Assessment and Care Planning for the Frail Elderly: A Problem Specific Approach

08/01/1986

U.S. Department of Health and Human Services

Assessment and Care Planning for the Frail Elderly: A Problem Specific Approach

Elizabeth Solan, B.S.N., Marilyn Grannemann, M.S.N., Elsie Carter, R.N., Helen Wells-Hunter, A.C.S.W., Patricia Decker, R.N., Suzanne Bulvanoski, B.S.N., Carol Coleman, R.N., Maryellen Kluxen, R.N., and Tambria Johnson, M.S.W.

Temple University, Institute on Aging

August 1, 1986

PDF Version: http://aspe.hhs.gov/daltcp/reports/1986/asmtcare.pdf (66 PDF pages)


The paper was written as part of contract #HHS-100-80-0157 between ASPE and Mathematica Policy Research, Inc., and contract #HHS-100-80-0133 between ASPE and Temple University. Additional funding was provided by the HHS Administration on Aging and HHS Health Care Financing Administration (now the Centers for Medicare and Medicaid Services). For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The Project Officer was Robert Clark.

This work was supported by DHHS contracts which funded the National Long Term Care Channeling Demonstration. The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.


TABLE OF CONTENTS

PREFACE
SECTION I
Introduction
Overview of the Care Planning Process
SECTION II. ASSESSMENT GUIDELINES FOR SPECIFIC PROBLEM AREAS
SECTION III. OPTIONS FOR CARE PLANNING
Stating to Problem
Outcome Standards
Common Types of Help Needed
Service Provider Options
APPENDICES
APPENDIX A: Care Plan Form
APPENDIX B: Summary of the Channeling Program Context
LIST OF CHARTS
Common Causes of Client Problems
Assessment Guideline #1: Fatigue/Weakness
Assessment Guideline #2: Hearing Impairment
Assessment Guideline #3: Incontinence
Assessment Guideline #4: Mobility Impairment/Paralysis
Assessment Guideline #5: Pain
Assessment Guideline #6: Poor Nutrition
Assessment Guideline #7: Speech Difficulty
Assessment Guideline #8: Untreated Health Condition
Assessment Guideline #9: Vision Impairment
Assessment Guideline #10: Alcohol Abuse
Assessment Guideline #11: Confusion
Assessment Guideline #12: Difficult Family Relationships
Assessment Guideline #13: Drug Abuse
Assessment Guideline #14: Emotional or Behavioral Problems
Assessment Guideline #15: Physical Abuse or Neglect
Assessment Guideline #16: Problem Person in the Household
Assessment Guideline #17: Architectural Barriers
Assessment Guideline #18: Inadequate Income
Assessment Guideline #19: Inadequate Level of Care at Home
Assessment Guideline #20: Unsafe Home or Neighborhood
Options for Care Planning #1: Abuse and Neglect
Options for Care Planning #2: Alcohol Abuse
Options for Care Planning #3: Confusion
Options for Care Planning #4: Drug Abuse
Options for Care Planning #5: Emotional or Behavioral Problems
Options for Care Planning #6: Fatigue/Weakness
Options for Care Planning #7: Hearing Problem
Options for Care Planning #8: Inadequate Level of Care
Options for Care Planning #9: Mobility Impairment/Paralysis
Options for Care Planning #10: Problem Person in Household
Options for Care Planning #11: Speech Problem
Options for Care Planning #12: Vision Problem
Options for Care Planning #13: Client Unable to Shop
Options for Care Planning #14: Client Unable to do Laundry
Options for Care Planning #15: Client Unable to do Housework
Options for Care Planning #16: Client Unable to Prepare Meals
Options for Care Planning #17: Client Unable to Manage Money
Options for Care Planning #18: Client Unable to Self Administer Medications
Options for Care Planning #19: Client Unable to Bathe Self
Options for Care Planning #20: Client Unable to Dress Self
Options for Care Planning #21: Client Unable to Perform Self Toileting
Options for Care Planning #22: Client Unable to Feed Self/Eat
Options for Care Planning #23: Client Has Difficulty With Ambulation/Mobility
Options for Care Planning #24: Client Has Difficulty With Transfers
Options for Care Planning #25: Client Unable to Maintain Informal Support System
Options for Care Planning #26: Client Unable to Maintain Social Contacts
Options for Care Planning #27: Client Has Difficulty With Financial Resources
Options for Care Planning #28: Client Has Difficulty Obtaining Adequate Medical Care
Options for Care Planning #29: Client Unable to Maintain a Safe Environment
Options for Care Planning #30: Client Unable to Secure Adequate Heat
Options for Care Planning #31: Client Unable to Secure Adequate Housing

PREFACE

Although a good deal has been written about the process of care planning, the context of care planning in case management has not received much attention in the literature. It has frequently been assumed that a care plan flows naturally and unambiguously from a comprehensive assessment. This implies that once a condition or problem is identified, the solution is obvious.

Overlooked in such an assumption are the complexities of problem definition; the influence exerted by goal setting; the importance of knowledge of the wide range of potential solutions; and the uncertainties introduced by client preference.

It is our assertion that converting a comprehensive standardized assessment into a care plan is not a simple straightforward process. These authors have begun for all of us the task of systematically setting down and cataloging care planning content, including its complexities. They have used generic terms so that the material can be of assistance in the evolution of case management practice for the elderly in a variety of program settings.

The authors are experienced case management practitioners, including nurses and social workers, supervisors, and directors. Most were employed by the Middlesex County (NJ) Visiting Nurses Association, providing case management services under subcontract for the Middlesex County, New Jersey site of the National Long Term Care Channeling Demonstration. The VNA is to be commended for supportin the completion of this innovative work. Betsy Solan, Program Director of the Channeling sub-contract at the VNA, was responsible for the conceptualization of this work and provided the leadership to see it through.

Barbara Schneider Project Director National Long Term Care Channeling Demonstration Technical Assistance Contract Temple University Institute on Aging

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SECTION I

Introduction

In recent years the field of community-based long term care has grown. Knowledge in the area has become more sophisticated, and operational lessons have been learned in demonstration and waiver programs around the country. Case management and home care services have been actively promoted as an intervention in the care of elderly and disabled people and are seen as an alternative to some unnecessary nursing home placements. Both clinicians and policy makers have acknowledged the value of the case management function, clinicians for its wholistic and practical approach to meeting client needs, and policy makers for its potential to save on long term care expenditures by controlling service costs.

Case management can be considered to include the following components:

  • Outreach to identify and attract the target population.

  • Screening to determine whether an applicant is part of that target population.

  • Comprehensive needs assessment to determine individual problems, resources, and service needs.

  • Care planning to specify the types and amounts of care to be provided to meet the identified needs of individual.

  • Service arrangement to implement the care plan through both formal and informal providers.

  • Monitoring to assure that services are provided as planned and modified as necessary.

  • Reassessment to adjust care plans to changing needs.

These functional areas are developed and implemented in a number of different ways to meet the objectives of various state and local case management programs. In addition, different program models utilize staff of varying backgrounds and levels of expertise. Case managers are most often nurses or social workers. Because of the variations among models, the clinical responsibilities and activities of case manager are not consistent. Major variables that may affect case manager functions are the structure of the setting, the philosophy and goals of the agency, the prescribed case management process, and the outcomes expected for staff and clients.

Case management is not taught as a separate function in most schools of nursing or social work. Therefore, it is particularly important that the role of the worker in a case management program be well-defined, and not based just on “they’ll know what to do because they are social workers (or nurses).”

Some successful “systems” of case management have been developed, but standards for practice are usually stated only generally, especially for the care planning function. Aspects of the case management process like the assessment form, the timing of monitoring visits, and guidelines for reassessment tend to be standardized to meet program requirements. Care planning, the “meat” of the case management process, is most often left to the clinical judgment of the worker. But what does this judgment consist of as it relates to the selection of formal and informal services?

As the picture of the client’s situation emerges during the assessment interview process, the case manager identifies and clarifies client problems, but how exactly does she identify them, and what concrete things does she do to begin to resolve them? Standards of practice can give substance to these intangibles of case management. However, there is no recipe book by which you take two parts home health aide, one part visiting nurse, a dab of legal aid, and a sprinkle of informal supports to solve clients’ problems. There are also no practical computer systems that can take a set of client problems and develop a care plan. It is a complex task to meet the multiple needs of frail elderly clients.

This paper presents some guidance to assist case managers in selecting appropriate services and interventions. There are two frameworks, assessment guidelines and care planning options. The guidelines deal with client problem definition and the options deal with problem resolution. These are intended to provide:

  • guidance in establishing what the client’s problem is;
  • insight into the range of problems a client can have;
  • examples of the most common problems;
  • direction as to goals for which the case manager and client should aim; and
  • ideas about sources of available help to reach those goals.

Overview of the Care Planning Process

Care planning is the link between assessment and service delivery, whereby facts about the client gathered in the assessment process are analyzed and translated into problem areas. Identifying problem areas enables the case manager to describe desired outcomes and recommend a package of services that will help the client achieve those outcomes. Care planning leads to the development of a service package for each client. The client and the client’s significant others are involved through the process. Good care planning incorporates a careful consideration of all possible service alternatives before a decision is reached regarding which alternative is best for the client.

Care planning may be defined as:

the process of developing an agreement between client and worker regarding problems identified, outcomes to be achieved, and services to be pursued in support of goal achievement.

The written product of the process is the care plan, which lists problem areas, outcomes, services the client will need, providers who will deliver the needed services, timing of the services (when services will being and terminate), and the amount of services (how many times per week, how many hours per visit, etc.). The care planning process, however, does not end with the preparation of the care plan. A care plan is carefully tailored to the needs of the client, and as the client’s needs change, so should the care plan. Thus, the case manager may have to repeat portions of the process in order to revise the plan to meet client needs over time.

Care planning calls for clinical judgment, creativity, and sensitivity. It requires the case manager to interpret subtle cues from family members and clients regarding their willingness to support clinical and functional goals. It requires translation of assessment information to useful problem statements and, ultimately, into service needs.

Problem areas in the system described here, (which was developed for use with frail elderly clients by the Temple University Institute on Aging,) will mainly relate to difficulties in the Activities of Daily Living (ADL) (eating, dressing, toileting, bathing, grooming, transferring), and Instrumental Activities of Daily Living (IADL) (telephone use, shopping, food preparation, housekeeping, laundry, using transportation, money management). Inability to provide these basic types of care for oneself is a frequent cause of institutionalization. The case manager should think in terms of the problems the client is having in maintaining independence and should attempt to define these problems as functionally as possible. That is, what is it that the client cannot do, which must be done in order for him/her to remain at home? A helpful format for writing problem statements is as follows:

CLIENT CANNOT_______________________________________________           orCLIENT HAS DIFFICULTY WITH___________________________________

This format guides the case manager to define the problem in terms of the essential activities that must be accomplished if the client is to remain at home.

It is necessary to provide reasons for these functional difficulties. The reasons help in determining appropriate services to be delivered. For example, a functional problem with meal preparation may have several causes, requiring very different solutions.

CLIENT CANNOT PREPARE MEALS, DUE TO WHEELCHAIR INACCESSIBILITY OF KITCHEN.

Stating the reason clarifies the problem further, making it possible for the case manager to address the cause as well as the problem in some cases.

Some problems are not readily defined in functional terms. For example, emotional problems and family tensions may require resolution in order for clients to remain at home. These, too, should be included in the problem list developed by the case manager. These types of problems, although not amenable in description in the format outlined above, should nevertheless be developed and described as clearly as possible, including stating the reason if possible. Problems in the environment that the case manager plans to address should be treated the same way. The format described above for writing problem statements is clear and simple to use. However, it should be deviated from whenever some other formulation results in a better statement of the problem.

Once the necessary information is collected, problem statements that include reasons can be formulated. The information obtained should also be sufficient to project realistic, time-specific goals in relation to each problem. The case manager can later turn her attention to determining the type of help best suited to meeting clients needs and identifying providers to render that help.

The remainder of the paper discusses the care planning process in more detail, one problem at a time. Section II describes the clinical information necessary to understand the reasons for problems. Section III follows each problem from the specification of outcome standards to the selection of providers.

II. ASSESSMENT GUIDELINES

The assessment guidelines address the end of the assessment function, where problems in performing activities of daily living are identified. The care planning process actually begins during the assessment, with the identification of functional problems and their causes. The assessment forms used by some programs are developed specifically for use by those programs. Other programs use statewide or standard assessment forms. All of the instruments contain standard data items, but frequently the process of conducting the interview is not standardized. Workers must often use their own conceptual frameworks and interviewing techniques to gather needed information from the client.

Whether an assessment form is four pages long or forty pages long, the information it contains gives the case manager only a beginning baseline of data. Once the standard assessment instrument is complete, it is up to the case manager to identify the areas of client functioning that seem problematic and investigate the details. The first general question may be, “why does the client have the problem?” That is, why can’t the client bathe himself, get meals or get to the doctor.

The reasons for functional problems may be divided into three major classifications. It may be a physical cause, an environmental cause, or a psychosocial cause. After clarification, the questions become:

  • Can the cause and therefore all of the problems stemming from it be eliminated?

  • Can the cause be modified to alleviate some of the attendant problems? or

  • Is the cause unalterable, so that all problems resulting from it require specific intervention?

To make this determination, the case manager may require far more in the way of information than was available from the baseline assessment.

The assessment guidelines address the issue of “What do you ask after all of the standardized questions have been asked?” Just as every client’s situation is different, so are the information needs in each situation different. However, by looking at some of the common causes of client problems, it is possible to identify some basic information needs in relation to those causes.

Note that in this discussion, ‘cause of problem’ and ‘reasons for problems’ do not refer to disease diagnoses. Neither the diagnosis of disease nor the treatment of disease are within the purview of functionally-based long term care case management. The case manager will, of course, want to know whether an apparent condition had been diagnosed and if it is being treated; and the case manager can, if necessary, see that the client gets to the appropriate professional for diagnosis and treatment. However, listing a diagnosis as a reason for a problem is not usually useful for the case manager’s own problem solving role. It doesn’t clarify what the case manager can do to solve a problem.

The first chart, on page 7, lists examples of common causes of client problems. They are divided into physical, psychosocial and environmental. In stating reasons for problems it becomes clear that not only are the causes themselves divisable into the categories of physical, psychosocial and environmental, but the information needs surrounding any one cause could also be divided in the same way. For example, in relation to the functional problem of incontinence, the case manager’s inquiries about the incontinence can be broken down as follows:

Where is the bathroom? Can you get to it? Do you have a commode?

Approaching the issue of “What information is needed or what questions should be asked” in an organized pattern of physical, psychosocial and environmental provides the case manager with a convenient and portable conceptual framework by which to proceed.

Subsequent charts focus on problem causes and outline information needs surrounding each one. The information needs are stated in the form of questions. Some questions are directed to the case manager him/herself, i.e., “What makes you think the client is addicted?” Other questions are most appropriately directed to the client or caregiver i.e., “How does the family feel about it?” Still other questions must be directed to an appropriate professional or provider, i.e., “Are medications given correctly?” should be asked of the physician, nurse or pharmacist. “Is the problem treatable?” should be asked of the physician, nurse or therapist. Remember that it is not up to the case manager to diagnosis, prescribe or treat. Her/his function is to gather information, seek recommendations, formulate plans which include the recommendations, and facilitate the execution of those plans in the interest of resolving client problems. If questions are unanswerable due to the lack of involvement of appropriate professions, it is then the case manager’s responsibility to arrange for the appropriate specialized assessment so that answers can be obtained.

The Assessment Guidelines for the problem causes follow. They are arranged in the order in which they are listed on below.

  COMMON CAUSES OF CLIENT PROBLEMS  
Physical      Fatigue/weakness      Hearing impairment      Incontinence      Mobility impairment/paralysis      Pain      Poor nutrition      Speech impairment      Untreated health condition      Vision
Psychosocial      Alcohol abuse      Confusion or unsafe judgment      Difficult family relationships      Drug abuse      Emotional or behavioral problems      Physical abuse/neglect      Problem person in household
Environmental      Architectural barriers      Inadequate income      Inadequate level of care at home       Unsafe home/neighborhood
ASSESSMENT GUIDELINE #1
When fatigue or weakness is causing a client problem
Information Needs:Are there physical reasons for it? Medical diagnoses? Medication side effects? Infections? Untreated health condition? Poor nutrition/hydration?  Are there psychosocial reason for it? Depression? Withdrawal/isolation?Are there environmental reasons for it? Client doing too much? Stair climbing?
ASSESSMENT GUIDELINE #2
When hearing impairment is causing a client problem
Information Needs: How do you know the client has a problem? How long has client had it? Has a physician/specialist examined the client? Is the loss treatable? Is treatment going on? How severe is the loss? If permanent, will an aide help? Has an audiologist evaluated? If the client has a hearing aide, who prescribed it, and when? Is it working? How often are batteries changed? How does the client feel about the hearing loss or wearing an aide?  Does the client appear confused? Does he/she know how and when to use it? Is speech/communication a problem? Can client use telephone? Is safety a problem? Can the home be modified to be safer? If deaf, can the client read lips? Are there special groups/services in the area for people with hearing loss?
ASSESSMENT GUIDELINE #3
When incontinence is causing a client problem
Information Needs: What makes you think the client is incontinent? What is the pattern of “accidents”? How long has this been happening? Has there been a medical evaluation? What was the result? Was a specialist consulted?  How does the client feel about the problem? Is there a confusion problem? How does the family feel about it? Is there a problem with personal care? Are toilet facilities adequate and accessible to the client? Is special equipment needed for toileting?
ASSESSMENT GUIDELINE #4
When paralysis or impairment of mobility is causing a client problem  
Information Needs: How long has it been a problem? What are the functional areas affected by it? What is the cause of the impairment? How does the client feel about it? How does the caregiver feel about it? How does the paralysis affect the client’s relationships? Has mobility been evaluated by a physical therapist? What special training for independence has client received? Can further treatment be helpful? What adaptive equipment or home modifications are in use or would be helpful?  How is client safety assured?
ASSESSMENT GUIDELINE #5
When pain is causing a client problem
Information Needs: Where is the pain? How long has the client had it? What was the outcome of the medical evaluation? What is the plan for further treatment?  How long is the pain expected to last? What medications is the client taking for the pain? Are they effective? Side effects? How does the client feel about the pain? How does the caregiver feel about it? Does the pain affect client’s relationships? What adaptations have been made to the environment? How is client safety assured?
ASSESSMENT GUIDELINE #6
When poor nutrition is causing a client problem
Information Needs: How do you know the client has a nutrition problem?  Is the physician aware of the problem? Has he/she recommended treatment? Is treatment being carried out? Who brings food to the home? How often? Who prepares meals? Daily and weekends? If client cannot prepare meals, why not? If client can prepare meals, does she? Why not? What medical conditions are involved? Are there dental or digestive problems? Constipation? Diarrhea? Does the client know when it is time to eat? How does the client feel about eating? Does client have proper facilities/equipment for cooking/storage of food? How is the clients appetite?
ASSESSMENT GUIDELINE #7
When speech difficulty is causing a client problem
Information Needs: Why does the client have difficulty with speech? How long has speech been a problem? When was the speech evaluation, by whom and what was the outcome? What activities of daily living are affected by the speech problem? How does the client feel about the problem? How does the caregiver feel? How are the client’s relationships affected? What adaptations have been made to the environment? What are the implications for client safety?  
ASSESSMENT GUIDELINE #8
When an untreated health condition is causing a client problem
Information Needs: Does the client have a physician? Has he had one in the past? How many physicians does the client see? Who is the primary care physician? Why is the client not receiving care? Is there a physical disability that prevents getting care? Are both the medical office and home accessible? Is transportation available? Does the client or family have medical insurance or money to pay medical bills?  Has the client refused medical care? Why?
ASSESSMENT GUIDELINE #9
When impaired vision is causing a client problem
Information Needs: How do you know the client has a vision problem? How long has the client had it? How severe is the vision loss? Has the vision problem been evaluated medically? When? What was the result?  Is the client wearing glasses, lenses, implants? Do they work? Has the client had special training in activities of daily living? Does the client use adaptive equipment? Special reading material? What activities of daily living are affected by the vision loss? How does the client feel about the vision problem? How does the family view the problem? Are there hazards in the client’s environment?
ASSESSMENT GUIDELINE #10
When alcohol abuse is causing a client problem
Information Needs: What makes you think the client is addicted? Are any physical or medical conditions being affected by alcohol? Does the client/family believe addiction is a problem? Is the physician aware of the alcohol problem? Does the client want to change lifestyle? What are realistic expectations for the client to change lifestyle? Do the family/friends want the client to change? What are the area resources for treatment of alcohol problems for people with the disabilities that the client has?  Is AA a possibility for the client?Is the meeting place accessible?Will someone from AA make a home visit?Is Al-anon available for the family?What is case managers response to client and family? To alcohol addiction in general?
ASSESSMENT GUIDELINE #11
When confusion is causing a client problem
Information Needs: How do you know the client is confused?How confused is the client? Is the confusion worse at sometimes than at others?  How long has this been a problem? What behavior problems does the client have?Does the client show poor judgement? How often?Has the confusion been evaluated medically? What was the result?Are medications given correctly?Could medications be contributing to the confusion?What is the family’s reaction?What orientation activities do the family and providers perform?What level of supervision does the client need?Is the client safe at home?Is the client legally competent?Is there a guardian/conservator/power of attorney?
ASSESSMENT GUIDELINE #12
When difficult family relationships are causing a client problem
Information Needs: Does the difficulty appear to be situational or the result of a long-standing pattern in family relationships?Are there medical factors affecting family relationships -- illness? fatigue, weakness?Does someone in the family have a mental health problem? Are they currently under treatment? By whom?What factors in the environment are affecting the problem: lack of space, scarce resources, lack of finances? legal issues/conflicts?  Is the impending death or recent death of a family member increasing family tensions?Are family members motivated to improve relationships, if possible?
ASSESSMENT GUIDELINE #13
When drug abuse is causing a client problem
Information Needs: How do you know the client is abusing drugs? Which drugs?Is the client “addicted”? How do you know?Is the client confused? Accidently misusing drugs?Are the drugs prescribed by a physician? more than one physician?Are the drugs helping a condition that the client has?Is the client terminally ill?Does the client believe he/she is “addicted”?What is the family’s attitude?Does the client or family want help?Whose wishes will prevail?Is the client obtaining drugs illegally?What are the resources for drug treatment in the area for people with disabilities that the client has?  
ASSESSMENT GUIDELINE #14
When emotional or behavioral problems are causing a client problem
Information Needs: How do you know the client has an emotional or behavioral problem?Is the client aware of the problem?How long has the client had it?Does the problem appear to be situational or long-standing? Connected to substance abuse?Has the problem been evaluated medically? Psychiatrically?If the problem is amenable to treatment, is the client willing, motivated?Is treatment going on?What is the effect of the problem on the client’s self care abilities? On the family relationships? On the informal caregiving?  Is the safety of the client or others a problem?Are there barriers to treatment which can be removed?     accessability of treatment?     availability of transportation?      financial resources to pay for treatment? If the treatment includes medication, can the client/family manage the medication?Is there a time of the day that is most difficult for the client/family? Why?Does the caregiver need relief on a regular basis?Has a recent death in the family contributed to the problem?Could the situation be improved by helping the family change its coping strategies. Is the behavior or emotional problem effecting people outside the home? Neighbors, police?
ASSESSMENT GUIDELINE #15
When physical abuse or neglect of the client is the reason for a client problem
Information Needs: How do you know the client is being abused?Who do you think is the abuser? Why do you think so?What are the physical signs that the client shows?What is the client’s emotional reaction? Is she afraid? secretive? defensive?What is the family’s reaction? Are they open? secretive? defensive?Do other family members need to become involved? What is their stress level?What is the environment like? Safe? Unsafe? How soon does client need help?  Can family continue to care for client? Do they need respite? Other help?
ASSESSMENT GUIDELINE #16
When the clients household includes a person with a severe problem
Information Needs: What is the nature of the household member’s problem. (e.g., mental retardation, severe physical disability, psychiatric disorder, suspected criminal activity, substance abuser).  Is the client dependent on this household member?Is this household member dependent on the client?Is the household member dependent on the client’s principal caregiver?What other service systems are involved with this household? Name of other worker(s)? Have any previously attempted interventions failed? Why?How does the client view this person’s problem? How does the family view this person’s problem?Is the client safe in the household?
ASSESSMENT GUIDELINE #17
When architectural barriers are causing a client problem
Information Needs: What is it that is keeping the client from traveling outside or maneuvering inside the home? Confined space? Narrow doorways? Stairs? Lack of a wheelchair? Lack of transportation? Lack of an escort?  How does the client feel about this? How does the family feel?Is there a need for a specialized assessment by a PT, OT or carpenter?Is new housing appropriate if the home cannot be modified to meet the client’s needs?Does the client of family have financial resources to modify the home?Would the client’s self-care abilities be improved if architectural barriers were removed?
ASSESSMENT GUIDELINE #18
When inadequate income is causing a client problem
Information Needs: What are the client’s income and expenses? Why is the income inadequate? What is the client’s attitude towards money? Towards accepting help?Is the client able to manage money, pay bills?Are financial resources available from the family? From church or private resources? From public programs?  Can client reduce expenditures?
ASSESSMENT GUIDELINE #19
When an inadequate level of care at home is causing a client problem
Information Needs: What makes you think the care at home is inadequate?Have available community services been tried?Is nursing home placement being sought? Why?What physical or medical conditions are involved? Is treatment needed?  Are care needs likely to decrease in the future?Does the client wish nursing or boarding home placement? When?Does the family wish nursing or boarding home placement? When? Are there financial resources for short term or long term placement?What do other involved providers, VNA nurse, MD, etc. think?Does the case manager agree/disagree with placement decision?Do forms need to be filled out by client, family, Medicaid?Is a bed available? When?
ASSESSMENT GUIDELINE #20
When an unsafe home or neighborhood is causing a client problem
Information Needs: What are the hazards in the client’s situation? danger from fails? fire? break-ins? other?Is the client aware of the hazards?Is the client capable of living in the current situation? Will she comply with safer practices?What options are available to modify the environment? disconnect stove? new bathroom equipment? locks? gates? bed rails? stair rails?  Is the safety of the home preventing service providers from attending to the client?Must new housing be sought?

SECTION III. OPTIONS FOR CARE PLANNING

The second portion of this paper deals with the care planning process from the point of the completed problem statement through the selection of appropriate providers. Beginning on page 23 Options for Care Planning charts are presented. For each problem, these charts offer general outcome standards, common types of help needed, and service provider options that a case manager can select. The format of the option charts includes the following column headings:

    Service Provider Options  
  Problem Type     Outcome Standards     Common Types of  Help Needed   Informal     Agency  

This format parallels that of the care plan form used in the National Long-Term Care Channeling Demonstration (see Appendix A for the care plan form.)

Stating the Problem

The statement of a client problem on a care planning option chart is different from a problem statement that would appear on the care plan since it does not include both a functional problem and a cause or reason. To include causes with each problem would produce a huge number of possible combinations of problems and causes, far too many to deal with on the option charts, which need to be clear in order to be useful to workers. It would also produce a considerable amount of repetition in this paper. The absence of reasons is important to keep in mind as the problems are worked across the chart. The functional problems identified in these columns are probably the most common ones identified by case managers, but the solution selected for an individual will vary according to many factors: the cause, the family situation, the clients preferences, funding, program requirements, etc.

Outcome Standards

Outcome standards illustrate what the goals of case management might be for each problem type shown in the charts. The more general term, outcome standard, is used here in place of the specific desired outcomes which would appear on a client care plan. Desired outcomes are individually tailored to the client and are time limited. Both the more general outcome standards included here and the specific desired outcomes written during care planning for a client should be expressed in terms of how the client will look, feel, function, or be, when the goal is achieved. Note that a problem may have more than one possible outcome. In that case, the options charts are completed for each possible outcome, and the case manager could include more than one desired outcome on a care plan.

Common Types of Help Needed

Identifying the causes of problems and the desired outcomes for clients assists the case manager to select the most appropriate types of help needed. Depending on the problem, the cause, and the desired outcome, a client may require only one or several types of help. The purpose of this column on the chart is to outline types of help case managers should find useful in resolving specific problems. There is a range of types of help listed, and they vary in intensity. Note that these are general types of help, not yet described in terms of a particular service or delivery system. The case manager would choose the most appropriate option or options rather than all of the listed options.

Service Provider Options

There are many variations in the services offered in different locations and service areas in a state. This contrast is even greater among states, so that generic service categories rather than specific program names are used on the charts. In the real world of practice, options would be modified to reflect the existing service environment in the area.

This column suggests appropriate providers of service for clients who have a particular problem and need a specified type of help. Generic terms for providers are used for the most part, but this was not always possible. It is true that many areas offer similar services under different names. For instance, what is called Medicaid in one state is called Medical in California, a Board of Social Service may be a Welfare Board elsewhere, or the Commission for the Blind may be the Division on the Blind in another state.

Eventually, all case managers come to suffer from an affliction know as abbreviationitis. We are no exception to this, so an Abbreviation Key is in order so that the options for care planning are clear. Although they could be written out in full in every case, efficiency required the use of such abbreviations.

V.A.   -   Veterans Administration
Dx   -   Diagnosis
C.I.   -   Contracted Individual - a person hired privately by the client to perform certain services  
O.T.   -   Occupational Therapist
P.T.   -   Physical Therapist
S.T.   -   Speech Therapist
V.N.   -   Visiting Nurse or Home Health Agency Nurse
E.R.   -   Emergency Room
HHA or Homemaker     -   Home Health Aide/Homemaker (used interchangeably here)
M.D.   -   Medical Doctor
MOW   -   Home Delivered Meals or Meal on Wheels

Although most generic names for providers are self explanatory, there are a few that could bear some explanation.

Diagnosis Related Organizations   e.g., Cancer Society, American Heart Association, Multiple Sclerosis Society, etc.
Service Organization e.g., Lions, Kiwanis, Elks, etc.
Retirement Groups e.g., Retired Senior Volunteers, Retired Executives, etc.
Senior Transport e.g., Local transportation programs for the elderly
Nutrition Project On site meal programs
Volunteer Usually refers to an unpaid individual who comes from an organization that provides volunteers  
Insurance Refers here to commercial insurance and Medicare, Medicaid

The Options for Care Planning charts are divided into two sections. In the first the problem causes or reasons are stated as separate problems. The second section contains the functional problems. If, in gathering further information about a functional problem and its cause, the case manager comes to a decision that the cause itself can be modified or alleviated, he/she may want to address the cause as a separate problem. The outcome of efforts to resolve the cause can impact heavily on approaches to other problems.

The charts on the following pages first address these causes as separate problems.

  1. Abuse and neglect
  2. Alcohol abuse
  3. Confusion
  4. Drug abuse
  5. Emotional or behavioral problems
  6. Fatigue/weakness
  7. Hearing problem
  8. Inadequate level of care
  9. Mobility impairment/paralysis
  10. Problem person in the household
  11. Speech problem
  12. Vision problem

Then the following functional problems are covered.

  1. Client is unable to shop
  2. Client is unable to do laundry
  3. Client is unable to do housework
  4. Client is unable to prepare meals
  5. Client is unable to manage money
  6. Client is unable to self administer medication
  7. Client is unable to bathe self
  8. Client is unable to dress self
  9. Client is unable to perform self toileting
  10. Client is unable to feed self
  11. Client has difficulty with ambulation/mobility
  12. Client has difficulty with transfers
  13. Client is unable to maintain informal support system
  14. Client is unable to maintain social contacts
  15. Client has inadequate financial resources
  16. Client has difficulty obtaining medical care
  17. Client is unable to maintain a safe environment
  18. Client is unable to secure adequate heat
  19. Client is unable to secure adequate housing

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OPTIONS FOR CARE PLANNING #1: ABUSE AND NEGLECT
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Abuse and Neglect   Client is safeorClient will not be abused Respite Care FamilyFriends HomemakerHome Health AideNursing HomeOvernight Companion  
    Counseling   ClergymanSocial Worker
    Family conference   Case Manager
    Legal Services   Lawyer/Legal Aid
    Reporting   Case Manager
    Protective Services   Welfare Board
          
OPTIONS FOR CARE PLANNING #2: ALCOHOL ABUSE
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Alcohol Abuse   Client controls alcohol intake  or Client does not drink alcohol Medical evaluation   MD Clinic Rehab
    Psychological evaluation     MH Center  
    Support group   AA Al-anon
    Monitoring Family  
         
OPTIONS FOR CARE PLANNING #3: CONFUSION
  Service Provider Options
  Problem Type   Outcome Standards   Common Types of  Help Needed Informal Agency
Confusion Client is no longer confused   Medical evaluation   Agency MD Clinic
    Psychological evaluation     Mental Health Center  
  and/or Family counseling   Clergymen Social Agency Mental Health Center
  Client is in a safe situation   SEE PROBLEM “Client unable to maintain safe environment (#29)
         
OPTIONS FOR CARE PLANNING #4: DRUG ABUSE
  Service Provider Options
  Problem Type   Outcome Standards   Common Types of  Help Needed   Informal   Agency
Drug Abuse Client as not addicted to drugs and/or Client obtains drugs legally and/or Client takes drugs as prescribed by MD   Medical evaluation   MD Clinic
    Psychological/Mental Health evaluation     Psychologist Psychiatrist MH Center
    Counseling   Clergyman MH Center Social Worker
    Monitoring/Supervision Family Friends Home Health
    Support groups   AA or other
    Drug Rehab   Drug Rehab Center  
         
OPTIONS FOR CARE PLANNING #5: EMOTIONAL OR BEHAVIORAL PROBLEMS
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Emotional or Behavior Problems   Client is no longer disturbed   Medical evaluation   MD Clinic
    Psychiatric evaluation   Mental Health Center
  and/or Psychiatric treatment   Mental Health Center Psychiatric Day Hospital Psychiatric In-patient Facility  
    Behavioral Therapy   Mental Health Center
    Situational Counseling     Social Agency Mental Health Center Clergyman
  Client is in a safe situation   SEE PROBLEM “Client unable to maintain safe environment” (#29)
         
OPTIONS FOR CARE PLANNING #6: FATIGUE/WEAKNESS
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Fatigue/Weakness   Client has energy for daily activities   Medical evaluation   MD
    Pharmacologic evaluation   Pharmacist
    P.T. evaluation   P.T.
    Mental Health evaluation   Mental Health Center  
    Evaluation of rest/ activity patterns     Home Health Agency
         
OPTIONS FOR CARE PLANNING #7: HEARING PROBLEM
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Hearing Problem   Client has maximum hearing   Medical evaluation   MD Specialist
  and/or Audiologic evaluation     Audiologist
    Hearing aid repair   Hearing Aid Company
  Client is safe Special equipment Family Friends Telephone Company  Deaf Association
    Monitoring Family Friends  
    Modify environment Family  
         
OPTIONS FOR CARE PLANNING #8: INADEQUATE LEVEL OF CARE
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Inadequate Level of Care   Client receives needed care  or Client is in safe situation Medical evaluation   MD Clinic
    Instruction in home care   Home Health
    Increase level of service   Case Manager
    Caregiver counseling   Social Worker
    Respite Family Friends Nursing Home  Home Health Homemaker
    Modify environment Family Home Health Case Manager
    Family conference   Case Manager
    Nursing home placement   Family  
       Temporary   Case Manager
       Permanent    
         
OPTIONS FOR CARE PLANNING #9: MOBILITY IMPAIRMENT/PARALYSIS
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Mobility Impairment/Paralysis   Client has optimal mobility and use of arms and legs Medical evaluation   MD Clinic
    P.T. evaluation   Home Health Rehab Clinic
    O.T. evaluation   Home Health Rehab Clinic
    Modify environment   Family Friends Volunteers Contractors
    Obtain equipment   Medical Supply House  Clubs Churches
         
OPTIONS FOR CARE PLANNING #10: PROBLEM PERSON IN HOUSEHOLD
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Problem Person in Household   Person receives care Medical evaluation of family member   MD
    Mental health care of family member   Mental Health Center
    Counseling client and family member   Social Worker
  and/or      
  Client is comfortable in home situation   Move client to other setting FamilyFriends Case Manager
    Provide Respite FamilyFriends Homemaker/Home-Health Aide  
    Legal/Advocacy for client to maintain rights     LawyerLegal Services
    Financial management FamilyFriends ConservatorPower of AttorneyBank
         
OPTIONS FOR CARE PLANNING #11: SPEECH PROBLEM
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Speech Problem   Client communicates needs  and/or Client has social contact Speech evaluation/ therapy     Home Health  ST
    Modify environment Family  
    Monitoring FamilyFriends  
    Escort FamilyFriends Volunteer
         
OPTIONS FOR CARE PLANNING #12: VISION PROBLEM
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Vision Problem   Client has maximum possible vision   Medical evaluation   MD
    Optometric evaluation and prescription   Optometrist
    Modify environment for safety and to promote independence   Family OT
    Obtain adaptive equipment   Commission for the Blind  Home Health NurseCase Manager
    Arrange for reading material (large type, talking books, etc.)   Case ManagerCommission for the Blind
    Monitoring and supervision FamilyFriendsNeighbors    
         
OPTIONS FOR CARE PLANNING #13: CLIENT UNABLE TO SHOP
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Shop   Client will have sufficient supplies of food and household goods to maintain adequate nutritional intake, hygiene, and safe, sanitary environment Someone to shop FamilyFriendNeighbor VolunteerHomemakerCIChore ServiceSenior Apartment Shopping Service
    Someone to write shopping list FamilyFriendNeighbor VolunteerHomemakerCI
    Transportation to grocery store FamilyFriendNeighbor VolunteerCIHomemakerSenior TransportTaxi
    Escort and assistance with carrying packages   FamilyFriendNeighbor VolunteersCIHomemakerTaxi Driver
    Delivery Service   Local storesSenior Housing Convenience Concessions  
    Financial Assistance for purchases Family Food StampsSenior DiscountsCouponsEmergency Food BankSurplus Food DistributionSSIService Organizations
         
OPTIONS FOR CARE PLANNING #14: CLIENT UNABLE TO DO LAUNDRY
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to do Laundry   Client will have available supplies of clean clothing and linens   Someone to do laundry FamilyFriendsNeighbors HomemakerCIChore ServiceVolunteerLaundry Service
    Someone to assist with laundry FamilyFriendsNeighbors HomemakerCIChore ServiceVolunteer
    Someone to move washer and dryer to accessible location FamilyFriendsNeighbors Handyman ServiceCIVolunteer
    Finances for purchase of washer and dryer ClientFamily Service Organization  Donation
    Increased supply of clothing and linens to reduce frequency of need for laundering   ClientFamily Service OrganizationDonation
    Instruction in independent laundering   OT
         
OPTIONS FOR CARE PLANNING #15: CLIENT UNABLE TO DO HOUSEWORK
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Do Housework   Client will have a clean environment   Someone to do light and heavy housework   FamilyFriendsNeighbors VolunteerCIChore ServiceCleaning CompanySenior Apartment Cleaning Service  
    Someone to do light housework FamilyFriendsNeighbors HomemakerChore ServiceVolunteer
    Instruction in independent housekeeping   OT
    Equipment for cleaning ClientFamily Donations
         
OPTIONS FOR CARE PLANNING #16: CLIENT UNABLE TO PREPARE MEALS
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Prepare Meals   Client will have meals prepared that meet nutritional requirements and are acceptable to client Meals pared in the home Family HomemakerCIVolunteer
    Hot meals delivered FamilyNeighbor MOWRestaurant DeliveryVolunteer
    Frozen meal a delivered FamilyNeighborFriend Volunteer
    Site for congregate meals   Nutrition ProjectDay Care
    Shared meals FamilyNeighborFriend  
    Instruction in independent meal preparation     OTCommission for the Blind  
    Specialized equipment   OT & Medical Supplier
    Instruction in special diet   NutritionistVN
    Financing of adequate cooking facilities ClientFamily Service OrganizationsHousing Rehab Program
    Relocation to handicapped equipped apartment     1) Information on available housing   Case ManagerHousing AuthorityLocal Housing Information Agency  
       2) Application ClientFamilyFriend Senior Housing PersonnelVolunteer
       3) Moving FamilyFriend VolunteerProfessional Movers
       4) Financing ClientFamily Service Organization
    Transportation to meal site FamilyFriendsNeighbors Senior TransportTaxiCIVolunteerNutrition Program Transport
    Escort for Transportation FamilyFriendNeighbor CIVolunteerHomemaker
         
OPTIONS FOR CARE PLANNING #17: CLIENT UNABLE TO MANAGE MONEY
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Manage Money   Clients finances will be managed effectively   Total budgeting and financial responsibility FamilyProtective PayeePower of Attorney  Legal GuardianConservatorFriend  
    Legal assistance in naming power of attorney, legal guardian, conservator     LawyerLegal AidProtective Services
    Assistance with financial management FamilyFriend Social WorkerProtective ServicesCommission for the Blind  
    Instruction in effective budgeting   Home EconomistSocial Worker
         
OPTIONS FOR CARE PLANNING #18: CLIENT UNABLE TO SELF ADMINISTER MEDICATIONS
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Self Administer Medications   Clients will take medications as prescribed by the physician   Administration of medications FamilyFriendNeighbor Private Duty NurseVN
    Pouring medications FamilyFriendNeighbor  
    Supervision and instruction regarding medications   VNMD
    Setting up a medication system Family VN
    Revision of medication dosage schedule   MD
    Reminder to take medications FamilyFriendNeighbor CIHomemakerHHA
    Easy open medication containers   Pharmacist
    Instruction in identifying medications (if vision problem exists)     Commission for the Blind  
    Assistive devices for medication administration   PharmacistSurgical Supplier
    Payment for assistive device ClientFamily Disease Specific Organization  Insurance
         
OPTIONS FOR CARE PLANNING #19: CLIENT UNABLE TO BATHE SELF
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Bathe Self   Clients will bathe/be bathed at intervals sufficient to maintain hygiene and skin integrity Someone to bathe client FamilyFriend HomemakerCI
    Someone to assist with bathing FamilyFriend HomemakerCI
    Someone to supervise bathing FamilyFriend HomemakerCI
    Instruction in bathing (independent)   VNOT
    Equipment for bathing    1) Assessment of need, instruction in use   VNOT
       2) Source Equipment donations   Medical Supplier
       3) Financing ClientFamily Service OrganizationDiagnosis Specific OrganizationInsurance
    Correction of Plumbing problems/architectural barriers      
       1) Evaluation/estimates   PlumberContractor
       2) Doing Corrections FamilyFriend VolunteersPlumberContractor
       3) Financing ClientFamily Housing Rehab ProgramHome Improvement LoansReverse MortgageHome Equity LoanService OrganizationInsurance
    Relocation to handicapped equipped apartment     1) Information on available housing   Case ManagerLocal Housing AuthorityLocal Housing Information Agency
       2) Assistance with application ClientFamilyFriend Senior/Handicapped Housing Personnel  Volunteer
       3) Moving FamilyFriend VolunteerProfessional Movers
       4) Financing of relocation ClientFamily Service Organization
       5) Assistance with rental payments ClientFamily Rental Assistance Program
         
OPTIONS FOR CARE PLANNING #20: CLIENT UNABLE TO DRESS SELF
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Dress Self   Client will change clothing/have clothing changed upon rising and retiring   Someone to dress client FamilyFriend HomemakerCI
    Assistance with dressing FamilyFriend HomemakerCIVolunteer
    Someone to supervise dressing FamilyFriend HomemakerCIVolunteer
    Instruction in independent dressing   VNOT
    Specialized equipment for dressing    1) Assessment of need, instruction in use     VNOT
       2) Source Donations   Medical Supplier
       3) Financing ClientFamily Service OrganizationsDiagnosis Specific Group  Insurance
         
OPTIONS FOR CARE PLANNING #21: CLIENT UNABLE TO PERFORM SELF TOILETING
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Perform Self Toileting   Client will toilet/be toileted at intervals sufficient to meet body requirements and to maintain hygiene  or Client will be clean and dry Reminder to toilet FamilyFriendsNeighbors HomemakerCIVolunteersDay Care
    Assistance with toileting FamilyFriend HomemakerCIDay Care
    Instruction in independent toileting   OTPTVN
    Equipment/supplies related to toileting/ incontinence care     1) Assessment of need, instruction in use   VNPTOT
       2) Source   Equipment DonationsMedical Supplier
       3) Financing ClientFamily InsuranceDiagnosis Specific Organization  Service Organization
    Medical Evaluation   MD
    Bladder and/or bowel training   Instruction   Follow-up Family VNCIHomemaker
    Medical procedure/interventions   MDVN
    Provision/assistance with incontinence care Family HomemakerCIVN
    Correction of plumbing problems/ architectural barrier     1) Evaluation   PlumberContractor
       2) Doing corrections FamilyFriend VolunteersPlumberContractor
       3) Financing FamilyFriend Housing Rehab ProgramHome Improvement LoansReverse MortgageHome Equity LoanService OrganizationInsurance  
         
OPTIONS FOR CARE PLANNING #22: CLIENT UNABLE TO FEED SELF/EAT
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Feed Self/Eat   Client will be fed/feed self meals sufficient to meet nutritional requirements   Someone to feed clients FamilyFriendNeighbors HomemakerCIVolunteersCompanion
    Assistance with eating FamilyFriendNeighbors VolunteerHomemakerCICompanion
    Supervision of eating and set up of food FamilyFriendNeighbors VolunteerHomemakerCICompanionDay Care
    Instruction in independent eating   VNOTCommission for the Blind  
    Medical assessment of feeding problems   MDVNOTST
    Instruction in specialized feeding procedures   VN
    Specialized equipment for eating/feeding    1) Assessment of need and instruction in use     VNOTCommission for the Blind
       2) Source   Medical SupplierCommission for the Blind
       3) Financing ClientFamily Service OrganizationDiagnosis Specific OrganizationInsurance
    Instruction in diet modifications     VNNutritionist
    Dental exam and follow-up   DentistDental Clinic
    Financing of dental work ClientFamily InsuranceLow Income Dental ClinicDental Discounts for Seniors
    Transportation to MD/Dentist FamilyFriendNeighbors Senior TransportTaxiCIVolunteerDiagnosis Specific Organization  Ambulance Service
    Escort for transportation FamilyFriendNeighbors CIVolunteerHomemaker
         
OPTIONS FOR CARE PLANNING #23: CLIENT HAS DIFFICULTY WITH AMBULATION/MOBILITY
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Has Difficulty With Ambulation/Mobility   Client will ambulate independently/be mobile   Assistance with ambulation/mobility FamilyFriend HomemakerCI
    Instruction in independent ambulation   PTVN
    Specialized equipment for ambulation/mobility (ambulation devices, wheelchairs, ramps, rails)     1) Assessment of need, instruction in use   VNPT
       2) Source Equipment donations Medical supplier
       3) Financing ClientFamily InsuranceMedicareMedicaid
    Specialized Transportation   Rescue SquadPrivate AmbulanceWheelchair equipped Seniors Van  
    License plates for handicapped individuals   Department of Motor Vehicles
    Information re: local businesses and services with access for handicapped persons   Case Manager
    Correction of in-home architectural barriers   1) Evaluation   ContractorRehabilitation Specialist
       2) Doing corrections FamilyFriends VolunteersContractor
       3) Financing ClientFamily Housing Rehab ProgramHome Improvement LoanBank for Reverse MortgageHome Equity LoanService OrganizationInsurance
    Relocation to handicapped equipped apartment     1) Information on available housing   Case ManagerLocal Housing AuthorityLocal Housing Information Agency
       2) Application ClientFamilyFriend Senior/Handicapped Housing Personnel  
       3) Moving FamilyFriend VolunteersProfessional Movers
       4) Financing of relocation ClientFamily Service Organization
       5) Assistance with rental payments ClientFamily Rental Assistance Program
         
OPTIONS FOR CARE PLANNING #24: CLIENT HAS DIFFICULTY WITH TRANSFERS (bed to chair, chair to commode, etc.)
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Has Difficulty With Transfers (bed to chair, chair to commode, etc.)   Client will transfer/be transferred at a frequency sufficient to maintain optimum mobility and to prevent adverse affects of immobility   Someone to transfer client FamilyFriend Home Health AideCI
    Assistance with transfer FamilyFriend Home Health AideCI
    Instruction in transfer techniques   PTVNRehabilitation Facility
    Follow-up on instruction ClientFamily VNHome Health Aide
    Assistive equipment for transfer    1) Assessment of need/instruction in use     PTVN
       2) Source Equipment donations Medical Supplier
       3) Financing ClientFamily InsuranceService OrganizationDiagnosis Specific Organization  
         
OPTIONS FOR CARE PLANNING #25: CLIENT UNABLE TO MAINTAIN INFORMAL SUPPORT SYSTEM
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Maintain Informal Support System   Informal caregivers will maintain their involvement in caring for client   Respite for caregivers FamilyNeighbor VolunteerHomemakerCompanionCIDay CareShort Term Nursing Home
    Counseling/support for caregiver   Family Support GroupCase ManagerSocial WorkerMental Health AgencyPrivate Counseling ServiceDiagnosis Related Organization  
         
OPTIONS FOR CARE PLANNING #26: CLIENT UNABLE TO MAINTAIN SOCIAL CONTACTS
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Maintain Social Contacts   Client will have established social contacts on a regular basis   Social visitors in the home FamilyNeighborFriends Church VisitorVolunteerCompanion
    Attendance at social gatherings   Family functions   Support GroupChurch ActivityDay Care
    Transport to social gathers FamilyFriendsNeighbors Senior TransportTaxiCIVolunteer
    Escort for transport FamilyFriendsNeighbor CIVolunteer
    Reassurance caller FamilyFriendsNeighbor Church GroupVolunteer Organization  Formal Agency Service
         
OPTIONS FOR CARE PLANNING #27: CLIENT HAS DIFFICULTY WITH FINANCIAL RESOURCES
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client has Difficulty with Financial Resources   Income will be adequate to maintain standard of community living   Assistance in obtaining income entitlements   Case ManagerSocial SecurityVeterans AdministrationMunicipal WelfareCounty WelfarePrivate Pension PlansLegal Aid
    Assistance in obtaining supplementary entitlements     Case ManagerMedicareMedicaidFood StampsHome Heating AllowancePharmaceutical AssistanceV.A. Aid and AttendanceInsurance ClaimsLegal AidSocial Services Block GrantArea Agency on AgingRental AssistanceHousing Restoration ProgramMedically Needy ProgramCommission for Blind
    Assistance in obtaining donated goods or services   Diagnosis Related OrganizationChurch GroupsFraternal OrganizationsService OrganizationsIndustryPublicity Request for Donations  Community AgenciesSchool GroupsMerchantsUnionsRetirement GroupsSenior Discount ProgramClinicsLocal Transportation Programs  
    Assistance with budgeting FamilyFriends Case ManagerSocial WorkerHome Economist
    Supplemental Financial Support Family Bank for Reverse Mortgage
         
OPTIONS FOR CARE PLANNING #28: CLIENT HAS DIFFICULTY OBTAINING ADEQUATE MEDICAL CARE
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client has Difficulty Obtaining Adequate Medical Care   Client will be at optimum level of health  orClient accepts need for medical careorClient receives medical care Medical home visit   M.D.Nurse Practitioner
  Information re: M.D.’s who make home visits     Medical Society
  Nursing Assessment   Visiting Nurse  
  M.D. office visit for evaluation   Private M.D.ClinicEmergency Room
    Financial assistance for medical care   MedicareMedicaidInsuranceSliding Fee ClinicsPublic ProgramsInstallment Payment PlanDiagnosis Specific Organization  
    Transport to medical facility FamilyFriendNeighbor Rescue SquadPrivate AmbulanceVolunteersSenior VanPublic Transport
    Financing Transport Family Medicare (to E.R.)MedicaidPublic ProgramsDiagnosis Specific Organization
    Counseling   Case ManagerVisiting NurseSocial Worker
            
OPTIONS FOR CARE PLANNING #29: CLIENT UNABLE TO MAINTAIN A SAFE ENVIRONMENT
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Maintain a Safe Environment   Client will be protected from environmental hazards   24 hour supervision FamilyFriendNeighbor Boarder VolunteerHomemakerCIDay CareLive-In Companion
    Periodic Monitoring FamilyFriendNeighbor    Neighborhood Watch Program   Home Delivered Meals Program  ClergyVolunteerPolice monitoringFire Department monitoringMail CarrierReassurance caller
    24 hours emergency signalling system     LifelineTelephone CompanyEmergency cords in apartment
    Alternative living arrangement Relative’s homeFriend’s home Senior HousingShare-a-HomeBoarding HomeSheltered Housing
    Emotional support for client FamilyFriendsNeighborsPet VolunteerCounseling Reassurance Caller Case Manager Companion Church Visitor CIHomemaker Peer Group
    Respite for caregivers FamilyFriendNeighbor VolunteerHomemakerCIDay Care Nursing Home
    Support for caregivers   Support Group Counseling Case Manager
    Instruction in home safety Family OTPTVN Police Programs Fire Department Programs  HomemakerCI Case Manager
    Building safety FamilyFriend Health Officers Fire Inspector Sanitation Department Landlord Handyman Program Housing Rehab Program Volunteer
    Safety equipment, locks, fire extinguishers, smoke alarms, grab bars, bed rails, ramps, table top appliances, gate, stair glides   1) Obtaining and installing ClientFamilyFriendNeighbor Volunteer Handyman Program CI
       2) Financing Family Client Service OrganizationInsurance Donations Commission for Blind
    Legal Intervention   LawyerLegal Aid Public Advance Protective Services Family Service Association  
            
OPTIONS FOR CARE PLANNING #30: CLIENT UNABLE TO SECURE ADEQUATE HEAT
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Secure Adequate Heat   Client’s environmental temperature will be maintained at a minimum of 68°F   Advocacy with landlord   Case Manager Legal Aid Health Department
    Housing relocation   See problem re: Inability to secure adequate housing (p. 44)  
    Financial Assistance for installation/repair of heating system, home weatherization   ClientFamily Housing Preservation Program Reverse MortgageHome Improvement Loan Public Weatherization Programs  Volunteer Programs
    Financial Assistance for bills Family Church Group   Energy Assistance Program -- Local/State  Emergency Heating Assistance Program
         
OPTIONS FOR CARE PLANNING #31: CLIENT UNABLE TO SECURE ADEQUATE HOUSING
  Service Provider Options
Problem Type Outcome Standards   Common Types of  Help Needed   Informal   Agency
Client Unable to Secure Adequate Housing   Client will live in safe, sanitary, affordable housing   Information on available housing FamilyFriends Case ManagerLocal Housing for Planning AgenciesNewspaper Community Agencies
    Financial Aid for housing Family Senior/Handicapped Subsidized Housing  Section 8 Housing Program
    Physical Assistance moving or financial assistance for moving FamilyFriendNeighbor Volunteers Service Organization
    Assistance with application for subsidized housing FamilyFriend Housing Personnel Case Manager
    Representation in housing related legal matters (evictions, foreclosures)     Private LawyerLegal Aid Tenants Rights Organization
         

APPENDIX A. CARE PLAN FORM

CHANNELING DEMONSTRATION CARE PLAN, Part 1
Client Date
I.D.  
Address  
Phone No.    
  Problems     Desired Outcome     Problem Revised/  Resolved-Date
1.       
     
     
2.    
     
     
3.    
     
     
4.    
     
     
5.    
     
     
Problems not addressed and why:
1.    
2.    
3.    
hlg/H-7 5/24/85
CHANNELING DEMONSTRATION CARE PLAN, Part 2
Client Initial Service Focus 1._____Maintenance in community 2._____Movement toward community 3._____Movement toward board & care 4._____Movement toward nursing facility  
Next Scheduled Reassessment  
Service Providers   Pattern of Delivery     Changes  
  Informal     Formal  
1.      
       
       
2.      
       
       
3.      
       
       
4.      
       
       
5.      
       
       
       
This care plan has been discussed with the client and/or significant family members or friends.
   
Case Manager Date
   
Supervisor Date
hlg/H-7 5/24/85

APPENDIX B. SUMMARY OF THE CHANNELING PROGRAM CONTEXT

by Nancy Wilson and Linda Sterthouse

History and Background

The problems and limitations of the current long-term care system have been described many times during the past decade. Policy-makers at all levels of government have stressed the need to resolve critical problems such as increasing public costs, excessive reliance on medical and institutional care, inadequate community resources, fragmentation, and service inaccessibility.

Since these problems affect a growing population of impaired elders, public officials and legislators have initiated a variety of long-term care demonstration projects to evaluate new approaches to services, increase understanding of the needs of impaired clients, and gather information about the costs of caring for them in the community.

To answer important remaining policy questions, Congress authorized funds for the National Long-Term Care Channeling Demonstration (known also as Channeling). From 1980 to 1985, three agencies within the Department of Health and Human Services jointly administered this demonstration project in ten states. The office of the Assistant Secretary for Planning and Evaluation coordinated and implemented the program, cooperating with staff from the Administration on Aging and the Health Care Financing Administration, the two principal funding sources.

The Channeling program has tested two organizational models of community-based long-term care for the functionally impaired elderly. Both models were tested as alternatives to institutional care and included these common features: a central point of intake, a standardized assessment process, and ongoing case management to arrange and monitor the provision of community-based services.

In the basic Channeling model, case managers coordinated existing community resources to meet individual needs. The complex (or financial control) model had additional authority and funding to purchase services for clients. These case managers had access to pooled funds from Medicare, Medicaid, Title III and Title XX and could authorize the amount, duration and scope of services for all of their clients within established site limits on total care plan costs.

Channeling Participants

Through DHHS contracts with ten states, ten community agencies were selected to carry out the Channeling demonstration. The basic case management model was tested in five sites: Eight counties in Eastern Kentucky; Portland, Maine; Baltimore, Maryland; New Brunswick, New Jersey; and Houston, Texas. The five complex model sites were operated in Miami, Florida; Greater Lynn, Massachusetts; Troy, New York; Cleveland, Ohio; and Philadelphia, Pennsylvania. All ten sites began operating in early 1982.

The official closing date of the Channeling Demonstration was March 31, 1985. Each of the ten sites has gone through a termination/transition process designed to safely discharge clients to existing agencies or to move program staff and clients to other sources of funding.

During the course of the demonstration, the ten channeling sites identified through outreach efforts over 9,000 very impaired older adults and served over 6,000 of these individuals as clients.

Design of Channeling Demonstration

Channeling was developed to achieve the following objectives:

  • Improved targeting of service resources to those in greatest need.

  • Improved matching of clients needs to formal and informal services.

  • Improved client outcomes.

  • Less costly, more efficient use of services.

Target Population for Channeling

Emphasis was placed on targeting those older people who would be institutionalized in the absence of community-based services.

The standard criteria for participation in the project were based on three factors (in addition to client interest):

  • Residence -- must reside in the service area, or if institutionalized, must be certified as likely to be discharged to a non-institutional setting within three months.

  • Functional Disability -- must have a minimum of two moderate ADL disabilities, or three severe IADL impairments, or two severe IADL impairments and one severe ADL disability.

  • Unmet Needs or Fragile Informal Support -- must have an unmet need expected to last at least six months for two major personal care or in-home services (meals, housework/shopping, medications, medical treatments at home, personal care), or must have a fragile informal support sytem that may no longer be able to provide needed care.

Utilizing these eligibility criteria for a defined target population, the Channeling sites recruited and screened applicants for services. The profile of Channeling clients selected using these criteria reveals a very impaired population. Most of the clients were unable to leave their homes without human assistance and many were bedbound. Most needed assistance with activities of daily living.

Core Functions of Channeling Agencies

To achieve improved client and caregiver outcomes and reduced costs for more appropriate services, the designers of Channeling prescribed seven essential core functions that each site was to carry out:

  1. Outreach to identify and attract appropriate clients. Channeling sites utilized a variety of outreach strategies including: written referral agreements with hospitals, home health providers and other agencies who referred clients, community education activities aimed at clients and families (such as letters to clergy and group presentations); and public information such as media announcements and brochures. The major sources of referral were hospitals, home health agencies, and families.

  2. Screening to determine whether an applicant was part of the target population. Designated staff typically conducted a telephone interview of 15-20 minutes with a client or referral source, using a standardized screening instrument. The instrument included questions designed to establish an individuals eligibility for the program based on the criteria previously discussed. Screeners decided when to rely upon a family member or other referral source instead of a client as a respondent to the screening questions.

  3. Comprehensive needs assessment to determine individual problems, resources, and service needs. Using a standardized assessment tool, the channeling staff made an in-person visit to collect information about a clients current functioning and support system. Staff used one version of the tool for clients assessed in an institution (hospital or nursing home) and another version for community clients. Both instruments explored aspects of the clients physical health, mental health, social functioning, activities of daily living, financial resources, living environment, current services and support and unmet needs. Additional information was collected as needed from other formal and informal providers involved with the client.

  4. Care planning to specify the types and amounts of care to be provided to meet the identified needs of individuals. At this stage, case managers translated identified needs and problems into a plan for services. Working with a standard care plan format, staff outlined problems, goals to be achieved, type of help to pursue in support of goal attainment, and sources and cost of services.

    Case managers were trained to be cost-conscious in their selection of service packages. They were encouraged to consider the full spectrum of public and private services available to a client before choosing an appropriate package. This included maximizing informal care already in place or potentially available to the client, and seeking volunteer help.

    An important aspect of the care planning process was establishing an agreement with the client and significant family members. In Channeling, a care plan agreement form was signed by clients signifying their knowledge and cooperation with the plan.

  5. Service Arrangement to implement the care plan through both formal and informal providers. Case managers had to be knowledgable about service availability in their respective communities. This step sometimes required extensive communication with client, family and providers to assure that quality help would be provided and services were scheduled appropriately.

  6. Monitoring to assure that services are provided as specified in the care plan. To monitor service provision and the circumstances of their frail clients, case managers maintained contact by telephone or in person with providers, clients, and family members. They encouraged informal and formal providers to call in the event of problems with services or changes in client status. Case managers relied on in-home providers to provide information about clients in crisis. Clients with no functioning informal care system often required more intensive follow-up.

  7. Reassessment to adjust care plans to changing needs. In Channeling, reassessment was conducted on a scheduled basis, three months after program entry and every five to six months thereafter. In addition, a clients status changed suddenly in some major way, an event-based reassessment was conducted to revise the care plan. The case manager conducted an in-person visit and, utilizing a structured form, re-examined the clients situation and functioning. The reassessment was the basis for continuing, revising or discontinuing services and for determining whether the client continued to need case management services.

Variations in Models

The channeling demonstration added other features to these essential functions to define two program models: the basic case management model and the financial control model.

Basic Case Management Model. The basic model sites relied primarily on the existing services and resources in their communities to meet long-term care needs of their clients. The Channeling site in each community represented a focal intake point for services to impaired elders and provided trained case managers to help clients and families utilize their entitlements fully and gain access to the best package of these available services.

One additional feature established as part of each basic model site was a gap-filling or service expansion fund. Project staff were allowed substantial flexibility to use these discretionary dollars for the purchase of non-traditional items (talking clocks, large print books) as well as more routine direct services (personal care, transportation).

Complex or Financial Control Model. The five complex sites combined the essential Channeling functions with six additional features that increased the case managers access to services as well as the programs ability to control overall service costs:

  1. Expanded Service Coverage.

    In the complex model, nineteen different service categories were reimbursable under the Demonstration. The included:

    • Day health and rehabilitative care
    • Day maintenance care
    • Home health aide
    • Homemaker/personal care
    • Housekeeping service
    • Chore services
    • Companion service
    • Home delivered meals
    • Respite care
    • Skilled nursing
    • Physical therapy
    • Speech therapy
    • Occupational therapy
    • Mental health services
    • Transportation
    • Housing assistance
    • Adult foster care
    • Non-routine consumable medical supplies
    • Adaptive and assistive equipment
  2. Pooling of Government Funds.

    The pooling of Medicare, Medicaid, state and in some cases local funds allowed all clients (who were eligible for Medicare, Part A) to be eligible for all of the services, based on the decision of the case manager that the service was necessary.

  3. Case Manager Authority Over Payment for Services.

    Case managers authorized payment from the funds pool and determined the amount, scope, and duration of the services. This allowed the case manager to increase and decrease amounts of service, to change services, and to change providers whenever necessary.

  4. A Cap on Aggregate Service Expenditures.

    In order to control the expenditures of Channeling sites from the funds pool, a cap was set for each site which limited average service expenditures to sixty percent of the average nursing home rate in the local area.

  5. Limits on Cost of Individual Care Plans.

    Individual Channeling clients were allowed to have plans that cost over 60% for relatively short periods of time. Case managers could write plans which kept annual costs at 85% or below. This meant that other clients had to average less than 60% in order to balance the extra spending.

  6. Cost Sharing by Clients.

    Based on income, some clients were required to contribute to the cost of their care.

Research in the Demonstration

The major policy questions were adressed by an extensive research effort. The evaluation contractor selected by DHHS, Mathematica Policy Research, used a randomized experimental design and conducted several studies examining service use, outcomes, costs and informal caregiving. In addition, an exploratory study of care plan practices was conducted by the technical assistance contractor, the Institute on Aging at Temple University. It examined questions of a more clinical nature which were not included in the overall evaluation.

se/h-18


OTHER REPORTS AVAILABLE

A Guide to Memorandum of Understanding Negotiation and Development
HTML   http://aspe.hhs.gov/daltcp/reports/mouguide.htm
PDF   http://aspe.hhs.gov/daltcp/reports/mouguide.pdf
An Analysis of Site-Specific Results
Executive Summary   http://aspe.hhs.gov/daltcp/reports/sitees.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/sitees.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/sitees.pdf
Analysis of Channeling Project Costs
Executive Summary   http://aspe.hhs.gov/daltcp/reports/projctes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/projctes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/projctes.pdf
Analysis of the Benefits and Costs of Channeling
Executive Summary   http://aspe.hhs.gov/daltcp/reports/1986/costes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/cost.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/cost.pdf
Applicant Screen Set
HTML   http://aspe.hhs.gov/daltcp/reports/1982/appscset.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1982/appscset.pdf
Assessment and Care Planning for the Frail Elderly: A Problem Specific Approach
HTML   http://aspe.hhs.gov/daltcp/reports/1986/asmtcare.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/asmtcare.pdf
Assessment Training for Case Managers: A Trainer's Guide
HTML   http://aspe.hhs.gov/daltcp/reports/1985/asmttran.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1985/asmttran.pdf
Case Management Forms Set
HTML   http://aspe.hhs.gov/daltcp/reports/1985/cmforms.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1985/cmforms.pdf
Case Management Training for Case Managers: A Trainer's Guide
HTML   http://aspe.hhs.gov/daltcp/reports/1985/cmtrain.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1985/cmtrain.pdf
Channeling Effects for an Early Sample at 6-Month Follow-up
Executive Summary   http://aspe.hhs.gov/daltcp/reports/6monthes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1985/6monthes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1985/6monthes.pdf
Channeling Effects on Formal Community-Based Services and Housing
Executive Summary   http://aspe.hhs.gov/daltcp/reports/commtyes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/commty.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/commty.pdf
Channeling Effects on Hospital, Nursing Home and Other Medical Services
Executive Summary   http://aspe.hhs.gov/daltcp/reports/hospites.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/hospites.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/hospites.pdf
Channeling Effects on Informal Care
Executive Summary   http://aspe.hhs.gov/daltcp/reports/informes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/informes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/informes.pdf
Channeling Effects on the Quality of Clients' Lives
Executive Summary   http://aspe.hhs.gov/daltcp/reports/qualtyes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/qualtyes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/qualtyes.pdf
Clinical Baseline Assessment Instrument Set
HTML   http://aspe.hhs.gov/daltcp/reports/cbainstr.htm
PDF   http://aspe.hhs.gov/daltcp/reports/cbainstr.pdf
Community Services and Long-Term Care: Issues of Negligence and Liability
HTML   http://aspe.hhs.gov/daltcp/reports/negliab.htm
PDF   http://aspe.hhs.gov/daltcp/reports/negliab.pdf
Differential Impacts Among Subgroups of Channeling Enrollees
Executive Summary   http://aspe.hhs.gov/daltcp/reports/enrolles.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/enrolles.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/enrolles.pdf
Differential Impacts Among Subgroups of Channeling Enrollees Six Months After Randomization
Executive Summary   http://aspe.hhs.gov/daltcp/reports/difimpes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1984/difimpes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1984/difimpes.pdf
Examination of the Equivalence of Treatment and Control Groups and the Comparability of Baseline Data
Executive Summary   http://aspe.hhs.gov/daltcp/reports/baslines.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1984/baslines.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1984/baslines.pdf
Final Report on the Effects of Sample Attrition on Estimates of Channeling's Impacts
Executive Summary   http://aspe.hhs.gov/daltcp/reports/1986/atritnes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/atritn.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/atritn.pdf
Informal Care to the Impaired Elderly: Report of the National Long-Term Care Demonstration Survey of Informal Caregivers
Executive Summary   http://aspe.hhs.gov/daltcp/reports/impaires.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1984/impaires.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1984/impaires.pdf
Informal Services and Supports
HTML   http://aspe.hhs.gov/daltcp/reports/1985/infserv.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1985/infserv.pdf
Initial Research Design of the National Long-Term Care Demonstration
HTML   http://aspe.hhs.gov/daltcp/reports/designes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/designes.pdf
Issues in Developing the Client Assessment Instrument for the National Long-Term Care Channeling Demonstration
HTML   http://aspe.hhs.gov/daltcp/reports/1981/instrues.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1981/instrues.pdf
Methodological Issues in the Evaluation of the National Long-Term Care Demonstration
Executive Summary   http://aspe.hhs.gov/daltcp/reports/methodes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/methodes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/methodes.pdf
National Long-Term Care Channeling Demonstration: Summary of Demonstration and Reports
HTML   http://aspe.hhs.gov/daltcp/reports/1991/chansum.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1991/chansum.pdf
Screening Training for Screeners: A Trainer's Guide
HTML   http://aspe.hhs.gov/daltcp/reports/1985/scretrai.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1985/scretrai.pdf
Survey Data Collection Design and Procedures
Executive Summary   http://aspe.hhs.gov/daltcp/reports/sydataes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/sydataes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/sydataes.pdf
Tables Comparing Channeling to Other Community Care Demonstrations
HTML   http://aspe.hhs.gov/daltcp/reports/1986/tablees.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/tablees.pdf
The Channeling Case Management Manual
HTML   http://aspe.hhs.gov/daltcp/reports/1986/cmmanual.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/cmmanual.pdf
The Channeling Financial Control System
HTML   http://aspe.hhs.gov/daltcp/reports/1985/chanfcs.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1985/chanfcs.pdf
The Comparability of Treatment and Control Groups at Randomization
HTML   http://aspe.hhs.gov/daltcp/reports/compares.htm
PDF   http://aspe.hhs.gov/daltcp/reports/compares.pdf
The Effects of Case Management and Community Services on the Impaired Elderly
Executive Summary   http://aspe.hhs.gov/daltcp/reports/casmanes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/casmanes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/casmanes.pdf
The Effects of Sample Attrition on Estimates of Channeling's Impacts for an Early Sample
HTML   http://aspe.hhs.gov/daltcp/reports/1984/earlyes.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1984/earlyes.pdf
The Evaluation of the National Long-Term Care Demonstration: Final Report
Executive Summary   http://aspe.hhs.gov/daltcp/reports/chanes.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/chanfr.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/chanfr.pdf
The Evaluation of the National Long-Term Care Demonstration
Executive Summary   http://aspe.hhs.gov/daltcp/reports/hsres.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1988/hsre.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1988/hsre.pdf
The Planning and Implementation of Channeling: Early Experiences of the National Long-Term Care Demonstration
Executive Summary   http://aspe.hhs.gov/daltcp/reports/implees.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1983/imple.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1983/imple.pdf
The Planning and Operational Experience of the Channeling Projects
Executive Summary   http://aspe.hhs.gov/daltcp/reports/proceses.htm
HTML   http://aspe.hhs.gov/daltcp/reports/1986/proceses.htm
PDF   http://aspe.hhs.gov/daltcp/reports/1986/proceses.pdf

DATA COLLECTION INSTRUMENTS AVAILABLE

Applicant Screen
HTML   http://aspe.hhs.gov/daltcp/instruments/AppSc.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/AppSc.pdf
Client Contact Log
HTML   http://aspe.hhs.gov/daltcp/instruments/ClConLog.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/ClConLog.pdf
Client Tracking/Status Change Form
HTML   http://aspe.hhs.gov/daltcp/instruments/ClTracFm.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/ClTracFm.pdf
Clinical Assessment and Research Baseline Instrument: Community Version
HTML   http://aspe.hhs.gov/daltcp/instruments/carbicv.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/carbicv.pdf
Clinical Baseline Assessment Instrument: Community Version
HTML   http://aspe.hhs.gov/daltcp/instruments/cbaicv.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/cbaicv.pdf
Clinical Baseline Assessment Instrument: Institutional Version
HTML   http://aspe.hhs.gov/daltcp/instruments/cbaiiv.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/cbaiiv.pdf
Eighteen Month Followup Instrument
HTML   http://aspe.hhs.gov/daltcp/instruments/18mfi.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/18mfi.pdf
Followup Instrument
HTML   http://aspe.hhs.gov/daltcp/instruments/FolInst.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/FolInst.pdf
Informal Caregiver Followup Instrument
HTML   http://aspe.hhs.gov/daltcp/instruments/ICFolIns.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/ICFolIns.pdf
Informal Caregiver Survey Baseline
HTML   http://aspe.hhs.gov/daltcp/instruments/ICSurvey.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/ICSurvey.pdf
Screening Identification Sheet
HTML   http://aspe.hhs.gov/daltcp/instruments/ScrIDSh.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/ScrIDSh.pdf
Time Sheet
HTML   http://aspe.hhs.gov/daltcp/instruments/TimeSh.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/TimeSh.pdf
Twelve Month Followup Instrument
HTML   http://aspe.hhs.gov/daltcp/instruments/12mfi.htm
PDF   http://aspe.hhs.gov/daltcp/instruments/12mfi.pdf

To obtain a printed copy of this report, send the full report title and your mailing information to:

U.S. Department of Health and Human ServicesOffice of Disability, Aging and Long-Term Care PolicyRoom 424E, H.H. Humphrey Building200 Independence Avenue, S.W.Washington, D.C. 20201FAX:  202-401-7733Email:  webmaster.DALTCP@hhs.gov


RETURN TO:

Office of Disability, Aging and Long-Term Care Policy (DALTCP) Home [http://aspe.hhs.gov/_/office_specific/daltcp.cfm]Assistant Secretary for Planning and Evaluation (ASPE) Home [http://aspe.hhs.gov]U.S. Department of Health and Human Services Home [http://www.hhs.gov]

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