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Policy Information Center Highlights: Vol. 3, No. 3

In This Issue:




The frail elderly are a population caught in the middle. While they need help performing one or more activities of daily living, like remembering medication or bathing, or help with household tasks like shopping or cleaning house, frail elders do not require skilled care of the sort found in nursing homes and hospitals. Assisted living is an increasingly popular answer for these individuals. Assisted living provides supportive care and services in a homelike environment which is designed to maintain an individual's independence and dignity by maximizing personal autonomy and functioning.

The report, Policy Synthesis on Assisted Living for the Frail Elderly, looks at several aspects of assisted living, including effectiveness and cost, regulatory issues, public financing, and states' experiences.

Assisted living is a relatively new term; related and similar terms include board and care, residential care, personal care, foster care, and congregate care. The services most commonly provided as part of assisted living programs are meals, personal care services, housekeeping and laundry services, and help with medications.

Assisted living is growing because the population it serves--the frail elderly--is a relatively large one. Depending on how the term is defined, the frail elderly comprise between seven and thirty percent of the over-65 population. Generally, the frail elderly are younger, with a lesser degree of functional impairment than the nursing home population. It is generally agreed that assisted living is suitable for the medically stable who do not need round-the-clock nursing care, with less consensus on the appropriateness of assisted living for cognitively impaired and non-ambulatory populations.

There is limited evidence that assisted living saves money when used as a replacement for nursing home care. Assisted living may also be cheaper than home-based care for the elderly. While there is little research on the attitudes of the elderly regarding assisted living, it is known that the elderly generally prefer staying in their home or congregate living to nursing homes.

Sources of financing for assisted living programs are also discussed. Among these are federal programs that may promote the creation of new assisted living facilities; rental subsidies for low-income frail elders; and options for financing services in assisted living settings using Medicaid waivers and optimal services provisions. A wide range of regulatory issues are also discussed, including board and care laws as applied to assisted living, personal safety issues, and the extent to which "aging in place" should be regulated.

The study was performed by Lewin-VHI, and sponsored by the Office of the Assistant Secretary for Planning and Evaluation. The study's project officer, Robert Clark, can be reached on 202- 690-6443. Copies of the Executive Summary, #4719, are available from the Policy Information Center.




The standard schedule for eight routine immunizations was developed by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control. For ages five and under, the immunizations are hepatitis B for infants (HBV), diphtheria, tetanus, and pertussis (DPT), oral polio (OPV), haemophilus b conjugate (Hib), measles, mumps, and rubella (MMR); for teens and adults, tetanus and diphtheria (Td) as a booster; and for those over 65, influenza and pneumococcal vaccines. Ninety-seven percent of Health Maintenance Organizations (HMOs), 65 percent of Preferred Provider Organizations (PPOs), and 47 percent of conventional fee-for-service plans fully covered immunizations in 1990. Ten states require that childhood immunizations be fully covered by all insurance plans offered in the state.

The study, Cost of Covering Immunizations as a Standard Benefit in Private and Public Health Insurance Plans, outlines the cost of providing full insurance coverage for immunizations under all types of public and private health insurance plans. The full course of childhood immunizations, including both office visits and the vaccine, averaged $484 under private insurers and $328 under Medicaid. Under a CDC contract with vaccine manufacturers, providers may purchase the vaccines alone for $289.

If coverage for immunizations were mandatory, the number of plan participants would determine how much insurance companies would charge. For children, the study uses participation rates of 97 percent for the three mandatory vaccines (DPT, OPV, and MMR), and 75 percent for HBV and Hib. For adults, a 50 percent participation rate is posited. The payments to providers and insurance expenses for vaccines and office visits would have totaled $2.9 billion in 1992. Employer-sponsored health plans would have assumed 61 percent of that cost; Medicaid and other public health programs would have paid 18 percent.

The benefit-cost data for universal coverage for immunization is encouraging. A benefit-cost ratio greater than 1 to 1 means that the benefits of the immunization (in reduced medical expenditures and other indirect costs) are greater than the cost of the immunization including any side effects. Benefit-cost ratios for the MMR and Hib vaccines are 6.8 to 1 and 2.7 to 1, respectively. The ratio for the DPT vaccine is even higher, at 11 to 1.

Generally, insurance companies oppose mandated coverage for immunizations because they value the ability to change plans to suit clients' needs. Insurers may also fear that a relatively inexpensive mandate, such as immunizations will lead to more costly mandates. Finally, some insurers do not cover preventive care because they see their role as protecting consumers against only large, unpredictable expenses.

This study was performed by the Actuarial Research Corporation under contract to the National Vaccine Program Office. The study's project officers, Cathleen Michaloski and Chester Robinson, can be reached on 301-443-6683. Copies of the report, #4949, are available from the PIC.




Community health care providers can often achieve more working collaboratively than working alone. Effective coordination among providers means that gaps in services are filled, duplication of services is reduced or eliminated, and services are delivered more cost-effectively.

The report, Community Models of Coordination in Primary Care Programs, describes three models of effective primary care coordination. The Discrete Project Model features providers working to co-sponsor a one-time event or program. The Multi-party Interactive Model is marked by participants working together on several projects to meet a variety of community needs. The System Integration Model is distinguished by providers formally organized into groups that identify immediate community health needs as well as larger health issues, and develop programs to meet those needs in both the short and long term.

Six communities which have designed and implemented innovative coordination efforts were chosen for site studies: Arrington, Virginia; Hidalgo County, Texas; Albany, New York; Miami, Florida; Seattle, Washington; and Chicago, Illinois.

These diverse communities had several characteristics in common. Each community progressed through several stages to achieve a successful program which was characterized by strong leaders who were not afraid of innovation and change; opportunities for cooperation among providers; adequate staffing and funding resources; open systems of communication among providers; efficient operations to encourage service utilization; and financial viability.

The Health Resources and Services Administration (HRSA) made significant contributions to the efforts of each case study community. HRSA can further assist and promote the coordination of primary care activities by: providing flexible funding for the development of primary care systems; rewarding community health centers and health deparments for collaborating; providing professional assistance to communities developing new efforts or enhancing existing efforts; and promoting evaluations to assist communities in developing successful coordination efforts.

This study was performed by Lewin-ICF and MDS Associates for the Health Resources and Services Administration. The project officer, Kyungeun Carol Han, can be reached on 301-443-1900. Copies of the executive summary, #4436, are available from the PIC.




Using nonphysician health care providers like nurse practitioners, physician assistants, certified nurse midwives, medical technologists, and occupational therapists in new and innovative ways could ease the shortage of health care personnel in some specialties and use limited resources more efficiently.

The report, Enhancing the Utilization of Nonphysician Health Care Providers, and its companion report, Enhancing the Utilization of Nonphysician Health Care Providers: Three Case Studies, describe the creative ways in which three health care facilities restructured patient care responsibilities and improved resource utilization.

Evercare, in Minneapolis, is a managed care delivery system providing acute care in nursing homes. Evercare relies on nurse practitioners specially trained in geriatrics (known as GNPs) working closely with physician partners. GNPs have the authority to make important decisions about patient care--they can write prescriptions and order tests, modify or discontinue orders, have a patient admitted to the hospital, perform examinations necessary for nursing home admission, and make visits required by state and federal regulations. GNPs are bound to the same quality standards as physicians. This detailed and comprehensive care means that patients have most problems treated in the nursing home, rather than in the hospital; as a result, Evercare patients experience about half the hospital inpatient days of the average nursing home patient. Physicians who work with GNPs regard the program very positively.

St. Joseph's Hospital in Atlanta restructured the work flow to provide more services at the patient's bedside by creating two new job categories, Service Associates and Clinical Associates. Service Associates were recruited from housekeeping, food service, and other departments and trained to provide basic patient care services. At the highest level, a Service Associate has completed a community college patient care technician program, and can provide phlebotomy, pharmacy technician, and respiratory therapy services.

The Clinical Associate program was not as successful overall due to resistance from respiratory therapists. However, a new position, that of Patient Care Pharmacist, met with more success. Staff memebers make rounds with physicians, participate in staff and unit meetings, and provide education and training to staff. They review prescriptions with physicians, often recommending cheaper alternatives, and review medications and dosages with patients.

In general, staff at St. Joseph's regard the changes positively. The program has been successful in bringing more services into the unit, and improving the coordination of care.

At Mercy Hospital and Medical Center in Chicago, personnel in some central hospital departments had narrow, specialized skills which could not be transferred to other tasks. Inefficient use of personnel and poor continuity of care for patients resulted from this narrow focus. In response, Mercy developed a Clinical Partners Program (CPP). Currently, 136 CPs are active. Clinical partners work in teams with registered nurses after they have completed a six-week training course. CPs draw blood, take EKGs, perform basic respiratory therapy, and reinforce occupational and physical therapies. Nurses in the CPP must also complete a course designed to enhance management skills. The CPP has improved the speed of service delivery and the coordination of care, allowing more time to be spent in patient care.

The barriers to implementing these types of efforts include professional territorialism, licensure restrictions, educational isolation, physician resistance, and institutional inertia. The report recommends correcting these by Public Health Service promotion of more efficient use of nonphysician health care providers, in order to increase access to care and to control costs without a corresponding decline in quality of care.

The study was conducted by the Office of the Inspector General, Office of Evaluation and Inspections. Copies of the studies, #5069 and #5069.1, may be obtained from the PIC.


Recently Acquired Reports

  • Assessment of Family Preservation Programs
  • Screening Criteria for Outpatient Drug Use Review
  • 1993 German Health Reforms: New Cost Initiatives



The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at:

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