 4. s. care facilities (S.N.F.s) Home health 1. 2. 3. 4. s. agencies Hospices 1. 2. 3. 4. 5. Rehabilitation 1. 2. 3. 4. 5. facilities Community 1. 2. 3. 4. 5. recreation centers Congregate living 1. 2. 3. 4. 5. housing Adult day care 1. 2. 3. 4. 5. facilities Personal care 1. 2. 3. 4. 5. boarding homes

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 204 Housing Needs Please indicate your agreement or disagreement with the following statements by circling the applicable numbers on each line below. Personal care boarding homes which provide "3 hots and a cot" would significantly improve the quality of life for some indigent elderly? Congregate living housing between generations could improve the quality of life for the indigent elderly and the younger generation in the same household? More aggressive social services involvement in skilled nursing facilities (S.N.F.s) would improve the routine day-to-day living for the indigent elderly? Strongly Agree 1. 1. 1. Neither Slightly Agree nor Agree Disagree 2. 3. 2. 3. 2. 3. Slightly Disagree 4. 4. 4. Strongly Disagree 5. 5. 5.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. '! Senior Centers Strongly Agree Do you believe 1. that senior centers should exist throughout the community regardless of neighborhood income level? Should government 1. provide Senior Centers throughout the community? Geriatric Nurse Practitioners Significantly Improve To what extent 1. do you agree that the use of geriatric nurse practitioners could improve the health status of the indigent elderly in the management of chronic diseases, medications, nutrition and other general information on self-care? 205 Neither Slightly Agree nor Slightly Strongly Agree Disagree Disagree Disagree 2. 3. 4. s. 2. 3. 4. 5. Slightly No Slightly Significantly Improve Change Decline Decline 2. 3. 4. 5.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i t l I I i I I I i I I I i I I i I j i i I L i! I Allied Health Professionls Strongly Agree To what extent do you agree that restructuring Medicaid in Colorado 1. to include services presently not reimbursed such as Allied Health Professionals (mental health workers, social workers, etc.) could improve the quality of life for indigent elderly? Communication Significantly Increase In your opinion, 1. would a communi-cation effort via free media (i.e., newspaper, commercial and educational TV, literature at grocery stores, drug stores, etc.) increase the level of information on assistance programs to the indigent elderly? Neither Slightly Agree nor Agree Disagree 2. 3. Slightly Disagree 4. 206 Strongly Disagree 5. Slightly No Slightly Significantly Increase Change Decrease Decrease 2. 3. 4. 5.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i Transportation Strongly Agree Do you agree or disagree that if government would reimburse private drivers or allow special tax credits or deductions for car expenses, people would gladly give their time to transport indigent elderly to (and from) doctors and hospitals? 1. Neither Slightly Agree nor Agree Disagree 2. 3. Centralized Case Management Functions Slightly Disagree 4. 207 Strongly Disagree 5. Which agency listed below do you believe is best qualified to implement an appropriate, efficient and cost-effective utilization of the limited resources available to the indigent elderly in Metro. Denver? (Please check just one) Community N.F.P. hospitals Department of Social Services Supraboard newly created for this purpose Other (Specify

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 208 Recommendations The Colorado Task Force on the medically indigent has recommended a certain combination of public and private initiatives. To what extent do you agree or disagree with these proposals listed below? A modest expansion of Medicaid Employment-based health insurance A basic level of charity care by providers Cost sharing by consumers Recommendations Strongly Agree 1. 1. 1. 1. Slightly Agree 2. 2. 2. 2. 1990 Neither Agree nor Slightly Strongly Disagree Disagree Disagree 3. 4. s. 3. 4. s. 3. 4. s. 3. 4. s. If there were one thing you could do to solve the problems of the indigent elderly in Metro. Denver, what would it be? Respondent Data Which professional role listed below best describes yourself regarding the indigent elderly in Metropolitan Denver? Administrator Clinician Consumer Policy Maker

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I ! I l I I I ij 1' 209 Other Comments In preparing this questionnaire, I attempted to address the most important issues facing the indigent elderly in Metro. Denver while keeping the effort to complete this questionnaire reasonable. Please use the space below to comment on any areas or issues you believe were not adequately covered. Attach additional pages of comments as necessary. I sincerely thank you for completing this questionnaire and sharing your valuable knowledge regarding the future options of the indigent elderly in Metro. Denver. I will soon report to you the results of Round II of the Delphi Study and send you Round III Questionnaire.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX C Cover Letter Round 3 Questionnaire

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ; i i I i I April 1, 1985 Dear Panelist: 211 Hilda Grey, R.N., M.H.A. 231 Adams Street Denver, CO 80206 Thank you for participating in Round 3, the final round, of this Delphi Survey regarding the indigent elderly in Metropolitan Denver. The purpose of this study is to identify and discuss the best future options for providing health and social services to the indigent elderly in Metropolitan Denver. In order to address these problems regarding the indigent elderly in Metropolitan Denver, a Delphi Technique is being used. The Delphi Technique is a method of soliciting and combining the opinions of a group of experiments. It also attempts to combine the knowledge and abilities of a diverse group of experts, such as yourself, in quantifying difficult questions. The results of Round 2 have been used to develop this questionnaire for Round 3. P1ease return your results by April 15 so that the final report can be sent to you. Thank you again for participating in this survey. Sincerely, Hilda Grey, R.N., M.H.A. HG/kjb

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. l I i I I i I i I I I I :I 212 Instructions: 1. This questionnaire should only take a few minutes of your time to complete. The questions solicit opinions and should be answered quickly, without discussion with others or any research. Of course, your answers will be kept strictly confidential and will not be identified with you in any way. 2. For each question reconsider your previous response with respect to the Round 2 results and then enter your Round 3 response. 3. Please answer each question. If you are unable to answer any question, leave the answer space blank. 4. Freely provide comments, especially if: a. your answer is outside the 80% range, or b. you disagree with the Round 2 results. 5. Round 2 results are sununarized for your consideration using the following measures: Mean: Arithmetic average PerCentage Distribution: In many instances the entire distribution of responses to a question has been reported. Answers to Round 2 which imply consensus (a single answer comprising either 40% or more if the total responses or two adjacent responses totaling 70% or more of the total responses) are enclosed in a box for ease in reviewing the Round 2 results. 6. Please reply by April 15. 1985 to help complete the survey process in a timely fashion. 7. A comprehensive copy of the final report will be sent to you upon completion of this round of the questionnaire. 8. Please return the questionnaire in the enclosed postage paid envelope to: Hilda Grey 231 Adams Street Denver, CO 80206

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. .I i I i I j t ROUND 3 QUESTIONNAIRE TO DETERMINE FUTURE OPTIONS FOR PROVIDING HEALTH AND SOCIAL SERVICES TO THE INDIGENT ELDERLY IN METROPOLITAN DENVER, COLORADO Problems of the Indigent Elderly 213 Fran the list provided rela.l, please tank the top five problems of the :ind:igent: elderly in Metropolitan Denver with 'T' as the mst important problan, "2" as the secaxl mst inp:lrtant problem, etc. Average Panel Panel Rourd 2 Frequent Round 3 Problem Response Ranking Ranking 1. Lack ci. mney 2.33 Ill 2. Isolation 3.33 112 3. Lack of family support 4.00 113 4. l.cM self :image 5.58 117 5. Lack of camurl.ty support 4.25 114 6. Fear of illness 5.17 116 7. Lack of cdequate 4.33 115 8. Other (specify -) Caments: Camunity Attitudes Toward Indigent Elderly Strongly To 'iilat: extent, do you that the responsibility for the elderly, in general, should confined to thenselves :imtead of the cCllllUlity? In your opinion, should physicians have the full responsibility for the health prograns of the elderly in the cammity? Caments: Believe 1. 1. Slightly Believe 2. 25% 2. Neither Believe nor Disbelieve 3. 3. Slightly Disbelieve 4. 33% 4. 25% .&weuw: Homd 3 Bespoa;e Disbelieve 5. 42% 5. 75% Not Useable Ranking 1

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I I I l I I l l i I i il l, II ij il Social Issues in J:ealth Care Please indicate your agreenEnt or di.sagreemant the applicable 1'l.lllDer m each lire bela
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I I j i i i I I I I I I I I I I I I l i l i I ; 215 Providers of Hospital Care to the Ixrligent Elderly By 1995, of the providets cr. hospital care listed belGiJ do yru believe will increase health care to the in:ligent elderly? Significantly Slightly Increase Increase Goverrment -1. 2. federal 8% 8% Govei1111Ent1. 2. state & local 8% 59% Religi.rus 1. 2. 8% 59% Other not-for-1. 2. profit H% 43% Investor-o\lllErl 1. 2. 8% 25% H.M.O. 's 1. 2. 17% 50% Qmxents: Medicaid Progran Coverage 1995 Not No Slightly Decrease 3. 4. 42% 3. 4. 8% 25% 3. 4. 25% 3. 4. 33% 8% 3. 4. 17% & 3. 4. 25% Significantly Decrease 5. 42% 5. 5. 8% 5. 8% 5. 42% 5. 8% Useable Response By the year 1995, cb you believe that M:!di.caid will expand or limit coverage for the services to tre in:iigent elderly that are listed below: 1995 Yoor Significantly Slightly No Roun:l 3 Expand Expand Olange Limit Limi.t Respoose Inpatient 1. 2. 3. 4. 5. hospital care 17% 17% 41% 25% Out patient 1. 2. 3. 4. 5. hospital care 8% 42% 33% 17% Skilled nUISitg 1. 2. 3. 4. 5. care 25% 17% 33% 25% Physician 1. 2. 3. 4. 5. services 25% 25% 25% 25% Hone health. 1. 2. 3. 4. 5. care 8% 67% 8'4 17% Hospice care 1. 2. 3. 4. 5. 25% 41% 17% 17% Rehabilitatioo 1. 2. 3. 4. 5. services 8% 34% 25% ..J4 8% Cannents

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 'i 216 Regula!:ion Please inlicate }'OUt' agreem:mt or disagreement with the follawi.ng stateuents regarding regulatoey d1anges that nay occur beo.Jeen I1G1 arxl 1995. Agree That the u.s. 1. will aiopt sene 33% fom of national health insurance State and local l. paynent: systaJE agencies will replace the M:dicare paymmt: system The criteria for 1. life am death 75% will be refired to all
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i l I I i l I 1 I !j It 'I Funding for tbl-institutional Services Agree To W1at eJitent 1. do you agree or 17% disagree that expanded governnent of noninstitutional services would increase, rot decrease, total govemnent long-tem care expenditures? Specialty Facility Needs Slightly Agree 2. 33% Neither nor Disagree 3. 25% Slightly Disagree 4. 8% Disagree 5 17% 217 Not Useable Respoose By the year 1995, ot ch you believe to be the tEed for specialty facilities for iniigent elderly? S:ignif icant:l y Greater Need Sk.illei 1. care facilities 17% (S.N.F.s) Hcma health 1. agencies 67% Ha;pices 1. 7'3% Rehabilitation 1. facilities 66% Coum.mity 1. recreation 42% centers Congregate living 1. 83Z Adult day care 1. facilities 67% Personal care 1. hales 59% Qxmrant:s: Slightly Greater Need 2. 75% 2. 2'3'1o 2. 17% 2. 17% 2. 33Z 2. 17% 2. 33Z 2. 33Z 1995 Slightly Significantly Your No Lesser Lesser Roorxl 3 Olange Need Need Respoose 3. 4. s. 8% 3. 4. 5. 8% 3. 4. 5. 8% 3. 4. 5. 17% 3. 4. s. 17% 8% 3. 4. 5. 3. 4. 5. 3. 4. 5. 8%

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 218 Housing Needs Please indicate your agreemmt or disagrE!ei!Eilt with the follCIIJi.ng stateDEDts by circlirg the applicablt! ID.JiileiS on each line belCM. Neither Not: Strorgly Slightly Agree nor Slightly Useable Agree Agree Disagree Disagree Disagree Response Personal care 1. 2. 3. 4. 5. OOardirg tx:ms 59% 25% 8% &: wch provide "3 oots aOO a cot" significantly :improve the quality of life for sooe indigent elderly? Congregate 1. 2. 3. 4. 5. li virg hrusirg 58% 42% between generations could :i.Jq>rove the quality of life for the indigent elderly and the younger generation in the lnlsehold? M>re aggressive 1. 2. 3. 4. 5. social services 59% 25% 8% 8% involveuent in skilled rursing facilities (S.N.F .s) 'WOUld :improve the rrutine day-to-day living for the indigent elderly? Cc:Jments:

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I i' Senior Centers Strongly Sligptly Agree Agree Ih yoo believe l. 2. that senior 59% 25% centexs should exist throughout the camurl.ty regardless of neighborlrlod itrODe level? Shoold govemnent 1. 2. provide Senior 43% 33% Centers throughout the COlll1IJility? Caments: Geriatric Nurse Practitioners Signific-antly Sligptly Inprove To 'ltilat extent 1. do you agree that 83% the use af geriatric IlliSe practitioners could the health status of the indigent elderly in the llBilBgelieilt of chronic diseases, uedications, rutrition and other general infoi'IIBtion on self-care? Canrents: 2. 17% Neither Agree oor Slightly Disagree Disagree Disagree 3. 4. 5. & 8% 3. 4. 5. 8% & 8% No Sligptly Sig:rl.ficantly
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I i I I I I I I I I I I j ; Allied Iealth Professionls Agree To Tliilat extent 1. do you agree 59% that in Colorado to inclu:le services ptesently rot reimbursed such as Allied Health Professionals (uental health lrl>rkers, social l>rkers, etc. ) could improve the quality of life for indigent elderly? C'.aments: Cammli.cation Signif i<".antly Increase In your opinion, 1. lNOUl.d a CCililllJli58% cation effort via free uedia (i.e. newspaper, camercial and educational TV, literature at grocery stotes, drug stores, etc.) increase the level of information on assistance prograns to the indigent elderly? Cament:s: Slii?J:ttly Agree 2. 33% Slightly Increase 2. 42% 220 Neither Yoor Agree ror Sli!?J:ttly Strongly Rourxi 3 Disagree Disagree Disagree Response 3. 4. s. & Yoor No Slightly Significantly Rourxi 3 Change Decrease Respoose 3. 4. 5.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 221 Trarsportation Neither Yoor Agree ror RouiXl 3 Agree Agree Disagree Disagree Disagree Response Ib yru agree or 1. 2. 3. 4. s. that if 17% 67% 8% govenment would teimb.Jrse private driveiS or al.lCM special tax credits or deductions for car el!pellSes, people glaily give their tinE to transport indigent elderly to (arxl fran) doctors and hospitals? Caments: Centralizal Case Managemant Fmctions Which agency listed relmr 00 :you relieve is rest qualified to implem:mt an appropriate, efficiert: an:l cost:-effective utilization of the liml.ted resources available to the indigent elderly :l.n Denver? (Please check just ere) Camm:i.ty N.F .P. OO&pitals 20% Departnent: of Social Services SO% Supraboani newly created for this purpose 30% Other (Specify rot u;eable) Caments: Roond 3 Response

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 222 The Colorado Task Force en the I!Ed.ically :indigent has IeCOIIIIeilded a rertain conirl.nation of public arxl private initiatives. To \tihat extent do yru agree or disagree with these proposals listed belaN? 1990 Neither Not Slightly Agree nor Slightly Useable Agree Agree Disagree Disagree Disagree Respoose A nodest 1. 2. 3. 4. 5. expansion of 33% 59% 8% MediC' .aid Euploymant-based 1. 2. 3. 4. 5. health insurance 34% 25% 25% 8% 8% A basic level of 1. 2. 3. 4. s. charity care by 41% 25% 17% 17% provide IS Cost by 1. 2. 3. 4. s. consUJJeiS S% 68% 8% 8% 8% Caments: Recamendations If ooe thing )'OU rould cb to solve the problens of the indigent elderly in Metro. Denver, W:lat 'WOUld it be? Respoment Data 'Which professional role listed lelc:M lEst describes yourself regarding the indigent elder:Jy in Denver? Administrator Clinician CoosmaPolicy Maker 5 5 4 5

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I 'I j I \ I i l l 1 l l i l I I I I I I I i ! :! 223 In this questionnaire, I attempted to address the uost :iup>rtant issues faci.rg the indi.geot: elderly in Metro. Denver keepirg the effort to caDplete this questiomaire reasonable. Please use the space belGJ to COIIIreJ11: en aey areas or issues yru believe -were not adequately covere::l. Attach additional pages of caments as necessary. I sincerely thark yru for canpletirg this questionnaire arxl shari.rg your valuable kro.7ledge regarding the future q>tions of the indigent elderly in Metro. Denver. I will sooo. report to yru the results of Roulxi 3 of the Delphi Stu1y arxl sen:l yru the final report.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX D Results of Round 3

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. l I I i i i I I I i l I I I l l \ i f j I I i i I l i l I l I I I l I I j l i I :I RESULTS OF ROUND 3 QUESTIONNAIRE TO DETERMINE FUTURE OPTIONS FOR PROVIDING HEALTH AND SOCIAL SERVICES TO THE INDIGENT ELDERLY IN METROPOLITAN DENVER, COLORADO Problems of the Irdi.gent Elderly 225 Frcm the list provided relrtant problem, "2" as the secorxi IOOSt important problem, etc. Average Panel Panel Round 2 Frequent Round 3 Item ReslXXlSe Rank:ing Ranki.ng 1. Lack of UDreY II 2. Isolaticn #2 3. Lack of family support 14 4. 1m self image 17 s. Lack of COIJIII.Jnity support 13 6. Fear of illness 16 7. Lack of adequate hoosing #S Ccxments: Camunity Attitmes Tamd Indigent Elderly 8. To llilat do yru believe that the responsibility for the elderly' in general, sboold be confined to thensel.ves instead of the cCliiiUli.ty? 9. Believe 1. In your q>:ini.on, 1. srould pb;ysicians haiTe the full responsibility for the health prognms of the elderly in the camun:l.ty? QJments: Neither Slightly Believe nor Slightly Believe Disbelieve Disbelieve 2. 3. 4. 11% 11% 21% 2. 3. 4. -lbul3 Besiow;e 1.421 3.368 4.315 5.789 3.947 5.!i> 4.789 Not Useable Disbelieve Ranking s. 1 5.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I 226 Social Issues in Health Care Please inlicate }'CUI' agre:eneut or disagreeuent with the following stat:enent:s the applicable l11lliler en each lire bel
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 227 ProvidetS of Hospital rare to the Ixxl.igent Elderly .By 1995, Wli.dl cr. the providets cr. hospital care listed belcw do yw believe will in:rease health care to the indigent elderly? 1995 rbt Significantly Slightly No Slightly Significantly Useable 14. Irerease Increase
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 228 Regulation Please indicate your agreement or disagreemmt with the follaw.ing statenents tegard:ing regulato:cy dlanges that may ocrur bet:loEen naJ and 1995. 1995 Your Slightly Agree nor SligJ:ltly Strorgly Rouni 3 Agree Agree Disagree Disagree Disagree Re.spoose 27. That the u.s. 1. 2. 3. 4. 5. will adq>t SCIIe form of national 21% 53% 5E 16% health insurance State and local 1. 2. 3. 4. 5. paynent systB'IB agencies will 21% 11% 11% 58% replace the Medi-care payment system 28. The criteria for 1. 2. 3. 4. 5. life and death will be refired 79% 16% St to withdrcwal. of life support S)'StE!IIS in cases of terminal illnesses 29. The Medicare 1. 2. 3. 4. 5. progran will place a cbllar 16% 53% 21% 5E !il ceilill?; for the extension of life for the chronically ill aged Caments:

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i I 229 FUnding for lbl-institutiooal Services Neither Not Slightly Agree nor Useable Agree Agree Disagree Disagree Disagree Response 30. To mat eKtent 1. 2. 3. 4. 5 do yru agree or disagree that expanded goverrmmt 16% 53% 5% 16% 5% of norrinstitutional services increase, mt decrease, total govemnent longtenn care expenditures? Specialty Facility Needs By the :year 1995, ltlat: cb you believe to b:! the reed for specialty facilities for indigent elderly? 1995 Significantly Slightly Slightly Significantly Your Grea:.:er Greater No lesser Roml:l 3 Need Need OJange Need Need Response 31. Sld.lled rursing 1. 2. 3. 4. 5. care facilities 53% Iii% (S.N.F.s) 32. Hcma health 1. 2. 3. 4. 5. agencies 791 16% 5% 33. Hospices 1. 2. 3. 4. 5. 79% 16% 5% 34. Rehabilitation 1. 2. 3. 4. 5. facilities 61% 32% 5% 35. Qmwnity 1. 2. 3. 4. 5. recreation m 3Z% 5% 5% centerS 36. Congl:egateliving 1. 2. 3. 4. 5. 61% 37% 37. Adult day care 1. 2. 3. 4. 5. facilities Wl% 16% 38 .sonal. care 1. 2. 3. 4. 5. boarding luJe; 84% 16%

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 230 lb.Jsing Needs Please indicate )'OUI' agreenett or disagreem:mt with the follcM.ng statem:mts by the applicable tUDbeis oo eadl line belt Slightly Agree nor Slightly Useable Agree Agree Disagree Disagree Disagree Response Personal care 1. 2. 3. 4. 5. OOarding loJes wch provide "3 rots and a 681: 21% 11% cot" 'WOUld significantly improve the quality of life for sooe indigent elderly? Congregate 1. 2. 3. 4. 5. betteen generations cruld improve 37% 31% 11% 11% the quality of life for the indigent elderly and the )'OUD.gei' generation in the SaJE hrusehold? 1. 2. 3. 4. s. social services involvement in skilled llliSing 58% 16% 11% 11% facilities (S.N.F .s) 'Wllld improve the routine day-to-day living for the indigent elderly? Camlmts: : i I' I

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Senior Centexs Strorgly Slightly Agree Agree Ih yen believe l. 2. that senior centets should exist t:lu:ooghout the. coom.nity regardless of neighborlDod incale le\Tel? Shruld govenment l. 2. provide Senior Centers throughout the CXIIIllJility? % Caments: Geriatric Nurse Practitionets Signifk.antly Slightly Improve Improve To lthat: eltt:ent 1. 2. do yen agree that the use of geriatric rurse 74% 21% practitionets could the health status of the :i.ndigent: elderly in the 11B08gelellt of chrooic diseases, medications, rutrition and other geoora1 inforu&tim on self-care? Qmmants: 231 Neither tOt Agree nor Slightly Useable Disagree 3. 3. 3. Disagree Disagree Respoose 4. 5. 4. 5. 51 tOt Slightly Significantly Useable Decline Decline Response 4. 5.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 'I l I I I I j l \ Allied Health Professiools Agree 39. To 'What eKtent 1. cb yru agree that restructuring 74% Medicaid in Colorado to include services presently not reimi1Jrsed such a; Allied Health Professionals (nental health wrkers, social etc.) could improve the quality of life for indigent elderly? Caments: Camu:rl.cation Signific-antly 40. In your q>inion, acamuni-Increase 1. cation effort via free ned:ia (i.e., 58% newspaper, camercial and educational 'IV' literature at grocery stores, drug stores, etc.) increase the level of information m assistance progrCIIB to the indigent elderly? Ccmrents: 232 Neither YCl.li' Slightly Agree ror Slightly R.ourrl 3 Agree Disagree Disagree Disagree Response 2. 3. 4. 5. 2.1% 51 YCl.li' Slightly No Slightly Significantly Rourrl 3 Increase
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I i Transportation Slightly Agree Agree 41. Do you agree or 1. disagree that if gove:rrment 'WOUld re:l.mh.u:se private 11% drivers or allow special tax credits or deductions for car expenses, people 'WOUld glally give their ti.rre to transport indigent elderly to (ani from) doctors and rospitals? Caments: 2. Centralize:l Managerrent Ft.nctions Neither Agree nor Disagree 3. Slightly Disagree 4. 11% 233 Your Rounl 3 Disagree Respoose s. Which listed b=low cb )'OU believe is rest qualified to impleuent al. appropriate, efficient ani cost-effective utilization of the limi.tai resources available to the intigent elderly in Denver? (Please check just ooe) 42. Camunity N.F.P. h>spitals 43. Department of Social Services 44. Supraboard IEWly created for this purpose 45. Other (Specify rot useable) Caments: Round 3 Resp:mse 47%

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. :I 234 The Colorado Task Force oo the nedically indigent has I'eCOIIIIelded a rertain loynent-based 1. 2. 3. 4. s. health insurance 32% 32% 11% 11% 51: 11% 48. A basic level of 1. 2. 3. 4. s. charity care by .58% 26% 51: 11% providets 49. Cost sharing by 1. 2. 3. 4. s. consunets 21% 37% 26% 51: 51: Si""" Caments: Recamermtions If there -were me thing you coold do to solve the problems of the indigent elderly :In M:!tro. Denver, W!at 'WOUld it be? Res).Xlndent Data Whl.ch professional role listed below rest descrites yourself regarding the indigent elderly in M:!trO).Xllitan Denver? Administrator Clinician C'.onstJ:Ier Policy Maker 5 5 4 5

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ,. I l ! ! l l l 235 In preparing this questionnaire, I atteq>ted to address tl'E UDSt important issues facixg the irxligent: elderly in Metro. Denver W1.e keepirg the effort to cauplete this questiomaire teaSonable. Please the spare bel.cM to cament: oo any areas or issues yru believe not CJde:Iuately covered. .Attadl a:lditional. pages oc caments as necessary. I sincerely thark yru for ccq>letirg this questiormaire arxl sharixg your valuable krow'ledge :regarding the future q>tions of the indigent elderly :in Metro. Denver. I will sooo reJX>rt to yru the results of Rourd 3 oc the Delphi Study am sen:l yru the final report.