In September 1980 the National Long Term Care (LTC) Demonstration--known as channeling-- was initiated by three units of the United States Department of Health and Human Services--the Office of the Assistant Secretary for Planning and Evaluation (ASPE), the Administration on Aging, and the Health Care Financing Administration. It was to be a rigorous test of comprehensive case management of community care as a way to contain the rapidly increasing costs of LTC for the impaired elderly while providing adequate care to those in need.
A. The Intervention
Channeling was designed to use comprehensive case management to allocate community services appropriately to the frail elderly in need of LTC. The specific goal was to enable elderly persons, whenever appropriate, to stay in their own homes rather than entering nursing homes. Channeling financed direct community services, to a lesser or greater degree according to the channeling model, but always as part of a comprehensive plan for care in the community. It had no direct control over medical or nursing home expenditures.
Channeling was implemented to work through local channeling projects. The core of the intervention (i.e., case management) consisted of seven features:
Outreach to identify and attract potential clients who were at high risk of entering a LTC institution.
- Standardized eligibility screening to determine whether an applicant met the following preestablished criteria:
- Age: had to be 65 years or older.
- Functional disability: had to have two moderate disabilities in performing activities of daily living (ADL), or three severe impairments in ability to perform instrumental activities of daily living (IADL), or two severe IADL impairments and one severe ADL disability. Cognitive or behavioral difficulties affecting ability to perform ADL could count as one of the severe IADL impairments.
- Unmet needs: had to have an unmet need (expected to last for at least six months) for two or more services or an informal support system in danger of collapse.
- Residence: had to be living in the community or (if institutionalized) certified as likely to be discharged within three months.
Medicare coverage: for the financial control model, had to be eligible for Medicare Part A.
Comprehensive inperson assessment to identify individual client problems, resources, and service needs in preparation for developing a care plan.
Initial care planning to specify the types and amounts of care required to meet the identified needs of clients.
Service arrangement to implement the care plan through the provision of both formal and informal in-home and community services.
Ongoing monitoring to ensure that services were appropriately delivered and continued to meet client needs.
Periodic reassessment to adjust care plans to changing client needs.
Two models of channeling were tested. The basic case management model relied primarily on the core features. The channeling project assumed responsibility for helping clients gain access to needed services and for coordinating the services of multiple providers. This model provided a small amount of additional funding to purchase direct services to fill in gaps in existing programs. But it relied primarily on what was already available in each community, thus testing the premise that the major difficulties in the current system were problems of information and coordination which could be solved largely by client-centered case management.
The financial control model differed from the basic model in several ways:
It expanded service coverage to include a broad range of community services.
It established a funds pool to ensure that services could be allocated on the basis of need and appropriateness rather than on the eligibility requirements of specific categorical programs.
It empowered case managers to authorize the amount, duration, and scope of services paid out of the funds pool, making them accountable for the full package of community services.
It imposed two limits on expenditures from the funds pool. First, for the entire caseload, average estimated expenditures under care plans could not exceed 60 percent of the average nursing home rate in the area. Second, for an individual client, estimated care plan expenditures could not exceed 85 percent of that rate without special approval.
It required clients to share in the cost of services if their income exceeded 200 percent of the state's Supplemental Security Income (SSI) eligibility level plus the food stamp bonus amount.
Ten sites participated in the demonstration. Their model designations were:
|Basic Case Management Model||Financial Control Model|
|Baltimore, Maryland||Cleveland, Ohio|
|Eastern Kentucky||Greater Lynn, Massachusetts|
|Houston, Texas||Miami, Florida|
|Middlesex County, New Jersey||Philadelphia, Pennsylvania|
|Southern Maine||Rensselaer County, New York|
The ten local projects opened their doors to clients between February and June of 1982, and were fully operational through June of 1984.
The goal of the evaluation, in addition to documenting the implementation of channeling, was to identify its effect on:
The use of formal health and LTC services, particularly hospital, nursing home, and community services.
Public and private expenditures for health services and LTC.
Individual outcomes, including mortality, physical functioning, unmet service needs, and social/psychological well-being.
Caregiving by family and friends, including the amount of care provided, the amount of financial support provided, and caregiver stress, satisfaction, and well-being.
To compare channeling's outcomes with what would have happened in the absence of channeling, the evaluation relied on an experimental design. Applicants found eligible for channeling were randomly assigned either to a treatment group or to a control group. In all, 6,341 persons were randomly assigned.
Several data sources were used. These included telephone and in-person surveys of the elderly members of the research sample and, for a subset, their primary informal caregivers; Medicare, Medicaid, channeling project, and provider records; and official death records obtained from state agencies. Finally, federal, state, local, and project staff were interviewed about the implementation and operation of the demonstration (these data are not included in the public use files).
B. The Nature of the Data
Some researchers will want to use the data to replicate the channeling results or explore certain issues in greater depth. They will simply have to master the complexity of the data base. Others will be interested in using the data to support efforts far removed from the original purposes of the evaluation. This section is written primarily for this latter group.
The channeling sample was designed to support the evaluation, it was not designed to be a statistically representative sample of the elderly. The sample consists of frail persons who voluntarily applied to channeling and were found to meet the demonstration's eligibility criteria. Channeling sought referral sources and engaged in outreach activities to identify applicants at risk of institutionalization. Hospitals, home health agencies and social service providers were the major referral sources. A breakdown of the referral sources is presented in Table 1.
|TABLE 1. Referral Sources of Persons Screened as Eligible for Channeling (percent)|
|Referral Source||Basic Case Management Model||Financial Control Model||All Sites|
|Social Service Agencies|
|SAMPE SIZES: Basic model 3,336; financial model 3,386.|
To determine whether channeling participants were similar to the national population of the disabled elderly, we compared the baseline characteristics of the channeling sample with a nationally representative sample of the elderly. Using data from the National Long Term Care Survey (NLTCS), we simulated channeling's eligibility process to identify a subsample who were eligible for channeling. The simulation was done by selecting individuals who would have qualified according to the channeling ADL or IADL criterion. We thus ended up with a subsample from the NLTCS who, at least according to the measures of functioning, resembled the channeling sample. On the basis of that simulation, we estimated that 4.9 percent of the total noninstitutionalized population age 65 or over in 1982 qualified for channeling.
The main differences between the channeling sample and the simulated nationally eligible sample were in living arrangements, income, and formal service use (see Table 2). Channeling clients were more likely to live alone and less likely to be married. Their use of regular informal in-home care was about the same as for the simulated national sample. The income of the channeling sample was lower than the income of the national sample. Substantial differences were found in every measure of formal service use. Before the receipt of channeling services, compared to the simulated national sample, channeling sample members were almost twice as likely to be receiving formal in-home services, more than twice as likely to have had a hospital stay in the last two months, more than six times as likely to have been in a nursing home, and almost five times as likely to have been on a nursing home waiting list. These differences provide strong support for the argument that persons often came to the attention of channeling because of some precipitating event and were probably more closely connected with the community care system as a result. The occurrence of such an event may have been a major factor that differentiated those who applied for channeling from those who did not.
|TABLE 2. Characteristics of Channeling Sample Compared with Nationally Simulated Sample That Was Functionally Eligible for Channeling|
|-||Channeling||Simulated National Eligible Sample|
|Mental functioning (number incorrect 1-10)||3.5||2.3|
|Pecent living alone||37.2||16.6|
|Regular informal in-home care (percent)||92.0||96.0|
|Monthly income (dollars)||570||644|
|Formal Service Use|
|Any formal in-home care (percent)||60.6||33.9|
|Any hospital stays (last two months)||48.7||20.1|
|Any nursing home admissions (last two months)||5.9||0.9|
|Percent on nursing home wait list||6.8||1.4|
We also compared the demographic and economic characteristics of the entire aged population in the channeling sites with the characteristics of the entire aged population of the country. As a group, the demonstration sites were broadly similar to the nation as a whole. The only characteristics on which they differed markedly was the proportion who were of Hispanic origin (4.6 percent of the channeling sample were Hispanic, compared with 2.7 percent of the national elderly population). This resulted mainly from the fact that a third of the aged individuals in Miami were of Hispanic origin. Despite the general correspondence with national data, as one might expect, there was substantial variation across sites and models.
With respect to the economic resources of the aged population in the channeling sites, monthly median family income was similar to the national data, although there were more people below the poverty threshold in the basic model than in the United States as a whole, and fewer below that level in the financial control model. The proportion of aged in the demonstration states enrolled in Medicare and monthly Medicare expenditures per aged resident were similar to the national data. For Medicaid participation, the basic states had slightly more people receiving Medicaid, and the financial control states somewhat less, than the national average. Monthly Medicaid expenditures per aged resident were somewhat less than the national average in the basic model states and somewhat greater in the financial control states because of high expenditures in New York and Massachusetts.
To this point the focus has been on comparing the characteristics of the research sample and the aged population in the channeling sites to the national elderly population. What about the sites' service environments, were they broadly representative of the service environments throughout the country? This is a tougher issue to address because comparative data are not readily available. On the basis of an examination of nursing home bed supply data and data on waiting times to nursing home admission collected in the demonstration, we concluded that nursing home beds were probably somewhat less available in the channeling sites than in the nation, although we do not believe this had a major effect on demonstration outcomes.
Data on the availability of community care are even more limited. We do know that there was substantial control group use of both comprehensive case management services (10-20 percent) and of community in-home services (60-69 percent). The demonstration projects applied to participate in the demonstration and were selected through a competitive process, and it could be that their case management and community care systems were more developed than those in other sites. Users of the data base should consider whether such differences could affect their research results.
Taken together, these comparisons indicate that, even though the channeling sample is not a statistically representative sample of the frail elderly, the data can be used for applications unrelated to the evaluation as long as the differences that do exist between the channeling sample and one that would be broadly representative are not central to a particular application, and as long as careful attention is paid to the limitations of the data set.
In using the data, the treatment and control groups can be exploited in useful ways. The control group data tell us what occurred in the sites in the absence of channeling. For example, the control group data reveal what services people who were eligible for channeling were using at the time channeling was in operation. The treatment group data indicate what services people used in response to the channeling intervention, although for this purpose, the model differences are obviously critical. These data could be used as the basis for estimating, for example, the cost of a new benefit, although such an exercise requires using a great deal of judgment in evaluating the similarities and differences between channeling and its participating population and whatever program and population are being analyzed. Furthermore, estimates of program participation must be made, a critical task which cannot be addressed using the channeling data. If possible, when using the channeling data for purposes unrelated to evaluating channeling, other data sources should be used and care taken to evaluate the effects of changing key assumptions.
The channeling data base is very comprehensive and detailed. In exchange for that richness, one gives up representativeness. Nevertheless, it can be a very useful source of data in support of applications far removed from the evaluation of channeling.