Tables Comparing Channeling to Other Community Care Demonstrations

05/01/1986

U.S. Department of Health and Human Services

Tables Comparing Channeling to Other Community Care Demonstrations

Robert A. Applebaum, Margaret N. Harrigan and Peter Kemper

Mathematica Policy Research

May 1986

PDF Version


This report was prepared under contract #HHS-100-80-0157 between the U.S. Department of Health and Human Services (HHS), Office of Social Services Policy (now known as the Office of Disability, Aging and Long-Term Care Policy) and Mathematica Policy Research, Inc. Additional funding was provided by the Health Care Financing Administration and the Administration on Aging. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.

The channeling demonstration was an intradepartmental long term care initiative funded by the Health Care Financing Administration (HCFA), Administration on Aging (AoA), and the Assistant Secretary for Planning and Evaluation (ASPE).


Over the past decade and a half, a series of demonstrations in addition to channeling have been fielded to test some form of case managed, community-based long term care. After a comprehensive review of these studies, we identified 14 community care demonstrations funded through federal government waivers which had interventions and research designs most relevant to the channeling demonstration. The purpose of this supplementary report is to facilitate comparisons of the interventions, evaluation designs, and estimated effects of these 14 demonstrations with one another and with the two models of channeling.

The demonstrations and the sources from which we draw the information appearing in the remaining tables of the report are presented in Table 1. Differences in methodology, level of detail with respect to the presentation, as well as differences in the treatment and evaluation designs themselves, make it impossible to produce completely comparable table entries.1 In addition, some of the reports from which the tables are compiled were in draft form and may be superceded in the future. Even if these problems did not exist, it still would be a matter of some judgment which specific variables and estimates best reflect in summary form outcomes which were typically measured differently across demonstrations.

For all these reasons, the point estimates appearing in these tables and the absolute differences among them should be interpreted with caution. However, we have used our best judgment about which estimates to display; and we believe that the basic direction of effects and relative differences indicated by the estimates shown are reliable indications of the differences among the demosntrations.

NOTES

  1. Berkeley Planning Associates (1985) made this task somewhat easier with their cross-demosntration study, but only a subset of the demonstrations was included in that work.

LIST OF TABLES

TABLE 1. Prior Community Care Demonstrations and Sources Used for Report

TABLE 2. Evaluation Methodologies

TABLE 3. Cost Controls and Eligibility Criteria

TABLE 4. Sample Characteristics

TABLE 5. Percent Receiving Direct Services from the Demonstrations

TABLE 6. Direct Services Covered

TABLE 7. Caseload Per Case Manager

TABLE 8. Informal Caregiving

TABLE 9. Nursing Home and Hospital Use During the 12 Months Following Enrollment

TABLE 10. Physician and Other Medical Service Expenditures

TABLE 11. Mortality Rates 12 Months After Enrollment

TABLE 12. Unmet Needs

TABLE 13. Social/Psychological Well-Being

TABLE 14. Functioning

TABLE 15. Case Management Costs

TABLE 16. Direct Service Costs

TABLE 1. Prior Community Care Demonstrations and Sources Used for Report
Demonstration(evaluation period) Source
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) Commonwealth of Massachusetts. "Final Report, Home Care : An Alternative to Institutionalization." Boston, MA: The Commonwealth of Massachusetts, Department of Elder Affairs, 1975. See also Sherwood, Sylvia, John N. Morris, and Claire E. Gutkin. "Final Report Concerning the Impact of Services on Health and Well-Being." Boston, MA: Department of Social Gerontological Research, Hebrew Rehabilitation Center for the Aged, 1975.
NCHSR Day Care/Homemaker Experiment (1975-1977) Weissert, William G., Thomas T.H. Wan, and Barbara B. Livieratos. "Effects and Costs of Day Care and Homemaker Services for the Chronically Ill: A Randomized Experiment." Washington, DC: U.S. Department of Health, Education and Welfare, Office of Health Research, Statistics, and Technology, National Center for Health Services Research (Publication No. PHS 79-3258), February 1980.
Georgia AHS (1977-1980) Georgia Department of Medical Assistance. "Alternative Health Services Project Final Report." Atlanta, GA: Georgia Department of Medical Assistance, January 1982.
Wisconsin CCO (1978-1980) Seidl, F., et al. "Delivering In-Home Services to the Aged and Disabled--the Wisconsin Experience." Madison, WI: Fay McBeath Institute, University of Wisconsin, 1980.
Project OPEN (1980-1983)   Mt. Zion Hospital and Medical Center. "Project OPEN: Final Report." San Francisco, CA: Mt. Zion Hospital and Medical Center, December 1983.
Berkeley Planning Associates. "Evaluation of Coordinated Community Oriented Long Term Care Demonstrations." Berkeley, CA: Berkeley Planning Associates, May 1985.
South Carolina LTC (1980-1984) Blackman, Donald, et al. "South Carolina Commuity Long Term Care Project: Reports of Findings." Spartanburg, SC: South Carolina State Health and Human Services Finance Commission, July, 1985 (Draft).
Florida Pentastar (1981-1983) Florida Department of Health and Rehabilitative Services. "Final Report and Evaluation of the Florida Pentastar Project" Tallahassee, FL: Florida Department of Health and Rehabilitative Services (Report E-84-7), 1984.
San Diego LTC (1981-1983) Allied Home Health Association. "Long Term Care Demonstration Project of North San Diego: Final Report." Washington, DC: U.S. Department of Health and Human Services, Health Care Financing Administration, April 15, 1984.
Berkeley Planning Associates. "Evaluation of Coordinated Community Oriented Long Term Care Demonstrations." Berkeley, CA: Berkeley Planning Associates, May 1985.
NONRANDOMIZED DESIGN
ACCESS (1977-1980) Price, Lewis C. and Hinda M. Ripp. "Third Year Evaluation of the Monroe County Long Term Care Program, Inc." Silver Springs, MD: Macro Systems, Inc., November 1980 (Draft).
Triage (1976-1979) Triage, Inc. "Triage Coordinated Delivery of Services to the Elderly: Final Report." Plainville, CT: Triage, Inc., December 1979.
On Lok (1979-1983) On Lok. "On Lok's CCODA: A Cost Competitive Model of Community-Based Long Term Care." San Francisco, CA: On Lok, February 1983.
Berkeley Planning Associates. "Evaluation of Coordinated Community Oriented Long Term Care Demonstrations." Berkeley, CA: Berkeleye Planning Associates, May 1985.
MSSP (1980-1983) Miller, Leonard, Marleen L. Clark, and William F. Clark. "The Comparative Evaluation of California's Multipurpose Senior Services Project." Berkeley, CA: Berkeley Planning Associates, 1984.
Nursing Home Without Walls (1980-1983) Birnbaum, Howard et al. "Nursing Home Without Walls: Evaluation of the New York State Long Term Home Health Program." Cambridge, MA: Abt Associates, January 23, 1984 (Draft).
New York City Home Care (1980-1983) City of New York. "Delivery of Medical and Social Services to the Homebound Elderly: A Demonstration of Intersystem Coordination." New York, NY: New York City Department for the Aging, 1984.
Berkeley Planning Associates. "Evaluation of Coordinated Community Oriented Long Term Care Demonstrations." Berekeley, CA: Berkeley Planning Associates, May 1985.
TABLE 2. Evaluation Methodologies
Demonstration(evaluation period) States Sites ComparisonMethodology SampleSize Months ofFollowup Data Sources
Worcester Home Care (1973-1975) 1 1 Random assignment 485 12 Individual interviewsProject records
NCHSR Day Care/Homemaker Experiment (1975-1977) 4 6 Random assignment 1,566 3, 6, 9, 12 Individual interviewsMedicare recordsProject records
Triage (1976-1979) 1 1 Comparison group outside area (age differences) 502 6, 12, 18, 24 Individual interviewsDiariesProject recordsMedicare recordsMedicaid records
Georgia AHS (1977-1980) 1 1 Random assignment 1,332 6, 12, 18, 24 Individual interviewsProject recordsMedicaid records (with Medicare crossover)
ACCESS (1977-1980) 1 1 County-level comparison -- 24 Department of Social Service records
Wisconsin CCO (1978-1980) 1 1a Random assignment 417 6, 12 Individual interviewsMedicaid recordsDeath records
On Lok (1979-1983) 1 1 Comparison group outside area, matched on characteristics (race, sex, and institutionalization differences) 140 6, 12, 18, 24 Individual interviewsProject recordsProvider records
MSSP (1980-1983) 1 8 Comparison group within and outside area, matched on whether in hospital, nursing home, or community (impairment differences) 4,200 6, 12 Individual interviewsMedicaid recordsMedicare records
South Carolina LTC (1980-1984) 1 1 Random assignment 1,867 3, 6, 12, 18, 24, 36 Individual interviewsProject recordsMedicaid recordsMedicare records
Project OPEN (1980-1983) 1 1 Random assignment 335 6, 12, 18, 24, 30, 36 Individual interviewsProject recordsMedicare records
Nursing Home Without Walls (1980-1983) 1 9 Comparison group within and outside area (age, race differences) 1,373 6, 12 Individual interviewsMedicaid recordsMedicare recordsFood stamp recordsSSI records
New York City Home Care (1980-1983) 1 1 Comparison group outside area (impairment differences) 704 6, 12 Individual interviewsDiariesMedicaid recordsMedicare records
Florida Pentastar (1981-1983) 1 5 Random assignment (plus comparison group outside area) 1,046 12, 18 Individual interviewsMedicaid recordsMedicare recordsFood stamp records
San Diego LTC (1981-1983) 1 1 Random assignment 819 3, 6, 12, 18 Individual interviewsMedicare records
Channeling (1982-1985) 10b 10b Random assignment 6,326 6, 12, 18 Individual interviewsProject recordsMedicaid recordsMedicare recordsProvider recordsDeath recordsCaregiver interviews
  1. Wisconsin CCO was administered in 3 sites. Only one site (Milwaukee) is included in our comparisons.
  2. Channeling included 2 other sites not part of this evaluation, in Hawaii and Missouri.
TABLE 3. Cost Controls and Eligibility Criteria
Demonstration(evaluation period) CommunityServiceAuthorizationPower CostMaximums CostSharing Eligibility Criteria
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) Expanded services No No 57 years or overMedicaid-eligibleAt risk of nursing home placementLiving in community but have high need for services
NCHSR Day Care/Homemaker Experiment (1975-1977) Expanded day care coverage/ homemaker coverage or combined No No At risk of nursing home placementMedicare-eligibleNeed services to maintain functioningFor homemaker and combined sites 3-day hospital stay in previous 14 days
Georgia AHS (1977-1980) Expanded services Maximum of 85 percent of the average of the Medicaid rates No Medicaid-eligible50 years or overEligible for nursing home placement as certified by professional review organization
Wisconsin CCO (1978-1980) Expanded services Maximum of $425 a month per care plan (equivalent to roughly 60 percent of the Medicaid cost of skilled nursing care for the period) No Over 18 yearsAt risk measured by functional criteriaMedicaid-eligible
Project OPEN (1980-1983) Expanded services No No 65 years or overAt risk as measured by functional criteriaMedicare-eligible
South Carolina LTC (1980-1984) Expanded services Maximum of 75 percent of the average of the Medicaid ICF and SNF rates Yes Medicaid-eligible18 years or overAt risk measured by nursing home preadmission screen
Florida Pentastar (1981-1983) Expanded services No No Medicaid-eligibleOver 60 yearsAt risk as measured by functional criteria
San Diego LTC (1981-1983) Expanded services No No Medicare-eligible65 years or overAt risk as measured by functional criteria
Channeling (1982-1984)
--  Basic Case Management Model Expanded services Limited aggregate project funds for gap-filling services; specific cost control mechanisms at descretion of the local project Cost sharing used at discretion of local project 65 or overService needAt risk as measured by functional criteria
--  Financial Control Model Medicaid/Medicare, expanded services Cap of 60 percent of the average of Medicaid ICF and SNF rates for the average care plan; maximum of 85 percent for individual care plan Yes 65 or overService needAt risk as measured by functional criteriaEligible for Medicare Part A
NONRANDOMIZED DESIGN
Triage (1976-1979)a Expanded services (plus dental, glasses, hearing aids) No No Over 60, Medicaid-eligibleNeed multiple servicesReside in unstable situation
ACCESS (1977-1980)a Medicaid and expanded services Maximum of 75 percent of the average of the Medicaid ICF and SNF rates Yes 18 years or overService need; at risk measured by nursing home preadmission screenMedicaid-eligible (Phase I)
On Lok (1979-1983) Expanded servicesb No No 55 years or overEligible for nursing home placement as measured by need for 24-hour nursingNursing-home certifiable
MSSP (1980-1983) Expanded services Maximum of 70 percent of the Medicaid SNF rate No Medicaid-eligible65 years or overAt risk of nursing home placement as measured by:Nursing home placement or applicationRecent hospitalizationOver 75Mental disorientation or loss of major caregiver
Nursing Home Without Walls (1980-1983) Expanded services Maximum of 75 percent of the average of the Medicaid ICF and SNF rates No No age requirementEligible for nursing home placement based on New York state nursing home preadmission assessment instrument (not actual applicant)
New York City Home Care (1980-1983) Expanded services No No Medicare, Part B65 years or overAt risk measured by functional criteria
  1. These demonstrations also included second generation projects which altered the original interventions. For example, ACCESS received a Medicare waiver to serve a broader target group in its second generation. The Access waiver also allowed the project to reimburse nursing homes at a higher rate in cases of high care clients awaiting hospital discharge without other options.
  2. On Lok also included authorization for institutional long term care services.
TABLE 4. Sample Characteristics
Demonstration(evaluation period) Percent75+a PercentWhite PercentFemale PercentMarried PercentLivingAlone PercentDisabled onAt LeastOne ADL PercentImpaired onAt LeastOne IADL PercentIncontinent Mental Status(Average NumberWrong 0-10)
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) -- -- 71 29 43 41 -- -- --
NCHSR 222 (1975-1977)b 55 91 75 -- 53 77 -- -- --
Georgia AHS (1977-1980) -- 53 74 25 33 60 -- -- 3.1
Wisconsin CCO (1978-1980)c 37 71 80 12 48 62 97 -- --
Project OPEN (1980-1983)c -- 69 70 31 55 50 81 24 0.6
South Carolina LTC (1980-1984) -- 77 69 28 28 95d 97d 58d 3.6
Florida Pentastar (1981-1983)c -- 56 83 18 53 58 97 22 1.4
San Diego LTC (1981-1983)c 67 98 69 44 52 55 97 43 2.3
Channeling (1982-1984) 73 73 71 32 37 84 100 53 3.5
NONRANDOMIZED DESIGN
Triage (1976-1979)c 73 -- 72 44 39 54 94 -- 1.7
ACCESS (1977-1980)c 80 70 92 23 -- 82 99 44 2.4
On Lok (1979-1983)c -- 22 49 30 46 85 93 60 3.2
MSSP (1980-1983)c -- 68 71 23 51 61 80 47 1.7
Nursing Home Without Walls (1980-1983) -- 82 79 16 46 76 -- -- --
New York City Home Care (1980-1983)c 68 69 78 45 35 78 100 38 2.6
  1. Not given for programs admitting clients under 65 unless data for 65 and over sample were available.
  2. Percentages refer to homemaker services sample.
  3. Data for this project come from the final report of Berkeley Planning Associates, 1985.
  4. For South Carolina, percent disabled on at least one ADL, percent impaired on at least one IADL, and percent incontinent are from the final report of Berkeley Planning Associates, 1985.
TABLE 5. Percent Receiving Direct Services from the Demonstrations
Demonstration(evaluation period) Direct Services Received(percent)
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) 59
NCHSR Day Care/Homemaker Experiment (1975-1977)   Day care   Homemaker   Combined  758092
Georgia AHS (1977-1980) 80
Wisconsin CCO (1978-1980) 75
Project OPEN (1980-1983) 94
South Carolina LTC (1980-1984) 52
Florida Pentastar (1981-1983) --
San Diego LTC (1981-1983) 100
Channeling (1982-1984)   Basic model   Financial model  7882
NONRANDOMIZED DESIGN
Triage (1976-1979) --
ACCESS (1977-1980) --
On Lok (1979-1983) --
MSSP (1980-1983) --
Nursing Home Without Walls (1980-1983) --
New York City Home Care (1980-1983) 98
NOTE: Receipt of direct services is defined as receipt of a formal service which is arranged and paid for by the project. For channeling, it was defined as completing the initial care plan. Some comparisons across projects are potentially misleading because some projects were designed to rely on existing programs before spending project funds, while others (including the channeling financial control model) were to use project funds for all services.
TABLE 6. Direct Services Covered
Demonstration(evaluation period) Services Paid for by Project Direct Service Expenditures Per Client Per Month (dollars)c Major Categories of Service Expenditures (percent receiving service)
Physicians Hospitals and Nursing Homes MedicalDay Care and Other Medical Services Nursing, Therapy, and Mental Health Counseling Home Health Aide, Personal Care, Homemaker, and Other In-Home Carea Means and Transportation Otherb
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) No No Visiting nurse Homemaker, chore, escort Transportation Linen 54 Transportation (35)Homemaker (33)Chore (27)Visiting Nurse (22)Linen (7)Escort (1)
NCHSR Day Care/Homemaker Experiment (1975-1977)
--  Day Care No Medical day care Part of medical day care No Transportation to day care, meals at day care -- 281 --
--  Homemaker No No No Homemaker, personal care, help with shopping, escort Transportation as part of escort service -- 232 --
--  Combined No Medical day care Part of medical day care Homemaker, personal care, help with shopping escort Transportation to day care or as part of escort service   243 --
Georgia AHS (1977-1980) No Medical day care Skilled nursing, therapies Personal care, homemaker, home health aidesd Home-delivered meals   152 Home-delivered meals (50)Adult day care (11)In-home personal service (11)
Wisconsin CCO (1978-1980) No Medical day care Skilled nursing, therapies Personal care, home health aides, companions Transportation, home-delivered meals Respite 131 Transportation (57)Home-delivered meals (56)Homemaker (52)Personal care (46)Social or medical day care (32)Home health aide (13)
Project OPEN (1980-1983) No Medical day care Mental health counseling,e nursing,e therapiese Homemaker/ chore,e home health aidese Home-delivered meals, transportation Respite, Interpreter 342 Homemaker (63)Escort transportation (57)Eyeglasses/ prosthetic devices (55)Physician services (50)Drugs (46)
South Carolina LTC (1980-1984) No Medical day care Medical social services, therapies Personal care Home-delivered meals Respite 77 Personal care (34)Medical day care (5)Therapies (3)Home-delivered meals (2)Medical social services (7)Respite (4)
Florida Pentastar (1981-1983) No Medical day care Skilled nursing care, therapies Personal care, home health aides Medical transportation Pest control, respite 202 Homemaker (78)Medical transportation (72)Personal care (51)Medical therapies (29)
San Diego LTC (1981-1983) No Medical day care Skilled nursing Home health aide, homemaker Transportation, home-delivered meals Health education 333 Home education (95)Homemaker/ home health aide (80)Transportation (47)Skilled nursing (35)
Channeling (1982-1984)
--  Basic Model No Medical day care, medical equipment Skilled nursing, therapies, mental health counseling Homemakers/ personal care, home health aides, companions, housekeeping/ chore Home-delivered meals, transportation Respite care, foster care, housing assistance 38 Homemaker/ home health aide (75)hMeals (4.5)Transportation (4.5)Day Care (3.7)Other (12.3)
--  Financial Model No Medical day care, medical equipment Skilled nursing, therapies, mental health counseling Homemakers/ personal care, home health aides, companions, housekeeping/ chore Home-delivered meals, transportation Respite 471 Homemaker/ home health aide (70)hSkilled nursing (11)Home-delivered meals (5)Therapies (4)Other (10)
NONRANDOMIZED DESIGN
Triage (1976-1979) No Dental care, glasses, hearing aids Nursing, therapies Homemaker, home health aide Home-delivered meals   -- --
ACCESS (1977-1980) Increased physician reimbursement for home visitsf No Traditional Medicaid coverage Homemaker, chore, friendly visiting Transportation Respite care, housing improvement, foster care -- --
On Lok (1979-1983) Hospitalization, nursing home use, hospice Medical day care services, physician services Nursing, therapies Homemaker, home health aide, personal care Home-delivered meals, transportation Nutrition group exercise 1,518g --
MSSP (1980-1983) No Day care Nursing In-home supportive services, personal care Transportation, home-delivered meals Protective services, legal services, housing -- Homemaker/ chore (67)Medical transportation (40)Nonmedical transportation (35)Personal care (27)Meals (16)
Nursing Home Without Walls (1980-1983) No No Skilled nursing, therapies, respiratory therapies, medical social services Homemaker, home health aide Transportation, congregate meals, home-delivered meals Moving assistance, housing improvements, respite, nutrition counseling 12 --
New York City Home Care (1980-1983) No Prescription drugs No Homemaker, personal care Transportation   446 Homemaker (99.8)Transportation (67)Drugs (67)
  1. Also includes companion, chore, and other in-home services.
  2. Includes a range of services such as linen service, various types of respite care, housing assistance, legal assistance, nutrition counseling, and foster care.
  3. Some comparisons across projects are potentially misleading because some projects were designed to rely on existing programs before spending project funds, while others (including the channeling financial control model) were to use project funds for all services. Dollar amounts are converted to constant dollars for the first quarter of 1984, using the GNP implicit price deflator.
  4. Georgia AHS offered these services in-home and in alternative living arrangements such as personal care homes.
  5. Project OPEN also paid deductibles and copayments on these services.
  6. In a second phase, ACCESS added funds to pay nursing homes for high care hospital patients.
  7. On Lok expenditures include all long term services in both community and institutions.
  8. Channeling data are percent of total project expenditures for the service rather than percent of clients receiving the service.
TABLE 7. Caseload Per Case Manager
Demonstration(evaluation period) Caseload per Case Manager
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) --
NCHSR Day Care/Homemaker Experiment (1975-1977) --
Georgia AHS (1977-1980) --
Wisconsin CCO (1978-1980) 55-60
Project OPEN (1980-1983) 45-60
South Carolina LTC (1980-1984) 75-80
Florida Pentastar (1981-1983) --
San Diego LTC (1981-1983) --
Channeling (1982-1984)--  Basic model--  Financial model  4549
NONRANDOMIZED DESIGN
Triage (1976-1979) 125
ACCESS (1977-1980) --
On Lok (1979-1983) --
MSSP (1980-1983) 55
Nursing Home Without Walls (1980-1983) --
New York City Home Care (1980-1983) 50
TABLE 8. Informal Caregiving
Demonstration(evaluation period) Measure Results
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) Availability of and resiliency of informal support system (7 items) No difference
NCHSR Day Care/Homemaker Experiment (1975-1977) -- --
Georgia AHS (1977-1980) -- --
Wisconsin CCO (1978-1980) -- --
Project OPEN (1980-1983) Type and amount of informal services received No differences
South Carolina LTC (1980-1984)a Type and amount (days per month) of informal assistance for ADL and IADL tasks No differences
Florida Pentastar (1981-1983) -- --
San Diego LTC (1981-1983)a Type and amount (episodes) of informal assistance for ADL and IADL tasks No difference in ADL help, significant decline in amount of IADL help especially in housekeeping and meal preparation
Channeling (1982-1984)
--  Basic Model Type and amount of informal care received No differences
Effects on caregivers (life quality, stress, personal and employment limitations) Caregivers of treatment group members reported significantly higher life quality and fewer limitations on privacy and social lives at 6 months
--  Financial Control Model Type and amount of informal care received No differences in number of visits received or hours of care from primary caregivers. Reductions (significant at 6 or 12 months or both) in the percent receiving care from visiting caregivers and from friends and neighbors, or relatives other than spouses or children; and in the percent receiving help with housework/laundry/shopping, meal preparation, money management, delivery of prepared meals, transportation, and general supervision.Increases in the percent receiving help with medical treatments (significant at 6 months).
Effects on caregivers (life quality, stress, personal and employment limitations) Caregivers of treatment group members reported higher life quality (significant at 6 and 12 months), greater satisfaction with service arrangements (significant at 6 and 12 months), and greater confidence in receipt of care (significant at 6 months).
NONRANDOMIZED DESIGN
Triage (1976-1979) -- --
ACCESS (1977-1980) -- --
On Lok (1979-1983) -- --
MSSP (1980-1983) -- --
Nursing Home Without Walls (1980-1983) -- --
New York City Home Care (1980-1983) Availability of caregivers No difference
Type and amount (days per week) of informal assistance for ADL and IADL tasks Treatment group members of subgroup with higher level of informal support at baseline had more informal help with ADL tasks -- significant at 6 and 12 months; treatment group members of subgroup with lower level of impairment received less informal help with IADL tasks -- significant at 6 months.
Type and amount of informal assistance for ADL and IADL tasksa Treatment group members had more days of informal help with ADL tasks -- significant at 12 months; treatment group members in subgroup with low impairment had fewer days of informal help with IADL tasks -- significant at 12 months.
  1. Results reported are from the final report of Berkeley Planning Associates, 1985.
TABLE 9. Nursing Home and Hospital Use During the 12 Months Following Enrollment
Demonstration(evaluation period) Nursing Home Use Hospital Use
Percentage Admitted Number of Daysa Percentage Admitted Number of Daysa
Treatment Group Mean Nonprogram Group Mean Treatment Group Mean Nonprogram Group Mean Treatment Group Mean Nonprogram Group Mean Treatment Group Mean Nonprogram Group Mean
RANDOMIZED DESIGN
Worcester Home Care (1973-1975)b -- -- 49 50 -- -- 4 4
NCHSR Day Care/Homemaker Experiment (1975-1977)c
--  Day care--  Homemaker--  Combined ------ ------ 534 745 ------ ------ 111615 121616
Georgia AHS (1977-1980) 15 16 22 29 -- -- 6 4
Wisconsin CCO (1978-1980)d 15 16 25 33 11* 17 3* 12
Project OPEN (1980-1983)e,f 4 5 .1 .3 19 26 9 12
South Carolina LTC (1980-1984) 42* 58 90* 130 44 39 18 20
Florida Pentastar (1981-1983)g 8 8 -- -- -- -- -- --
San Diego LTC (1981-1983)c -- -- .5 .9 46 46 9 10
Channeling (1982-1984)f,h
--  Basic Model--  Financial Model 811 1111 2926 3230 3639 3638 1926 2027
NONRANDOMIZED DESIGN
Triage (1976-1979)e,j 10 4 6 4 37 21 8 6
ACCESS (1977-1980)l -- -- -- -- -- -- -- --
On Lok (1979-1983)j,k 49 56 20* 117 20 57 6 8
MSSP (1980-1983)j,l -- -- 39 22 -- -- 20 9
Nursing Home Without Walls (1980-1983)l
--  Upstate Project--  New York City Project ---- ---- 6*5* 9940 ---- ---- 1918 1616
New York City Home Care (1980-1983)l 7 7 -- -- 39 42 11 15
  1. Estimates of number of days are from the final report of the Berkeley Planning Associates 1985 for Project OPEN, San Diego, on On Lok.
  2. Worcester Home Care estimates are converted to days from mean percent of time institutionalized (or hospitalized) which was reported.
  3. San Diego LTC and NCHSR day care/homemaker results are based on Medicare data.
  4. Wisconsin measured outcomes over a 14-month period using only Medicaid data. The 14-month unadjusted figures for percent admitted are reported. Number of days have been prorated to 12 months.
  5. For Project OPEN and Triage, nursing home days include skilled facility days only.
  6. For Project OPEN and channeling, percent admitted to a hospital or a nursing home are for the 6-12 month period.
  7. Florida Pentastar data on percent admitted are for the 1-18 month period.
  8. Channeling estimates of days are the sum of estimates for the first and second six months after randomization for those alive at the beginning of the period.
  9. Standard comparisons were not made for the Access project; rather the study compared Medicaid costs in Monroe County to six comparison counties. Medicaid costs for nursing homes rose 5.7 percent in Monroe County compared to 26.8 percent for the six comparison counties between 1976 and 1980, suggesting nursing home placement may have been reduced. Hospital expenditures increased 36.3 percent from 1976 to 1980 in Monroe County as compared with 37 percent in the six comparison counties.
  10. No statistical tests were reported.
  11. On Lok data on percent admitted are for the 1-24 month period.
  12. For MSSP and Nursing Home Without Walls, days are average per month for one year period multiplied by 12.

* Different from zero statistically at the 5 percent significance level, using a two-tail test.

TABLE 10. Physician and Other Medical Service Expenditures(dollars per month)
Demonstration(evaluation period) Physician Expenditures Outpatient Expenditures Other Expenditures
Treatment Group Mean Nonprogram Group Mean Treatment Group Mean Nonprogram Group Mean Treatment Group Mean Nonprogram Group Mean
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) -- -- -- -- -- --
NCHSR Day Care/Homemaker Experiment (1975-1977) -- -- -- -- -- --
Georgia AHS (1977-1980) (Medicare and Medicaid) 29 47 10 10 29a 26a
Wisconsin CCO (1978-1980) (Medicaid) -- -- 569b 740b 212c 263c
Project OPEN (1980-1983) -- -- -- -- -- --
South Carolina LTC (1980-1984) 89 61 25 9 231c 179c
Florida Pentastar (1981-1983) -- -- -- -- -- --
San Diego LTC (1981-1983) -- -- -- -- -- --
Channeling (1982-1984)d
--  Basic Model--  Financial Model 102138 97136 ---- ---- 4758 43e56e
NONRANDOMIZED DESIGN
ACCESS (1977-1980) -- -- -- -- -- --
Triage (1976-1979) 45 21 8 2 60 24
On Lok (1979-1983) -- -- -- -- -- --
MSSP (1980-1983) -- -- -- -- -- --
Nursing Home Without Walls (1980-1983)
--  Upstate--  New York City ---- ---- ---- ---- ---- ----
New York City Home Care (1980-1983) -- -- -- -- -- --
NOTE: All dollar amounts are converted to constant dollars for the first quarter of 1984, using the GNP implicit price deflator. Time periods to which the original cost data apply are shown in Table 16.
  1. Drugs and Other.
  2. Physician and outpatient.
  3. Drugs.
  4. Channeling estimates include services covered by Medicaid and Medicare and estimated deductibles and coinsurance associated with them.
  5. These include expenditures as well as other medical services.
TABLE 11. Mortality Rates 12 Months After Enrollment
Demonstration(evaluation period) Percentage Deceased
Treatmen/EnrolleeGroup Mean NonprogramGroup Mean
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) 13 16
NCHSR Day Care/Homemaker Experiment (1975-1977)
--  Day Care--  Homemaker--  Combined 173021 183524
Georgia AHS (1977-1980) 13 21*
Wisconsin CCO (1978-1980) 6 8
Project OPEN (1980-1983) 7 10
South Carolina LTC (1980-1984) 30 32
Florida Pentastar (1981-1983) 11 16a,b
San Diego LTC (1981-1983) 21 23
Channeling (1982-1984)
--  Basic Model--  Financial Model 2727 3027
NONRANDOMIZED DESIGN
Triage (1976-1979) 8 7b
ACCESS (1977-1980) -- --
On Lok (1979-1983) 15 23
MSSP (1980-1983) -- --
Nursing Home Without Walls (1980-1983)
--  Upstate--  New York City 1217 22*24
New York City Home Care (1980-1983) 19 16
*Different from zero statistically at the 5 percent significant level, using a two tail test.
  1. At 18 months.
  2. No statistical tests reported.
TABLE 12. Unmet Needs
Demonstration(evaluation period) Measure Results
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) New needs developed after baseline No differences
Architectural barriers No differences
NCHSR Day Care/Homemaker Experiment (1975-1977) -- --
Georgia AHS (1977-1980) Satisfaction with service arrangements Treatments more satisfied -- significant 12 months
Wisconsin CCO (1978-1980) -- --
Project OPEN (1980-1983) Physical environment checklist (20 item) No differences
South Carolina LTC (1980-1984) Berkeley PlanningaDependency in ADL and IADL and inadequate informal help Treatments with more unmet needs at 12 months -- significant
Florida Pentastar (1981-1983) -- --
San Diego LTC (1981-1983) Berkeley PlanningaDependency in ADL and IADL and inadequate informal help Treatments with more unmet needs in ADL at 12 months and IADL at 6 and 12 months -- significant
Channeling (1982-1984)
--  Basic Model Unmet need index (8 item) Treatments with fewer unmet needs at 12 months -- significant
Physical environment checklist (6 item) Treatments with fewer environmental hazards at 12 months -- significant
Confidence and satisfaction with receipt of care Treatments more confident and satisfied with care arrangements at 6 and 12 months -- significant both time periods
--  Financial Control Model Unmet need index (8 item) Treatments with fewer unmet needs at 6 and 12 months -- significant both time periods
Physical environment checklist (6 item) No differences
Confidence and satisfaction with receipt of care Treatments with more confidence and satisfaction with care arrangements at 6 and 12 months -- significant both time periods
NONRANDOMIZED DESIGN
Triage (1976-1979) -- --
ACCESS (1977-1980) -- --
On Lok (1979-1983) -- --
MSSP (1980-1983) -- --
Nursing Home Without Walls (1980-1983) -- --
New York City Home Care (1980-1983) Unmet ADL needs Treatments with fewer unmet needs at 6 months -- significant
Unmet IADL needs Treatments with fewer unmet needs at 6 and 12 months -- significant
Unmet medical needs Treatments with fewer unmet needs at 6 and 12 months -- significant
Physical environment (16 items) Treatments with few problems with physical environment at 6 and 12 months -- significant
Berkeley PlanningaDependence in ADL and inadequate informal help Treatments with more unmet needs at 6 and 12 months -- significant
Dependence in IADL and inadequate informal help Treatments with more unmet needs at 6 and 12 months -- significant
  1. These measures were constructed by Berkeley Planning Associates in the context of measuring substitution of formal for informal care. For example, one of the categories of unmet needs was the presence of formal care (which was taken to imply that the available informal care was inadequate).
TABLE 13. Social/Psychological Well-Being
Demonstration(evaluation period) Measure Results
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) Emotional/psychological domain (35 items) No differences
Isolation/social contacts (15 items) No differences
Social activities (16 items) No differences
NCHSR Day Care/Homemaker Experiment (1975-1977) Contentment index Day care, combined, and homemaker had higher contentment at 12 months -- significant for homemaker and combined samplesa
Social activities No differences for homemaker sample. Day care and combined had higher percent with maintained/improved social activity -- significant for combined sample.a
Georgia AHS (1977-1980) 12-item morale scale No differences
Wisconsin CCO (1978-1980) 8-item life quality measure No differences
Project OPEN (1980-1983) Social network scale checklist (20 items) Treatment had more social contact -- significant at 6, 12, and 18 months
Morale No differences
Psychological status Treatments had higher scores at 6 months -- significant (but a significant difference at baseline)
South Carolina LTC (1980-1984) -- --
Florida Pentastar (1981-1983) Social activities (5 items) Treatments reported more activities at 18 months -- significant
San Diego LTC (1981-1983) PGC morale scale Treatments had higher morale at 6 months -- significant
Social resources and activities No differences
Self-perceived health Treatments had higher self-perceived health at 6 months -- significant
Channeling (1982-1984)
--  Basic Model Global life satisfaction (2 items) Treatments had higher self-reported life quality at 6 months -- significant
Contentment index (5 items) No differences
Self perceived health No differences
Social interaction and loneliness (2 items) Treatments were less lonely at 12 months -- significant
--  Financial Control Model Global life satisfaction (2 items) Treatments had higher self-reported life quality at 6 and 12 months -- significant both time periods
Contentment index (5 items) No differences
Self perceived health No differences
Social interaction and loneliness (2 items) No differences
NONRANDOMIZED DESIGN
Triage (1976-1979) -- --
ACCESS (1977-1980) -- --
On Lok (1979-1983) Social requirements of living (social network, communication, personal fulfillment, service agency orientation) Treatments had higher scores at 12 and 24 months -- significant
MSSP (1980-1983) -- --
Nursing Home Without Walls (1980-1983) -- --
New York City Home Care (1980-1983) 9-item morale scale Treatments had higher morale at 12 months -- significant
Social contacts Treatments with more social contacts at 6 and 12 months -- significant
  1. The analysis sample included only those members of the treatment group who received program services and only those controls who did not receive services similar to the program.
TABLE 14. Functioning
Demonstration(evaluation period) Measure Results
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) ADL (measure not known) No differences
NCHSR Day Care/Homemaker Experiment (1975-1977) ADL (Katz)a No differences
Georgia AHS (1977-1980) ADL (OARS) No differences
IADL No differences
Wisconsin CCO (1978-1980) ADL (OARS) No differences
Project OPEN (1980-1983) ADL (Katz) No differences
IADL No differences
South Carolina LTC (1980-1984) ADL (measure not known) Treatments significantly less disabled than controls at 6 months only
IADL No differences
Florida Pentastar (1981-1983) ADL (measure not known) No differences
IADL Treatments significantly more impaired at 12 months
San Diego LTC (1981-1983) ADL (Katz)b Treatments significantly more disabled at 12 monthsTreatments significantly less disabled at 18 months
Restricted Days Treatments reporting lower number of restricted days -- significant at 6 months
Channeling (1982-1984)
--  Basic Model ADL (Katz) No differences
IADL No differences
Restricted days Treatments with fewer restricted days at 6 months -- significant
--  Financial Control Model ADL (Katz) Treatments more disabled at 6 and 12 months -- significant both time periods
IADL No differences
Restricted days No differences
NONRANDOMIZED DESIGN
ACCESS (1977-1980) -- --
Triage (1976-1979) ADL (Katz) No differences
IADL No differences
On Lok (1979-1983) ADL (measure not known) No differences
IADL Treatments less impaired at 12 months -- significant
MSSP (1980-1983) ADL (Katz) No differences
IADL Treatments less impaired at 6 months -- significant
Nursing Home Without Walls (1980-1983) ADL (Katz) Treatments less disabled at 6 and 12 months -- significant for New York City sample
New York City Home Care (1980-1983) ADL (Katz)b Treatments significantly more disabled at 12 months
IADL Treatments significantly mroe impaired at 12 months
  1. The Katz measure was originally developed to be completed by clinicians (Katz et al. 1970). However, in most studies a self-reported measure asking whether the individual does perform the task was used. The OARS in contrast asks capacity, whether the respondent can perform the task.
  2. In these two studies both clinical observation and self-report measures were used, and no major differences in results were reported for the two approaches (personal communication, Capitman, October 1985).
TABLE 15. Case Management Costs(dollars)
Demonstration(evaluation period) Case Management Costper Client per Month
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) --
NCHSR Day Care/Homemaker Experiment (1975-1977) --
Georgia AHS (1977-1980) --
Wisconsin CCO (1978-1980) --
Project OPEN (1980-1983) 128
South Carolina LTC (1980-1984) 49
Florida Pentastar (1981-1983) --
San Diego LTC (1981-1983) 145
Channeling (1982-1984)a--  Basic Model--  Financial Model  10699
NONRANDOMIZED DESIGN
Triage (1976-1979) --
ACCESS (1977-1980) --
On Lok (1979-1983) 85
MSSP (1980-1983) --
Nursing Home Without Walls (1980-1983) --
New York City Home Care (1980-1983) 104
  1. Channeling cost estimates differ from estimates persented elsewhere. For comparability with estimates available for other demonstrations, channeling case management costs have been divided by all months clients spent in channeling. They include reported in-kind costs and demonstration-related costs. Other estimates are based on Berkeley Planning Associates (1985) and have been converted to 1984 dollars. See Thornton, Will, and Davies. The Evaluation of the National Long Term Care Demonstration: Analysis of Channeling Project Costs. Table VI.1. [Executive Summary]
TABLE 16. Direct Service Costs(dollars per month)
Demonstration(evaluation period) TimePeriod FundingSources Nursing Home Hospital Communitya Physician andOther Medical Total
Treatment Control Treatment Control Treatment Control Treatment Control Treatment Control
RANDOMIZED DESIGN
Worcester Home Care (1973-1975) 26 months Project 0 0 0 0 54 0 0 0 54 0
NCHSR 222 (1975-1977)
--  Day Care 12 months ProjectMedicareTotal 0---- 0---- 0---- 0---- 281--281 0---- 0---- 0---- 281533813 0534534
--  Homemaker 12 months ProjectMedicareTotal 0---- 0---- 0---- 0---- 232--232 0---- 0---- 0---- 2328641095 0786786
--  Combinedb 12 months ProjectMedicareTotal 0---- 0---- 0---- 0---- 243---- 0---- 0---- 0---- 24310001243 0847847
Georgia AHS (1977-1980) 24 months ProjectMedicaidMedicareTotal 072172 075075 02973101 0117890 13151137 0617 0373067 0503182 131143104377 0143111254
Wisconsin CCO (1978-1980) 14 months ProjectMedicaidTotal 07070 09797 05858 0158158 18884271 0133133 09292 0119119 188307494 0507507
Project OPEN (1980-1983)c 35 months ProjectMedicareTotal 022 01616 0489489 0628628 34243385 05353 000 000 342534876 0697697
South Carolina LTC (1980-1984) 36 months ProjectMedicaidMedicareTotal 01644168 02536259 01095105 067682 7751395 021012 0213152 0132841 77200143420 0274119393
Florida Pentastar (1981-1983)d 12 months ProjectFood stampsHousing assistanceMedicare/ MedicaidOther PublicTotal 000--0-- 000--0-- 000--0-- 000--0-- 2024327--18290 194228--21110 000--0-- 000--0-- 202432720718497 19422819921312
San Diego LTC (1981-1983)c 12 months ProjectMedicareMedicaidTotal 05--5 08--8 0444--444 0473--473 47813--491 063--63 0------ 0------ 478462781018 0543129672
Channeling (1982-1984)
--  Basic Case Management Model 18 months ProjectMedicareMedicaidOther PublicClients and FamiliesTotal 01167045123 01562168145 044017029486 042623028477 1081282763324650 --1133079341563 --11613024153 --10816022145 108695124634221412 0661131804591330
--  Financial Control Model 18 months ProjectMedicareMedicaidOther PublicClients and FamiliesTotal 01760154132 01559166141 059735043675 057536039650 4081011433308864 01813067322600 016217029208 015715029201 408877125344341878 0928140684561592
NONRANDOMIZED DESIGN
ACCESS (1977-1980) -- -- -- -- -- -- -- -- -- -- -- --
Triage (1976-1979) 12 months Diary accounting of costs (Total) 35 2 213 124 93 18 114 47 455 191
On Lok (1979-1983)c 12 months ProjectDiary accounting of costsTotal 0143143 0679679 0469469 011451145 98387485 0263263 0421421 0110110 9814201518 021982198
MSSP (1980-1983) 12 months MedicaidMedicareTotal ------ ------ ------ ------ ------ ------ ------ ------ 2489061154 164362606
Nursing Home Without Walls (1980-1983)
--  Upstate project 12 months MedicareMedicaidTotal ------ ------ ------ ------ ------ ------ ------ ------ 299533825 2248941117
--  New York City project 12 months MedicareMedicaidTotal ------ ------ ------ ------ ------ ------ ------ ------ 51811431633 5285391159
New York City Home Care (1980-1983)b 8 months ProjectMedicareMedicaidTotal --3--3 --10--10 --554--554 --527--527 55147--598 050--50 -------- -------- 551603601215 0598124713
NOTE: Costs per month were calculated by dividing costs reported for the time period by the number of months in the time period. All dollar amounts are converted to constant dollars for the first quarter of 1984, using the GNP implicit price deflator. Detail may not sum to total due to rounding.
  1. Includes case management and formal community services, wherever available. In the case of channeling, this column also includes room and board in the community.
  2. Project costs are understated and Medicare costs overstated by the costs of services received when a client was assigned to both services but received only one.
  3. Data came from the final report of Berkeley Planning Associates, 1985. The data from Project OPEN's final report (Skiar and Weiss, 1983) show treatments to have lower total costs, however.
  4. The Pentastar project reported the costs of the initial assessment for the control group members as project services for controls.
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