The only other constraint is that respite care may not exceed 30 days, or hours, during a calendar year. Like some of the other expanded-care bills, Kennedy's specifies function-based criteria for determining program eligibility. To be eligible for community-based services a person must fall into one of the following three categories :.
Nursing home eligibility criteria are identical to those for community-based care, and criteria for respite care are also the same as those for community-based services, with the additional following stipulation:. Senator Kennedy's legislation contains very specific definitions of what constitutes ADL impairments.
The five ADLs which are included are: bathing, dressing, toileting, transferring, and eating. Persons applying for benefits under this proposal would be judged eligible based upon the outcome of a screen administered by a Long-Term Care Screening Agency. The screening process would be a two-pronged activity.
On the basis of this initial information, an in-person screening would be conducted for those having passed the first screening component. The second screen would be administered by a team that must include a physician, nurse practitioner, or registered nurse. Once deemed eligible by the Screening Agency, a Long-Term Care Management Agency would conduct a comprehensive needs assessment and develop a care plan. The only exception to this eligibility determination process would be in the case of those applying for respite care services; eligibility for these applicants would be conducted by the Long-Term Care Management Agency.
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Proposed amendments to the Social Security Act seek, for the most part, to expand long-term care benefits. Nearly all of these bills include some mention of physical functioning as a criteria for determining eligibility for benefits. Some bills are more specific than others in defining criteria. Most of the bills, however, also specify additional eligibility criteria other than physical functioning ADL. These include indicators of cognitive impairment e. Besides criteria relating to the condition of the beneficiary, the expanded care bills also stipulate other criteria that serve to limit the beneficiary pool.
These other factors include waiting periods, co-payments for services, and limits on the amount and duration of care. In this regard, the proposed programs are similar to existing federal programs e. There is considerable discussion in the policy arena regarding an expanded Federal role in financing long-term care services for functionally impaired elderly and disabled persons, and it is commonly assumed that under this expanded Federal initiative, long-term care benefits will be allocated on the basis of functional measures of performance in the Activities of Daily Living.
This chapter discusses the implications of this assumption, drawing upon what can be learned from the research on ADL measurement and from existing programs which already allocate long-term care benefits using functional eligibility criteria. The review of long-term care eligibility criteria presented in Chapter 3 shows that while measures of ADL performance are often included in the eligibility determination process under existing long-term care programs, ADL impairments are never the sole eligibility criteria.
Indeed, one general observation is that the broader the entitlement nature of the program, the less likely that benefit allocation decisions are based on ADL measures. Medicare, our broadest entitlement program, has strictly shied away from using ADLs as eligibility criteria in the allocation of benefits. Medicare's Skilled Nursing Facility benefit and home health care benefit are still primarily based upon a physician's certification of the need for care, and upon a determination that the individual is need of skilled, rather than custodial, care. In fact, care needs related to deficits in ADL performance are specifically cited as needs which are not covered by the Medicare benefit package.
This exclusion of coverage for assistance in ADLs reinforces the position that Medicare is strictly an acute care insurance program, and that chronic care needs are not addressed by the Medicare benefit package. It is interesting to note, however, that the proposed respite care benefit, enacted as part of the Medicare Catastrophic Coverage Act, did propose to use ADLs as eligibility criteria in allocating benefits, although policymakers were sure to include other criteria to limit access to the benefit i.
However, our review of State long-term care eligibility criteria shows that service allocation decisions are only loosely tied to standardized measures of functional performance in most States.
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In most States, a combination of physician authorization, clinical judgment, and functional assessment are used in determining eligibility for Medicaid payment for nursing home care. More importantly, we cited recent research which demonstrates that even within those States which rely more heavily on functional assessment, that objective measures of "need" in ADLs vary significantly from State to State depending upon the overall availability of Medicaid resources to pay for long-term care services.
There is little available data on how States use functional criteria in allocating home and community-based care services under Medicaid. ADLs are used in many private long-term care insurance policies as eligibility triggers for nursing home and home care benefits, although it is interesting to note that only 8 of 28 plans which cover home care services rely on ADLs.
Others require either a prior nursing home stay or a physician's certification of need. We believe this reflects the skittishness of insurers to promise benefits strictly based on ADL measures. Since benefit eligibility in the long-term care insurance market is more hypothetical than actual at this stage, we believe the subject of functional eligibility criteria for benefits will become a much larger issue once claims for covered services begin to increase.
Although there is considerable agreement that functional measures are superior to diagnostic or other approaches for assessing the need for long-term care services, it is difficult to develop accurate estimates of the number of elderly persons who are functionally impaired.
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To address this question, the Committee on Definitions of Functional Limitations, under the direction of the Forum on Age-Related Statistics and comprised of representatives from various government agencies, reviewed estimates of the functionally impaired elderly population based upon several national surveys. Initial examination of these estimates revealed considerable discrepancies.
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One major reason for the differences is that definitions of functional impairment varied somewhat from survey to survey. In an attempt to reconcile the differences among the estimates the Committee applied a uniform definition of impairment to each survey. Prevalence estimates of impairment were generated for the five ADL items common to the surveys bathing, dressing, toileting, transferring and eating. Receipt of human assistance in the performance of an ADL was taken as evidence of impairment.
Even after the estimates of ADL functioning were standardized by number, type and definition of impairment, discrepancies remained. For example, data from the Supplement on Aging show that that 5. Since most of the current legislative proposals discussed in Chapter 3 propose to trigger long-term care benefits when someone is impaired in two or more ADLs, estimates of the elderly population dependent in two or more ADLs are of greater policy interest. While the Committee on Definitions of Functional Limitations did not report these estimates, it is possible to develop estimates based on prior research of the hierarchical nature of ADLs.
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Research has shown that loss of function occurs in an orderly and hierarchical fashion whereby loss of ability to bathe oneself is very likely to occur before loss of function in other ADLs. For example, a person dependent in dressing is likely to be dependent in bathing as well. Persons with disabilities further on down the hierarchy are very likely to also be dependent in bathing and dressing.
Another policy option is to limit benefit eligibility to persons who require ADL assistance more than once daily, i. Persons with three ADL impairments are likely to need assistance in toileting, the ADL limitation which is most strongly associated with increased future needs for assistance. Somewhere between 2. Even if all discrepancies between data sources could be resolved, there will continue to be uncertainty about estimates that are derived from national survey data. Estimates derived from survey data may underestimate the true prevalence of impairment in the population.
There is some evidence which suggests that the elderly may underreport the extent of their impairments, perhaps in order to present themselves in the best possible light, i. In developing estimates of the eligible population under an ADL-triggered benefit program, it is important to account for these factors in projecting program utilization and costs. In the long-term care policy debate, there is an emerging consensus that eligibility criteria for long-term care benefits should include cognitive as well as physical impairments.
This trend can be observed in both legislative proposals and in private long-term care insurance policies. While loss of ADL functioning is considered the "final common pathway" of decline for conditions associated with both physical and cognitive etiologies, persons in the early to middle stages of Alzheimer's disease and related disorders may not exhibit any dependence in ADLs, but may not safely reside in the community without some level of supervision.
Cognitively impaired persons may be able to bathe and dress themselves, but many should not be left unattended for long periods of time because they may wander off, get lost, or put themselves or others at risk, e. Eligibility criteria based on physical functioning alone will exclude some individuals who are in need of less intense human assistance but who may require fairly consistent supervision, and who would otherwise be at risk. Recent research estimates this population to be approximately one-half million persons.
There is no standard measure for identifying cognitive impairments. The measures and approaches which do exist are not universally accepted in the way ADL impairments are accepted as measures of physical functioning.
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This dilemma is reflected in the Federal legislative proposals, which detail the number and types of ADL eligibility criteria, but which are notably non-specific regarding indicators for cognitive impairment. One approach proposed in both the Rockefeller S. This is not a terribly satisfactory approach since a definitive diagnosis of Alzheimer's Disease can only be made post mortem.
But more importantly, most persons in the very early stages of Alzheimer's do not need long-term care. These individuals may have some difficulty in recall, but in the early stages of the disease process are not likely to present a safety hazard to themselves or others. Relying upon a diagnostic approach may result in some misspecification of the target population, i.
Surveys of the elderly have typically used the Short Portable Mental Status Questionnaire, a ten-item scale tapping orientation and memory, or some variant of the measure, to identify persons with cognitive impairments. The difficulty with this strategy is that such measures provide only gross approximations of impairment level.
They are able to identify persons in the later stages of decline with a good deal of certainty, but not necessarily those in the early to middle stages. And it is precisely those persons in the middle stages of decline who are not as likely to also be ADL dependent, but who may need some amount of assistance and supervision. Depending upon the specific cut-off points employed, use of an MSQ-type approach could result in considerable targeting inefficiencies.
Another method of identifying cognitively impaired persons in need of assistance, which has promise, is the "behavior problems" approach. Many nursing home preadmission screening programs utilize this approach, and a few of the legislative proposals suggest this approach as well, although the content of the bills provide no guidance regarding actual measures. Abusiveness : Physically causing harm to self or others; verbal assaults such as threatening physical attack or menacing in other ways;.
Unacceptable Hygiene or Habits : Gross and unacceptable hygiene or eating habits, such as throwing or smearing food or excrement; disrobing in inappropriate situations; screaming; making dangerous or inappropriate sexual advances;.