U.S. Department of Health and Human Services
Channeling Effects on the Quality of Clients' Lives
Robert A. Applebaum and Margaret Harrigan
Mathematica Policy Research, Inc.
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 the Office of Disability, Aging and Long-Term Care Policy) and Mathematica Policy Research, Inc. 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, initiated by the U.S. Department of Health and Human Services in 1980, tested whether a managed approach to providing community-based long term care could help control costs while maintaining or improving the well-being of its clients and their informal caregivers. These effects were expected through more appropriate decisions on institutionalization and more rational use of services in the community. This report presents channeling's impacts on the quality of clients' lives.
Channeling was designed to work through ten local projects, each using client-centered case management that was uniform across sites. Two models were tested:
The basic case management model, which augmented the case management intervention with a small amount of direct service purchasing power to fill service gaps; and
The financial control model which, through the pooling of categorical program funds in the catchment area, permitted channeling case managers to order the amount, duration, and scope of services they deemed necessary subject to a number of cost controls.
The two components of the channeling intervention--comprehensive case management and direct provision of formal services--were expected to affect life quality through two mechanisms. The first was a direct effect, the result of providing more comprehensive case management and expanded services to people who would have been in the community even without channeling. The second was an indirect effect, resulting from an expected reduction in institutionalization.
Effects were expected in three major dimensions of life quality: unmet need/satisfaction with service arrangements; social/psychological well-being; and functioning. The first dimension was expected to be affected primarily through impacts on the group who would have remained in the community in any case. The second was expected to have its effect more or less equally for both groups. The third was expected to be affected primarily through impacts on those who would have been institutionalized in the absence of channeling. Since channeling had no significant impact on institutionalization, the effects on the third dimension were expected to be weak.
The results generally bear out these expectations. For both models at both 6 and 12 months, the treatment group reported more satisfaction with service arrangements, more confidence about receiving needed services, and fewer unmet needs than did the control group. An event-based subgroup analysis suggested that impacts were largest among those with deteriorating health. Under the basic case management model, channeling treatments had a significantly lower number of observed physical problems in their environments at 12 months (although the differences were small in size).
There were no substantial differences by model in unmet needs, satisfaction with service arrangements, or confidence about receiving needed services--an unexpected finding, given the much greater direct service purchasing power of the financial control model. It might have been due to the fact that the financial control model was tested in more service-rich environments. Perhaps the additional services in such an environment produced less extra effect per unit of service. It is also possible that having a case manager as an advocate in regular contact is as important for satisfaction with service arrangement and the perception of needs as are the actual services.
With respect to impacts on general social/psychological well-being, channeling had a pattern of small positive effects on the global life satisfaction measures, which were somewhat stronger under the financial control model than the basic case management model. Generally there were no significant impacts across a series of other variables used to measure this dimension.
With respect to functioning, there were no impacts under the basic case management model (except on bathing at 6 and 12 months), and no impacts on the IADL and restricted day measure under the financial control model. There was a significant difference for ADL functioning under the financial control model: treatments reported being more disabled than controls. There are two possible explanations for this result, both related to service use but with very different substantive implications. The first is the possibility that increased formal service use induced to some degree the kind of atrophy effect on functioning which has been reported to occur as a result of institutionalization. The second is that the result is an artifact of the way we asked the question about ADL functioning of sample members ("Do you" rather than "Can you"), which led to more "no" answers by those sample members who received more formal services, without any real differences in functional ability. We cannot distinguish between these two possibilities with our data.