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The use of modified Delphi/Nominal Group Technique to set priorities for a system of long term care for the elderly

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The use of modified Delphi/Nominal Group Technique to set priorities for a system of long term care for the elderly

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Content THE USE OF MODIFIED DELPHI/NOMINAL GROUP TECHNIQUE TO SET PRIORITIES FOR A SYSTEM OF LONG TERM CARE FOR THE ELDERLY by Carolyn Vick Koegler A Thesis Presented to the FACULTIES OF THE SCHOOL OF PUBLIC ADMINISTRATION AND OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degrees MASTER OF PUBLIC ADMINISTRATION and MASTER OF SCIENCE IN GERONTOLOGY December 19 85 UMI Number: EP58918 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. D issartaü o rr Pu!&!isWng UMI EP58918 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 UNIVERSITl OF SOUTHERN CALIFORNIA LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY PARK LOS ANGELES^ CALIFORNIA 90007 Gtrot) ’85- K77 This thesis, t^vltten by Carolyn Vick Koegler under the dlreator of % er Thesis Committee, and approved by all Its members, has been pre sented to and aooepted by the Dean of the Leonard Davis Sohool of Geroyi.totogy and the Dean of the Sohool of Pubtio Administration or Urban Planning (underline one). In partial fulfillment of the requirements for the degree of Dean Date THESIS COMMITTEE C nazrman 11 ACKNOWLEDGMENTS The "Staying at Home" Decision Conference was the culmination of several months of planning and effort. During that time many people were generous with their advice and help. To the Andrus Center Volunteers a big thank you for so cheerfully folding, stuffing, and stamping the invitations and materials sent to conference participants, and for their invaluable assistance at the conference. Thanks also to Polly McConney, who coordinated the volunteers and was helpful in many other ways; to Marlene Onodera for hours of telephoning; to Ralph Marino for clerical help; to Mary Jackson and Gary Kennedy who manned the electronic equipment that made the whole thing work. I would like to express my thanks to Dr. Robert Myrtle, who found time to offer valuable advice and serve on my Thesis Committee. To Dr. Kate Wilber, who chaired my Thesis Committee, I offer my special thanks for "seeing me through." But most of all, I am grateful to Dr. Raymond Steinberg for giving me the opportunity to become part of the "Staying at Home" Project— for letting me build Ill a thesis around his idea to use "an electronically assisted Modified Delphi Technique" to set priorities for a LTC system that would assist frail, older people in maintaining independent lifestyles. IV TABLE OF CONTENTS Page ACKNOWLEDGEMENTS .............................. il LIST OF TABLES ................. . vi Chapter I. INTRODUCTION............ 1 Purpose of the Thesis Organization of the Remainder of the Study II. LONG TERM CARE LITERATURE REVIEW . . . 4 Introduction What is Long-Term Care? Why LTC is Important LTC Services in Los Angeles County The "Staying at Home" Project Delphi in LTC Summary III. LITERATURE REVIEW OF DECISION MAKING TECHNIQUES . ................. 15 Introduction Delphi Nominal Group Technique Force-Field Analysis Summary IV. METHODS ................... . 27 Introduction Delphi Nominal Group Technique Force-Field Analysis Definitions of Terms Study Design Instrument The Conference Summary Chapter V. RESULTS Priority Setting Did the Model Work? V Page 48 VI. SUMMARY AND CONCLUSIONS Summary Conclusions 60 BIBLIOGRAPHY ............... ......... APPENDIXES ..... ..................... A. "Staying at Home" Conference Workbook B. Diagram of Decision Model ......... C. Copy of Invitation to Conference D. Delphi Round Ballot . . . ......... E. Facilitator's Guidelines ..... F. Force Field Worksheets ...... G. Force Field Voting Card ........... H. Form for Recording Mean Scores . . . I. Post-Conference Evaluation Form . . 72 78 79 114 116 120 122 127 131 133 135 VI LIST OF TABLES Table Page 1. Distributions of Participants by Organizational Setting, Civic or Professional Role, and Discipline . . . 37 2. The Conference ......... .. 40 3. Preconference Delphi Round 1 ..... 49 4. Conference Vote Round 2 ............... 52 5. Analysis Results............. 55 6. Conference Vote Round 3 ............... 55 7. Comparison of Feasibility Ratings and Final Vote Results ............. 5 7 8. Priorities— Rank Order of Goals in Three Rounds of Voting ............. 5 8 CHAPTER I INTRODUCTION This thesis is based on a priority-setting decision conference. The conference used the Delphi technique in an innovative way to analyze the findings of a two-year study. The study examined programs and policies that contribute to inappropriate institutionalization of the elderly in Los Angeles County. The study, called the "Staying at Home" Project, was funded by the John Randolph and Dora Haynes Foundation and was directed by Raymond M. Steinberg, DSW, Institute for Policy and Program Development, Andrus Gerontology Center, University of Southern California. The "Staying at Home" Project conducted the first systems study of long-term care (LTC) in Los Angeles County; only a few previous studies had been done. All were small-scale evaluations of particular programs or policies. Purpose of the Thesis This thesis develops a model of decision-making using knowledgeable, experienced leaders in LTC. These leaders were asked to set priorities for action on findings from the "Staying at Home" Project. Findings were presented in the form of goal statements, or goals. The purpose of this thesis is twofold. First, it addresses the question: Could the model be used as a way of testing what degree of support existed for the goals identified by the study? In other words, does the model work as a means of setting priorities in long term care? Second, what can be learned by actually applying the model that will facilitate and enhance future use by other communities? To accomplish this the Delphi Method was modified for use with an interacting group of participants who were asked to set priorities on a set of pre-established goals. Small group process, using Nominal Group Technique and force-fieId analysis, was incorporated to rate the feasibility of the goals. Organization Of the Remainder of the Study This thesis is organized as follows: Chapter II defines long-term care; discusses why LTC is important; offers some examples of studies done in Los Angeles County; briefly describes the "Staying at Home" Project; and pre sents the rationale for choosing the Delphi Method. Chapter III describes the Delphi, Nominal Group Technique, and force-field analysis techniques of decision 3 making and cites several research studies where priority- setting is a major objective. Chapter IV describes the steps taken to develop the Modified Delphi Technique and defines terms used in this thesis. Discussed are: limitations of the study; selection of participants; the invitational process ; the instrument developed; and a step-by-step description of the methods used. Chapter V describes and analyzes the results of the three rounds of voting and the final outcome of the conference. Chapter VI summarizes the priorities, describes implementation efforts, and suggests that this decision model is one that other communities can use to set priorities for improvement. Finally, the study ends with the Bibliography and Appendixes. CHAPTER II LONG TERM CARE LITERATURE REVIEW Introduction This chapter defines long-term care; discusses why it is important; offers some examples of studies in Los Angeles County; briefly describes the "Staying at Home" Project; and presents the rationale for adapting the Delphi Method for use in the decision conference. What is Long-Term Care? In the past, the term long-term care (LTC) most often referred to "care provided in an institutional setting over an extended period of time" (Cohen, 1974). Typical institutions are hospitals, nursing home, psychiatric hospitals, and Veteran's Administration facilities. The levels of care can range from extended, skilled, and intermediate care to personal and boarding care ; facilities may be public, private non-profit, or proprietary organizations (Gelfand & Olsen, 1980). Although this is still an accurate description of care in an institution, the term, long-term care, par ticularly when it refers to long-term care of the elderly, has come to have a much broader meaning. The Task Force of the Gerontological Society of America proposes the following definition: Long term care consists of a broad range of health and social support ser vices in community and institutional settings. These services are available at varying levels of intensity to meet the acute and chronic care needs of physically and mentally impaired persons and their caregiver support system. Long-term care refers to physical, social, environmental and mental interventions; it provides assessment and case manage ment, preventive services, rehabilitation, support, supervision, and/or maintenance for those persons whose functional and/or health status is compromised. It refers to a variety of settings, i.e., the home, residential care facilities, community- based programs, such as day care or out patient services, and institutional setting; and it is an easily accessible system which may be used episodically or continuously as needed, with ease in movement between levels of care. (1985, n.p.) Criteria for an effective system of long-term care are that it provide both comprehensive and co ordinated services. For the frail elderly to live as independent a lifestyle as is practical, there must be "movement between levels of care." And for this there must be cooperation and support at all levels of the LTC delivery system; providers must be aware of what each has to offer the frail elderly persons they serve 6 Why LTC is Important The need and the demand for LTC services is expected to grow as the population of the old-old in creases, making the provision of LTC services an important local, state, and national issue. In the United States the ratio of older people to the general population has been increasing at a rapid rate since 1900 when individuals over 65 comprised only 2.9 percent of the population. By 1977, 10,8 percent of the population was over 65, and by 2035 those over 65 are expected to be 18 percent of the population (Gelfand & Olsen, 1980). Recent surveys suggest that 13 percent of the 65- 74 year old group have at least some limitations in functional capacity with the incidence of impairment increasing to 33 percent in the 75-84 age groups and to 66 percent in those over 85, The proportion of the population 65 and over that is also 75 or older is increasing, but the population group 85 and over is growing even more rapidly (Callahan, 1981), In the City of Los Angeles, the 1980 census showed an increase of 12.9 percent in those age 65 and over from 1970-1980. Most of the increase was attributed to the old-old, those over 75. The increasing numbers of elderly, especially the old-old who proportionately need more LTC services, make the provision of LTC an important policy issue. Any policy 7 that is developed to provide comprehensive LTC must facilitate independent living in the community. At the same time, it is recognized that the cost of services cannot be separated from the provision of them, and that any policy that is developed to provide LTC must include affordable services and institutionalization when appropriate. Long-term care is an important policy issue, but it is also important at the level of the individual. Long-term care is what allows many frail older people "to live as independent a lifestyle as is practical" (Koff, 1982) and to avoid premature or inappropriate institu tionalization. The benefits to the individual are prolonged life and a higher quality.of life (Koff, 1982; Quinn, Raisz, & Johnson, 19 82; Steinberg, 1983). The vignette presented here is an example of the lack of adequate LTC services and how the individual is affected. Gaps in service/licensing rules: Ms. J. is ready to be released from the hospital after a fall and broken hip. She has no family in Los Angeles and is not quite ready for total self-care* On the other hand she does not need the medically- supervised care of a skilled nursing facility. The hospital discharge planner finds that less-costly board and care homes are not permitted to accept resi dents who use a walker (licensing regula tions) and that intermediate care facilities are virtually non-existent in Los Angeles even though Medicare would pay for intermediate care. Consequently, Ms, J. remains in the hospital five addi tional days until a placement can be found and then enters a skilled nursing facility extremely depressed and hypochondriacal. (Steinberg, 1983, p. 3) LTC Services in Los Angeles County Four studies conducted in Los Angeles County were all concerned with the city and/or county Area Agencies on Aging (Cebula, 1983; Hashemi, 19 84; SCAN, 1982; Wasserman, 19 82). Area Agencies on Aging were established in 1973 after an amendment to the Older Americans Act. These agencies are mandated to coordinate services for older people at the local level. Many of the recommendations made by the studies were for improving the workings of the Area Agencies on Aging (AAA); improving communications between AAAs and the Multipurpose Senior Centers (MPCs); and with overcoming the lack of integration between city and county AAAs due to jurisdictional boundaries. Other recommendations were made for the AAAs to increase and improve their contacts with local agencies and organizations in the area of LTC who can serve the frail elderly. None looked at the system as a whole or specifically at ways to reduce the number of impaired elderly people who may be unnecessarily or prematurely institutionali zed. In 1983 United Way in Los Angeles brought together a wide spectrum of organizations representing service providers, consumers, and insurers. They focused on developing programs in selected portions of the county to demonstrate methods for reducing health costs through strategies of prevention, comprehensive assessment and case management, and the use of social supports as substitutes for institutional care. But none of these local efforts emphasized county- wide system analysis as a baseline for evaluating the impact of their efforts. Nor did they plan to promote public awareness of presently available alternatives to institutionalization (Steinberg, 1983). The "Staying at Home" Project was designed to do what none of the other studies had done : (1) To undertake local, system-wide studies which cut across the public and private sectors and which examine inter- organizational linkages. (2) To estimate the current social and economic costs of mismatching between what is needed and what is provided and to compare these with the costs of improving the service system and the policies which influence it. (3) To recommend feasible changes in policies, programs, and practices. (4) To involve in the project's activities (of research, problem-solving, and priority-setting) a wide spectrum of organizations which have the capacity and responsibility for implementing the recommen dation s. (5) To disseminate the findings and recommendations to a wide public in Los Angeles County. (6) To demonstrate a model of fact finding and decision-making which can be replicated in other communities. (Steinberg, 19 83, p. 1) 10 The "Staying at Home" Project The "Staying at Home" Project consisted of five phases: The "Bottom Up" study; the "Top Down" study; the Board and Care study; the Geographic Equity study; and a Decision Conference. The "Bottom Up" study and the "Top Down" study were completed the first year. 1. The "Bottom Up" study used small group inter views to examine the views of front-line practitioners from a variety of public and private agencies (Steinberg & Trejo, 1984). 2. The "Top Down" study'conducted a mailed - survey of key informants who were asked to respond to questions about LTC and the elderly, based on their own experience and opinions (White, 1984). Though there was a lack of agreement by study participants about what is needed in a LTC system, the issues that emerged from these two studies determined the subjects of two sub-studies done the second year. 3. The Board and Care study used a structured survey form to interview administrators of board and care homes in Los Angeles County (Goodman & Stevenson, 1985). 4. The Geographic Equity study collected data from agency files to identify factors that account for variations in supply of services in the different geographic areas of Los Angeles County (Lowe, 1985).. 11 5. The last phase of the study was an invita tional, community priorities conference. This thesis describes and analyzes the adaptation of the Delphi Method for use at that conference. Findings from the four studies mentioned were synthesized into a series of con clusions and recommendations, called goals or goal state ments in this thesis (for a complete description of the goals, see the "Staying at Home" conference workbook. Appendix A). Delphi in LTC Delphi is a method that lends itself to adaptation; indeed, Linstone and Turoff (1975) described the Delphi and its applications as a process which is still evolving and stressed that it was not a "neatly wrapped package" to be used as is. In addition, the literature described many variations beyond the original one of forecasting. According to Delbecq, Van de Ven, and Gustafson (19 75), Delphi has evolved so that it is now used to set goals and priorities, and to identify problems and problem solutions. And, when it is used to provide participants with informa tion and to poll them for differences of opinion, it can be an important pre-conference planning tool. Although the literature research revealed several studies in which Delphi was used to set priorities (Chapter III), and one that used a list of pre-determined 12 items, it did not reveal any studies that used Delphi in the way it is used in this thesis. The conventional Delphi Method is one that simu lates discussion. Participants are sent open-ended questions by mail; they do not meet face-to-face (DaIkey & Helmer, 1963). For the "Staying at Home” Decision Con ference, however, the Delphi Method .was used in a new and different way (see diagram of decision model. Appendix B): 1. Participants were brought together. 2. Participants were asked to set priorities on a set of pre-established goals. 3. Small group process was used between the second and third rounds of voting to rate the feasibility of some of the goals. There are several reasons for using Delphi in this way in LTC. First, there is a general lack of agreement about what is needed in a LTC system; Crystal (19 82) calls it a "many splintered thing." Second, the issues are too complex for one or a few persons to solve. Third, there is an urgent need to ensure that information about LTC is disseminated to a wide audience and that planned changes are implemented. Conventional Delphi might have accomplished the first two objectives. Priorities could be set by mail and involve a large number of key people. However, 13 dissemination of the findings of this particular study would not have been a certainty. The literature suggests that wide dissemination of research findings is more likely to occur if experts in the field participate in determining the importance of the findings for community use (Delbecq et al. , 1975; Maier, 19 78; Weatherman & Swenson, 1974). For this conference, Delphi was adapted to give participants the opportunity to discuss and clarify the findings sent to them in a preliminary report of the "Staying at Home" Project; to meet with others in LTC; to find out what others were doing; to tell others what they were doing; to assess the thinking of others on some issues; and to express their opinions by voting on important goals for a LTC system. In short, to become working participants in a conference that was designed to involve them. Thus, the Delphi model that was adapted for use in the decision conference proposed to use Delphi to; (1) bring together civic and community leaders in LTC to gain their collective opinions on priorities for a compre hensive system of LTC; and (2) to ensure the dissemination of the findings of the "Staying at Home" Project and of the goals selected at the conference. 14 Summary The sheer complexity of the issues surrounding LTC make the use of Delphi important. Inherent in Delphi is the ability to take difficult, complex problems for which there are no right or wrong answers, present them to key, knowledgeable persons, and to arrive at a decision that most people can live with. That is what the "Staying at Home" Decision Conference, using a Modified Delphi, attempted to do. 15 CHAPTER III LITERATURE REVIEW OF DECISION MAKING TECHNIQUES Introduction This chapter examines the conventional formats of the Delphi, Nominal Group Technique, and force field analysis techniques of decision-making, and cites several research studies where priority-setting is a major objective. Delphi The Delphi Method was named for the ancient Greek oracle because of its original use to forecast techno logical developments, but Delphi is best known as a method of obtaining "the most reliable consensus of opinion of a group of experts" (Dalkey & Helmer, 1963). Description of the Process In its pure form, it differs from other group processes in that participants do not meet face-to-face, and may remain anonymous throughout the process. The general procedure is as follows; A group of experts on a particular subject is selected; those who agree to respond to a series of questionnaires by mail 16 become the Delphi panel. Several rounds of questionnaires are mailed; the first one asks the experts to answer questions and make predictions. The results of this round are tabulated and reported back to the panel in the next round of questionnaires. Thus, all participants know where they stand in relation to all other participants. Those whose answers differ from the group consensus are asked to explain their positions. The results of the second round are tabulated and areas of consensus reported to each participant in a third round of question naires. A summary of reasons why the minority did not agree may also be included. The rounds end when consensus has been achieved or when the prospects of a higher level seem unlikely. In current use, rounds may be as few as two, though the original Delphi consisted of five rounds (Dalkey & Helmer, 1963). Advantages of Delphi 1. People who are widely dispersed geographically can be polled. 2. Group size is limited only by the time and money of the organizers. 3. Group members can express their view anonymously without being influenced or intimidated by others. 4. A variety of questions and/or issues can be presented. 17 5. It can produce a high quantity of ideas, 6. It is a democratic process; each person contributes to the best of his/her ability. 7. There is a sense of closure in that some conclusion is reached in a set number of rounds. Limitations of Delphi 1. It is time consuming for the researchers ; it may take several rounds to complete a Delphi. 2. Results must be analyzed, new questionnaires compiled and mailed out quickly, and an effort must be put forth to avoid bias in wording the feedback, 3. It cannot be used with groups who have difficulty in reading and writing. 4. The process requires high participant motivation. 5. The lack of social contacts throughout the process may make some participants lose interest in continuing the rounds. Use of Delphi in Health and Aging Several studies have utilized the Delphi technique to determine goals and set priorities in the area of health and aging. The Delphi technique has been used to set research priorities in gerontological nursing for LTC (Brower & 18 Crist, 1985), and to set priorities in general nursing research (Ventura & Waligora-Serafin, 1981). Mansfield and Seaton (19 81) conducted Delphi rounds with health educators to find out why there was so little agreement about interdisciplinary continuing education activities, and to identify problems. The result was a list of goals to develop a statewide network for continuing education. In earlier studies, Moskovice, Armstrong, and Shorten (19 77) described the use of Delphi to determine health priorities in health services research; Thomson and Ponder (19 79) described its use in developing a survey instrument to identify priorities for state allied health associations. Romm and Hulka (1979) used a two-round Delphi to set criteria for ambulatory care assessment. Participants were given a list of items and instructed to choose those they considered most essential. After two rounds of voting, the items with the most votes became the "criteria for ambulatory care assessment." Nominal Group Technique ■ The Nominal Group Technique (NGT) was developed by André Delbecq and Andrew Van de Ven at the University of Wisconsin in 196 8 as a participation technique for social-planning situations. It was used in social work 19 studies of problems surrounding citizen participation in program planning. Since then it has been applied to problems in health, social service, education, industry, and government organizations (Delbecq et al., 19 75; Van de Ven, 19 74). According to Delbecq et al. (19 75), NGT is an appropriate and useful group process in the following circumstances : 1. To identify elements of a problem situation. 2. To identify elements of a solution program. 3. To establish priorities where the judgments of several individuals must be decoded and aggregated into a group decision. Description of the Process NGT is a structured method of decision making that differs from other interacting group techniques in that, although participants work in the presence of others, they only interact at times designated by the group leader. In its traditional form, once the problem has been identified and questions presented to the group, the following procedure takes place : Imagine a meeting room in which seven to ten individuals are sitting around a table in full view of each other; however, at the beginning of the meeting they do not speak to each other. Instead, each individual is writing ideas on a pad of paper in front of him or her. At the end of five to ten minutes, a structured sharing of ideas takes 20 place. Each individual, in round-robin fashion, presents one idea from his or her private list. A recorder writes that idea on a flip chart in full view of other members. There is still no dis cussion at this point of the meeting-- only the recording of privately narrated ideas. Round-robin listing continues until all members indicate they have no further ideas to share. The output of this nominal phase of the meeting is a list of prepositional statements usually numbering eighteen to twenty-five. Discussion follows during the next phase of the meeting; however, it is structured so that each idea re- receives attention before independent voting. This is accomplished by asking for clarification, or stating support or nonsupport of each idea listed on the flip chart. Independent voting then takes place. Each member, privately, in writing, selects priorities by rank-ordering (or rating). The group decision is the mathematically pooled outcome of the individual votes. (Delbecq et al., 19 75, p. 8. The above description of NGT is summarized into four. steps : (1) Silent generation of ideas in writing. (2) Round-robin feedback from group members to record each idea in a terse phrase on a flip chart. (3) Discussion of each recorded idea for clarification and evaluation. (4) Individual voting on priority ideas with the group decision being mathematically derived through ranje-ordering or rating. (Delbecq et al., 1975, p. 8) Though NGT is described by Bartunik and Murnighan (1984) as "one of the best, if not the best, process for reaching effective and efficient decisions," NGT, like 21 Delphi and other decision models, has advantages and limitations. Advantages of NGT 1. The highly structured process provides an orderly procedure to arrive at decisions. 2. All group members have an equal opportunity to contribute. 3. It avoids dominance by one individual and thus encourages divergent opinions. 4. It offers the social-emotional advantages of group membership, but at the same time is task oriented so that a sense of accomplishment is fostered. 5. The silent generation of ideas, followed by the round-robin listing of each participant's ideas, encourages further thought and more ideas from each group member. 6. It can be used with groups that do not have high writing skills. 7. The process can identify priority concerns by means of ranking or rating and a group decision can be rendered. 8. The discussion/clarification phase provides an important opportunity to participants for finding out the logic behind ideas presented. 9. There is a perceived sense of closure a,nd accomplishment to the meetings._____________________________ 22 Limitations of NGT 1. To be successful, the process requires skilled leaders. 2. It requires a great deal of advance prepara tion to clearly identify the problem area and to provide the necessary supplies. 3. Once the meeting is underway, the procedure cannot be adjusted to new or unexpected topics; the group is "locked in" to the prepared subject area. 4. The highly structured format, and the obliga tion to participate, may be unacceptable to some people (Delbecq et al., 1975; Van de Ven, 1974). Relevant Studies NGT has been widely used and recommended for use in education, health education programs, and health planning. In a study to facilitate statewide planning in allied health education, NGT was used to identify the common needs of three different populations, and to rank the needs according to perceived attainability (King & Breegle, 1983). Another study used NGT to evaluate an existing curriculum in a university diatetic program by ranking and weighing problem statements. The ranked problem 23 statements were then used to revise the program (Rhoades, Gines, Manasco, & Schweitzer, 1981). Malone (1976) developed a model to promote and guide the development of a systematic approach to coordinating program planning in vocational education. NGT was used to identify problem areas and achieve a consensus on priority items. Force-Field Analysis Force-field analysis is a technique that enables its users to visualize and analyze the elements of a problem— to dissect a problem into its major parts or "forces." In force-field theory, there are forces working for change and forces working to keep change from occurring. Driving forces are those that tend to change the existing level or tend to help reach the desired level. Restraining forces are those which tend to resist change or preserve the status quo. The status quo, or the existing situation, is the result of the combination of these forces (Lewin, 1951). Force-field analysis is not used to plan programs to set priorities or to establish consensus (Delbecq et al., 1975); it is useful, however, for determining the feasibility of an issue or problem for change (Brager & Holloway, 19 78). The technique can be used by one person to analyze a personal problem, or by many working in a 24 group to analyze organizational or community problems. When used with groups, force-field analysis, like Delphi and NGT, is a special purpose technique that can tap the judgments of many "to arrive at decisions which cannot be calculated by one person"(Delbecq et al., 1975). Description of the Process According to force-field theory, there are four steps after the problem has been identified, and when used with a group, the participants have been selected. Step 1; Problem Solving. The individual, or group of individuals, analyze the problem by making a list of the driving and restraining forces affecting a solution to the problem. Step 2; Change. Change involves making a decision about whether to strengthen a driving force, to weaken a restraining force, or to attempt some of both in order to bring about change in a program or personal problem. This is described as "unfreezing" a less-than- desirable situation. Step 3; Move to New Level. When the planned combination of strengthening and/or weakening of identi fied "forces" has brought about the desired change, the new situation is ready for "refreezing" at the improved level. 25 Step 4: Evaluation and Monitoring. Both programs and personal life changes, that have undergone successful change, must be constantly evaluated and monitored to ensure that they stay at the new level (Sanders, 1977).. Although all four steps in the technique are mentioned, for the purposes of the "Staying at Home" Decision Conference model, only the first of the four steps is relevant. At the conference the process was used with small groups to (.1) elicit the forces for or against change for eight different goals for a ETC system, and (2) to make a determination of each goal's feasibility for change. Relevant Studies In reviewing the literature, the influence of Lewin's (1951) theory of "forces" is apparent. While not identified by name, force-field analysis was employed in several studies which used a NGT structure. Using NGT structure. Collison and Dunlap (19 78) examined factors "fostering or inhibiting" implementation of career education programs. Fox (1984) also using NGT structure, applied force-field theory to identify institutional conditions that "facilitated or inhibited" part-time teachers' effectiveness. 26 Studies Using Delphi and NGT Together The literature search revealed several studies in which Delphi and NGT were used together. In a study to determine professional development needs of school principals, a one-round Delphi was con ducted to collect data about principals* competency. Data from the questionnaire were analyzed, and NGT used to identify the most important needs for in-service education (Seagren, 19 80), A modified Delphi/NGT was used with family medicine and psychiatric faculty to examine the principal elements of the role of family physicians in mental health delivery; to identify the most important elements to incorporate into a family medicine residency program (Jones, Knopke, Parlour, Maxwell, & Davis, 19 81). Summary The model of decision-making developed for use in the "Staying at Home" Decision Conference borrowed from the three techniques described in this chapter: Delphi, Nominal Group Technique, and force-field analysis. The technique used for the conference can best be described as a Modified Delphi/NGT. Chapter IV will describe how Delphi, NGT, and force-field analysis were adapted for use in the con ference. 27 CHAPTER IV METHODS In tro duc ti on This chapter describes the steps taken to develop the modified Delphi/NGT method that was used for the "Staying at Home" Decision Conference, A brief overview of the techniques used is presented, followed by defini tions of terms, and limitations of the study. Next, selection of participants, the invitational process, and the instrument developed are discussed. A description of the conference includes the equipment used to enhance the presentation of the rounds of voting and how the conference was structured. The aim of the decision conference was to bring together knowledgeable, key persons from many disciplines in ETC to set priorities for action on a limited number of ETC goals; to determine the areas around which some coalition formation could take place. A model of decision making was needed that was based on theory, yet was both flexible and practical. Criteria for flexibility included a structure that ; 28 1. could accommodate a somewhat unorthodox presentation of materials— findings from a two-year study of frail elderly and the availability of LTC in Los Angeles County. 2. could be applied to a wide mix of goals, 3. was amenable to individuals acting alone or with a group to reach independent judgments. A practical structure required; 1. One whose theory was not so abstract as to be difficult to put into action. 2. One whose theory could be translated into a format that was acceptable to a diverse group of participants. 3. One that would be easily understood and acceptable to the academic community, practitioners at large, community and civic leaders, legislators, and volunteers. 4. One that would, in an orderly and systematic way, move the group toward agreement on priorities. No one decision model appeared to offer all that was needed. By combining and adapting the Delphi, NGT, and force-field analysis, however, a model was devised that promised to accomplish the objectives of the study and to meet the requirements outlined; Each model was chosen for a specific step in the decision-making process. 29 though each can be adapted for use in many different kind of problem situations (Delbecq et al., 1975). Delphi The Delphi Method is best known for its ability to create consensus, but also because it offers the advantage of polling participants by mail (Delbecq et al., 19 75). Thus, a one-round Delphi in which participants were polled by mail was employed to establish what the level of agreement was among the participants before any interaction took place, and to save time at the conference. Nominal Group Technique NGT allows a structured group format. It allows for discussions and/or clarification of issues. The opportunity for clarification accounts for the tendency of group judgments to be superior to isolated judgments (Delbecq et al., 1975). In addition, it offers the advantage of face-to-face contact, but preserves the integrity of independent voting. It has been used to set priorities and, like Delphi, moves the group toward agreement (Delbecq et al., 1975; Huber & Delbecq, 1972). NGT structure was used with force-field analysis in the small group process portion of the conference. 30 Force-Field Analysis Force-field analysis provides a means for dis secting a problem into its major parts or "forces" (Sanders, 1977). In this conference, force-field analysis was used to elicit "opportunities" and "barriers" for the eight goals voted by the participants as most important in the first two rounds of voting. Small groups, each working on a different goal, discussed opportunities and barriers identified, voted, and produced a group score on the feasibility of one goal. The vote results were presented to the conference as a whole. This step, to assess the feasibility of the goals in the final round of voting, was included to give participants additional information. The assumption was that the final vote, based on importance and feasibility, would be influenced by the feasibility scores. There are several characteristics common to Delphi and NGT that made them appropriate methods to use for the decision conference; 1. Both methods focus the attention of the participants on the problem at hand (Delbecq et al., 19 75). Theoretically, with NGT, once the participants understand that they are there to be a part of a unique experience to produce new ideas and not to talk about how it is done somewhere else, they are cooperative and not offended by being directed. In the traditional Delphi, 31 instructions are included with the mailed questionnaire and very specific information is requested to be returned by mail. Since it was expected that the decision con ference would require an intense effort on the part of all participants, and time was limited, it was important to have methods with these features built in. 2. Judgments of individual group members are made independent of other group members in both Delphi and NGT. Independent judgments of high level decision makers would be sought at the conference so that the final ranking of goals would reflect the best thinking of the group. According to Delbecq et al. (1975), this was best accomplished by secret ballot. 3. Both offer the sense of accomplishment that comes with completing a task. Delphi and NGT have a definite termination point which affords a sense of closure not often found in unstructured group meetings (Delbecq et al., 19 75). 4. Both Delphi and NGT are concerned with judgmental or creative decision-making; they are not appropriate for use in routine meetings. In particular, these decision methods are used when the nature of the problem is not clearly defined, or when there is a lack of agreement about the components that would make for a successful solution to a problem (Delbecq et al., 19 75). ^ 32 The model used for the "Staying at Home" Decision Conference was an adaptation of these special-purpose techniques and has been called a Modified Delphi, NGT. In this conference it was used with a group of high level decision-makers to set priorities on the components for a system of LTC in Los Angeles County. Definitions of Terms The following terms are used in this thesis : Goal statements : In this con ference, goal state ments and goals are used interchangeably. Usually, however, goal statement refers to the full description of the goal found in the "Staying at Home" workbook, and goal, used alone, refers to the shortened description used on the Delphi round voting card and throughout the con ference for convenience. The goals developed for the conference are a distillation of problems identified in the two-year "Staying at Home" study of LTC in Los Angeles County. . Each goal statement is a partial solution to the overall dilemma of lack of a LTC system in the county. It is recognized that some goals have more potential for solving the problem than others. Groupthink: Janis (19 78) coined the term. Refers to excessive like-mindedness. When group cohesiveness is so strong that it creates among members a desire for 33 uniformity and consensus rather than a desire for accuracy and correctness (Back, 1951; Berkowitz, 1954). Hitchhiking (in NGT): Refers to the fact that ideas listed on the flip chart in a typical NGT format may stimulate another member of the group to think of an idea he/she had not written on his/her worksheet during the silent writing period. In this case, he/she is free to add the idea to his/her worksheet and report it for listing on the flip chart when his/her turn arrives (Delbecq et al., 1975). Nominal group: Refers to processes which bring individuals together but do not allow the individuals to communicate verbally (Delbecq et al., 1975); sometimes called a "paper group." Strength of agreement; Refers to the percentage of votes on each item: the higher the percentage of votes, the more agreement an item is presumed to have.. Study Design Introduction The decision conference was invitational and selection of participants was based on the need for a diverse group of individuals who were knowledgeable about LTC and were from all parts of Los Angelas County. 34 Limitations of the Study In this Modified Delphi/NGT method, certain assumptions were made. These assumptions are as follows: 1. Convergence of the votes toward certain goals assumes that these goals are the most important and that consensus is desirable. 2. Assumption that goal statements are equally weighted. 3. Assumption that participants will use their own best judgment in voting and not be swayed by majority votes. 4. Assumption that participants are not motivated by what would be in their own best interests in voting for particular goals. Two limitations common to invitational conferences are (1) selection of participants is dependent on those who choose to come, and (2) the method cannot, be pre tested under the conditions of the conference. A further limitation was that the selection of participants was purposeful, not random. The use of experts replaced randomization. Selection of Participants Since the value of the outcome of the conference was dependent upon the expertise of those invited (Delbecq et al., 1975), and to ensure a qualified list 35 of potential participants, the following criteria were establi shed : 1. Participants must have been previously identified as knowledgeable and experienced in the area of LTC and the elderly in Los Angeles County. 2. The participant group must represent many disciplines and agencies within the LTC delivery system. 3. The participant group must include persons from all parts of the county. 4. The participant invitation list must be large enough to result in approximately 10 0 participants. The aim was for high level decision-makers, not merely numbers of participants. The principal investigator and project staff were responsible for identifying who met the criteria established for conference participation. The final potential participant list included "key informants" from earlier phases of the study. These "key informants" were part of the "Top Down" and "Bottom Up" studies of the "Staying at Home" Project. In addi tion to this multidisciplinary, multi-agency group, other nominations included; governmental officials who make and influence policy, administrative personnel in both public and private organizations, and practitioners from both the public and private sector. Where gaps were found to exist in disciplines and/or geographic areas, additional nominations were solicited and 36 potential participants were contacted by mail and by phone. The final list consisted of 155 individuals who were invited to participate in the decision conference. Invitations Invitations were designed to inform the potential participants that if they agreed to be participants, they would be part of a study in research utilization. Detailed instructions stated what was expected of participants before the conference: (1) to receive and review summaries of findings from the "Staying at Home" Project; (2) to vote and mail back a ballot; and (3) at the conference to deliberate with others to arrive at final recommendations (Copy of Invitation in Appendix C). The Executive Summary (preliminary report) with a cover letter and ballot for round one was mailed to all those who responded positively to the invitation. Of the 155 invited, 114 accepted; five were unable to attend, but suggested alternates who were accepted as appropriate substitutes. One hundred and ten voted in the first round by mail; 113 attended the conference through the second round of voting, 99 participated in the final round of voting,. The 114 who accepted represented a cross-section of disciplines and agencies (Table 1). 37 o u JD ^ ^ CD r— H C\J e n e T e n T —) LO e n o o C V J 1 ' ■ ' ! o o C V J o CD r— 1 ' — ---- - ' — — ----- ----- ' ------- ----- en O U e n o O J T —) O e n •vf" CD e j- C \j o o n3 z 1 ' ■ ' ! O r— 4 1 ' ■ ' ! o O T —1 CD O Q 4-> C C O » o o s - 4-> en 5 C D > e n C 4-> o 4-> e n o 4-> d en en 3 ou ta o O p '- - o e n en e n c o C L I^ O) se U c : ou c : z : o 4-» O 4-» • o c : fC (D C D Z c Z ta s - O II c : E en > ) (D o O D O U en 3 4-» JD - a en u s - Z en > 3 s - s 3 Jd z o e n Q C - o o CL Z o o Z S : Cl. CD —1Z CD c 4 -ï 4-> O U OO <D C fO C Q l o O 4 -) en _Q Q en c : CL: O U ou en <4- (D s - 4 -) o S- o c : fO s - ou 4-> fO c : CL. 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One round of voting was by mail, two took place in a conference setting in the ballroom of a local hotel. The instrument developed for use in the con ference was a set of 14 goal statements to be voted on for relative importance in the first two rounds of voting, and for importance and feasibility in the third round of voting. The numbered goal statements to be voted on were presented in a 30-page Executive Summary (Appendix A); each goal statement is followed by action examples and research briefs. The goal statements are based on problems identified in the two-year "Staying at Home" study of LTC, and on the judgment and experience of the principal investigator. In formulating the goal statements, care was given to make the statements as equal and as specific as possible (Gardiner & Edwards, 19 75), though it was recognized that some had more potential for solving the problem than others. Additionally, the number of goals to be voted on was kept at 14; more than 14 was felt to be too many for participants to sort out and vote on in the first two rounds, yet when narrowed down to eight in the final round, a real choice would still be possible. 39 As a voting aid, to help participants choose among the 14 goals, each numbered goal statement was printed on a 3 x 5-1/2" card. The 14 cards could then be sorted, and by a process of elimination, seven goals selected. A simple ballot (Appendix D) was designed for use by mail. Participants were instructed to circle the number of the seven goals they considered most important. The Conference The following section includes the steps taken before and during the conference to set priorities. Table 2 is an outline of the entire process. Settings for Rounds of Voting Preconference. The Executive Summary workbook and first-round ballots were mailed to participants two weeks before the conference to give participants an equal opportunity and time to study the goals they would be voting on, and to inform them about the conference prior to their attendance. Participants were instructed to vote for 7 of 14 goals by circling numbers on the ballot provided, and to mail the ballots back one week before the con ference. This one-round Delphi was conducted to aid in preconference planning (Delbecq et al., 1975), and in 40 Table 2 The Conference I. Preconference Step 1; One-round Delphi First round of voting prior to the conference on item importance. Instructions to participants; Choose 7 of 14 items (goals), mark ballot, and return by mail. II. At the Conference Step 2; Large Group DiscUssion/Voting Time: 1 hour, 30 minutes (a) Presentation of results of first round of voting (b) Discussion/clarification (c) Vote Second round of voting, also on item importance. Instructions to participants: Choose 7 of 14 items (goals,), mark the choices on a Scantron Card. Small Group Process Step 3; Force-Field Analysis Using NGT Format ■ Time: 1 hour, 15 minutes (a) Independent listing of "forces" for or against change occurring for individual goals (b) Round-robin recording of ideas on flip chart (c) Discussion/clarification of ideas ("forces") identified (d) Vote on feasibility of goal (e) Tally votes; calculate mean average of scores General Assembly Step 4; Third and Final Round of Voting Time; 45 minutes Third and final round of voting; on item importance and feasibility. (a) Report of feasibility scores from small groups to the general assembly (b) Discussion/clarification of feasibility ratings (c) Final vote Instructions to participants; Choose 4 of 8 items (goals), mark the choices on a Scantron Card. 41 addition to the reasons listed above, offered the follow ing advantages in planning; 1. Follow-up phone calls could be limited to those not responding. 2. A more accurate count of attendance would allow for adjusting the number of facilitators and recorders needed for the small group process portion of the conference. 3. It was a way to introduce a more comprehensive body of study findings. 4. It would save time at the conference; participants would be equally informed about the findings--start from a common information base (Gardiner & Edwards, 19 75). 5. It would save money; the conference could be a half-day instead of all day, 6. The conference could open with the results of the first round of voting which would provide base line data for the next step; the discussion and clarifica tion phase. One week after the deadline for return of ballots an intensive follow-up effort by phone was directed toward those who had not returned them. Two days before the conference 112 ballots had been received. Two ballots were rejected because eight instead of seven choices were marked, leaving 110 votes in the first round. 42 At the Conference Setting. The setting for the decision conference was luncheon in the large ballroom of a local hotel. There were 111 participants at 16 tables; each table was assigned a table leader. Voting Equipment. IBM Scantron equipment was used to tally votes and project results onto two large screens for all participants to see. Voting was done by marking selections on Scantron cards which were then run through a Scantron Model 1100 Optical Mark Reader. The Scantron Reader electronically senses marks made on the Scantron cards. Votes sent in by mail were recorded on Scantron cards by the researcher for use with the Scantron Reader. The Scantron Reader interfaced directly to an IBM PC which performed the tabulations. An Apple-lie computer was used to run Digital Paint Brush graphic software; the screen display was echoed directly to a system of video projectors which displayed the graphic summaries of the votes. Opening of the Conference The conference opened with the results of the Delphi round of voting projected onto the two large screens via a computer monitor. A general introduction outlined the steps that would be taken to reach agreement on the importance and feasibility of the goals the 43 participants had voted on prior to coming to the con ference. How the Afternoon Proceeded The following sequence of tasks took place: During lunch all participants were expected to discuss the issues/goals voted on in the first round. Table leaders served as facilitators of this discussion. After lunch an open discussion/clarification phase took place. An opportunity was provided for each table to appoint a speaker; the speaker was identified and invited to address the conference. This was done to bring out new or conflicting ideas, and also to establish the camaraderie that is needed with so large a group (Bartunik & Murnighan, 19 84). The second vote (first vote of the conference) followed the clarification phase, and like the first one, 7 of the 14 goals were voted on for relative importance. The results of the Delphi round gave the participants feedback on the goals their peers considered important, as well as an opportunity to reconsider their initial choices. They also could take into consideration criteria they may have overlooked during the first round (Warner & Holloway, 19 78). 44 Votes were marked by participants on Scantron cards and run through the Scantron Reader for immediate projection of the results onto the screen. Small Group Process The top eight goals were selected for discussion. Eight small groups worked on one goal from the point of feasibility to effect change. The importance of this step to the purposes of the decision conference was that it provided a "window" into the thinking of others on some of the reasons why a particular goal might or might not become a reality. The end result of this effort was a rating from each group of the feasibility of that individual goal. In order to get an equal number of participants in the small groups, each table had one set of eight goals voted most important. Participants chose one, and this became their ticket to the small group. Eight small conference rooms were used for this phase with 90 minutes allotted for the small group process. Eight skilled leaders, using a NGT format, led the groups in a force-field analysis of eight different goals. The need for skilled leaders is considered of utmost importance, particularly when introducing an unfamiliar technique (Bartunik & Murnighan, 19 84; Delbecq et al., 1975). Consequently, experienced leaders 4 5 were chosen to conduct the small groups. A two-hour training session was held one week before the conference to familiarize the leaders with the technique to be used (Facilitator's Guidelines for complete description of method, Appendix E) . Leaders provided participants with force-field worksheets and asked that they consider the following questions in listing the forces for or against change of a particular goal: 1. What are the opportunities that exist for change? 2. What are the barriers that keep change from occurring? Copy of force-field worksheets are in Appendix F, The groups followed the NGT format to elicit the forces for or against change. In round robin fashion participants offered their ideas, which were recorded on a flip chart. Flip chart pages were posted on the walls around the room in view of all participants. NGT was chosen to elicit the forces because, in NGT, participants are encouraged to "hitchhike" on one another's ideas, thus it was expected that this step would enhance the force-field analysis technique and produce more ideas (Delbecq et al., 1975; Van de Ven & Delbecq, 1974). In addition, NGT offered the structure needed to move the group toward a decision about the feasibility of the goal under consideration. Discussion 46 of the identified forces followed, after which the participants were given a voting card and asked to independently rate the feasibility of the goal by marking a response on a rating scale (Copy of voting card included in Appendix G). Independent voting here, as in the rounds of voting at the conference, was built into the method in an attempt to preserve the integrity of each partici pant's vote— to avoid "groupthink" (Janis, 1978). After vote cards were collected, individual votes were tallied and a mean was obtained for the group. This average was then reported as the group score to the conference as a whole (form for recording mean scores in Appendix H). Report of Small Groups When the group reconvened, facilitators reported the mean scores, which were put onto the computer and projected onto the screens for all to see. At this point the floor was opened for discussion and/or clari fication before the final vote. Participants were asked to consider the feasibility ratings of the goals as they prepared to vote. Final Vote Final vote instructions were to vote for 4 of the 8 goals identified as most important in the second round, but to base the vote on importance and feasibility to 47 effect change in the LTC system. Votes were again marked on Scantron cards. The last phase of the decision conference was a wine and cheese reception. This step provided partici pants time to consider the final vote results and to discuss them informally. The opportunity to exchange ideas and assess "who was there" might be important and might influence individual feelings about the final results of the conference, perhaps providing motivation to disseminate the findings. A list of participants and their affiliations was provided as part of the information material when attendees checked in. Post-conference evaluation forms were sent to participants 10 days after the conference (Appendix I). Summary The rationale, limitations, definitions, and a step-by-step description of the Modified Delphi/NGT Method used in the decision conference was presented in this chapter. The next chapter will present the results of the voting in the three founds and the feasibility ratings from the small group. 48 CHAPTER V RESULTS Results of the three rounds of voting will be presented in table form, and the changes in goals selected from round to round will be discussed. Since the task of the conference was to set priorities, a summary Priorities table of all rounds of voting is also presented, which will allow comparisons across rounds of priority items. Priority Setting Goals will be listed in order of votes received. The total vote and percentages will be an indication of the "strength of agreement" on each goal. Preconference; Delphi Round Vote Results In Table 3, priorities are listed in order of descending "strength of agreement." In this round participants were asked to vote on item importance for 7 of the 14 goals. The goals with the highest level of agreement were: Home Care Incentives (78%), Case Management (73%), Caregivers Supports (65%), Basic Services (62%), Levels of Care (60%), and Access Equity (53%). 49 Table 3 Preconference Delphi Round 1 Goal Total Vote P er e en t a ge^ Home Care Incentives 86 0. 78 Case Management 80 0. 73 Caregivers Supports 71 0.65 Basic Services 68 0.62 Levels of Care 66 0.60 Access Equity 58 0.53 Public Information 52 0.47 Financial Management 49 0.45 Planning Organization 45 0.41 DRG Adjustments 40 0. 36 Quality 38 0. 35 Physicians 37 0. 34 Advocacy/Coalitions 23 0. 21 Volunteers in LTC 22 0. 20 n = 110 There was less agreement on these goals: Public Information (47%), Financial Management (45%), Planning Organization (41%), DRG Adjustment (36%), Quality (35%), and Physicians (34%). Receiving the least agreement were: Advocacy/ Coalition (21%) and Volunteers (20%). The results of this round of voting indicates a high level of agreement was achieved on several goals with this disparate group of decision-makers in the first round of voting. The question raised here is, how much did reading of the Executive Summary influence voting? 50 A number of phone calls were received from participants who wanted to let the researchers know how difficult the choice making was for them. "All are important; how can I eliminate any?" was asked. In the evaluation forms mailed to participants after the conference, two questions addressed the pre- conference materials received by the participants. One asked to what extent they read the preliminary report. All but two participants (3%) answered "a great deal" (55%) or "some" (41%). A second question asked if they were influenced by having read the preliminary report. Twenty-two percent answered "a great deal," 6 3 percent answered "some," and 14 percent answered "very little." Only one person (1%) answered "none." One conclusion that can be drawn from these answers is that these individuals recognized enough common problems from those identified in the report that they were able to quickly agree on the importance of a large number of them. And they reached these conclusions independent of other influences than the information provided in the Executive Summary and their own knowledge and expertise as far as the researchers are able to determine. 51 At the Conference Table 4 presents the vote results of the second round of voting. Priorities are listed in order of descending "strength of agreement." In round two, as in round one, participants were asked to vote on item importance for 7 of the 14 goals. Again, there was a high level of agreement on several of the goals, and though four of the goals changed in rank order, the same six goals were voted as most important in both rounds. In order of votes receiving the most agreement; Caregiver Supports received 87.6 percent of the vote compared with 65.0 percent in round one. Case Management received 80.5 percent compared with 73.0 percent in round one. Home Care Incentives received 75.2 percent, less than the 78.0 percent received in round one. Equitable Access tied with Levels of Care to receive 6 3.7 percent compared with 53.0 percent and 60.0 percent, respectively, in round one. Basic Services received 59.2 percent, less than the 62.0 percent received in round one. There were three goals with more than 4 0.0 percent; Financial Management (45% round one) tied with Public Information (47% round one) with 46.0 percent; and Quality (35% round one) received 42.4 percent. One received more than 30.0 percent; Planning Organization, down from 41.0 Table 4 Conference Vote Round 2 52 Goal Total Vote Percentage^ Caregivers Supports 99 87.6 Case Management 91 80.5 Home Care Incentives 85 75.2 Equitable Access 72 63. 7 Levels of Care 72 63.7 Basic Services 67 59.2 Financial Management 52 46.0 Public Information 52 46. 0 Quality 48 42. 4 Planning Organization 42 37.1 Volunteers 29 25, 6 Advocacy/Coalitions 2 7 23.8 Physicians 26 2 3.0 DRG Adjustments 2 0 17.6 N = 113 percent in round one to 37.1 percent in round two. Those remaining were: Volunteers (20% round one) increased to 25.6 percent, Advocacy/Coalitions (21% round one) slight increase to 23.8 percent. Physicians (34% round one) down to 23.0 percent, and DRG Adjustments (36% round one) lost support to end up with 17.6 percent of the vote. There was less agreement from round one to round two for: Home Care Incentives (-1%), Planning Organiza tion (-3.9%), Physicians (-11%), Basic Services (-2.8%), Public Information (-1%), and DRG Adjustments (-16.4%). 53 Only the goals. Physicians and DRG Adjustments lost enough votes to account for the increase in agree ment for Caregiver Supports and Case Management in this round. Prior to this vote a discussion/clarification phase had taken place. During lunch each table group, guided by a table leader, questioned and discussed the issues to be voted on. After lunch the group as a whole participated in the discussion/clarification phase. This step took longer than the time allotted, but because this step was so important to the success of the method being used, it was decided to extend the question and answer period. A number of questions were raised by representatives of several table groups that had to be resolved before the second vote. One group proposed that another goal be added; others raised questions about whether or not specific content areas were included under the umbrella of one of the goal statements. It was decided by a show of hands (only two voted for) not to add another goal, and the content items were determined to be subsumed under one or more of the 14 goals. It is not known if the discussion/clarification phase and the resulting interaction among participants con tributed to the increase in agreement for goals 1, 2, 3, 4, 5, 7, 9, and 12 or the decrease in agreement for goals 54 6, 8, 10, 11, 13, and 14. However, the movement of these votes in this round suggests the possibility that clarification of goal statements and/or new information did influence the vote. Small Group Process Phase Table 5 presents the results of a vote on the feasibility of eight of the goals voted most important in the second round of voting. Individual votes were tallied and a mean obtained for each group. For a complete description of the small group process used, see Appendix E. The results of the force-field analysis on the feasibility of eight individuals goals were reported by the group leaders, and mean scores were projected onto the screens. The participants were urged to consider these scores as they prepared for the third and final vote which was to be based on the importance of the goal and its feasibility. Table 6 presents the results of the final round of voting. This vote took place in the general assembly after an opportunity was given for further discussion and/or clarification of the goals. Priorities are listed in order of descending "strength of agreement." In round three participants were instructed to vote for four of the eight goals that had been voted 55 Table 5 Analysis Results Goal Feasibility Rating (X) Levels of Care 1. 0 Caregivers Supports 0. 9 Public Information 0. 9 Case Management 0. 8 Equitable Access 0.6 Basic Services 0.6 Financial Management 0.6 Home Care Incentives 0.4 Table 6 Conference Vote Round 3 Total Goal Vote. P ercentage^ Case Management 74 75. 0 Caregivers Supports 68 69.0 Home Care Incentives 50 51. 0 Levels of Care 46 46. 0 Public Information 46 46.0 Basic Services 42 42,0 Access Equity 39 39.0 Financial Management 19 19.0 N = 99 56 most important in the second round. However, for this vote, selection should be based on the importance of the goals and the feasibility of the goals to effect change. In this final vote, strong agreement was achieved on only two of the goals: Case Management (75%) and Caregivers Supports (6 9%), from round one to round two these two goals rotated positions of relative importance. However, there was considerable agreement about the remaining five goals. Home Care Incentives (51%), Levels of Care and Public Information tied with 45 per cent, Basic Services (42%), and Access Equity (39%). The remaining goal, Financial Management had the least agreement (19%) . Feasibility scores did not appear to influence the vote in round three. As can be seen in Table 7, vote rankings do not match the feasibility score ranking. It should be mentioned here that these results were not unexpected. Part of the process was concerned with determining whether there were goals that would have a large base of support, even if difficulty was foreseen in implementing the objectives of the goals. Table 8 presents the vote results of all three founds of voting to allow for a comparison of priorities across rounds. 57 Table 7 Comparison of Feasibility Ratings and Final Vote Results Feasibility Final Vote Ratings Results Goal Goal Levels of Care 1.0 Case Management Caregivers Supports 0.9 Caregivers Supports Public Information 0.9 Home Care Incentives Case Management 0. 8 Levels of Care Equitable Access 0.6 Public Information Basic Services 0.6 Basic Services Financial Management 0.6 Equitable Access Home Care Incentives 0.4 Financial Management Did the Model Work? The Modified Delphi/NGT Model employed in the conference was successful in setting priorities. In the final round of voting two clear priorities emerged. Throughout the conference all of the goals had some support; none had less than 17 percent. And though participants expressed difficulty in priority-setting because all items are important ones, they nevertheless appeared to accept the project's premise that "effective community action requires widely-shared concentration on a limited set of changes." All participants voted for the requested number of goals per found. Had individual CO eu JO < X 3 C U 0 0 0 0 0 0 0 0 0C O s -c u L T ) C D« — » C Ot oC V J C DC D » c uC D C OL O< d - < d " C O t “ H C L .0 3 C O 4 - > C OC U C 4 - >> c C U L _ 0 E 0+ - > C Oc u C D + - >C Lc 4 - > C OC D C D \ cC O . c u< U0 3C OC U0 3 c u3( Us -Ec u 0c E C Oc0 3S - 0 00 3 c ut o c u C O ,0 < z : < u C D s -4 - > 0 3L _O S C OJ D 0 t o( U 0 3C U 0 X 3 C D c u 4 - >c > c0 3 C U( U< u_ QC O3C 4 - 0 0 0 30 3 0 c u30 3C T 0 a:1 — C _ ) C _ ) D = _1 O -Q ÛL UL i C O X J i (U s - o s- Q_ I 4-> I 4-> c (U O C O S - O ) c 0 0 3 > X 3 1 — C 03 3 -M c 0 0 03 on 1 — Qc: t o i n CM CM 0 0 <d" 1— < t o 0 0 0 t o C O 0 to c u C to 4-> > C Uc 4-> c s - C O E0 0 3 0 CO 0 ■ + - > C O c u N 1— 1 C L 4 -) cc u CD 4 ^ 4-> 1 1 C Lcc u 0 c u to O S0 3 C 4-> 3 4 - 0 C O CU C O 4-> + - > s - 03 c u , 03 3 3 - >o3 03 JD t o > > cc u (U T - ) Z 0 03 C O 0 0 4-> 4-> 03 0 X J CD 4-> cu C C c 0 03 C U C U C U C U 03 c 3 0 C O 4-> s - C OE 33 > C O C -Q 03 03 >> )C £ > 0 03 03 0 c rc u 03 3 3 0 X J 0 ^ 1 — 0 0 z c LU __1 DO u _ Q_ czrCL. CL. CD o o rO L n cs jo o o r^ L O ’— •coLO’^d-’— < o f ^ r ^ c o c o c o c n - î d - ' ^ ' ^ c o c o o o c s j c M • • • • • • • • • • • • • • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CO +-> c: + - > s- o Q . Q. t o S ic'E cu (U > CO CD cu cu •!— %- CO < X 3 < X 3 O C C 3 CO *1 — CO +-> c u c u « 3 S - U E fO U S - cu <c o cu 4- O jQ (D t o O r — + - > * 1 — G J * 1 — r — > C3 JO C U CT 3 I LU Q_ 4-> O C T' e u - M E 0 3 C U N CD •!— f T 3 C - 4 - > C 03 C 03 CD C U r — C / ) fd C 7 > Z5 •I— c >> O ' 1 — XJ +J C C . r - 03 C r - c 03 CD 03 •I— r — C t C 3 u u . d . o czr CO § ■ 4 -> 03 q CO O t o C \ S - 03 >> cu I- O C U O 03 - 4 - > r - U C O 3 > r— Q_ <C > CO >5 » # * * * * # # # # * # # # r-ic\jro<3-Lf)cor^cx)cDO'-Hc\i|CD<d- 59 participants only cared about a particular goal, of several particular goals, they could have registered their preferences by only voting for those and the Scranton Reader would have rejected the vote cards. Two cards were rejected because participants voted for too many goals; none voted for less than seven. The results of these rounds of voting appear to suggest that priorities can be set with the methods used on a limited set of goals, and that support extends to several more goals around which coalitions might be expected to form. However, the assumption that feasibility scores would influence the vote in round three was unsupported by the vote results. In the final round of voting the priority items did not match the Feasibility ratings. The final vote in this conference determined the outcome of the meeting and the priorities that were set documented the group's judgment. It also provided, a sense of closure and accomplishment for the conference participants and for the staff. 60 CHAPTER VI SUMMARY AND CONCLUSIONS The Modified Delphi/NGT used in the "Staying at Home" Decision Conference proposed to accomplish two things: (1) to bring together more than 100 participants to set priorities on goals for a LTC system in Los Angeles County, and (2) to disseminate the findings of the project and the goals selected at the conference. This chapter summarizes what was learned by applying the model and makes recommendations for future research. Summary Priority Setting In three rounds of voting in this decision con ference, the Delphi led to two strong priorities: Case Management (74%) and Caregivers Supports (6 8%), and to close agreement among two other groups of goals : Home Care Incentives (51%), Levels of Care (46%), and Public Information (46%), and Basic Services (42%), and Access Equity (39%). Financial Management (19%) had the least agreement. These results suggest that the Modified Delphi/ NGT method used in this conference was workable and 61 achieved the expected outcomes: priorities were set on issues in LTC with a knowledgeable, experienced group of participants who agreed to use the process. Parti cipants cooperated in mailing in votes and in voting at the conference to narrow down the list of goals. The force-field analysis session using the NGT format was successful in that it produced a large number of ideas from each group and the groups and their leaders were able to arrive at a consensus about the feasibility of the individual issues. However, the feasibility ratings failed to influence the final vote; final vote results do not match the force-field feasibility scores. Post-conference Evaluations Several things that appeared to contribute to the success of the conference from an organizational stand point were : 1. The invitational aspect— that participants were "asked." When asked why they chose to participate in the conference, many participants responded "Because I was invited," or "I was pleased to have been asked to give my opinion." 2. The high quality, intriguing format of the invitation. A number of unsolicited favorable comments regarding the invitation adds credence to the literature which reports that "decision makers are influenced in 62 their choice activities even by what type of format the information is presented to them on" (Luthans & Koester, 1981). 3. The preconference "Staying at Home" Executive Summary of the findings of the study. As was mentioned before, only 3 percent of those returning the evaluations had not read the report prior to coming to the conference. Comments indicate that many participants view the work book as a valuable reference for their future work in LTC. 4. The equipment used to count and display the votes. The use of the Scantron Reader and the video projection of the results of the rounds of voting drew many comments about the "excellent and exciting use. of computers." 5. The mix of methods which kept participants interested. One indication of the acceptance and success of the method may be the answers to the post-conference evaluation question which asked participants to what extent they would recommend the conference method. Of those returning the questionnaire, 61 percent answered "a great deal," 33 percent answered "some." Comments indicate that the change of pace from large group to small group, and back to large group, made the process more interesting. In addition, several participants 63 asked for more detailed information about how to use or adapt parts of the method for use at the agency level. Dissemination of Priorities A test of the value of the decision conference will be the extent to which others are made aware of and can use the priorities identified. The following events or activities were early attempts to utilize the findings of the conference : 1. Educating the public through newspaper articles about what constitutes a LTC system; "Case Management Looms as No. 1 Issue for Elderly," Los Angeles Times article, June 27, 1984. 2. Legislative and other governmental repre sentatives requested reports of "Staying at Home" Project findings to use at the state and local level with committees that set policy. 3. The Los Angeles City/County LTC Task Force is expected to follow up by creating "action steps" for several priorities identified at the conference as most important and most feasible to act on at the local level. 4. Organizations which co-sponsored the "Staying at Home" Project are expected to study the outcomes of the conference. These include: City and County Area Agencies on Aging, United Way, and UCLA/USC LTC Gerontology Center. 64 5. The "ripple effect": Participants returning to agencies, etc. and telling others about the priorities, is one way to disseminate information quickly, as well as a way to educate other practitioners about priority needs. The majority of the participants in this conference were those who will be responsible for implementing any actions or program changes that may result from the decisions made at this conference. Seventy-five percent had been contributors to earlier phases of the project. Therefore, support would be expected from these parti cipants in disseminating the findings of the conference. Positive comments on returned evaluation forms and follow-up phone calls by conference participants indicate that this is occurring. An example of the use of a priority item is the report that the priority status given one of the goals (Case Management) at the conference will "enable the channeling of funding into this service" (United Way). Other participants reported their plans to publicize an overview of the process and summary of the findings; still others listed specific actions they intend to take as a result of the conference findings: "strengthen support of our nursing home advocate," "promote the use of case management," "expand staff awareness of LTC alternatives," and "push for uniform and standardized accessible LTC services country- 65 wide." And a number of those replying mentioned using the project findings to shape the long-range planning of their agencies. Suggestions for Future Research The manner in which small group process (NGT and force-field analysis) is used in this decision model should make the results of the meetings pertinent to the last phase of the model. It is a step that is included to provide the participants with additional information on which to base a final decision choice and, thus, would be expected to influence that decision. In this conference it did not; the final vote results indicate that feasibility scores did not influence the final vote. Although no conclusions could be drawn as to why participants appeared to ignore the feasibility scores, we can speculate. First, if the forces identified in the force-field analysis had been discussed before the vote, would the feasibility scores then have influenced the final vote? And second, although the same parti cipants were voting, did giving fewer goals to vote on in the final round somehow influence them to ignore the feasibility issue? Or, as mentioned in the Results Chapter, did participants support an issue with a low feasibility score, because in their opinion, the 66 importance of the goal outweighed any difficulties there might be in implementation? Why the results of the successful small group sessions did not influence the voting is not clear. Therefore, investigation of the questions posed might yield some answers for those who attempt to use this model in the future. Usefulness of the Technique to Others One of the objectives of the "Staying at Home" project was to develop a model of decision making that could be duplicated in other communities. The model developed is described in this thesis and was used successfully with a diverse group of community leaders to set priorities on pre-established goals for a system of LTC in Los Angeles County, Although the Modified Delphi/NGT was developed for use as part of a two-year research project, it need not be limited to use with large research efforts. It is a flexible method that can be Used by any size community with any number of participants. It is appropriate for use any time priorities need to be set on pre-established goals, issues or problems. It can be useful in several ways : 1. It can help analyze the findings of local studies or investigations. / 2. It can serve as a vehicle for dissemination of information to a wide audience. 3. It can be used to gain the opinions of knowledgeable people on subjects that require the judgments of many to decide priorities before action is taken to implement changes. 4. It can be used to determine levels of support or levels of resistance for proposed policy changes. Additionally, if the priority items are not clearly defined, the NGT format, described in detail in the Facilitator Guidelines (Appendix E) can be used with small groups to generate goals or a list of problems or issues to be voted on. The Modified Delphi/NGT can then be used with a large community of experts to set priorities on the goals, problems, or issues. Conclusions Two questions were posed in this thesis. One, could the decision method be used as a way of testing what degree of support existed for the goals identified? And two, by applying these techniques, what can be learned about the method that will make it more useful to other communities? First, the Modified Delphi/NGT method used in the conference was successful in setting priorities in LTC. Out of the 14 goals, the Delphi established two 68 strong priorities and close agreement among four other goals. The force-field analysis step, using NGT format accomplished its task to rate the feasibility of eight goals, but failed to influence the final vote. Despite this unanticipated result, the small group process appears to be a valuable step. It brought the parti cipants closer to the goals and gave them a sense of ownership about the conference. Participants themselves expressed a great deal of satisfaction at having participated in the small groups. In addition, the small group process added a change of pace that was important in this working conference. For these reasons it is suggested that the small group process step be included in future attempts to duplicate the model. Second, several things were learned about the Modified Delphi/NGT method that will be useful to others attempting to duplicate the techniques. That the method worked so well in setting priorities in this conference can be attributed to the following : (1) participants liked the process and became involved; (2) participants were given information that they valued about LTC; and (3) participants were intrigued with the use of the latest technology to count and display the votes. Post-conference evaluations and comments at the conference indicate that participants left the conference with a high level of personal satisfaction and a feeling 69 that the priorities that were set were "their" priorities. The participants apparently accepted the entire process beginning with the Delphi round when they received study materials and a ballot to return by mail. The Delphi round was successful in this conference and was deter mined to be an important step in the process. It served to involve participants early in the process and to let them know that this was to be a serious, working con ference. Others who use this method should keep in mind that this step does require an intense effort by staff to encourage participants to mail in ballots. The advantage of this effort is a clear idea of who is coming to the conference. The conference was viewed by several participants as a "post-graduate course in LTC." And indeed, the decision model, though designed to set priorities, was also designed to be an education dissemination model whose purpose was to educate not only conferees, but others about a LTC system. The method worked well in fulfilling this purpose. After the preliminary report was mailed out many phone calls came in from uninvited others who requested to either be invited to the con ference and/or to receive the materials. In an invita tional conference space and budget often set limits on the number of participants and the amount of written materials that can be disseminated. 70 The importance of the latest technology in this conference should not be overlooked. One reason for its use is the sense of excitement it adds to what could be a dull meeting. The IBM Scantron equipment used in this conference gave many participants the feeling that they were on the "cutting edge" of new technology. Several stated in post-conference evaluations that they came to the conference to take part in what sounded like "new and exciting methods." However, another reason to use the equipment is that it is a vital part of the process. When using this method with a large number of participants some way of counting votes quickly must be used. One thing learned from using the equipment in this conference was that participants' enthusiasm was kept at a high level by the quick turnaround time to count and display the vote results. This enthusiasm was exhibited throughout the conference and carried over to the wine and cheese reception where final vote results were discussed informally. The reception was the only step in this process that allowed participants unstructured discussion and is considered a valuable addendum to ensure the dissemination of changes when they occur. And again, post-conference evaluations indicate that participants were following up on contacts made at the conference. It 71 is felt that many of these contacts took place during the post-conference reception. 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A long-term care study in relation to the senior multipurpose centers for the City of Los Angeles. Los Angeles, CA; Los Angeles City Department of Aging. Weatherman, R. & Swenson, K. (1974). Delphi technique. In S. P. Henchley & J. R. Yates (Eds.), Futurism in education. Berkeley, CA: McCutcheon Publishing Co. White, M. (1984). Perspectives on long-term care in Los Angeles county; A survey of key informants. Los Angeles, CA; Ethel Percy Andrus Gerontology Center, Institute for Policy and Program Development, University of Southern California. 78 APPENDIXES 1 9 APPENDIX A STAYING AT HOME" CONFERENCE WORKBOOK 00 STAYING AT HOME "A Study With Built-In Implementation" This study has examined current public policies, governmental and non governmental programs and interorganizational practices which affect opportunities for vulnerable older persons to remain in their own homes. The study has identified specific ways to reduce the num ber of impaired elders who may be unnecessarily or prem aturely institutionalized in Los Angeles County. Through a cumulative sequence of research phases begun in July 1983, the project has attem pted to assess the system-as-a-whole and then focus on those policies and conditions w hich are m ost amenable for improvement through local planning and action. In volvem ent of key organizations and individuals in the data- gathering, priority-setting, and dissem ination processes has been a keystone of the project design to help ensure completeness of the findings and, ultimately, broad com m unity awareness of the project recommendations. Among the activities associated w ith the project, from w hich findings are being distilled, are: a county-wide survey of key in formants in long-term care, group debriefings of front-line practi tioners; a secondary analysis of geographic equity in services supply; a study of board and care facilities; a networking-training conference,- a client-tracking study of alternatives to conservatorship and protec tion; a study of assistance programs and helpful hints for family caregivers; and a study of involvement of religious organizations in long-term care. Most of the participants in the concluding Decision Conference, June 1985, will have previously contributed to one or several of these activities. Among the num erous cooperating agencies and organiza tions are the initial project endorsers; C ity and C ounty Area Agen cies on Aging, U nited Way, C om m unity C oalition for Affordable H ealth Care, UCLA/USC Long Tferm Care Gerontology C enter and the Long Tferm Care Task Force. Co-Directors: Raymond M. Steinberg D.S.W . and Monika White Ph.D. 81 FORA COMPREHENSIVE LONG TERM CARE SYSTEM IN L.A. COUNTY RESEARCH BRIEFS ACTION EXAMPLES Pr-el i mi n a r y X lE:0 L J1 I E E . : and W o r k b o o k -for Los A n g e 1 es Civic and Pro-fessional L e a d e r s R a y m o n d M- S t e i n b e r g Project Director " S T A Y I N G AT H O M E " Funded by the John R a n d o l p h and D o r a H a y n e s F o u n d a t i o n June 1985 Andrus Gerontology Center University of Southern California Los Angeles, CA 90089—0191 8.2 Introduction T h i s E x e c u t i v e S u m m a r y h a s b e e n p r e p a r e d for u s e b y c i v i c a n d p r o f e s s i o n a l l e a d e r s parti c i p a t i n g in t h e D e c i s i o n C o n f e r e n c e on J u n e 18, 1985 at t h e U n i v e r s i t y H i l t o n Hotel. At t h a t e v e n t a d i v e r s e m i x t u r e of p e r s o n s c o n c e r n e d wi t h l o n g - t e r m c a r e ( L T C ) of t h e e l d e r l y and o t h e r h a n d i c a p p e d a d u l t s will a t t e m p t to a r r i v e at c o n s e n s u s a b o u t p r i o r i t i e s for a c t i o n b a s e d o n the r e l a t i v e i m p o r t a n c e a n d f e a s i b i l i t y of g o a l s for c h a n g e w h i c h h a v e b e e n i d e n t i f i e d in the t w o - y e a r " S t a y i n g at H o m e " r e s e a r c h p r o j e c t . A l t h o u g h t h i s final C o n f e r e n c e w a s pa r t of t h e initial r e s e a r c h d e s i g n , it h a s a s s u m e d g r e a t e r - t h a n - a n t i c i p a t e d s i g n i f i c a n c e for t h e p r o j e c t r e s u l t s . T h i s s i g n i f i c a n c e a r i s e s f r o m f i n d i n g s of t h e P r a c t i t i o n e r D e b r i e f i n g s a n d K e y I n f o r m a n t S u r v e y of t h e f i r s t year. T h e m o s t s t r i k i n g c o n c l u s i o n of bo t h s t u d i e s w a s t h a t , a m o n g p e r s o n s k n o w l e d g e a b l e a b o u t l o n g - t e r m c a r e in L.A. C o u n t y , t h e r e w e r e w i d e l y — d i s p a r a t e v i e w s r e g a r d i n g w h i c h c o r r e c t i v e a c t i o n s t o t a k e t o w a r d s a c o m p r e h e n s i v e , e f f e c t i v e s y s tem . T h e D e c i s i o n C o n f e r e n c e is n ot o n l y for d i s s e m i n a t i n g m a n y of t h e f i n d i n g s , b ut a l s o for o b t a i n i n g , t h r o u g h a m o d i f i e d D e l p h i t e c h n i q u e , a n s w e r s t o our final r e s e a r c h q u e s t i o n : to w h a t e x t e n t c a n L o s A n g e l e s a r r i v e at a l i m i t e d set of c h a n g e g o a l s f o r w h i c h t h e r e m a y be w i d e a c c e p t a n c e a n d J o i n t e f f o r t ? T h e final c o n c l u s i o n s will be d i s s e m i n a t e d in a final r e p o r t t o c o n f e r e e s and o t h e r L.A. C o u n t y deci si o n - m a k e r s w h o c o u l d n o t be i n c l u d e d in t h e m e e t i n g . T h e c o — s p o n s o r i n g or g a n i zati o n s of t h e " S t a y i n g at H o m e " p r o j e c t (s e e i n s i d e f r o nt cover) will s t u d y t h e o u t c o m e s of t h e D e c i s i o n C o n f e r e n c e a nd t h e C i t y / C o u n t y L o n g T e r m C a r e T a s k F o r c e , w h i c h h a s s e r v e d a s an a d v i s o r y b o d y t o t h e p r o j e c t , i n t e n d s t o d e v o t e f o r t h c o m i n g a g e n d a s t o p r o j e c t r e c o m m e n d a t i o n s . How t o Use This Book -for- the Decision Conf erence T h e t i m e r e q u i r e d t o r e a d t h i s m a t e r i a l a nd m a r k y o u r b a l l o t is e s t i m a t e d to b e u p t o o n e hour. P l e a s e k e e p in m i n d t h e f o l l o w i n g poin t s : o T h e r e p o r t c o n t a i n s 14 s u m m a r i z e d goal s t a t e m e n t s f o l l o w e d b y a c t i o n e x a m p l e s . T h e s e e x a m p l e s a r e f o r i l l u s t r a t i v e p u r p o s e s o n l y a n d s h o u l d n o t d e t e r m i n e y o u r v o t e on t he i m p o r t a n c e of t h e g o a l s . A l a t e r v o t e at t h e c o n f e r e n c e will c o n s i d e r t h e f e a s i b i l i t y of the g o a l s and at t h a t t i m e t h e a c t i o n e x a m p l e s will b e r e l e v a n t to s e l e c t i o n . o T h e r e a re n o " c o r r e c t " a n s w e r s . C o m m u n i t y d e c i s i o n s a r e i n e v i t a b l y s h a p e d b y v a l u e j u d g e m e n t s . T h e i m p o r t a n t t h i n g for t h i s v o t e is y o u r p o i n t of view, u s i n g p a r t or all of t h e i n f o r m a t i o n p r e s e n t e d here. o T h e g o a l s a n d a c t i o n e x a m p l e s are n u m b e r e d f o r c o n v e n i e n c e o n l y — not in a n y i m p l i e d o r d e r of i m p o r t a n c e . 83 To m a r k y o u r d e c i s i o n b a l l o t ; o U s e t h e goal s t a t e m e n t c a r d s in t h e e n v e l o p e to a i d y o u in s o r t i n g out 7 c h o i c e s . It is n o t n e c e s s a r y t o r a n k your s e l e c t i ons. o C i r c l e t h e n u m b e r s on t h e b a l l o t th a t c o r r e s p o n d to t h e n u m b e r s of t h e 7 g o a l s y o u h a v e c h o s e n . o E v e n t h o u g h y ou i n d i v i d u a l l y m a y b e c o m m i t t e d to m o r e t h a n 7 of t h e s e , w e ask y o u t o a c c e p t t h e p r o j e c t ' s p r e m i s e th a t e f f e c t i v e c o m m u n i t y a c t i o n r e q u i r e s w i d e l y — s h a r e d c o n c e n t r â t i on on a l i m i t e d set of c h a n g e s . F i n a l l y . p l a c e t h e b a l l o t in t h e e n c l o s e d s t a m p e d r e t u r n e n v e l o p e a n d mail it t o u s b v J u n e 10th. P l e a s e a l s o p l a c e t h e b o o k w h e r e y o u w i l l b e s u r e to b r i n g it a l o n g to t h e C o n f e r e n c e on J u n e 18 t h . If y o u h a v e a n y q u e s t i o n s a b o u t t h e m a t e r i a l s or p r o c e d u r e , p l e a s e call C a r o l y n K o e g l e r at (213) 7 4 3 - 6 4 6 2 . C a r o l y n K o e g l e r C o n f e r e n c e C o o r d i n a t o r Ac krtowl edgements T h e f a c u l t y , s t u d e n t s a n d v o l u n t e e r s w h o c o n d u c t e d s u b s t u d i e s a l s o a u t h o r e d r e p o r t s w h i c h a r e l i s t e d o n t h e final p a g e s of t h i s d o c u m e n t . T h e s e l i s t i n g s d o n o t r e f l e c t t h e c o m m i t t e d t e a m w o r k w h i c h s u p p o r t e d e a c h a u t h o r a n d t h e r i c h i n t e l l e c t u a l e x c h a n g e a n d u n g l a m o u r o u s m u n d a n e d e t a i l s in w h i c h t h e e n t i r e p r o j e c t s ta f f e n g a g e d . A s P r i n c i p a l In v e s t i g a t o r , I w i s h to t h a n k a n d c o n g r a t u l a t e e v e r y c o l l e a g u e on t h i s p r o j e c t . In a d d i t i o n t o t h e l i s t e d a u t h o r s , t h e r e w a s v a l u a b l e a n d e s s e n t i a l b a c k up b y P o l l y M c C o n n e y , M a r y J a c k s o n , R i t a H a r w o o d , M a r i e M a n d e l , R a l p h M a r i n o , J a n i c e C r o o k s , a n d G a r y K e n n e d y , as well a s t h e admi n i s t r a t i v e a n d s u b s t a n t i v e l e a d e r s h i p of J o n P y n o o s w h o a s s i s t e d t h e p r o j e c t s i n c e t h e f i r s t p r o p o s a l s u b m i s s i o n t o t h e H a y n e s F o u n d a t i o n , o u r p r i m a r y f u n d e r . A l o n g w i t h M o n i k a W h i t e , w h o w a s c o — d i r e c t o r d u r i n g t h e f i r s t y e a r , I w i s h t o a c k n o w l e d g e t h e m a n y c o o p e r a t o r s at all l e v e l s of t h e L T C s y s t e m in L.A. C o u n t y , w i t h o u t w h o m d a t a c o u l d n o t h a v e b e e n c o l l e c t e d ; 104 P r a c t i t i o n e r s f r o m 27 h e a l t h a n d s ocial s e r v i c e a g e n c i e s w h o e n g a g e d in a g a m e d s i m u l a t i o n in smal l d e b r i e f i n g g r o u p s ; 129 K e y I n f o r m a n t s r e p r e s e n t i n g a w i d e v a r i e t y of d i s c i p l i n e s and s e t t i n g s ; o f f i c i a l s of 81 i n c o r p o r a t e d c i t i e s a n d L.A. C o u n t y w h o p r o v i d e d p a p u l a t i o n a n d b u d g e t data; 66 o p e r a t o r s of B o a r d a nd C a r e H o m e s (B & C s ); a nd u n c o u n t e d o t h e r s w h o a s s i s t e d as p l a n n i n g a d v i s o r s or as r e s p o n d e n t s in t e l e p h o n e s u r v e y s , l i t e r a t u r e s e a r c h e s , a n d t a s k f o r c e s . R. M. S. 84 r e s i d e n t s o-f t o a t o-f 1 o mi ni mum set ACTION EXAMPLES 1. C o u n t y g o v e r n m e n t s h o u l d d e v e l o p a p l a n to a l l e v i a t e t h e lack of u n i f o r m i t y of r e s o u r c e s a c r o s s g e o g r a p h i c a r e a s w h i c h lim i t s ca r e o p t i o n s of r e s i d e n t s in u n d e r s e r v e d c o m m u n i t i e s . 2. J u r i s d i c t i o n a l b o u n d a r i e s w h i c h i m p e d e c o s t - e f f e c t i v e s h a r i n g of l i m i t e d r e s o u r c e s , s u c h a s in t r a n s p o r t a t i o n for t h e frail, s h o u l d be w a i v e d in spe cial cases. A m e c h a n i s m for c a s e r e v i e w for w a i v e r s s h o u l d b e e s t a b l i s h e d . 3. T h e A r e a A g e n c i e s on A ging, or a n o t h e r d e s i g n a t e d a g e n c y , s h o u l d e x a m i n e a l l e g e d i n e q u i t i e s , b a s e d on e t h n i c i t y , r a c e or l a n g u a g e , in a c c e s s to l o n g - t e r m c a r e o p t i o n s and t a k e c o m p e n s a t o r y a c t i o n if needed. 4. O p p o r t u n i t i e s for i n f o r m a t i o n e x c h a n g e b e t w e e n c i t i e s and r e g i o n s of t h e C o u n t y s h o u l d b e e s t a b l i s h e d so t h a t u n d e r s e r v e d a r e a s can 1 e a r n a b out r e s o u r c e m o b i l i z a t i o n a nd p r o g r a m d e v e l o p m e n t f r o m t h e m o r e d e v e l o p e d a r e a s a nd cities. RESEARCH BRIEFS 1. L o w e ' s s u b s t u d y of G e o g r a p h i c I n e q u i t y i l l u s t r a t e d t hat L T C r e s o u r c e s w e r e q u i t e u n e v e n a c r o s s t h e C o u n t y , and w i t h i n L.A. City. To b r i n g all c i t i e s to t h e 1 9 0 0 a v e r a g e w o u l d r e q u i r e an a d d i t i o n a l 9 . 3 m i l l i o n d ollars. (See Chart, ne x t page) 2. T h e 1981 P l a n of t h e H e a l t h S y s t e m s A g e n c y r e c o m m e n d e d that “s e r v i c e s s h o u l d be g e o g r a p h i c a l l y d i s t r i b u t e d so as to be a c c e s s ! b l e ...". 3. P r a c t i t i o n e r s r e p o r t e d b a r r i e r s to u s e of L T C s e r v i c e s by m i n o r i t i e s b a s e d on 1a n g u a g e and c u l t u r e , as well a s p r o b l e m s of j u r i s d i c t i o n a l b o u n d a r i e s for all frail e l d e r l y , e s p e c i a l l y in t h e u s e of t r a n s p o r t a t i o n s ervice s. 4. T h e B o a r d a nd C a r e s u b s t u d y c o n c l u d e d that “e t h n i c i t y was a s i g n i f i c a n t d i s c r i m i n a t o r “ b e t w e e n e v i c t e d a nd r e t a i n e d r e s i dents. 65 a COMMUNITY RANK BASED ON SELECTED LTC EXPENDITURES PER POOR ELDERLY Compared with Rankings Obtained from I&R Workers HIGHEST THIRD (alphabetical order): City Range *4727 - 593 oer capita CITIES OF L.A. COUNTY: Arcadia-, Azusa— , Baldwin Park#, Burbank#, Claremont-, Commerce— , Cudahy— , Culver City#, Duarte-, Gardena#, Glendora-, Inglewood-, Irwindale— , La Canada/FIintridge-, La Mirada— , La Puente», La Verne-, Lakewood#, Lancaster— , Long Beach#, Palos Verdes— , Pomona#, Rancho Palos Verdes— , Rolling Hills— , San Dimas-, Santa Fe Springs-, West Covina*. L.A. CITY PLANNING AREAS: Boyle Heights— , Hollywood#, North East LA— , North & East Central City-, North Hollywood#, San Pedro-, Sherman Oaks/Studio City#, Si 1verlake/Echo Park— , West Adams/Baldwin-, Westlakm-, Wilshirm#. MIDDLE THIRD: Citv Ranoe <5B8 - 302 per capita CITIES OF L.A. COUNTY: Alhambra#, Bell#, Carson#, Compton*, Covina#, Downey*, El Monte#, El Segundo#, Glendale#, Hawaiian Gardens-, Hawthorne#, Lawndale-, Los Angeles, Manhattan Beach-, Monrovia#, Montebello#, Norwalk#, Palmdale-, Pasadena#, Rolling Hills Estates-, San Gabriel#, Santa Monica#, Sierra Hadre#, South Gate*, Torrance#, Walnut-, Whittier#. L.A. CITY PLANNING AREAS: Central City#, Chatsworth/Porter Ranch-, Granada Hills/KnolIwood-, Mission/Panorama/Sepulveda#, Northridge*, South Central LA#, South East LA-, Torrance/Gardena Strip#, Van Nuys/N. Sherman Oaks#, West LA#, Westchester/POR#, Wilmington/Harbor City-. LOWEST THIRD: Ci tv Ranoe *294 - 0 per capita CITIES OF L.A. COUNTY: Artesia#, Avalon#, Bell Gardens#, Bel 1 flower#, Beverly Hills##, Bradbury*, Cerritos#, Hermosa Beach#, Hidden Hills#, Huntington Park#, Industry#, La Habra Heights#, Lomita#, Lynwood#, Maywood*, Monterey Park##, Paramount#, Pico Rivera#, Redondo Beach#, Rosemead##, San Fernando##, San Marino#, Signal Hill#, South El Monte##, South Pasadena##, Temple City##, Vernon*. L.A. CITY PLANNING AREAS: Arleta/Pacoima#, Bel Air/Beverly Crest#, Brentwood/Pacific Palis.#, Canoga Park/Woodland His#, Encino/Tarzana##, Palms/Mar Vista/HOR##, Reseda##, SunValley#, Sunland/Tujunga#, Sylmar*, Westwood#, Venice## #«ranked in same 1/3 by I&Rs (convergent validity); — ranked in nmxt lower 1/3; #«ranked in nmxt higher 1/3; — «ranked in lowest third; ##«rankmd in highest 1/3 NOTES: 1980 census data. Governmental and non-profit expenditures in 19G0-G1 include non-entitiement programs such as homm-delivermd mmals, I&R, transportation, escort, telephone reassurance, home health, Nome chore, case management and adult day care. Limitations of findings, such as ambiguities of service boundaries and non-inclusion of unincorporated areas, discussed in report. 86 ISIrTlM^n @ & A coapr thens ivt systea of lopç-tera care aeaas thait T h e r a m u s t : b e a b a l a n c e d c o n t i n u u m o -f l e v e l s o f c a r e b e t w e e n i n d e p e n d e n t l i V i n g a n d s k i 1 l e d n u r S 1 n g - f a c i l i t y c a r e . ACTION EXAMPLES 1. B o a r d a n d C a r e level r e q u i r e s a s p e c i a l c a t e g o r y f o r p e r s o n s w h o h a v e e x t r a s e r v i c e ne e d s . T h i s s p e c i a l level of c a r e s h o u l d b e r e c o g n i z e d a s m e r i t i n g a d d i t i o n a l c o s t s t o b e p a i d b y r e i m b u r s e m e n t b o d i e s and c o n s u m e r s . 2. C o m m u n i t y — b a s e d s e r v i c e s m u s t d e v e l o p l i n k a g e s w i t h B o a r d C a r e f a c i l i t i e s in o r d e r t o m e e t t h e n e e d s of r e s i d e n t s . a n d 3. F i n a n c i a l i n c e n t i v e s m u s t b e p r o v i d e d t o i n c r e a s e t h e a v a i l a b i l i t y in L.A. C o u n t y of I n t e r m e d i a t e C a r e L e vel (ICF) p l a c e m e n t s . 4. N o n - p r o f i t o r g a n i zati o n s n e e d t o d e v e l o p a nd e v a l u a t e a l t e r n a t i v e l i v i n g a r r a n g e m e n t s s u c h as f o s t e r f a m i l y c a r e , h o u s e - s h a r i ng for frail e l d e r s , a n d e m e r g e n c y r e s p i t e beds. RESEARCH BRIEFS 1. T h e r e a r e w i d e l y d i s p a r a t e i m a g e s of B o a r d a n d C a r e ( B & C ) . A m o n g K e y I n f o r m a n t s o n e — h a l f c o n s i d e r e d B & C to b e "i n st i tuti o n a l i zati o n " w h i l e t h e o t h e r h a l f d i d not. W h i l e t h e L i t t l e H o o v e r C o m m i s s i o n w a s c a l l i n g f o r " c l e a n - u p " of s u b s t a n d a r d c o n d i t i o n s in s o m e B & C s , t h e P r a c t i t i o n e r s w e r e d i s c u s s i n g B & C s , a l o n g w i t h s e n i o r h o u s i n g d e v e l o p m e n t s , as m u c h - n e e d e d a l t e r n a t i v e l i v i n g a r r a n g e m e n t s . 2. P r a c t i ti o n e r s r e p o r t e d t h a t B & C p l a c e m e n t s d i f f i c u l t t o f i n d for t h e m o d e r a t e i n c o m e e l d e r l y w h o w e r e m e n t a l 1 y-i mpai r e d . K e y I n f o r m a n t s h o u s i n g of all t y p e s a s t h e t h i r d m o s t s e r i o u s gap I n f o r m a n t s r e p o r t e d t h a t " w a i t i n g l i s t s " w e r e a ch u t i l i z i n g c o n g r e g a t e h o u s i n g . M e a n w h i l e , t h e G o o d P y n o o s s t u d y f o u n d that f a m i l y B & C s w e r e o p e r a t i n g c a p a c i t y a n d t h a t l a r g e r n o n - p r o f i t a n d investor— o p e r a t i n g at a p p r o x i mate l y 8 0 % of c a p a c i t y . w e r e e s p e c i a l l y a n d f o r t h o s e a n k e d c o n g r e g a t e ; 4 0 % of t h e K e y ief o b s t a c l e in man, S t e v e n s o n & at a b o u t 6 0 % of o w n e d h o m e s w e r e 3. T h e B & C s t u d y d o c u m e n t e d t h a t " b e h a v i o r a l p r o b l e m s " ( oft en r e l a t e d t o m e n t a l i m p a i r m e n t s ) w e r e m o s t o f t e n r e a s o n s f o r n o n — a d m i t t a n c e or e v i c t i o n of r e s i d e n t s . W h i l e n o n - p r o f i t h o m e s e x h i b i t e d m o r e f l e x i b i l i t y a b o u t r e t e n t i o n of r e s i d e n t s , a n d w e r e m o r e l i k e l y t o h a v e p r i v a t e r o o m s , all B & C s f o u n d it d i f f i c u l t t o m e e t e x t r a p e r s o n a l c a r e n e e d s a s s o c i a t e d w i t h r e s i d e n t s w h o w e r e b e h a v i o r a l l y d e v i a n t a n d / o r l a c k e d s o c i a l s u p p o r t s . T h e s t u d y c o n c l u d e d t h a t t h e r e w a s a n e e d f o r "an a d d i t i o n a l level of n o n — m e d i c a l c a r e f o r t h e e l d e r l y " . 87 4. T h e B & C s t u d y a l s o c a l l e d for "a s y s t e m l i n k i n g b o a r d a n d c a r e r e s i d e n t s to c o m m u n i t y r e s o u r c e s " s i m i l a r t o t he p r o g r a m s of t h e V e t e r a n s A d m i n i s t r a t i o n a n d J e w i s h F a m i l y S e r v i c e of L.A. a n d as a c o m p o n e n t of c a s e m a n a g e m e n t p r o g r a m s . " S i n c e m a n a g e m e n t of b e h a v i o r a l p r o b l e m s is i m p o r t a n t for e x t e n d i n g t h e b o u n d a r i e s of B & C , it is e s s e n t i a l t h a t r e s i d e n t s b e c o n n e c t e d t o s p e c i a l i z e d p r o g r a m s f o r a l c o h o l t r e a t m e n t , p s y c h i a t r i c h e l p , e v a l u a t i o n of m e n t a l f u n c t i o n i n g , d a y car e , r e c r e a t i o n f a c i l i t i e s , a n d o t h e r c o m m u n i t y a g e n c i e s . " 5. O v e r h a l f (52%) of t h e K e y I n f o r m a n t s a s s e r t e d t h a t 10% o r m o r e of t h e r e s i d e n t s in s k i l l e d n u r s i n g f a c i l i t i e s (SNFs) d i d n o t b e l o n g at th a t level. B o t h K e y I n f o r m a n t s a n d F r o n t - l i n e P r a c t i t i o n e r s c i t e d la c k of I n t e r m e d i a t e C a r e F a c i l t i e s (ICFs) a s a m a j o r g a p in t he c o n t i n u u m of care. 6. In t h e "A 1 t e r n a t i v e s t o C o n s e r v a t o r s h i p " s t u d y a b o u t 10% of t h e 2 7 0 c a s e s r e v i e w e d a p p e a r e d to ICF r a t h e r t h a n S N F level w h i c h w o u l d b e l e s s r e s t r i c t i v e , a n d l e s s c o s t l y to i n d i v i d u a l s , f a m i l i e s a n d t a x p a y e r s . W h i l e t h e r e a r e n e a r l y 3 8 , 0 0 0 S N F b e d s in L.A. C o u n t y (some i n c l u d e ICF l e v e l ) , t h e r e a r e o n l y 6 3 3 f r e e - s t a n d i n g ICF beds. T h e u r g e n c y for m o r e ICF b e d s is e x a c e r b a t e d b y t h e u s e of d i a g n o s t i c a l l y - r e l a t e d g r o u p s (DRGs) in M e d i c a r e . T h e p r e s s u r e s to d i s c h a r g e p a t i e n t s f r o m a c u t e h o s p i t a l b e d s r e s u l t in r e f e r r a l s (and s o m e t i m e s c a s h b o n u s e s ) t o S N F ® f or s u b - a c u t e care. T h e t r i c k l e — d o w n e f f e c t is t h a t 1 e s s - c a r e S N F r e s i d e n t s h a v e n o p l a c e to g o s i n c e t h e y n e e d m o r e c a r e t h a n a b o a r d a n d c a r e f a c i l i t y is a l l o w e d t o p r o v i d e . ICFs w o u l d n e e d s p e c i a l r e s o u r c e s t o h a n d l e " d i f f i c u l t " c a s e s s u c h a s t h o s e r e f e r r e d t o P u b l i c G u a r d i a n . C o n s e q u e n t l y , t h e m a i n t e n a n c e of I C F — level b e ds, as c o m p a r e d w i t h S N F - l e v e l , d o e s n o t a p p e a r to i n t e r e s t t h e p r o p r i e t a r y s e c t o r . 7. In t h e B & C s t u d y , S t e v e n s o n r e p o r t e d t h a t t h e n o n - p r o f i t h o m e s w e r e m o r e f l e x i b l e in r e t a i n i n g d i f f i c u l t c a s e s a n d h a d a d m i n i s t r a t o r s w i t h h i g h e r l e v e l s of p r o f e s s i o n a l p r e p a r a t i o n . S i n c e ICFs, as well as i n n o v a t i v e n o n - m e d i c a l l i v i n g a r r a n g e m e n t s s u c h as f o s t e r f a m i l y c a r e a n d s h a r e d h o u s i n g , m a y n o t be p r o f i t a b l e a n d r e q u i r e s p e c i a l e x p e r t i s e for h e a v y c a r e r e s i d e n t s , a d v a n c e s a r e m o s t 1 i k e l y to b e d e m o n s t r a t e d in t h e n o n - p r o f i t s e c t o r . Â co»pr ehens i vt systea of long-terw care aeans that: Familie» and o t h ee r i nformal c a r * g i vers o-f frail elders should have access t o commun!ty supports. ACTION EXAMPLES 1. In o r d e r to m a i n t a i n a n d e x p a n d t h e c a r e g i vi ng p r o v i d e d at h o m e b y -family a n d f r i e n d s of frai 1 e l d e r s , i n c e n t i v e s or c o m p e n s a t i o n s h o u l d b e p r o v i d e d in t h e f o r m of tax c o n c e s s i o n s a n d rei m b u r s e m e n t or s u b s i d y f or h o m e c a r e c o s t s i n c l u d i n g r e s p i t e . 2. L o s A n g e l e s n e e d s a c o h e r e n t t e l e p h o n e — b a s e d s y s t e m f or l o c a t i n g h o m e c a r e a n d r e s p i t e r e s o u r c e s . S u c h a s y s t e m m u s t be a c c e s s i b l e to i n f orma l a n d f o r m a l c a r e g i v e r s a s well a s t o the e l d e r l y t h e m s e l v e s . T h i s i n f o r m a t i o n a nd r e f e r r a l s y s t e m m u s t l i n k t o c a s e m a n a g e m e n t p r o g r a m s f o r t h o s e m o r e c o m p l e x or d i f f i c u l t c a s e s w h e n a s s e s s m e n t a n d " b r o k e r a g e " of s e r v i c e s are n e e d e d . T h e r e shoLil d b e wi d e d i s t r i b u t i o n of e d u c a t i o n a l and i nspi r a t i onal r e s o u r c e m a t e r i a l s s u c h a s t h o s e p r e p a r e d b y t he A n d r u s V o l u n t e e r s <"Who C a r e s ? : H e l p f u l h i n t s f or t h o s e w h o c a r e f or d e p e n d a n t o l d e r p e r s o n s at h o m e " a nd " B i b l i o g r a p h y for C a r e g i v e r s " ). 4. B o t h c o m m u n i t y - b a s e d a g e n c i e s a n d h o s p i t a l s s h o u l d a s s i s t in d e v e l o p i n g d e c e n t r a l i z e d s u p p o r t g r o u p s a n d o t h e r n e i g h b o r h o o d m u t u a l a i d p r o g r a m s for i n f o r m a l c a r e g i v e r s . RESEARCH BRIEFS 88 1. B o t h F r o n t - l i n e P r a c t i t i o n e r s a n d K e y I n f o r m a n t s r a n k e d as n u m b e r o n e t h e n e e d s for s u p p o r t s f or f a m i l y a nd o t h e r i n f o r m a l c a r e g i v e r s of t h e frail. 2. P r a c t i t i o n e r s r e p o r t e d n u m e r o u s e x a m p l e s of b u r n - o u t of c a r e g i v e r s l e a d i n g to n e g l e c t , a b u s e , a n d u n n e c e s s a r y i n s t i t u t i o n a l i z a t i o n . K e y I n f o r m a n t s r a n k e d a m o n g t h e f i v e m o s t i m p o r t a n t f a c t o r s to o v e r c o m e : l a c k of i n f o r m a t i o n a b o u t a v a i l a b l e o p t i o n s ; u n a v a i l a b l e f a m i l y or o t h e r i n f o r m a l s u p p o r t s ; a n d , lack of i n f o r m a t i o n or s k i l l s a m o n g i n f o r m a l s u p p o r t s . A m o n g t h e r e c o m m e n d a t i o n s w e r e : i n c r e a s e f u n d s a n d t r a i n i n g f o r c a r e g i v e r s a n d v o l u n t e e r s ; d e v e l o p m o r e d a y c a r e a n d 2 4 - h o u r r e s p i t e ; e n c o u r a g e n e i g h b o r h o o d p a r t i c i p a t i o n in LTC; m o r e p e e r n e t w o r k s of e l d e r s a n d of c a r e g i v e r s ; m o r e d o l l a r s , rei m b u r s e m e n t s , and r e s p i t e i n c e n t i v e s t o f a m i l i e s . 89 3. In a T e l e p h o n e S u r v e y b y O n o d e r a , t w e n t y a g e n c i e s w e r e a s k e d t o "tell me a b o u t y o u r r e s p i t e c a r e s e r v i c e s " . N o n e o-f t h e i n d i v i d u a l s a n s w e r i n g t h e p h o n e had a c o n c e p t of t h e w o r d " r e s p i t e " a n d f e w w e r e at all k n o w l e d g e a b l e a b o u t l o n g - t e r m c a r e , m o s t c o u l d n o t g i v e t h e n a m e s or n u m b e r s of o t h e r a g e n c i e s in t h e i r c o m m u n i t y . 4. In a p a r a l l e l s u r v e y b y S t e i n e r , o n l y 12 of 4 9 m u l t i p u r p o s e c e n t e r s s t a t e d t h a t t h e y p r o v i d e d r e s p i t e s e r v i c e s for c a r e g i v e r s ; 8 c e n t e r s w h i c h l a t e r a c k n o w l e d g e d t h a t t h e y c o n d u c t c a r e g i v e r s u p p o r t g r o u p s f a i l e d t o m e n t i o n t h e m w i t h o u t f u r t h e r i n q u i r y . 5. In a l i t e r a t u r e r e v i e w b y t h e A n d r u s V o l u n t e e r s , 3 6 m o d e l p r o g r a m s f or c a r e g i v e r s u p p o r t (in a d d i t i o n to d a y c a r e , c a s e m a n a g e m e n t , or h o m e c h o r e v a r i a t i o n s ) w e r e l o c a t e d in all p a r t s of t h e c o u n t r y . O n l y t h r e e of t h e s e e x a m p l e s w e r e in L o s A n g e l e s C o u n t y . 6. In a p l a n n i n g s t u d y t o d e v e l o p a r e s p i t e c a r e s y s t e m in L.A. C o u n t y , W I S E (Westsi d e I n d e p e n d e n t S e r v i c e s for t h e E l d e r l y ) , in c o o p e r a t i o n w i t h A n d r u s C e n t e r , f o u n d t h a t m a n y e x i s t i n g r e s o u r c e s c o u l d b e m o b i l i z e d b ut a c o h e r e n t s y s t e m w o u l d r e q u i r e d e c e n t r a l i z e d p l a n n i n g a n d n e t w o r k i n g u n i t s in at l e a s t f i v e g e o g r a p h i c s u b d i v i s i o n s of t h e C o u n t y . S i n c e t h e s e c o u l d n o t b e m a i n t a i n e d for r e s p i t e p u r p o s e s a l o n e , t h e r e c o m m e n d a t i on is f o r d e c e n t r a l i z ed focal p o i n t s (with r e q u i s i t e s t a f f i n g ) for t h e m a n y c o n c e r n s of t he L T C s y s t e m i n c l u d i n g r e s p i t e . 7. S t u d i e s at b o t h R a n c h o L o s A m i g o s H o s p i t a l (Kahan et al) a n d at A n d r u s O l d e r A d u l t C e n t e r (Tod d et al) d o c u m e n t t h e e f f i c a c y of, a n d t h e p r o f e s s i o n a l e x p e r t i s e n e e d e d f o r , c a r e g i v e r s u p p o r t p r o g r a m s . T h e l a t t e r e v a l u a t i o n a l s o h i g h l i g h t e d t h e i m p o r t a n c e of e a r l y i n t e r v e n t i o n . 90 A coaprehensifg systea of loag-tera care aeaas that: T h m r~ m m u * t toe adequate case management servi ces to asses care needs, assist elders to arrange suitatole care plans, and monitor coordinated and e-f-fective service delivery. ACTION EXAMPLES 1. C i t y a n d C o u n t y A r e a A g e n c i e s o n A g i n g s h o u l d j o i n t l y e s t a b l i s h m i n i m u m s t a n d a r d s a n d m o n i t o r t h e p e r f o r m a n c e of t h e c a s e m a n a g e m e n t p r o g r a m s w h i c h t h e y fund. T h e y s h o u l d a l s o c o n c u r in a m a s t e r p l a n for L T C w h i c h m a y s e r v e as a f r a m e of r e f e r e n c e , n o t o n l y f or t h e i r o w n i n v e s t m e n t s , but a l s o f o r o t h e r f u n d e r s ' i n v e s t m e n t s in c a s e m a n a g e m e n t w i t h i n L. A. C i t y a n d C o u n t y . 2. T h i s m a s t e r p l a n s h o u l d i n c l u d e p r o g r a m s u p p o r t s on a r e g i o n a l b a s i s t o p r o v i d e s p e c i a l i z e d a s s e s s m e n t a nd p u r c h a s e d s e r v i c e s for c a s e s w h i c h a r e d i f f i c u l t d u e t o such f a c t o r s as a l l e g e d a b u s e , c o m p l e x m e d i c a l / m e n t al c o n d i t i o n s , e t h i c a l d i l e m m a s of c l i e n t or f a m i l y r e f u s a l s of h e l p , or h a r d - t o - f i nd p l a c e m e n t s . 3. C a s e m a n a g e m e n t p r o g r a m s m u s t e s t a b l i s h c l e a r w o r k i n g a g r e e m e n t s w i t h s p e c i a l — f o c u s c a s e m a n a g e m e n t p r o g r a m s (such as M S S P , P u b l i c G u a r d i a n , A d u l t P r o t e c t i v e S e r v i c e s , D e v e l o p m e n t a l D i s a b i l i t i e s , e t c.) a n d k e y s e r v i c e p r o v i d e r s in o r d e r t o a v o i d p i n g - p o n g i n g of c l i e n t s t h r o u g h i n a p p r o p r i a t e r e f e r r a l s . 4. A s s e s s m e n t s of c l i e n t s m u s t b e i m p r o v e d t o r e c o g n i z e and i m p l e m e n t o p p o r t u n i t i e s for r e h a b i 1 i tati o n , a d j u s t m e n t s in level of c a r e , a n d p r o f e s s i o n a l r e a s s e s s m e n t of u n s u b s t a n t i a t e d d i a g o s t i c labe l s . 5. C a l i f o r n i a m u s t m o v e b e y o n d t h e f u n d i n g of p i e c e m e a l d e m o n s t r a t i o n pr e x p e r i m e n t a l p r o g r a m s in c o m m u n i t y - b a s e d L T C and b e g i n t o i m p l e m e n t t h e c o h e r e n t c o n c e p t s a n d b r o a d c o v e r a g e set f o r t h in A B 2 8 6 0 - t h e L o n g T e r m C a r e R e f o r m Act of 1983 ( d e c e n t r a l i z a t i o n of a u t h o r i t y , c o n s o l i d a t i o n of f u n d s , c a s e m a n a g e m e n t , a n d a c c o u n t a b i 1 i t y ) . RESEARCH BRIEFS 1. In t h e K e y I n f o r m a n t s t u d y . W h i t e r e p o r t e d t h a t "the s u b j e c t of c a s e m a n a g e m e n t w a s p e r v a s i v e ; it is c l e a r l y c o n s i d e r e d an i m p o r t a n t p a r t of t h e c o n t i n u u m of c a r e a n d t h e long t e r m c a r e s y s t e m " . T h e m o s t f r e q u e n t l y m e n t i o n e d b a r r i e r t o c a r e w a s "lac k of c o o r d i n a t i o n l i n k a g e s " . 2. T h e r e w a s l i t t l e m e n t i o n of c a s e m a n a g e m e n t , as s u c h , b y F r o n t - l i n e P r a c t i t i o n e r s b u t r a t h e r c o n s t a n t c o n c e r n s a b o u t a c c u r a t e a s s e s s m e n t , a p p r o p r i a t e c a r e p l a n n i n g a n d c o n t i n u i t y .in s e r v i c e c o o r d i n a t i o n . In a s i m u l a t i o n of s y s t e m — b u i 1 d i n g , p r a c t i t i o n e r s i n v e s t e d 3 3 % of a v a i l a b l e d o l l a r s in t h e c a t e g o r i e s of a s s e s s m e n t a n d c a r e p l a n c o u n s e l i n g . 91 3. B o t h t h e W a s s e r m a n a n d H a s h e m i s t u d i e s of M u l t i p u r p o s e C e n t e r s i n d i c a t e d t h a t v e r y f e w M F C s w e r e e q u i p p e d (and s o m e w e r e n o t i n t e r e s t e d ) to p r o v i d e q u a l i t y c a s e m a n a g e m e n t . All M F C d i r e c t o r s " a g r e e d t h a t t h e i r c e n t e r s s h o u l d b e t h e e n t r y s t a g e f or c a s e m a n a g e m e n t ". H a s h e m i r e c o m m e n d e d t h a t t h e A A A d e s i g n a t e o n e to t h r e e of i ts m o r e q u a l i f i e d c e n t e r s a n d p r o v i d e t h e m w i t h n e c e s s a r y s t a f f a n d p u r c h a s i n g p o w e r for c a s e m a n a g e m e n t . 4. T h e C o u n t y A A A L T C p l a n n i n g s t u d y ( L S 3 . ) c a l l e d f o r e v e n t u a l c o u n t y - w i d e c o v e r a g e of c a s e m a n a g e m e n t . T h i s s t u d y , w h i c h a n t i c i p a t e d t h e p a s s a g e a n d i m p l e m e n t a t i o n of AB 2 8 6 0 r e c o m m e n d e d a c o n t i n u i n g C i t y - C o u n t y T a s k F o r c e on L o n g T e r m C a r e a n d m o d e r a t e d e c e n t r a l i zati on of p l a n n i n g a nd c o o r d i n a t i o n of t h e c a s e m a n a g e m e n t o r i e n t e d l o n g t e r m c a r e system. 5. A t r i a d s t u d y at S e p u l v e d a V A ( L S 1 2 . ) r e p o r t e d t h a t f u n c t i o n a l a s s e s s m e n t s c a n b e e x t r e m e l y i n n a c c u r a t e b a s e d on t i m e , p l a c e a n d b i a s e s of t h e a s s e s s o r . 6. T h e "A l t e r n a t i v e s " p r o j e c t f o u n d n u m e r o u s c a s e s of o l d e r p e r s o n s r e f e r r e d for c o n s e r v a t o r s h i p w i t h d i a g n o s e s t h a t w e r e no m o r e t h a n i n f o r m a l l a b e l s , h e a r s a y , a n d s o m e t i m e s u n f o u n d e d e x a g g e r a t i o n s in o r d e r t o g e t P u b l i c G u a r d i a n to h a n d l e t h e case. N i n e of e a c h 10 s u c h r e f e r r a l s w e r e r e j e c t e d , but t h e r e f e r r a l s i m p o s e d u n n e c e s s a r y i n v e s t i g a t i o n s on e l d e r p e r s o n s a n d t h e i r s i g n i f i c a n t o t h e r s . T h e p r o j e c t ' s P o l i c y g r o u p c o n c u r r e d t h a t g a p s in p r o v i s i o n of c o m p r e h e n s i v e c a s e m a n a g e m e n t s e r v i c e s to t h e e l d e r l y in t h i s C o u n t y c o n t r i b u t e d t o i n a p p r o p r i a t e r e f e r r a l s a n d p r e m a t u r e i n s t i t u t i o n a l i z a t i o n . T h e c a s e c o n f e r e n c e r e v i e w s r e v e a l e d t h a t t h e s e i n a d e q u a c i e s w e r e in s u p p l y a n d c o m p r e h e n s i v e n e s s . 7. T h e " A l t e r n a t i v e s " p r o j e c t a l s o d o c u m e n t e d that c a s e m a n a g e m e n t p r o g r a m s t e n d e d to r e f e r t h e c a s e t o P u b l i c G u a r d i a n w h e n c l i e n t s w e r e u n p l e a s a n t , h ad t h r e a t e n i n g or i n d i f f e r e n t r e l a t i v e s , n e e d e d h e l p w i t h m o n e y or p r o p e r t y m a n a g e m e n t , n e e d e d a n e w p l a c e m e n t , or h a d b e h a v i o r p a t t e r n s (such a s s u b s t a n c e a b u s e or d e v i a n t l i f e s t y l e s ) w h i c h i n t e r f e r e d w i t h " c o s t — e f f e c t i v e n e s s " . 8. In S t e i n e r ' s s u r v e y of c e n t e r s s h e i d e n t i f i e d as m a n y a s 5 8 " c a s e w o r k e r s " of w h o m n e a r l y o n e - t h i r d w e r e r e p o r t e d to be w i t h o u t f o r m a l t r a i n i n g . S h e s u m m a r i z e d h e r f i n d i n g s t h a t " C a s e m a n a g e m e n t a s p e r f o r m e d b y L.A. C i t y and C o u n t y s e n i o r c e n t e r s is, s i m p l y , a m e s s . " 9. If L.A. C i t y a n d C o u n t y w e r e to a t t e m p t to p r o v i d e c a s e m a n a g e m e n t t o t h r e e p e r c e n t of t h e e l d e r l y (the l o w e s t e s t i m a t e of t h o s e n e e d i n g c a s e m a n a g e m e n t ) w i t h M S S P — t y p e c a s e m a n a g e r s w h o w o u l d c a r r y a 100 p e r s o n c a s e l o a d , t h e r e w o u l d n e e d t o b e 3 1 7 q u a l i f i e d c a s e m a n a g e r s at a n a p p r o x i m a t e total a n n u a l c o s t of ♦ 3 4 , 1 8 9 , 0 0 0 (based on a v e r a g e c o s t p er cli e n t - m o n t h of t h r e e s i t e s in L . A . ). O n e c o u l d r e d u c e t h i s e s t i m a t e by t h e n u m b e r of c a s e s s e r v e d in s p e c i a l i z e d p r o g r a m s s u c h as MSSP, R e g i o n a l C e n t e r s , L i n k a g e s , I n d e p e n d e n t L i v i n g C e n t e r s a n d P u b l i c G u a r d i a n . ( 1 , 0 5 5 , 2 0 8 p e r s o n s 60 a n d o v e r , t i m e s 3 p e r c e n t d i v i d e d b y lOO or m u l t i p l i e d b y $ 9 0 t i m e s 12 m o n t h s . ) 92 A cowprehensiye systea of Joag-tera care aeans that: There m u % t be as*i stance for frail elders neediriQ financial management to conserve assets, handle routine money transactions and mobilize resources for care- ACTION EXAMPLES 1. I n c r e a s e c a p a c i t i e s of a s s e s s m e n t a n d c a s e m a n a g e m e n t p r o g r a m s t o p e r f o r m m o n e y m a n a g e m e n t f u n c t i o n s a n d / o r to p u r c h a s e t h i s s e r v i c e f r o m f r e e - s t a n d i n g n o n - p r o f i t o r g a n i z a t i o n s w i t h special e x p e r t i se. 2. D e t e r i n a p p r o p r i a t e r e f e r r a l s to P u b l i c G u a r d i a n for t h e e x t r e m e r e m e d y of c o n s e r v a t o r s h i p w h e n t h e c l i e n t s i m p l y n e e d s a s s i s t a n c e w i t h f i n a n c i a l a f f a i r s s u c h as o b t a i n i n g e n t i t l e m e n t s , p a y i n g r o u t i n e b i l l s , b a n k i n g a nd m a i n t a i n i n g p r o p e r t y . 3. E s t a b l i s h c o m m u n i t y - s p o n s o r e d p r o g r a m s to a s s i s t m o d e r a t e a n d l o w — i n c o m e e l d e r s in t h e m a n a g e m e n t of t h e i r f i n a n c i a l a f f a i r s w h e n n e e d e d o u t s i d e t h e c o n t e x t of c o n s e r v a t o r s h i p to s u p p l e m e n t s e r v i c e s a v a i l a b l e for t h e a f f l u e n t f r o m t h e p r o p r i e t a r y s e c t o r . 4. Ca l l a t t e n t i o n of f u n d i n g b o d i e s s u c h as U n i t e d W a y a n d A r e a A g e n c i e s on A g i n g to t h e n e e d to e s t a b l i s h e f f e c t i v e and a c c o u n t a b l e f i n a n c i a l m a n a g e m e n t p r o g r a m s in L.A. for t h e v u l n e r a b l e e l d e r l y . 5. P r o v i d e l i c e n s i n g and m o n i t o r i n g of p r o p r i e t a r y f i n a n c i a l m a n a g e m e n t p r o g r a m s for the e l d e r l y to i n s u r e t h a t c a r e p l a n s a r e b a s e d on l e a s t r e s t r i c t i v e e n v i r o n m e n t and, w h e n f e a s i b l e , l e s s c o s t l y a l t e r n a t i v e s to i n s t i t u t i o n a l i z a t i o n . Q % RESEARCH BRIEFS 1. In t h e d e b r i e f i n g of P r a c t i t i o n e r s , c o n s e r v a t o r s h i p a n d m o n e y m a n a g e m e n t n e e d s w e r e d i s c u s s e d in a l m o s t all g r o u p s . N u m e r o u s c a s e e x a m p l e s w e r e r e p o r t e d of o l d e r p e r s o n s w h o c o p e i n d e p e n d e n t l y in m o s t all w a y s e x c e p t for t he m a n a g e m e n t of t h e i r m o n e y . S o m e w o r k e r s or v o l u n t e e r s p r o v i d e d h e l p w i t h s o r t i n g b i l l s a n d w r i t i n g c h e c k s , but w e r e not s u r e of t h e i r a u t h o r i t y o r c o m p e t e n c e t o d o so. I n s t i t u t i o n a l i z a t i o n or c o n s e r v a t o r s h i p s e e m e d t o o r a d i c a l a n d r e s t r i c t i v e a r e m e d y . 2. K e y I n f o r m a n t s d i d n ot a d d r e s s m o n e y m a n a g e m e n t , per se, b u t d i d r a n k p r o t e c t i v e s e r v i c e s as t h e f o u r t h h i g h e s t u n m e t need. 3. T he " A l t e r n a t i v e s ' s t u d y g a v e d e t a i l e d a t t e n t i o n t o t h i s need. In t h e f i r s t a n a l y s i s of 118 c a s e s r e f e r r e d t o P u b l i c G u a r d i a n s i n c e t h e b e g i n n i n g of 1985, 62% of t he p r o p o s e d c o n s e r v a t e e s h a d n e e d s f or m o n e y m a n a g e m e n t as t h e p r e s e n t i n g p r o b l e m a n d / o r as t h e u n r e s o l v e d issue. T h e s e p e r s o n s w e r e in S N F s a n d B & C s a s well as in i n d e p e n d e n t l i v i n g s i t u a t i o n s . 4. T h e " A l t e r n a t i v e s " p r o j e c t s e p a r a t e d t h e k i n d s of n e e d s in t h i s area. T w o k i n d s of c a s e d i d n e e d P u b l i c G u a r d i a n to p r o t e c t a n d m a n a g e t h e i r a s s e t s : t h o s e w h o s e p h y s i c a l o r m e n t a l i m p a i r m e n t s w e r e so s e v e r e a n d w h o w e r e s o l a c k i n g in i n f o r m a l s o c i a l s u p p o r t s t h a t t h e y n e e d e d p u b l i c c o n s e r v a t o r s h i p ; and, t h o s e p e r s o n s w h o w e r e b e i n g v i c t i m i z e d b y e x p l o i t a t i o n or t h e f t of t h e i r a s s e t s a n d q u i c k , a s s e r t i v e p r o t e c t i v e i n t e r v e n t i o n w a s n e e d e d . T w o k i n d s of c a s e s w e r e p r e v a l e n t w h i c h d id not r e q u i r e c o n s e r v a t o r s h i p : t h o s e p e r s o n s w h o c o u l d c o p e in m o s t o t h e r w a y s e x c e p t k e e p i n g b i l l s p a i d , a p p l y i n g f o r b e n e f i t s , a nd s h o p p i n g for c a r e s e r v i c e s ; and, t h o s e w h o w e r e h o m e l e s s or w h o p r e f e r r e d a s t r e e t — o r i e n t e d l i f e s t y l e a n d n e e d e d a " r e p r e s e n t a t i v e p a y e e " t o r e c e i v e and r a t i o n o u t t h e i r m o n t h l y b e n e f i t c h e c k s t o a v o i d t h e f t or e x p l o i t â t ! on. 5. A l t h o u g h t h e a f f l u e n t h a v e a c c e s s to p r o p r i e t a r y c o n s e r v a t o r s h i p a g e n c i e s a m d p r a c t i t i o n e r s or r e l a t i v e s to s e r v e as c o n s e r v a t o r s , t h e P r o b a t e C o u r t o n l y h a s six i n v e s t i g a t o r s to m o n i t o r 9 0 0 0 p r i v a t e p r o b a t e c o n s e r v a t o r s h i p s in L.A. C o u n t y . U l t i m a t e l y s o m e of t h e s e c a s e s a r e r e f e r r e d t o P u b l i c G u a r d i a n w h e n f a m i l y m e m b e r s " b u r n o u t " and wh e n a s s e t s a r e " s p e n t d o w n " by f o r - p r o f i t a g e n c i e s . In b o t h f a m i l y and f o r - f e e a r r a n g e m e n t s , t h e r e s p o n s i b l e p a r t y m a y n o t b e i n f o r m e d a b o u t h o m e - c a r e a l t e r n a t i v e s t o i n s t i t u t i o n a l i z a t i o n t h u s r e s t r i c t i n g t h e q u a l i t y of life, n e g l e c t i n g c a r e n e e d s , a n d / o r over— s p e n d i n g t h e a s s e t s of t h e c o n s e r v a t e e . 1 O 94 O m o n i tor- and coordi nate ACTION EXAMPLES 1. T h e L T C s y s t e m in L.A. C o u n t y n e e d s d e c e n t r a l i z e d p r o g r a m c e n t e r s w h i c h a r e a d e q u a t e l y s t a f f e d t o f a c i l i t a t e i n t e r o r g a n i z a t i o n a l l i n k a g e s a n d p r o g r a m d e v e l o p m e n t in g o v e r n m e n t a l , v o l u n t a r y a n d p r o p r i e t a r y s e c t o r s of s e r v i c e deli very. 2. T h e r e n e e d s t o b e a d e s i g n a t e d L T C local a d m i n i s t e r i n g a g e n c y t o h a n d l e c o u n t y - l e v e l p o o l i n g a n d c o n s o l i d a t i n g of s u b s i d y f u n d s t o fill s e r v i c e g a p s a n d c u s t o m i z e i n d i v i d u a l s e r v i c e p l a n s . 3. L o c a l fo cal p o i n t s f or g e n e r a l p u b l i c i n f o r m a t i o n (I&R) m u s t b e b e t t e r e q u i p p e d to h a n d l e L T C r e q u e s t s a n d s u c h p r o g r a m s m u s t r o u t i n e l y f e e d i n f o r m a t i o n a b o u t u n m e t n e e d s t o a L T C p l a n n i n g a g e n c y . 4. A local p l a n n i n g a n d c o o r d i n a t i n g a g e n c y m u s t p r o v i d e l e a d e r s h i p in t he d e v e l o p m e n t of L T C s y s t e m - b u i l d i n g s t r a t e g i e s s u c h as m a n d a t o r y p r e s c r e e n i n g , c l e a r i n g h o u s e s f o r h o m e c h o r e s e r v i c e s , n e i g h b o r h o o d c a r e g i v e r s u p p o r t n e t w o r k s , a n d p u b l i c i n f o r m a t i o n c a m p a i g n s . 1 1 95 RESEARCH BRIEFS § 1. W h i t e r e p o r t e d t h a t " B o t h L.A. C i t y a n d C o u n t y A A A s w e r e c i t e d m o r e t h a n o n c e f o r t h e i r i n c r e a s i n g i n t e r e s t a n d s t r o n g e r r o l e s (in L T C). M o s t c o m m e n t s , h o w e v e r , n o t e d t h e g e n e r a l lack of m e a n i n g f u l g r o w t h in t h e a r e a of p l a n n i n g a n d c o o r d i n a t i o n . " K e y I n f o r m a n t s r e c o m m e n d e d s u c h r e m e d i e s as: •* P r o v i d e m o r e f u n d s f o r A A A s t o i n c r e a s e c o o r d i n a t i o n role; * B o a r d of S u p e r v i s o r s s h o u l d d e s i g n a t e L T C Task F o r c e ; * M a n d a t e p l a n n i n g & c o o r d i n a t i o n in s e r v i c e c o n t r a c t s ; * D e v e l o p m a s t e r s e r v i c e plan; P r i o r i t i z e s e r v i c e s ; * I m p r o v e c o m m u n i c a t i o n s r e g a r d i n g n e w L T C d e v e l o p m e n t s ; * C o m b i n e s e p a r a t e p l a n n i n g e f f o r t s . 2. In t h e S C A N et al L T C P L a n for t h e C o u n t y AAA, it w a s r e c o m m e n d e d t h a t f u t u r e L T C p l a n s b e i n t e g r a t e d i n c l u d i n g C i t y a nd C o u n t y r e g a r d l e s s of j u r i s d i c t i o n a l b o u n d a r i e s . T h e P l a n a l s o r e c o m m e n d e d a d i v i s i o n of t a s k s b e t w e e n a c e n t r a l a n d m a n y d e c e n t r a l i z e d " local c o m m u n i t y l o n g t e r m c a r e a g e n c i e s " . H a s h e m i a l s o c o n c l u d e d t h a t b e t t e r l i n k a g e s a n d "a m o r e c o o p e r a t i v e n e t w o r k s y s t e m " s h o u l d e x i s t b e t w e e n t h e C i t y a n d C o u n t y AAAs. 3. W a s s e r m a n c a l l e d u p o n t h e C i t y A A A to c r e a t e a L T C u n i t s t a f f e d by "a p r o f e s s i o n a l g e r o n t o l o g i s t w i t h e x p e r i e n c e in L TC a nd c o m m u n i t y o r g a n i z a t i o n " w h i l e t h e S C A N s t u d y c a l l e d for t h e C o u n t y A A A to i n c r e a s e i t s s t a f f c a p a b i l i t y in t h e h e a l t h a r ea. B o t h W a s s e r m a n and C e b u l a r e c o m m e n d e d that t h e C i t y s p o n s o r t r a i n i n g w o r k s h o p s a n d c o n f e r e n c e s on L T C t o i n c r e a s e k n o w l e d g e a n d s k i l l s w h i l e e s t a b l i s h i n g l i a i s o n w i t h local o r g a n i z a t i o n s in LTC. 4. T h e g e o g r a p h i c i n e q u i t i e s i l l u s t r a t e d b y L o w e s u g g e s t t h e n e e d not o n l y for r e d i s t r i b u t i o n s of f u n d s w i t h i n a r e a a g e n c i e s b u t a l s o t h e n e e d f o r t h e s e p l a n n i n g o r g a n i z a t i o n s t o p r o v i d e t e c h n i c a l a s s i s t a n c e in u n d e r s e r v e d a r e a s s o t h a t local a g e n c i e s c a n f o r m u l a t e p r o g r a m s a n d o b t a i n d e m o n s t r a t i o n a nd f o u n d a t i o n g r a n t s a s well as c o r p o r a t e g i f ts. 5. T he 1 9 8 4 - 1 9 8 5 C o u n t y G r a n d J u r y e n t i t l e d i t s F e b r u a r y 4 th r e p o r t , " N eed f o r G r e a t e r C o o r d i n a t i o n of S e r v i c e s t o A d u l t s " . "It is e v i d e n t t h a t t h e r e is a g r e a t n e e d t o b r i n g t o g e t h e r t he v a r i e t y of (County) s e r v i c e s n o w p r o v i d e d in a f r a g m e n t e d m a n n e r . . . S o m e p r o g r a m s a r e d e c e n t r a l i z e d , o p e r a t i n g in 18 l o c a t i o n s , w h i l e o t h e r r e l a t e d p r o g r a m s a r e c e n t r a l i z e d d o w n t o w n . . . S e r v i c e s t o a d u l t s s h o u l d b e b e t t e r l i n k e d , c o o r d i n a t e d or c o n s o l i d a t e d . . . W e b e l i e v e t h a t m o r e c a n be a c c o m p l i s h e d w i t h t h e s a m e l i m i t e d f u n d s in a t t a c k i n g t h e g r o w i n g n e e d s . " 6. K e y I n f o r m a n t s e x p r e s s e d c o n c e r n a b o u t t h e g r o w i n g n u m b e r of f o r — p r o f i t h e a l t h o r g a n i z a t i o n s e n t e r i n g i n t o t h e L T C f ield. S p e c i f i c a l l y t h e y w e r e c o n c e r n e d a b o u t t h e n e e d for m o n i t o r i n g , c o o r d i n a t i o n a n d m e c h a n i s m s of a c c o u n t a b i l i t y b a s e d in t h e n o n - p r o f i t s e c t o r . On t h e o t h e r h a nd, t h e s e i n f o r m a n t s e x p r e s s e d t h e n e e d for s o c i a l s e r v i c e p r o g r a m s to b e " m o r e b u s i n e s s - l i k e " a n d c o s t c o n s c i o u s . 1 2 ^ conprebeDsive syste» of long-ter» care »eans that: There must be local and stat advocacy organizations and action coalitions to assess and the promote servi ce developme system in n t o -f LTC. ACTION EXAMPLES 1. A n a d v o c a c y c o a l i t i o n in LTC, w h i c h d o e s n o t r e p r e s e n t a n y p a r t i c u l a r k i n d o-f s e r v i c e p r o v i d e r , m u s t be d e v e l o p e d in L.A. C o u n t y . T h i s c o a l i t i o n w o u l d b r i n g t o g e t h e r r e p r e s e n t a t i v e s o-f e x i s t i n g m u t u a l s u p p o r t a n d a d v o c a c y o r g a n i z a t i o n s (such as " C a r i n g C h i l d r e n of A g i n g P a r e n t s " , A D R D A , etc . ) a s we ll as s e n i o r a c t i v i s t s f r o m a d v i s o r y c o u n c i l s , s t a t e c o m m i s s i o n on a g i n g a n d t h e silver— h a i r e d l e g i s l a t u r e w h o w i s h to b e i n v o l v e d b e y o n d t h e m i s s i o n of t h e i r i n d i v i d u a l g r o u p s . A s p o n s o r f o r t h i s c o a l i t i o n m a y b e O A S A C (Older A m e r i c a n So c i a l A c t i o n C o u n c i l of L o s A n g e l e s C o u n t y ) , O l d e r A m e r i c a n s A l l i a n c e or t h e r e g i o n a l u n i t of t h e C o n g r e s s of C a l i f o r n i a S e n i o r s . 2. E f f e c t i v e c h a n n e l s of c o m m u n i c a t i o n a n d j o i n t a c t i o n m u s t be e s t a b l i s h e d b e t w e e n p r o f e s s i o n a l a n d l a y o r g a n i z a t i o n s t o a d v o c a t e b e s t u s e s of a v a i l a b l e r e s o u r c e s a n d e x p a n s i o n of r e s o u r c e s a v a i l a b l e f o r LTC. 3. S i n c e m a n y local d e v e l o p m e n t s in L T C a r e c o n t r o l l e d b y s t a t e — level a c t i o n or i n a c t i o n , L.A. a d v o c a t e s s h o u l d i n i t i a t e a s t a t e - w i d e a s s o c i a t i o n a n d m e e t i n g s f or i n f o r m a t i o n a n d a c t i o n r e g a r d i n g L T C i s s u e s . 4. S e r v i c e a n d p l a n n i n g a g e n c i e s s h o u l d a s s i s t in t h e f o r m a t i o n of c a r e g i v e r s u p p o r t g r o u p s a n d e n c o u r a g e e m e r g e n t l e a d e r s to e x t e n d b e y o n d m u t u a l a i d to a d v o c a c y of r e f o r m in LTC. 1 3 97 RESEARCH BRIEFS 1. S o m e K e y I n f o r m a n t s s a w L T C r e f o r m s b e i n g f u r t h e r e d b y s e n i o r s ' g r o w i n g a w a r e n e s s of p a t i e n t s ' r i g h t s a n d t e n d e n c i e s t o b e c o m e a s s e r t i v e c o n s u m e r s . S o m e w h a t m o r e o p t i m i s m e x i s t e d a b o u t r e p o r t e d i n c r e a s e s in s e n i o r a d v o c a c y g r o u p s w h i c h w e r e w i l l i n g t o l o b b y f o r L T C s y s t e m c h a n g e . R e s p o n d e n t s c a l l e d for m o r e a d v o c a c y a n d e d u c a t i o n , i n c r e a s e d o p p o r t u n i t i e s f or a d v o c a t e s t o " n e t w o r k " , a n d m o r e f u n d s for d e v e l o p i n g a d v o c a c y o r g a n i z a t i o n s . I n f l u e n c i n g s t a t e l e g i s l a t i o n w a s c o n s i d e r e d a h i g h p r i o r i t y . 2. F r o n t - l i n e p r a c t i t i o n e r s d e a l t p r i m a r i l y w i t h c a s e e x a m p l e s , t h e r e f o r e , c a s e a d v o c a c y a r o s e r a t h e r t h a n g r o u p a d v o c a c y . H o w e v e r , in t h e c o n c l u d i n g s i m u l a t i o n , in w h i c h i n d i v i d u a l s i n v e s t e d h y p o t h e t i c a l d o l l a r s in L T C s y s t e m n e e d s , t h r e e r e s p o n d e n t s u s e d t h e " o t h e r " c a t e g o r y t o i n v e s t all or p a r t of t h e i r a l l o c a t i o n in l e g i s l a t i v e a d v o c a c y w h i c h h a d n o t b e e n i n c l u d e d a m o n g t h e c h o i c e s . 3. M i l l ' s s t u d y of t h e r e l i g i o u s s e c t o r ' s r o l e in L T C r e c o m m e n d e d i n c r e a s e d a t t e n t i o n b e y o n d s e r v i c e d e l i v e r y t o a d v o c a c y of r e f o r m a n d d e v e l o p m e n t of L T C r e s o u r c e s . 4. E v i d e n c e of g r o w i n g a t t e n t i o n t o L T C b y s e n i o r a d v o c a t e s w a s t h e l a r g e a t t e n d a n c e of s e n i o r s at a w o r k s h o p of t h e T r a i n i n g C o n f e r e n c e (TLC in LTC) w h i c h p r e s e n t e d an o v e r v i e w of t h e L T C s y s t e m , a s e s s i o n d e s i g n e d to a d d r e s s t h e t e c h n i c a l q u e s t i o n s of l a y p e r s o n s . 1 4 98 4 cotpr ehen s iv e systet of 1onq-tera care aeans that i G o v e r n m e n t a l a n d p r i v a t e Meal t M insurances must r e v i s e p a y m e n t p o l i c i e s to o v e r c o m e -fi n a nc i a l d i s i n c e n t i v e s -for h o m e c a r ACTION EXAMPLES 1. T h e c o s t - e f f e c t i v e p r i n c i p l e s of H e d i C a l w a i v e r s f or h o m e c a r e (such as n o w u s e d f or M S S P a n d R e g i o n a l C e n t e r s for D e v e l o p m e n t a l D i s a b i l i t i e s ) s h o u l d b e c a r r i e d f o r w a r d i n t o o t h e r s o u r c e s of m e d i c a l c a r e p a y m e n t s u c h a s B l u e C r o s s a n d s i m i l a r p r i v a t e i n s u r a n c e s a n d H M O s , a s well a s in t h e f e d e r a l l y - c o n t r o l l e d M e d i c a r e p r o g r a m . 2. E m p l o y e r a s s o c i a t i o n s , l a b o r g r o u p s a n d s e n i o r m e m b e r s h i p o r g a n i z a t i o n s n e e d t o e v a l u a t e and d i s s e m i n a t e i n f o r m a t i o n a b o u t e x i s t i n g p r i v a t e l o n g - t e r m c a r e i n s u r a n c e s . RESEARCH BRIEFS 1. P r a c t i t i o n e r s p r e s e n t e d d o z e n s of c a s e e x a m p l e s in w h i c h f i n a n c i a l r e s o u r c e s , i n s u r a n c e c o v e r a g e s , a nd i n d i v i d u a l a t t i t u d e s of o l d e r p e o p l e r e g a r d i n g t h e s p e n d i n g of m o n e y w e r e i m p o r t a n t i n f l u e n c e s on p l a c e m e n t d e c i s i o n s — i n f l u e n c e s w h i c h f a v o r e d i n s t i t u t i o n a l p l a c e m e n t s o v e r h o m e c a r e o p t i o n s . S i n c e M e d i C a l p r o v i d e d w i d e r c o v e r a g e t h a n M e d i c a r e , it. w a s o f t e n a d v a n t a g e o u s f o r p e r s o n s w i t h b o r d e r l i n e a s s e t s and i n c o m e to " s p e n d d o w n " in o r d e r to q u a l i f y f o r M e d i C a l . C a s e s w e r e a l s o p r e s e n t e d in w h i c h h o m e c a r e w a s m o s t a p p r o p r i a t e but t h e c o s t s e x c e e d e d t h a t of S N F care. S o m e p e r s o n s c h o s e t h e n u r s i n g h o m e b e c a u s e t h e i r h o u s i n g a n d f o o d c o s t s w e r e t h e n i n c l u d e d . L o w i n c o m e p e r s o n s in n u r s i n g hom e s , e v e n w i t h M e d i C a l c o v e r a g e , c o u l d n ot c a r r y t h e c o s t s of t h e i r o w n h o m e — t h e r e f o r e , t h e l i k e l i h o o d of r e t u r n i n g t o i n d e p e n d e n t l i v i n g w a s d i m i n i s h e d . S e v e r a l of t h e p r a c t i t i o n e r d e b r i e f i n g g r o u p s b r o u g h t a t t e n t i o n to t h e p a r t i c u l a r p l i g h t of e l d e r l y s p o u s e s of p e r s o n s n e e d i n g l o n g — t e r m care. T h e h i g h c o s t of c a r e f o r o n e s p o u s e e m p o v e r i s h e d t h e r e t i r e m e n t of t h e o t h e r u n l e s s legal s t e p s w e r e t a k e n t o s e p a r a t e c o m m u n i t y p r o p e r t y . In n u m e r o u s c a s e s a r e l u c t a n t d i v o r c e w a s a r r a n g e d . On t h e o t h e r h a n d , w h e n b o t h s p o u s e s n e e d e d h o m e c a r e it w a s p o s s i b l e t o s t r e t c h t h e i r e n t i t l e m e n t s or e x p e n d i t u r e s s i n c e s u c h s e r v i c e s a s a t t e n d a n t s or l i v e - i n c o m p a n i o n s c o s t n o m o r e f o r t w o t h a n f o r one. 1 5 99 2. W h i l e t h e i n s t i t u t i o n a l a n d a c u t e c a r e b i a s e s in M e d i c a r e a n d p r i v a t e i n s u r a n c e s h a v e b e e n w e l l — d o c u m e n t e d n a t i o n a l l y in s t u d i e s a n d in C o n g r e s s i o n a l h e a r i n g s , t h e K e y I n f o r m a n t s r a n k e d r e i m b u r s e m e n t p o l i c i e s a s a b a r r i e r t o u t i l i z a t i o n of S N F s a n d ICFs as well as of h o m e c a re. " I n a d e q u a t e r e i m b u r s e m e n t l e a d s to i n a p p r o p r i a t e p l a c e m e n t s . " K e y I n f o r m a n t r e c o m m e n d a t i o n s i n c l u d e d : * I n c l u d e r e i m b u r s e m e n t for p s y c h o l o g i c a l care; * I n c r e a s e h o m e c a r e r e i m b u r s e m e n t s ; d e c r e a s e r e s t r i c t i o n s ; * R e i m b u r s e m e n t s s h o u l d b e o u t c o m e b a s e d ; * C o v e r a g e s h o u l d i n c l u d e s u p p o r t s f o r i n f o r m a l c a r e g i v e r s ; * R e v i s e e l i g i b i l i t y a n d i n c o m e r e q u i r e m e n t s (of M e d i C a l ) ; * I n - h o m e s e r v i c e s s h o u l d b e c o v e r e d b y all i n s u r a n c e s ; * I n c r e a s e M e d i C a l d a i l y ra t e s ; * P r o v i d e tax i n c e n t i v e s to a t t r a c t i n v e s t m e n t s in ICFs; * N e e d m o r e (home care ) w a i v e r s in T i t l e s 18, 19, 20; * N e e d m o r e l o b b y i n g t o i n c r e a s e h e a l t h c o v e r a g e ; * P r o v i d e i n c e n t i v e s t o ke e p s p o u s e s t o g e t h e r ; * I n c r e a s e tax i n c e n t i v e s * I n d u c e f o u n d a t i o n s t o i n c r e a s e (LTC) p r o g r a m f u n d i n g . 3. A l t h o u g h M e d i c a r e p o l i c y is c o n t r o l l e d n a t i o n a l l y a n d n o t by local or s t a t e a u t h o r i t i e s , C a l i f o r n i a ' s L T C R e f o r m A c t (AB2860) c a l l s u p o n t h e s t a t e a d m i n i s t r a t i o n t o p e t i t i o n t h e f e d e r a l g o v e r n m e n t t o a m e n d M e d i c a r e t o p e r m i t w a i v e r e d u s e of f u n d s for l o n g - t e r m h o m e care. 1 6 100: 4 coaprehensive systea of long-tera care aeans that : Many more vol u n t e e r s must b e recruited, trained and supervised to work with ■frail elders in LTC programs ACTION EXAMPLES 1. L o n g - t e r m c a r e p r o g r a m s m u s t e v a l u a t e t h e i r c u r r e n t u s e s o-f v o l u n t e e r s a n d f u r t h e r d e v e l o p job d e s c r i p t i o n s , s c r e e n i n g c r i t e r i a a n d staff s u p p o r t s f o r m e a n i n g f u l r o l e s a n d s u i t a b l e r e c o g n i t i o n . E x a m p l e s of n e e d e d v o l u n t e e r r o l e s a r e f r i e n d l y v i s i t o r s , t e l e p h o n e r e a s s u r a n c e w o r k e r s , a n d c a s e a i des. 2. C l e a r i n g h o u s e s for v o l u n t e e r r e c r u i t m e n t a n d t r a i n i n g s h o u l d i n c r e a s e t h e i r a t t e n t i o n t o v o l u n t e e r o p p o r t u n i t i e s in L T C and d e s i g n r e c r u i t m e n t s t r a t e g i e s t o t a p n e w s o u r c e s of v o l u n t e e r s s u c h as f o r m e r c a r e g i v e r s , r e t i r e d p r o f e s s i o n a l s , a n d e m p l o y e e g r o u p s . 3. T h e r e l i g i o u s s e c t o r m u s t a s s e s s i ts p o t e n t i a l f o r r e c r u i t i n g v o l u n t e e r s a n d s p o n s o r i n g s e r v i c e s t o i n d i v i d u a l e l d e r s w h o a r e i n s t i t u t i o n a l i z e d or h o m e b o u n d . E x a m p l e s of s u c c e s s f u l m o d e l s of r e l i g i o u s l y — s p o n s o r e d v o l u n t e e r p r o g r a m s f o r t h e frail e l d e r l y s h o u l d b e d i s s e m i n a t e d . 4. A p a r t i c u l a r l y u r g e n t n e e d is for v o l u n t e e r s to s e r v e as " r e s p o n s i b l e p a r t i e s ' for i n s t i t u t i o n a l i z e d e l d e r s w h o d o n o t h a v e f a m i l y or f r i e n d s . B u i l d i n g o n local e x p e r i e n c e s w i t h u s i n g v o l u n t e e r s in s u c h p r o g r a m s as t h e N u r s i n g H o m e O m b u d s m a n , G u a r d i a n C i r c l e , a n d h o s p i c e s , a n d in c o o p e r a t i o n w i t h t h e C o u n t y H e a l t h F a c i l i t i e s D i v i s i o n , an a g e n c y m u s t b e d e s i g n a t e d t o a s s u m e a c a t a l y t i c r o l e t o w a r d s m e e t i n g t h i s need. RESEARCH BRIEFS 1. K e y I n f o r m a n t s f l a g g e d n e e d s f o r p e e r c o u n s e l o r s vi si t o r s . and f r i e n d l y 2. P r a c t i t i o n e r s d i s c u s s e d c a s e s in w h i c h a s u r r o g a t e f a m i l y m e m b e r w a s n e e d e d . T h e y r e c o m m e n d e d r e c r u i t m e n t of f a m i l y s u r r o g a t e s f r o m t h e r e l i g i o u s s e c t o r , f r o m e m p l o y e e r e t i r e m e n t a s s o c i a t i o n s , a n d f r o m m e m b e r s h i p o r g a n i z a t i o n s t o w h i c h t h e frail p e r s o n h a d b e l o n g e d . 3. T h e A l t e r n a t i v e s p r o j e c t d i r e c t e d i t s a t t e n t i o n t o L.A. County n e e d s f o r s u r r o g a t e f a m i l y m e m b e r s for t h o s e o l d e r p e r s o n s w h o w e r e r e f e r r e d t o P u b l i c G u a r d i a n . T h e f o l l o w i n g is an e x c e r p t f r o m t h e f i n d i n g s : 1 7 101 It is estimated that in Los Angeles County there are over 9000 elders in SNFs or ICFs who have no relatives or friends to speak in their behalf when the elder is too incapacitated to make informed decisions. Many of the referrals since January 2 are from nursing home operators who are concerned about the isolation and helplessness of one or several residents. Among the first 118 cases analyzed, 16% concern persons who need a surrogate family member to act as "responsible party*. In meetings of both the Policy Group and the Case Conference Group reference was made to the "Lopez letter” of 1978 in which the Chief of Health Facilities reminded operators of their obligation under licensing to assure that outside responsible parties are identified for each case. This resulted in a rush of requests for conservatorship which were impossible for existing agencies to handle. The gap remains. Not only this research project but also recommendations of the Little Hoover Commission and consequent legislation give new impetus for facing this gap and devising feasible solutions. At the national level, the Federal Council on Aging has recommended a policy for entitlement to not only comprehensive assessment and case management but also to a "significant other" for frail elders. While Public Guardian employs volunteers to visit conservatees, there is no known program which mobilizes and connects volunteers with individual elders who are alone in institutional settings. Friendly visiting programs are in short supply and tend to focus on elders who are in their own homes. Ombudsman programs trouble-shoot individual complaints and are now attempting to recruit and train volunteers to assist, but so far Ombudsman has no long-term responsibility for individuals. The small but growing numbers of case managers are usually required to terminate their case when the client enters any institution. Religious and educational groups make group visits to nursing homes, but generally do not establish one-on-one ongoing relationships with the most disabled residents. The gap remains. 4. T h e H e a l t h S y s t e m s A g e n c y P l a n r e c o m m e n d e d t h a t R S V P c r e a t e a g r o u p of r e t i r e d t h e r a p i s t s and n u r s e s to p r o v i d e i n - h o m e s e r v i c e s on a d o n a t i o n b a s i s to p e r s o n s u n a b l e t o pay. 5. B o t h W a s s e r m a n a n d H a s h e m i r e c o m m e n d e d i n c r e a s e d r e c r u i t m e n t a n d t r a i n i n g of v o l u n t e e r s b y t h e s e n i o r m u l t i p u r p o s e c e n t e r s . 6. In t h e M i l l s s t u d y , of 9 5 c o o r d i n a t i o n e f f o r t s b e t w e e n t h e r e l i g i o u s s e c t o r a n d A A A s , o n l y f o u r p e r c e n t h a d t o d o w i t h v o l u n t e e r s , as c o m p a r e d w i t h f a c i l i t i e s (19%), F u n d s (12%), p r o g r a m m a t e r i a l s (10%), a n d n e w s l e t t e r s (5%). T r a n s a c t i o n s h a v i n g t o d o w i t h v o l u n t e e r s in r e l a t i o n to t h e C o u n t y A A A (5.3%) w e r e d o u b l e t h e f r e q u e n c y r e p o r t e d in t h e d o m a i n of t h e C i t y A A A (2. 77.) . 7. B a s e d on t h e e v a l u a t i o n of t h e L I N C p r o j e c t , P y n o o s et al c o n c l u d e d th a t " M o b i l i z a t i o n of v o l u n t e e r s to p r o v i d e p e r s o n a l c a r e s e r v i c e s on a n e i g h b o r h o o d b a s i s c a n n o t r e p l a c e s e r v i c e s a v a i l a b l e t h r o u g h t h e f o r m a l s y s t e m . ... B o t h f o r m a l a n d i n f o r m a l s u p p o r t s y s t e m s m u s t b e s t r e n g t h e n e d . . . S u c c e s s f u l m o b i l i z a t i o n of m u t u a l h e l p r e q u i r e s : p r o f e s s i o n a l l y — t r a i n e d c o m m u n i t y o r g a n i z e r s ; t r a n s p o r t a t i o n w i t h e s c o r t t o f a c i l i t a t e p a r t i c i p a t i o n ; r e c i p r o c i t y of s e r v i c e a m o n g n e i g h b o r s ; t a r g e t i n g of a p p r o p r i a t e v o l u n t e e r s ; and n e t w o r k s o r g a n i z e d a r o u n d s p e c i f i c c o n c e r n s . 1 e 102 D RC3 - M e d i car p a y m e s t t o m r e d u c * o ACTION EXAMPLES 1. M e d i c a r e - c o v e r e d p a t i e n t s a n d t h e i r f a m i l i e s s h o u l d r o u t i n e l y b e i n f o r m e d b y h o s p i t a l s a n d n u r s i n g h o m e s r e g a r d i n g t h e i r r i g h t s of a p p e a l w h e n d i s c h a r g e is a l l e g e d l y p r e m a t u r e or d i s c h a r g e p l a n n i n g i n c o m p l e t e . 2. C a l i f o r n i a M e d i c a l R e v i e w , Inc. w h i c h is c o n t r a c t e d t o g i v e o v e r s i g h t t o a d m i s s i o n s a n d d i s c h a r g e s , s h o u l d c o n d u c t an i n v e s t i g a t i o n of t h e u n i n t e n d e d s i d e e f f e c t s on t h e e l d e r l y of D R G — r e l a t e d p r e s s u r e s for e a r l y d i s c h a r g e f r o m a c u t e c a r e . S p e c i a l a t t e n t i o n s h o u l d b e g i v e n t o i n a d e q u a t e r e s o u r c e s f o r d i s c h a r g e p l a n n i n g w h i c h r e s u l t s in i n s t i t u t i o n a l i z a t i o n r a t h e r t h a n a f e a s i b l e p l a n for h o m e - b a s e d care. 3. T h e s t a t e l e g i s l a t u r e s h o u l d p e t i t i o n t h e f e d eral g o v e r n m e n t t o e s t a b l i s h r e w a r d s or o t h e r i n c e n t i v e s , in t h e D R G s y s t e m of M e d i c a r e p a y m e n t , f or h o s p i t a l s w h i c h s u p p l e m e n t r e s o u r c e s a n d a l l o w s u f f i c i e n t t i m e f or d i s c h a r g e p l a n n i n g s o as to a v o i d i n s t i t u t i o n a l i z a t i o n w h e n a f e a s i b l e h o m e c a r e p l a n c a n b e devi sed. RESEARCH BRIEFS 1. B y f a r t h e p r e v a i l i n g c o n c e r n of P r a c t i t i o n e r s w a s t h a t D R G s will f o r c e m o r e s u b — a c u t e p a t i e n t s to be d i s c h a r g e d i n t o t h e n u r s i n g h o m e s w h e r e t h e y will n e e d a h i g h e r level of c a r e t h a n S N F s a r e e q u i p p e d to p r o v i d e w i t h i n t h e p r e v a i l i n g r a t e s . It w a s f e a r e d t h a t s h o r t e r s t a y s in a c u t e h o s p i t a l s will n o t a l l o w h o s p i t a l d i s c h a r g e p l a n n e r s t o a s s e s s t h e o l d e r p e r s o n p r o p e r l y or t o a r r a n g e for c o m p r e h e n s i v e h o m e care. A c c o r d i n g t o a n u r s e , "A lot of t h e o l d e r p a t i e n t s a r e c a u g h t in a r e v o l v i n g d o o r b e c a u s e t h e y a r e d i s c h a r g e d b e f o r e w e c a n d o a n y t h i n g to s t o p t h i s v i c i o u s c y c l e . So, we just keep t a k i n g c a r e of t h e c r i s i s s i t u a t i o n s a n d n o t t h e c h r o n i c p r o b l e m s t h a t ke e p b r i n g i n g t h e m b a c k . " 1 9 103 A f e w d i s c h a r g e p l a n n e r s a c k n o w l e d g e d that, s i n c e D R G s , s o m e p h y s i c i a n s w e r e m o r e c a r e f u l t h a n in t h e p a s t t o p r o v i d e d i s c h a r g e u n i t s w i t h a d v a n c e n o t i c e of p r o b a b l e d i s c h a r g e . T h i s p r a c t i c e a l l o w e d m o r e lead t i m e f o r a s s e s s m e n t and c a r e p l a n n i n g . A n u r s i n g h o m e p h y s i c i a n s t a t e d t h a t r e c e n t c o u r t c a s e s h a d p u t "on h o l d " s o m e of t h e p r e s s u r e s for r e l e a s i n g p a t i e n t s t o o e a r l y f r o m f a c i l i t i e s . But in g e n e r a l t h e h e a l t h p r o f e s s i o n a l s s a i d t h e y fe l t c o n t i n u i n g p r e s s u r e s t o d i s c h a r g e t h e i r p a t i e n t s t o o s o o n in o r d e r t o k e e p c o s t s down. As w a s t h e c a s e w i t h M e d i - C a l , u t i l i z a t i o n r e v i e w s of M e d i c a r e w e r e s e e n as s o m e w h a t e f f e c t i v e in e n s u r i n g t h a t o n l y t h o s e in real n e e d of s k i l l e d n u r s i n g c a r e s t a y in t h e n u r s i n g h o m e s . M a n y p r o f e s s i o n a l s s t a t e d t h a t in p a s t y e a r s f e w i n c e n t i v e s e x i s t e d f o r t h e d i s c h a r g e of t h o s e p a t i e n t s w h o n o lo n g e r r e q u i r e d s k i l l e d n u r s i n g c a r e . C o n c e r n w a s e x p r e s s e d t h a t "it's v e r y h a r d t o p a s s t h e u t i l i z a t i o n r e v i e w a n d k e e p t h e b e s t i n t e r e s t of t h e p a t i e n t in m i n d " in t h o s e c a s e s of p a t i e n t s w h o m a y b e n e f i t f r o m a l o n g e r s t a y t h r o u g h c o n t i n u e d r e h a b i l i t a t i o n s e r v i c e s o r f o r m a k i n g a d e q u a t e a r r a n g e m e n t s f o r c a r e at h o m e. 2. W h i l e K e y I n f o r m a n t s e x p r e s s e d g e n e r a l s u p p o r t f or s h o r t e r h o s p i t a l s t a y s , t h e r e w e r e c o n c e r n s a b o u t t he u n i n t e n d e d s i d e e f f e c t s of DRGs: * D R G s c a u s e p a t i e n t s to b e r e l e a s e d sicker; * D R G s m a y i n c r e a s e i n a p p r o p r i a t e i n s t i t u t i o n a l i z a t i o n ; * D R G s will s h i f t p a t i e n t a c u t e c a r e to n o n - a c u t e s e t t i n g s ; * D R G s m a y m e a n t h e e n d of r e i m b u r s e m e n t s for g o o d w o r k - u p s ; * D R G s c a u s e " u r g e n t a nd q u i c k — fix r e s p o n s e s " ; * D R G s n e e d c a r e f u l e v a l u a t i o n t o a s s u r e a d e q u a t e care. R e c o m m e n d a t i o n s i n c l u d e d m o n i t o r i n g t o p r e v e n t m u l t i p l e h o s p i t a l s t a y s , a d j u s t m e n t of D R G p a y m e n t b a s e d on a g e o r n e e d s f o r h o m e t r a n s i t i o n , a n d m o d i f i c a t i o n to i n c l u d e L T C needs. 3. K a n e a n d M a t t h i a s a l s o p r e d i c t e d t h a t p r o s p e c t i v e r e i m b u r s e m e n t w o u l d i n c r e a s e d e c i s i o n s to m o v e p a t i e n t s i n t o n u r s i n g h o m e s i n s t e a d of ■d i s c h a r g e t o home. T h e y r e c o m m e n d e d t h a t s i n c e t h e p r o p o r t i o n of e l d e r l y p a t i e n t s at r i s k of SNF p l a c e m e n t w a s n o m o r e t h a n 10%, t h e r e c o u l d b e c o s t s a v i n g s if " t h e s e p a t i e n t s m i g h t b e a s s i g n e d t o a s p e c i a l d i a g n o s t i c a l l y r e l a t e d g r o u p t h a t w o u l d a l l o w a d d i t i o n a l r e s o u r c e s t o c a r r y out e f f e c t i v e d i s c h a r g e p i a n n i n g ". 20 104 There must g m e n t e d Mich basic services i n ACTION EXAMPLES 1. T h e r e m u s t b e an i n c r e a s e d s u p p l y o-f b a s i c s e r v i c e s for t h e fra i l e l d e r l y s u c h as h o m e c h o r e , p r o t e c t i v e s e r v i c e s , a d u l t d a y c a r e a n d m e n t a l h e a l t h s e r v i c e s , (see a l s o G o a l s 2, 3, 4, 5, & 8) 2. N o n — g o v e r n m e n t a l f u n d i n g s o u r c e s , s u c h a s U n i t e d Way, s h o u l d r e e x a m i n e t h e i r r o l e s in d e v e l o p i n g a n d m o n i t o r i n g that p a r t of t h e l o n g - t e r m c a r e s y s t e m w h i c h i s n o t p r o v i d e d by g o v e r n m e n t a l s o u r c e s . 3. D u e to t h e c e n t r a l i m p o r t a n c e of h o m e m a k e r / c h o r e s e r v i c e s in h o m e c a r e a l t e r n a t i v e s , a n d t h e p r e s e n t d i f f i c u l t i e s of frail e l d e r s at all i n c o m e l e v e l s t o l o c a t e r e l i a b l e help, t h e r e n e e d s t o b e a c o o r d i n a t i n g or c l e a r i n g h o u s e p r o g r a m to i m p r o v e a c c e s s , c o v e r a g e , r e s p o n s e time, a n d a c c o u n t a b i l i t y in h o m e m a k e r / c h o r e . At t h e s a m e t i me, su c h a p r o g r a m w o u l d p r o v i d e e c o n o m i c a n d legal p r o t e c t i o n s a n d c a r e e r l a d d e r s f o r h o m e c h o r e workers. 4. B o t h s t a t e a n d c o u n t y g o v e r n m e n t m u s t p r o v i d e m o r e a d e q u a t e p r o f e s s i o n a l r e s o u r c e s to t h o s e e n t i t i e s (such a s D P S S ' s A d u l t P r o t e c t i v e S e r v i c e s a n d P u b l i c G u a r d i a n ) r e s p o n s i b l e for i n v e s t i g a t i n g a n d i n t e r v e n i n g in r e p o r t e d a d u l t a b u s e s i t u a t i o n s . Q u a l i f i e d , e f f e c t i v e p s y c h o — s o c i a l , legal a nd medica l t e a m s a r e b e y o n d t h e p r e s e n t c l i n i c a l s t a f f r e s o u r c e s of e x i s t i n g a g e n c i e s . RESEARCH BRIEFS I. K e y I n f o r m a n t s w e r e a s k e d t o r a t e t h e a d e q u a c y of s u p p l y of 21 k i n d of s e r v i c e s . F o u r t e e n of t h e 21 w e r e r a t e d “ lo w " by a majorit y . SERVICE/FACILITY SUPPLY LEVEL Caregiver Respite Adult Day Health Congregate Housing Protective Services Adult Day Social Friendly Visiting Transportati on Case Management Homemaker/Chore Personal Care Legal Assistance Guardianship Telephone Reassurance Intermediate Care (ICF) MEDIUM (Ranoe 2.3 to 2.1) Meals on Wheels Info & Referral Senior Centers Home Health Care Conoreoate Meals Skilled Nursino Facilities HIGH (1.3) Acute Care Hospitals 2 1 2. T h e p r e v a i l i n g v i e w of P r a c t i t i o n e r s w a s that t h e local s y s t e m d i d not so m u c h n e e d i n n o v a t i v e k i n d s of p r o g r a m s but, r a t h e r , a m o r e a m p l e a n d / o r b a l a n c e d s u p p l y of e x i s t i n g a l t e r n a t i v e s t o i n s t i t u t i o n a l i z a t i o n . S e r v i c e g a p s i d e n t i f i e d by P r a c t i t i o n e r s in m o s t w a y s r e p l i c a t e d t h e r e s p o n s e s of t h e K e y I n f o r m a n t s ; 105 respite care (that is affordable) information & education for caregivers (incl. peer support groups) intermediate level care facilities B&Cs & retirement hotels for moderately-i mpai red & moderate-i ncome elders B&Cs for older persons with behavior problems related to dementia case managers, case advocacy, and care monitoring social day care (that will take severely impaired people) homemakers and home chore workers (for those not now covered) friendly visitors escort services and transportation house sharing programs with matching and counseling assistance financial assistance/ medical care coverage shopping assistance senior housing (including for the physi cal1y-handicapped older person) live-in companions (to share expenses and/or assist) provision of home care equipment home modification programs help with writing checks and related money management 3. T h e H e a l t h S y s t e m s A g e n c y P l a n c a l l e d for i n c r e a s e d d e v e l o p m e n t of a d u l t d a y h e a l t h c a r e c e n t e r s a n d a d u l t d a y (social) c a r e . T h e H S A a l s o r e c o m m e n d e d t h a t t h e C o u n t y seek U n i t e d W a y fu n d s , p r i v a t e f o u n d a t i o n g r a n t s , a n d o t h e r n o n - g o v e r n m e n t a l f u n d i n g s o u r c e s to s u b s i d i z e s e r v i c e s of n o n - p r o f i t h o m e h e a l t h a g e n c i e s f o r p e r s o n s u n a b l e to p a y t h e f u l l c o s t of care. 4. B o t h t h e P r a c t i t i o n e r and K e y I n f o r m a n t s t u d i e s w e r e r i c h in o p e n - e n d e d c o m m e n t s a b o u t t h e s e r i o u s n e e d s of t h e d e p r e s s e d or m e n t a l l y - i m p a i r e d o l d e r p e r s o n s . T w o — t h i r d s of t h e K e y I n f o r m a n t s r a t e d t h e c h r o n i c a l l y m e n t a l l y — i m p a i r e d as a h i g h e s t p r i o r i t y t a r g e t g r o u p . T h e L i t e r a t u r e S e a r c h i d e n t i f i e d s e v e r a l e x p e r i m e n t s at A n d r u s C e n t e r a n d U C L A w h i c h d e m o n s t r a t e d e f f i c a c y of t r e a t m e n t of d e p r e s s i o n . 5. U n m e t n e e d s to P r a c t i t i o n e r a nd u n r e s o l v e d i s s u e as w e l 1 a s th d o c u m e n t e d c o u n t y t r y to c o n n e c t a f f o r d a b l e h o m e c M u l t i p u r p o s e S e n c h o r e w a s t h e s e v e r 1y — i mpai r e d deal w i t h r e p o r t e d a d u l t a b u s e w e r e n o t e d in t h e K e y I n f o r m a n t s t u d i e s , and w e r e a s e r i o u s in t h e A l t e r n a t i v e s s tudy. T h e s e t h r e e s t u d i e s , t e l e p h o n e s u r v e y s by O n o d e r a a n d S t e i n e r , — w i d e f r u s t r a t i o n s of w o r k e r s and f a m i l i e s w h o a n d m a t c h f ra i l e l d e r s w i t h a c c e p t a b l e and h o r e s e r v i c e s . T h e s t a t e - w i d e e v a l u a t i o n of t h e ior S e r v i c e s P r o j e c t (MSSP) r e p o r t e d t h a t h o m e m o s t c r u c i a l r e s o u r c e for c a r i n g for e l d e r s at home. 22 106 A cotpr theits ivt systet of long-tert care teats that, E x i s t i n g pr-ogr-aims o-f I_TC must have substmnti ml impf-ovemsnts in a u a 1 i t v - ACTION EXAMPLES 1. Local f u n d i n g b o d i e s , i n c l u d i n g t h e A r e a A g e n c i e s o n A g i n g , s h o u l d i n c r e a s e t h e i r e f f o r t s to i m p r o v e a n d r e g u l a t e s t a n d a r d s of p r a c t i c e a n d p r o g r a m s in t h e A g i n g N e t w o r k . 2. E d u c a t i o n a l a n d t e c h n i c a l a s s i s t a n c e o r g a n i z a t i o n s s h o u l d i n c r e a s e t h e i r o u t r e a c h t o p r a c t i t i o n e r s a n d a d m i n i s t r a t o r s a n d p r o v i d e p r a c t i c a l i n - s e r v i c e t r a i n i n g for w o r k w i t h t h e e l d e r l y a s well as f o r m a l e d u c a t i o n f or p r o f e s s i o n a l c a r e e r s in a g i n g servi c e s . 3. A d m i n i s t r a t o r s s h o u l d t a k e a d v a n t a g e of a v a i l a b l e r e s e a r c h e x p e r t i s e t o c o n d u c t r i g o r o u s e v a l u a t i o n r e s e a r c h of t h e e f f i c a c y of t h e i r p r o g r a m s a n d of s y s t e m c o n d i t i o n s w h i c h m a y d i m i n i s h p r o g r a m i m p a c t . 4. T h e A r e a A g e n c i e s on A g i n g , in c o o p e r a t i o n w i t h s e r v i c e p r o v i d e r s , s h o u l d c o n t i n u e to c o n v e n e p e r i o d i c t r a i n i n g c o n f e r e n c e s at b o t h c o u n t y — w i d e and s u b - c o u n t y l e v els. RESEARCH BRIEFS 1. T h i s s t u d y w a s d e s i g n e d t o e v a l u a t e t h e L T C s y s t e m L.A. C o u n t y a n d n ot i n d i v i d u a l p r o g r a m s , s p e c i f i c p r o f e s s i o n s , or p a r t i c u l a r d e c i s i o n — m a k e r s . H o w e v e r , in t h e c o u r s e of d i s c u s s i o n s , s o m e g e n e r a l i z a t i o n s w e r e m a d e b y P r a c t i t i o n e r s a b o u t s e t s of a c t o r s w i t h i n t h e s y s t e m . M a n y c a n d i d c o m m e n t s of h u m i l i t y a n d c o n c e r n s w i t h p r o f e s s i o n a l c o m p e t e n c e w e r e e x p r e s s e d . "There is somewhat of a double standard; what we recommend for our patients is not always what we would do for our own families.* "We sometimes provide (our kind of service) because it is available, yet in some cases a different kind of care might be better for them." "Some older persons and families respect our professional Judgement, yet sometimes, in crises, we may not have all the necessary facts." "Often we professionals and providers suffer from lack of knowledge about available services. Staffs need to be better informed.” It w a s r e c o g n i z e d t h a t w r o n g t r e a t m e n t of a p r o b l e m c o u l d c a u s e d e c r e a s e d f u n c t i o n a l a b i l i t y . "The p a t i e n t c a n s u f f e r i a t r o g e n i c d a m a g e in t h e h e a l t h c a r e s y s t e m , n ot o n l y p h y s i c a l l y b ut a l s o in t e r m s of l e a r n e d h e l p l e s s n e s s and d e p e n d e n c e . " S o m e t y p e s of w o r k e r s w e r e th e o b j e c t s of d i r e c t c r i t i c i s m , e.g. s o m e h o m e - c h o r e a t t e n d a n t s w e r e " u n d e p e n d a b l e " a n d " u n w i l l i n g t o d o t h e d i r t y w o r k " . S u c h c o m m e n t s w e r e n o t g e n e r a l i z a t i o n s a b o u t t h e e n t i r e g r o u p b u t r a t h e r p l e a s f o r c l o s e r s u p e r v i s i o n t o r e c o g n i z e a n d c o r r e c t b a d e x a m p l e s w h e r e t h e y ex i s t . 107 A n o t h e r set of c r i t i c i s m s c e n t e r e d on n u r s i n g h o m e so c i a l s e r v i c e d e s i g n e e s . " T h e r e a r e n o q u a l i f i c a t i o n s t o b e c o m e a so c i a l s e r v i c e d e s i g n e e so y o u c a n n o t b e s u r e h o w well t h e y will d o t h e i r job." E f f e c t i v e d e s i g n e e s w e r e r e p o r t e d to b e l i a i s o n s b e t w e e n t h e p a t i e n t , f a m i l y , S N F a n d o u t s i d e r e s o u r c e s . O t h e r s w e r e r e g a r d e d t o be "on p a p e r o n l y " t o meet l i c e n s i n g s t a n d a r d s . In o r d e r to o v e r c o m e a la c k of a w a r e n e s s , o n e M P C d e v e l o p e d an a u d i o v i s u a l p r e s e n t a t i o n d e p i c t i n g i ts s e r v i c e s w h i c h w a s s h o w n t o h o s p i t a l d i s c h a r g e u n i t s t o p r o m o t e h o m e care. P r a c t i t i o n e r s r e v e a l e d m i s p e r c e p t i o n s of t h e f u n c t i o n s of o t h e r a g e n c i e s a n d t h e i r u n a w a r e n e s s of I n f o — line. M a n y p u r c h a s e d t h e g a m e d s i m u l a t i o n " D e c i s i o n s a nd D i l e m m a s " , u s e d b y t h e S t a y i n g at H o m e r e s e a r c h (and s o l d at O r e g o n S t a t e U n i v e r s i t y ) , f o r a t r a i n i n g a i d a b o u t L T C f o r s t a f f a n d B o a r d g r o u p s . 2. K e y I n f o r m a n t s w e r e q u i t e s p e c i f i c a b o u t t h e i r c o n c e r n s th a t the q u a l i t y of s e r v i c e s t o t h e f r a il e l d e r l y in L.A. C o u n t y w a s d e f i c i e n t . P r a c t i t i o n e r s in a g i n g p r o g r a m s w e r e n o t s e e n as k n o w l e d g e a b l e a b o u t l o n g t e r m care. T h e r e w a s r e p o r t e d t o b e a " d e t e r i o r a t i o n of s t a f f e x p e r t i s e in all i n s t i t u t i o n s " . T h e y r e c o m m e n d e d : * I n c r e a s e t r a i n i n g for h e a l t h & s o c i a l s e r v i c e s p e r s o n n e l ; * R e q u i r e p r o f e s s i o n a l s c h o o l s t o i n c l u d e a g i n g in c u r r i c u l a ; * R e q u i r e s o c i a l w o r k s k i l l s f or p r o t e c t i v e s e r v i c e s sta f f ; * I n c r e a s e g e r i a t r i c f e l l o w s h i p s ; * I n i t i a t e i n c e n t i v e s to h i r e m a s t e r s - 1 e v e l g r a d u a t e s ; » E n c o u r a g e u s e of m u l t i - d i s c i p l i n a r y t e a m c a re. W h i l e t h e s e r e p o n d e n t s e m p h a s i z e d f o r m a l t r a i n i n g r e m e d i e s , t h e y r a n k e d c o n f e r e n c e s well a b o v e J o u r n a l s / B o o k s , R e p o r t s , E d u c a t i o n a l C o u r s e s , or M a s s M e d i a a s t h e i r m a j o r s o u r c e s of n e w p r o f e s s i o n a l i n f o r m a t i o n . T r a i n i n g C o n f e r e n c e s as m e a n s fo r u p g r a d i n g k n o w l e d g e a n d s k i l l s w e r e a l s o r e c o m m e n d e d in C e b u l a ' s r e p o r t to t h e C i ty A A A ( L S 4 ) . 3. R e p o r t s b y H a s h e m i , W a s s e r m a n , O n o d e r a a n d S t e i n e r a s s e r t e d that m a n y M P C s d i d n o t h a v e s t aff w i t h s u f f i c i e n t k n o w l e d g e and skills f o r LTC. W a s s e r m a n r e c o m m e n d e d L T C p e r f o r m a n c e - b a s e d f u n d i n g b y t h e C i t y A A A a n d c o n s i d e r a t i o n of p r o g r a m d i r e c t o r q u a l i f i c a t i o n s in s e l e c t i n g g r a n t e e s . 4. G o o d m a n , S t e v e n s o n a n d P y n o o s r e p o r t e d t h a t m a n y B & C o p e r a t o r s l a c k e d p r e p a r a t i o n f or d e a l i n g w i t h t h e n e e d s of r e s i d e n t s . 5. T h e H e a l t h S y s t e m s A g e n c y r e c o m m e n d e d m o d i f i c a t i o n of s t a t e r e g u l a t i o n s g o v e r n i n g t h e t r a i n i n g of R N s a nd L V N s t o i n c l u d e i n s t r u c t i o n in g e r i a t r i c s a n d f u r t h e r s t u d y of p r o b l e m s of r e c r u i t i n g a n d r e t a i n i n g n u r s e s ' ai d e s . 6. T h e c h o i c e s of w o r k s h o p s at t h e " T L C in L T C " T r a i n i n g C o n f e r e n c e w e r e e v i d e n c e of p r i o r i t i e s in t r a i n i n g . Of 26 w o r k s h o p s , t h e l a r g e s t e n r o l l m e n t s w e r e t h o s e a b o u t c a s e m a n a g e m e n t , e t h n i c i t y , A l z h e i m e r ' s a n d o t h e r d e m e n t i n g i l l n e s s e s ; n e w r o l e s in L T C for M P C s , e t h i c a l d i l e m m a s in LTC, a d u l t d a y c a r e, a n d an o v e r v i e w of t h e L T C s y s t e m . 24 108 A cotpr ehens ive systet of long-tert care teats that: The p ui b 1 i c — at — Imrge, includ ing elder-B and practi ti oners must have easier- access to i nf ormat i on about LTC option and how to find them. ACTION EXAMPLES 1. F u n d e r s a n d p r o v i d e r s o-f v a r i o u s -forms o-f i n f o r m a t i o n a n d r e f e r r a l a n d "hot l i n e s " m u s t d e v e l o p j o i n t l y a c o h e r e n t , e f f e c t i v e s y s t e m of I&R in LT C . S u c h a n e t w o r k , w h i c h s h o u l d i n c l u d e t h e M P C s , h o s p i t a l d i s c h a r g e u n i t s a n d I n f o l i n e , m u s t be c o m p r e h e n s i b l e t o c o n s u m e r s a n d p r a c t i t i o n e r s a n d b e m o n i t o r e d f or q u a l i t y a s s u r a n c e a nd r e l i a b i l i t y . 2. T h e A r e a A g e n c i e s on A g i n g s h o u l d m o b i l i z e m e d i a a n d p u b l i c r e l a t i o n s e x p e r t i s e t o p l a n a n d i m p l e m e n t an o n - g o i n g c a m p a i g n to i n f o r m e l d e r s a n d f a m i l i e s a b o u t h o m e c a r e a l t e r n a t i v e s . 3. I n d i v i d u a l s e r v i c e p r o v i d e r s and, in p a r t i c u l a r , t h e m u l t i p u r p o s e c e n t e r s , s h o u l d t a k e t h e i n i t i a t i v e in k e e p i n g h o s p i t a l a n d n u r s i n g h o m e d i s c h a r g e p l a n n e r s i n f o r m e d a b o u t h o m e c a r e r e s o u r c e s in t h e s e r v i c e a r e a. 4. N e w s u r v e y r e s e a r c h i s n e e d e d to u p d a t e k n o w l e d g e of t h e p u b l i c ' s p e r c e p t i o n s a n d m i s p e r c e p t i o n s a b o u t t h e " i n e v i t a b i l i t y " of i n s t i t u t i o n a l i z a t i o n . a n d t h e r e s o u r c e s a v a i l a b l e for h o m e - b a s e d care. S u c h k n o w l e d g e w o u l d p r o v i d e a b a s e for d e s i g n i n g p u b l i c i n f o r m a t i o n s t r a t e g i e s . RESEARCH BRIEFS 1. P r a c t i t i o n e r s t e n d e d t o p l a c e q u o t a t i o n m a r k s a r o u n d t h e w o r d " s y s t e m " w h e n d i s c u s s i n g l o n g - t e r m care. T h e y i m p l i e d t h a t t h e s y s t e m w a s m o r e like a p a t c h w o r k or R u b i e s cube. F o r t h n e c e s s i t y in o r d e r to b e a w a r e of f r o m s e r v i c e s . O f t e n it w a s n o t t h e p r o b l e m - it w a s t h e a b i l i t y " F i g u r i n g o u t t h e s y s t e m " w a s i n d e p e n d e n c e . M a n y of t h e f r a i l frail e l d e r l y , a c q u i r i n g i n f o r m a t i o n w a s d e e m e d a t h e i r c h o i c e s a n d t o b e n e f i t t h e l a c k of i n f o r m a t i o n t h a t w a s t o m a k e u s e of i n f o r m a t i o n , a key b a r r i e r t o m a i n t a i n i n g r e p o r t e d l y d i d n o t h a v e t h e e n e r g y to a r r a n g e s e r v i c e s f o r t h e m s e l v e s . F a m i l y m e m b e r s , too, o f t e n l a c k e d i n f o r m a t i o n a n d s y s t e m k n o w - h o w . T h e y o f t e n f a i l e d to s e e k o ut i n f o r m a t i o n a b o u t a l t e r n a t i v e s b e c a u s e t h e y a s s u m e d t h a t c h r o n i c a l l y ill o l d e r p e o p l e m u s t i n e v i t a b l y b e i n s t i t u t i o n a l i z e d . F a m i l i e s d o h e l p o b t a i n i n f o r m a t i o n a n d p r o v i d e m o b i l i t y t o t h o s e p a t i e n t s w h o n e e d a c c e s s t h r o u g h t r a n s p o r t a t i o n or e s c o r t . T h e f a m i l y - l e s s e l d e r l y h a d e v e n g r e a t e r d i f f i c u l t i e s in a c c e s s to a n d a c q u i s i t o n of s e r v i c e s . 2 5 10 9 1 It was a s s e r t e d t h a t h e a l t h a n d s o c i a l s e r v i c e w o r k e r s l a c k e d u p - t o - d a t e k n o w l e d g e a b o u t w h a t w a s a v a i l a b l e in t h e c o m m u n i t y or w h a t s t e p s t o t a k e t o o b t a i n s e r v i c e s . In v i r t u a l l y n o c a s e s h a d t h e w o r k e r m a d e e f f e c t i v e u s e of I n f o - l i n e (the g e n e r i c c o u n t y — w i d e i n f o r m a t i o n a n d r e f e r r a l a g e n c y ) or of o n e of t h e local I&Rs t h a t s p e c i a l i z e in aging. O c c a s i o n a l l y t h e r e w e r e s u g g e s t i o n s f o r i n c r e a s e d e f f o r t s to e d u c a t e t h e e l d e r l y a n d t h e p u b l i c — a t - l a r g e t h r o u g h t h e m a s s media. P r a c t i t i o n e r s a l l o c a t e d 12% of t h e i r s i m u l a t i o n d o l l a r s t o t h i s o b j e c t i v e . I n t e r p r e t a t i o n of r a t i n g s m u s t t a k e i n t o a c c o u n t t h a t c h o i c e s w e r e u n d o u b t e d l y a m i x t u r e of c o n c e r n a b o u t t he p r o b l e m a nd c o n f i d e n c e in t h e e f f i c a c y of t h e s o l u t i o n . A s o n e p a r t i c i p a n t s t a t e d , " I w o u l d h a v e p u t m o r e m o n e y i n t o p u b l i c a t t i t u d e s ' b u t I d i d n ' t s e e h o w m o n e y w o u l d m a k e a d i f f e r e n c e " (i.e. w e d o n ' t h a v e a n y e f f e c t i v e w a y s t o c h a n g e a t t i t u d e s ) . 2. K e y I n f o r m a n t s r a n k e d " l a c k of i n f o r m a t i o n a b o u t a v a i l a b l e o p t i o n s " at t h e t o p of t h e list of c h a r a c t e r i s t i c s i m p o r t a n t t o o v e r c o m e . T h e y s a w e f f e c t i v e i n f o r m a t i o n as a c o m b i n a t i o n of a c c e s s to i n f o r m a t i o n a n d a t t i t u d e s w h i c h m a k e t h a t i n f o r m a t i o n u s e a b l e . M o s t v i e w e d r e c e n t m a s s m e d i a c o v e r a g e a s m a k i n g a p o s i t i v e c o n t r i b u t i o n to L T C i n f o r m a t i o n a n d a t t i t u d e s e x c e p t t h a t "rec e n t e m p h a s i s o n a l t e r n a t i v e s t o i n s t i t u t i o n a l i z a t i o n c r e a t e s a f a l s e i m p r e s s i o n t h a t o n e is a s u b s t i t u t e f or t h e o t h e r . " T h e r e w e r e m a n y s u g g e s t i o n s in t h i s a r e a , s u c h as: * P r o v i d e m e d i a w i t h i n f o r m a t i o n o n n e w L T C d e v e l o p m e n t s ; * L T C a g e n c i e s s h o u l d h a v e " o pen h o u s e " w i t h m e d i a c o v e r a g e ; * D e v e l o p i n f o r m a t i o n c a m p a i g n s ; I m p r o v e L T C o u t r e a c h ; * S c h o o l s s h o u l d i n c l u d e a g i n g c o n t e n t f o r youth; * D e v e l o p c o n s o r t i a of L T C g r o u p s t o e d u c a t e m edia; * I n c r e a s e p u b l i c m e e t i n g s of c o n s u m e r s a n d p r o f e s s i o n a l s ; * D i s s e m i n a t e i n f o a b o u t i n s u r a n c e s e l e c t i o n ; * D i s s e m i n a t e i n f o a b o u t o r g a n i c b a s e s of d e m e n t i a ; 3. O n o d e r a ' s t e l e p h o n e s e a r c h f o r r e s p i t e c a r e r e v e a l e d t y p i c a l o b s t a c l e s t o o b t a i n i n g i n f o r m a t i o n . " G e n e r a l l y I f o u n d t h e f r o n t - l i n e i n d i v i d u a l s (who a n s w e r e d t h e p h o n e ) to b e p o l i t e b u t u n k n o w l e d g e a b l e a b o u t t h e long t e r m c a r e s y s t e m . T h e b r e a d t h of t h e i r k n o w l e d g e u s u a l l y c e n t e r e d on t h e i r o w n a g e n c y . ... M a n y k n e w t h a t o t h e r s e r v i c e s e x i s t e d but c o u l d n ' t n a m e them. ... F o u r to f i v e t e l e p h o n e c a l l s w e r e r e q u i r e d t o m a k e c o n t a c t w i t h t h e ( a p p r o p r i a t e ) s e r v i c e p r o v i d e r . T h e t e l e p h o n e l i n e s w e r e f r e q u e n t l y b u s y a n d t h e i n q u i r e r w a s o f t e n p u t on h o l d f o r as l o n g as f i v e m i n u t e s . T h e q u a l i t y of i n f o r m a t i o n a v a i l a b l e t h r o u g h t h e s e c h a n n e l s w a s m o d e r a t e to p o o r " . 2 6 im. Â coaprehens syste» of Jonç-ter» care aeans that: Effect! ve r*e — education and incentives must be devised to change behaviors of oHvsician g d ding e h a b i di agnose litation , placement of elder's. ACTION EXAMPLES 1. T h e r e s h o u l d b e in L.A. C o u n t y a p r o g r a m o-f m a n d a t o r y p r e s c r e e n i n g to p r e v e n t p h y s i c i a n s f r o m i n s t i t u t i o n a l i z i n g e l d e r s ■for w h o m a f e a s i b l e h o m e — c a r e p r o g r a m c a n b e d e v i s e d . P u b l i c f u n d i n g b o d i e s s h o u l d r e f u s e t o r e i m b u r s e n u r s i n g h o m e c o s t s u n l e s s t h e r e is e v i d e n c e of p r i o r c o n s i d e r a t i o n of a l t e r n a t i v e s a n d / o r a r e h a b i l i t a t i v e t r e a t m e n t p l a n w h e n f e a s i b l e . 2. A g e n c i e s w i t h c h a n n e l s of c o m m u n i c a t i o n to t h e e l d e r l y or t h e i r f a m i l i e s s h o u l d i n c r e a s e e f f o r t s t o i n f o r m t h e m of c o n s u m e r r i g h t s t o a s e c o n d p r o f e s s i o n a l o p i n i o n , to r e h a b i l i t a t i v e t r e a t m e n t , full p a r t i c i p a t i o n in t h e p l a c e m e n t d e c i s i o n , a n d at l e a s t l i m i t e d a c c e s s to h o m e — c a r e r e s o u r c e s . 3. E d u c a t i o n a l p r o f e s s i o n a l s o p t i o n s a n d r e s o u r c e s . p r o g r a m s f o r p h y s i c i a n s a n d a l l i e d h e a l t h s h o u l d i n c l u d e a m p l e e x a m i n a t i o n of h o m e - c a r e i n f o r m a t i o n a b o u t h o w t o a c c e s s a p p r o p r i a t e 4. P h y s i c i a n s w h o a r e a l r e a d y w e l l - i n f o r m e d a b o u t g e r i a t r i c s a n d h o m e - c a r e o p t i o n s s h o u l d f o r m a P h y s i c i a n ' s C o m m i t t e e for L T C R e f o r m . S u c h a c o m m i t t e e w o u l d n o t o n l y f o c u s on s y s t e m n e e d s a nd i n f o r m i n g o t h e r p h y s i c i a n s , but w o u l d a l s o b e an i n f o r m a t i o n s o u r c e f or a d m i n i s t r a t o r s and p r a c t i t i o n e r s s e e k i n g p h y s i c i a n p e r s p e c t i v e s a n d e f f e c t i v e i n t e r a c t i o n s . RESEARCH BRIEFS 1. T h e m a j o r i t y of p a r t i c i p a t i n g p r a c t i t i o n e r s a p p e a r e d t o a c c e p t t h e p h y s i c i a n ' s r o l e as m o s t c r u c i a l r o l e in L T C d e c i s i o n s . But w h e n s p e c i f i c c a s e s w e r e d i s c u s s e d t h e p h y s i c i a n o f t e n e m e r g e d as t h e o b j e c t of c r i t i c i s m . P h y s i c i a n s w i t h m a n y g e r i a t r i c p a t i e n t s w e r e s e e n as m o r e s e n s i t i v e to n e e d s of the e l d e r l y . It w a s n o t e d that o l d e r p e r s o n s or r e l a t i v e s o f t e n e x a g g e r a t e d t he p o w e r of t h e M.D. a n d w e r e t i m i d a b o u t a s k i n g q u e s t i o n s . S o m e t i m e s d o c t o r s , r e c e p t i v e t o a l t e r n a t i v e s , w e r e p r e s s u r e d by r e l a t i v e s to a p p r o v e i n s t i t u t i o n a l care. H o s p i t a l w o r k e r s r e p o r t e d a p o s i t i v e c h a n g e in M D s ' c o o p e r a t i o n w i t h d i s c h a r g e p l a n n i n g a s a r e s u l t of p r e s s u r e s for c o s t c o n t a i n m e n t . P r a c t i t i o n e r s a c k n o w l e d g e d t h a t p h y s i c i a n s w h o a s s i s t e d in k e e p i n g a frail p e r s o n at h o m e w a s s u b j e c t to t h e s a m e b u r n o u t p r o b l e m as h o m e - c a r e w o r k e r s a n d i n f o r m a l c a r e g i v e r s . 2 7 I l l E x a m p l e * w e r e g i v e n of p h y s i c i a n s m a k i n g d e c i s i o n s b a s e d on a g e i s t a t t i t u d e s or p r o t e c t i o n of t h e i r own v a l u a b l e t i m e ( " y o u ' r e just g e t t i n g old, d e a r y " ) . " S o m e t i m e s d o c t o r s u n d e r e s t i m a t e the i m p o r t a n c e to p a t i e n t s a n d c a r e g i v e r s of r e g a i n i n g o r m a i n t a i n i n g j ust a l i t t l e f u n c t i o n a l a b i l i t y t h r o u g h r e h a b i l i t a t i o n . " O n e r e h a b i l i t a t i o n w o r k e r c o n t a c t e d six p h y s i c i a n s b e f o r e f i n d i n g o n e w h o w o u l d a u t h o r i z e a p r o s t h e t i c limb for an 8 0 y e a r o l d p a t i e n t . O t h e r s r e l a t e d d i f f i c u l t i e s in o b t a i n i n g p h y s i c i a n o r d e r s f or p h y s i c a l or o c c u p a t i o n a l t h e r a p y . P r a c t i c e s w i t h m e d i c a t i o n s for the e l d e r l y w e r e a l s o c r i t i c i z e d . " P h y s i c i a n s p r e s c r i b e m e d i c a t i o n s that a r e v e r y e x p e n s i v e or not c o v e r e d by M e d i - C a l , a n d t h e p a t i e n t is n ot i n f o r m e d t h a t t h e r e a r e a l t e r n a t i v e s . " M a n y d o c t o r s f a i l e d t o m o n i t o r d o s a g e s and c o m b i n a t i o n s of m e d i c a t i o n s used by o l d e r p a t i e n t s r e s u l t i n g in p s e u d o — d e m e n t i a s . O n e g e r i a t r i c i a n s t a t e d , " D o c t o r s d o n ' t e q u a t e m e n t a l c h a n g e s w i t h a n y t h i n g that t h e y c o u l d p o s s i b l y b e d o i n g . " F a l s e d i a g n o s e s w e r e s e e n t o b e s u f f i c i e n t l y p r e v a l e n t t o w a r r a n t s e c o n d m e d i c a l o p i n i o n s b e f o r e r e l o c a t i n g or m a k i n g s i g n i f i c a n t l i f e s t y l e c h a n g e s for t h e frail elder. P h y s i c i a n s w e r e f r e q u e n t l y r e p o r t e d to b e r e s i s t i v e t o t h e u s e of h o m e h e a l t h c a r e b e c a u s e t h e y " d i d n ' t w a n t t o b e b o t h e r e d " by i n q u i r i e s f r o m h o m e h e a l t h w o r k e r s and f a m i l y c a r e g i v e r s . In s o m e c a s e s w h e r e p h y s i c i a n s w e r e r e p o r t e d to h a v e d i s c h a r g e d a p a t i e n t to home, i n s u f f i c i e n t a t t e n t i o n w a s p a i d t o e n v i r o n m e n t a l b a r r i e r s . H o m e c a r e w o r k e r s w e r e seen as b e t t e r i n f o r m e d a b o u t t h e s e a s p e c t s , b u t w e r e n o t con s u l t e d . L i k e m a n y o t h e r k i n d s of p r o f e s s i o n a l s , p h y s i c i a n s w e r e c r i t i c i z e d for not k n o w i n g e n o u g h a b o u t o p t ional s e r v i c e s , n o t t a k i n g e n o u g h t i m e to e x p l a i n w h a t is h a p p e n i n g to t h e p a t i e n t , a n d n o t b e i n g s e n s i t i v e t o t h e e m o t i o n a l s t r e s s e s b e i n g e x p e r i e n c e d b y p a t i e n t s and f a m i l y m e m b e r s . 2. K e y I n f o r m a n t s a l s o h a d h o p e s a n d f r u s t r a t i o n s c o n c e r n i n g n o n — g e r i a t r i c p h y s i c i a n s . T h e i r r e c o m m e n d a t i o n s i n c l u d e d : * Increase consciousness & education of physicians; * Narrow distance between medical & social personnel; « Improve geriatric training; More geriatric fellowships for MDs; * More geriatric nurse practitioners; * A multi-disciplinary approach with a dedicated primary care MD; t Educate MDs regarding elder rights. It w a s n o t e d t h a t n e w e r c o h o r t s e n t e r i n g t h e r a n k s of t h e e l d e r l y w e r e l i k e l y to d e m a n d m o r e h o m e care o p t i o n s , b e c o m e k n o w l e d g e a b l e a b o u t e n t i t l e m e n t s , and t a k e c h a r g e of t h e i r o w n h e a l t h c a r e . 3. T h e H S A r e c o m m e n d e d t h a t L.A. C o u n t y d e v e l o p s t a n d a r d s for p l a c e m e n t and e v a l u a t i o n f or c o n t i n u e d s t a y s . T h e P l a n a l s o s u g g e s t e d that t h e L.A. C o u n t y Medical A s s o c i a t i o n a n d h o s p i t a l s s p o n s o r i n f o r m a l m e e t i n g s to a c q u a i n t L T C p r o f e s s i o n a l s wi t h b e n e f i t s of h o m e h e a l t h s e r v i c e s . 4. E v a l u a t i o n s of t h e V A ' s G e r i a t r i c E v a l u a t i o n U n i t a n d U C L A ' s t r e a t m e n t of g e r i a t r i c d e p r e s s i o n s u g g e s t e f f e c t i v e r e h a b i l i t a t i v e i n t e r v e n t i o n s g e n e r a l l y o v e r l o o k e d in g e n e r a l p r a c t i c e . 20 112T S O U R C E S OF I N F O R M A T I O N u m e d in t h i m r e o o r t The suaaêr t es o1 findings in this report ere brief references fron 12 substudies conducted as part of the “Staying at Hoae” Project and fron 13 independent studies conducted in Los Angeles County Nhich were identified in our literature searches. He apologize in advance for the inevitable distortions mhich result fron ’out-of-context’ excerpts fron full reports tthich are listed belou. "STAYING AT HOME" REPORTS bv ANDRUS CENTER FACULTY. STUDENTS and VOLUNTEERS 1. F r o n t l i n e P r a c t i t i o n e r s ' V i e w s of L o n g - t e r m C a r e in L o s A n g e l e s C o u n t y , J u l y 1984, by S t e i n b e r g , P.M. & Tr e j o , L. 2. P e r s p e c t i v e s on L o n g T e r m C a r e in L o s A n g e l e s C o u n t y : A S u r v e y of K e y I n f o r m a n t s , O c t o b e r 1 9 8 4 b y Whi t e , M. 3. F i n a l R e p o r t : L o n g - T e r m C a r e T r a i n i n g C o n f e r e n c e , S e p t e m b e r 1984, by C e b u l a , D. 4. A S t u d y of G e o g r a p h i c a l I n e q u i t y , M a y 1985, b y L o w e , B. 5. G a t e k e e p i n g in B o a r d a n d C a r e for O l d e r A d u l t s : T h e M a r g i n a l R e s i d e n t , April 1985, b y G o o d m a n , C.C. (with S t e v e n s o n , L.M. & P y n o o s , J .) 6. A n A n a l y s i s of H o w A u s p i c e s a n d A d m i n i s t r a t o r P r e p a r a t i o n A f f e c t W h o Is S e r v e d by B o a r d a n d C a r e H o m e s f o r t h e E l d e r l y , ( M a s t e r s T h e s i s ) , M a y 1985, b y S t e v e n s o n , L. M. 7. C a r e g i v e r s P r o j e c t : W h o C a r e s ? H e l p f u l H i n t s f o r t h o s e w h o c a r e f o r a d e p e n d e n t o l d e r p e r s o n at h o m e (vol 1); B i b l i o g r a p h y f o r C a r e g i v e r s (vol 2); I n v e n t o r y of C a r e g i v e r S u p p o r t P r o g r a m s (vol 3) b y A n d r u s V o l u n t e e r s , 1 9 8 5 8. A l t e r n a t i v e A p p r o a c h e s t o C o n s e r v a t o r s h i p a n d P r o t e c t i o n of O l d e r A d u l t s : Final R e p o r t , (in p r o c e s s ) by S t e i n b e r g , R.M. 9. T h e R e l i g i o u s S e c t o r ' s R o l e in t h e P l a n n i n g , P r o m o t i o n , a n d P r o v i s i o n of S u p p o r t i v e S e r v i c e s for t h e E l d e r l y in L o s A n g e l e s C o u n t y : C a l 1 a b o r a t i o n w i t h A r e a A g e n c i e s on A g i n g , ( M a s t e r s T h e s i s , in p r o c e s s ) b y M i l l s , V. L. 1 0 . T e l e p h o n e S u r v e y of R e s p i t e C a r e P r o v i d e r s , M a r c h 1985, b y O n o d e r a , M. 1 1 . T e l e p h o n e S u r v e y of S e n i o r C e n t e r s I n - H o m e S u p p o r t i v e S e r v i c e s , A p r i l 1985, b y S t e i n e r , A. ( P r e p a r e d f o r R e s p i t e Mod e l P l a n , W e s t s i d e I n d e p e n d e n t S e r v i c e s f o r t h e E l d e r l y : WISE) 1 2 . L i t e r a t u r e S e a r c h of L T C R e s e a r c h a n d R e c o m m e n d a t i o n s f o r L.A. C o u n t y , M a y 1985, Trejo, L . , K o e g l e r , C . , & S t e i n b e r g , R.M. 2 9 113 SELECTED REFERENCES from the LITERATURE SEARCH LSI. H e a l t h S y s t e m s A g e n c y P l a n , 1981 Final Report; A L o n g T e r m C a r e S t u d y in R e l a t i o n to t h e S e n i o r M u l t i p u r p o s e C e n t e r s In the C i t y of L o s A n g e l e s , 1982, W a s s e r m a n , I. ( G e r o n t o l o g i c a l S o c i e t y of A m e r i c a a n d L os A n g e l e s C i t y D e p a r t m e n t of A ging) LS3. D e v e l o p i n g L o n g T e r m C a r e : A F r a m e w o r k f o r t he L o s A n g e l e s C o u n t y AAA, 1982, A P r o j e c t of SCAN, U S C A n d r u s G e r o n t o l o g y C e n t e r & U C L A / U S C L o n g T e r m C a r e G e r o n t o l o g y C e n t e r LS4. E v a l u a t i o n R e p o r t a n d R e c o m m e n d a t i o n s t o t h e Los A n g e l e s C i t y A A A on the L o n g T e r m C a r e P r o j e c t for S e l e c t e d M u l t i p u r p o s e C e n t e r s , 1983, b y D o t t i e C e b u l a LS5. Fr F r o m H o s p i t a l to N u r s i n g Home; T he L o n g - t e r m C a r e C o n n e c t i o n , D e c e m b e r 1984, b y K a n e , R.L. & M a t t h i a s , R. (in T h e Gerontologist, 24, 6) LSÀ. O r g a n i z a t i o n a l C a p a b i l i t i e s of N i n e L o s A n g e l e s M u l t i p u r p o s e C e n t e r s in I m p l e m e n t i n g C a s e M a n a g e m e n t , S e p t e m b e r 1984, H a s h e m i , L.A. ( G e r o n t o l o g i c a l S o c i e t y of A m e r i c a a n d L o s A n g e l e s C i t y D e p a r t m e n t of A g ing) LS7. The S e p u l v e d a VA G e r i a t r i c E v a l u a t i o n U n it: D a t a o n Foui— y e a r O u t c o m e s and P r e d i c t o r s of I m p r o v e d P a t i e n t O u t c o m e s , J u l y 1984, b y R u b e n s t e i n , L. Z. et al (in J o u r n a l of t h e A m e r i c a n G e r i a t r i c S o c i e t y , 32, 7) LSS. T r e a t i n g G e r i a t r i c D e p r e s s i o n : A 2 6 - w e e k I n t e r i m A n a l y s i s , N o v e m b e r 1982, b y J a r v i k , L.F. et al, (in J o u r n a l of t h e American G e r i a t r i c S o c i e t y , 30, 11) LS9. N e e d f or G r e a t e r C o o r d i n a t i o n of S e r v i c e s t o A d u l t s , F e b r u a r y 1985, b y G l o r i a T i s c a r e n o , C h a i r , S e n i o r C o n c e r n s C o m m i t t e e , L o s A n g e l e s C o u n t y 1 9 8 4 - 1 9 8 5 G r a n d J u r y , G l o r i a D e W i t t , F o r e m a n L S I O . D i f f e r e n c e s O v e r T i m e in S u b j e c t i v e B u r d e n B e t w e e n M e n a n d W o m e n C a r e g i v e r s , (in p r e s s ) b y Todd, P. A., Zarit, J. M. R, Zarit, S. H. L S l l . D e c r e a s i n g B u r d e n in F a m i l i e s C a r i n g f o r a R e l a t i v e w i t h a D e m e n t i n g Illness: A C o n t r o l l e d Study, 1984, by K a h a n , J., Kem p , B . , S t a p l e s , F.R. & B r e u m m e l - S m i t h , K. ( R e h a b i l i t a t i o n R T C e n t e r on A g i n g , R a n c h o L o s A m i g o s ) L S 1 2 . S y s t e m a t i c B i a s e s in F u n c t i o n a l S t a t u s A s s e s s m e n t of E l d e r l y A d u l t s : E f f e c t s of D i f f e r e n t D a t a S o u r c e s , N o v e m b e r 1984, b y R u b e n s t e i n , L.Z. et al (in J o u r n a l of G e r o n t o l o g y , 3 9 , 6) L S 1 3 . I n t e r g e n e r a t i o n a l N e i g h b o r h o o d N e t w o r k s : A B a s i s f o r A i d i n g t h e F r a i l E l d e r l y , J u n e 1984, by P y n o o s , J. et al (in The' G e r o n t o l o g i s t , 24, 3) 30 11.4 APPENDIX B DIAGRAM OF DECISION MODEL 115 M 1 —1 m Q* ( d O 1 p < D +j f d o p c 6 u PQ "H U1 o 0 ) -P ;> M t f d o Ü Qa ■H Q ) Pm (U <1 0 4J Q ) 4J O fi 0 P Ü Ü fi o 4J > -r4 < d g O P « E H > •H 13 0 'U < d fd fi 0 0) 4 -1 fi fi p Ui fU -H g rfi O fil fil E H O E - 4 o fi S O fi \ - H O ■ H Ui •r4 rfi -ri fi -P eu ü o fd 1 — 4 d) •r4 ü 0 Q W ■ H f i Q W 4-4 0 fi •P 0 H nd 0) ü M (A fi P 0 g w fd fd O fd ■ H O ■ H • — 1 rfi •H ü 4-4 % Q U P U Ui H •p4 Ui 4H Tî 4 -> fi p4 (D O fd O P Ui s r* en fd fd E r4 1-4 rfi 4-4 fi % Q U fU O t4 -P 1-4 U 0 13 g 0 0 O Q fi fd 4 -> -P eu p Ui P 0 4H o tn = > K O P u fd 1 ■ H Q .1 Ui 4J 13 eu O 0 fil fi rH 1 — 1 fil 4-4 o r4 -H C Q O p fd S O 0 m :s H -p Ui U] p H 0 s* U] o r-4 0 C eu fd O H 0 g p fi; pi; ü3 P U M a fiî s P u M fi» Pî Q W o fi: Q 116 APPENDIX C COPY OF INVITATION TO CONFERENCE 117 ' 6 0 C Q Mlllli % 6 ^ 60 3 60 o 2 'fill! I3d5 S C O u llllli îillli Q f ^ - S • § Œ I 118 c C f ) s li} if1 i 11 (/) C/D II Cfi O >-l -l CJ i ! B-2 S-s c u c m bC c u I I I 2 -Q c m i i n3 bO i l iî ^ c m C l , p ’ l i * c ^ c m r2 3 I I -G I t c S If II G G y <u Ui • ^ G <u G a O o G cu O <u o G 'rt -Q 1 CO a o -O rG 'a G a <u c3 G 4-1 O CÜ <u G -G s G g O -g 1 c .2 G "G G gj G u O .G <u CÜ U3 'G a G c G .2 2 o s a : < OO CJ a gj cu 119 I will participate in the June 18 Decision Conference of "Staying at Home" and accept the participant responsibilities described in the invitation. (signed)______________________________________ Please send the advance materials and follow-up report to: the same address used for the invitation, or the correct/changed address on this card I regret that I cannot participate: (signed)_____________________ NOTE: This is an invitational event and, due to goals for balanced representation, this invitation is not transferable. If you cannot attend, you may recom mend an alternate on the reverse side of this card. Please return this card in the enclosed envelope by May 15, 1985. For further questions call Conference Coordinator, Carolyn Koegler (213/743-6462) or Polly McConney (213/743-4108). 120 APPENDIX D DELPHI ROUND BALLOT 121 UO C J T J CU • H + J U h Q l x: D» Q . 122 APPENDIX E FACILITATOR'S GUIDELINES 123 COPY TRAINING FOR FACILITATORS STAYING AT HOME DECISION CONFERENCE June 18, 1985 - 12:00-4:00 University Hilton Hotel Facilitators* Guidelines On the day of the conference, please check in to receive name tag and packet. At the luncheon, seating will not be assigned for participants; however, we request that faciliators sit at separate tables. The reason for this will be explained later. Supplies for each group will be in the small rooms. Flip chart Force-Field Worksheets Felt pens Voting cards Masking -tape Form to record final vote Pens, pencils Large manila envelope Seating will be at conference tables with the flip chart at one end. Total Time : 75 minutes II. Welcome and brief explanation (.5 minutes--l:45~l:5Q) A. Purpose of structured small group process: to produce in a short time frame the best thinking of each individual in this group about the feasibility of the issue under consideration. B. QueStion/Statement : (Each group will have a different one.) C. The results of our effort will be reported to the entire group at 3:15 p. m. 124 III. Group Process Steps Step 1; 1:50-2:00 (10 minutes) Writing of key ideas silently and independently. Instruct the group that in the next 10 minutes they are to make two lists using brief phrases or a few word to describe: 1. What are the positive driving forces or pressures which are at work now or could be in the future to make this change occur? 2. What are the restraining (or counter) forces which might keep this change from occurring? The facilitator (and recorder) should set an example by silently writing also. For this method to work, the leader (and recorder) must be working participants. It is important to have an atmosphere that allow for silent, independent reflection and writing. After 10 minutes, call time. Step 2: 2:00-2:20 (2 0 •minutes) Round-robin recording of driving forces (10 minutes) and then the restraining forces (10 minutes Describe step to the group: "We will be going around the table ; for one idea from each member at a time, and will begin by listing the driving force; then the restraining forces. After all the ideas have been recorded we will have a discussion period, so let's hold discussion until then and just concentrate on getting all the ideas out." Go around the table asking for one idea at a time. Record ideas on the flip chart using the member's words whenever possible. Step 3: 2:20-2:40 (20 minutes) (Tell the group there are 20 minutes alioted for this step and that after this they will be asked to vote on the feasibility of the issue.) 125 Discussion and Clarification Begin with the driving forces. Read item one aloud and ask if there are any statements of agreement or disagree ment or statements of clarifications anyone would like to make. Do not ask the individual who proposed the item to explain it, clarify it, or discuss it, though he/she may volunteer to do so. You can say, "The author of an item need not feel obligated to clarify or explain the item— any member can feel free to do this." After discussion move on to the next item, etc. The point of this step is to insure that all members understand the statements--the logic or analysis behind them— not for arguing for or against any of them. Step 4; 2:40-3:00 (20 Minutes) A. Vote on feasibility of issues (independent voting will be by ballot) . Distribute ballots . Instruct the group to now carefully consider all the issues that have been presented and to vote their personal opinion on the ballot provided. . Tape up the illustration of the voting card numbers. B. Collect ballots— Tally votes To tally the votes: have the recorder read the votes; record individual votes under appropriate number on illustration. C. Record and calculate mean score of group on form provided. Use for report to entire group at 3:15 p.m. 126 After the vote tally, thank participants and instruct to return to the dining room for a coffee break--to be followed by group reports and a final vote. Report of Vote (at 3:15, after coffee break) Facilitators will be asked to stand and report results of the group vote. After Reports Open discussion of the individual issues will follow before the final vote. THANK YOUi 127 APPENDIX F FORCE FIELD WORKSHEETS 128 IL 129 0) - C w o o tu 130 o 1 — t t3 OC Û- < D U 1 3 1 APPENDIX G FORCE FIELD VOTING CARD 132 u M 0 1 o 3 0 ) O M l m O xz C O o C O O u 1 — 4 0 ) C D 0 ) U 0 0 o ( U O O 1 — 4 c M l 3 3 c o C O C > 0 ) X I C O O 3 3 E u 0 ) C E 1 - 4 O O O C O u c, c r — 4 O r - 4 o C O C O M l 3 w C M xs O 0 3 o 3 O x: • 4 - > C O 1 - 4 r - 4 C C O M 0 ) X) o • H r- 4 o u • H 3 u • H X a ; C M M "O X Z O • H M l x > - H 0 ) M > C M E E O- C O 1 - 4 C O M M l o D O 0) • H 0 0 O 3 C ' H 1 - 4 X C C M w r- 4 M C O 0 ) • H 3 0) C O 'iH O " O O O û C l » J= c C O C O r- 4 0) O c o 3 1 - 4 0 ) 0 ) p- M l 3 w m M • H > E xz CJ 0 ) u M ( U M > (U • H 3 1 - 4 o a : 1 - 4 0) O x : •r4 1 - 4 u 3 O U CL C L 4 J C 43 3 > u [L. U C L 3 1 - 4 C 3 o • H C l O M l M l C O C O W 1 - 4 L M a i CJ 3 C O M O 3 O O M l O O 00 M l U r - 4 3 f c * •• C M C L 1 - 4 c 3 S - i 3 O e n < U 3 C L • H O O U C O c C Û t- 4 U O a ; 1 — 4 C M O 3 a i o c r - 4 O -C 1 - 4 M r-4 X Z <c •H • H l-H 4 - + 1 1 133 APPENDIX H FORM FOR RECORDING MEAN SCORES 134 COPY REPORT OF SMALL GROUP VOTING RESULTS Room _____ Goal__________________ _____________ RESULTS ; Consensus: Plus (check if all votes above 0) Minus (check if all votes below 0) If there is consensus (e.g./ all above or all below zero) please report that in verbal report to entire group FOR ALL VOTES— PLEASE COMPLETE TO GET AVERAGE 4-2 X 4-1 X = Total 4 - A -1 X -2 X ___ = Total A minus B ______________ Total no. of voters -p- ___________ = Average ______________ (round to first decimal) Total Participants _______ 135 APPENDIX I POST-CONFERENCE EVALUATION FORM 136 I' P 1 c at s e h e l p us czt>mpJc±^ t h a " S t a y i Tt Ç s t Hume" project HI J t h a -f e HI more of your opinion As we mentjoried at the Decisiari CoTt-fer ence oti Jurie 1,9, we need your ev'aJ uat ion of' the Decision Cont'erencef and of arty other phases t.»f "Staying at Home"’ in mhich you par t i c i pated. This eyaJuation tuill be iTt eluded in our final report as gui dan ce to other commun i t i es mhich might seek to replicate our methods for research^and dissemination Appreciatioely^, Raymorld H. Steiiberg Carolyn ¥, Koeglei Andrus Ctr ontology Center , Un iver s ity of Southern California Los Angeles, CA 90099-0191 (213) 743-6462 A B O U T YOU: {Please circle appropriate category) S e x : M a l e F e m a l e Ages u n d e r 3 0 3 0 - 4 0 4 0 - 5 0 5 0 - 6 0 o v e r 6 0 O r g a n i z a t i o n a l S e t t i ng : (Circle nuwber only) ill hospital (51 SNF/ICF (21 HMD or S/HMO (61 acadesiic (31 social service (7) private practice (9> legislative body {10} other governmental {11} other non-governmental {4} residential (non-medical) (8) planning/coordination {12} advisory body C i v i c or P r o f e s s i o n a l Role: {1} clinician (4} planner (2) supervisor C5> educator (31 administrator (6} advocate {10} other;________________________ {7} volunteer {8} consultant {9} researcher Di sci pii ne : {1} public admin. {2} business {3} social work (10) other; {4} nursing {5} medicine/psychiatry {6} psychology {7} gerontology {9} law/politics {9} education A B O U T T H E P R E - C O N F E R E N C E P H A S E S : In w h i c h of t h e " S t a y i n g at H o m e " p h a s e s did y o u p a r t i c i p a t e ? {1} P r a c t i t i o n e r s ' D e b r i e f i n g s ■C23- K e y I n f o r m a n t s ' S u r v e y {3} T r a i n i n g C o n f e r e n c e : " T L C in L T C " (S e p t '84) {4} S e l e c t e d m e e t i n g s of L T C T a s k F o r c e {5} O n e of s u p p o r t i n g o r g a n i z a t i o n s {6} C a r e g i v e r s P r o j e c t ( A n d r u s V o l u n t e e r s ) {7} S t u d y of R e l i g i o u s O r g a n i z a t i o n I n v o l v e m e n t (V.L. M i l l s ) ■CB3 S t u d y of G e o g r a p h i c E q u i t y ( L o w e ) {93- B o a r d a nd C a r e S t u d y (G o o d m a n et al ) {103- R e s p i t e C a r e P l a n n i n g P r o j e c t (with WISE) {113 A l t e r n a t i v e s t o C o n s e r v a t o r s h i p , etc. C12) N o n e of t h e a b o v e Do y o u t h i n k that y o u r par t i c i pat i on (in t h e a b o v e p h a s e s ) m a d e a d i f f e r e n c e in t h e p r o j e c t ' s r e s u l t s ? A G R E A T D E A L S O M E V E R Y L I T T L E N O N E ( O V E R ) — > 137 A B O U T T H E D E C I S I O N C O N F E R E N C E : To w h a t e x t e n t d id y o u m a n a g e t o r e a d t h e " P r e l i m i n a r y R e p o r t " b e f o r e t h e D e c i s i o n C o n f e r e n c e ? A G R E A T D E A L S O M E V E R Y L I T T L E N O N E In v i e w of t h e fa c t t h a t y o u w e r e a l r e a d y k n o w l e d g e a b l e a b o u t a g i n g a n d / o r l o n g - t e r m c a re, d i d t h e r e p o r t i n f l u e n c e y o u r v o t i n g ? A G R E A T D E A L S O M E V E R Y L I T T L E N O N E Do y o u t h i n k t h a t y o u r p a r t i ci p a t i o n m a d e a d i f f e r e n c e in t h e C o n f e r e n c e r e s u l t s ? A G R E A T D E A L S O M E V E R Y L I T T L E N O N E W e r e y o u r e x p e c t a t i o n s m e t ? A G R E A T D E A L S O M E V E R Y L I T T L E N O N E T o w h a t e x t e n t d i d y o u f i n d our w r i t t e n a n d s p o k e n i n s t r u c t i o n s , a b o u t e a c h s t e p in t h e C o n f e r e n c e p r o c e s s , c l e a r and u s e f u l ? A G R E A T D E A L S O M E V E R Y L I T T L E N O N E W h a t w a s t h e r e l a t i v e i m p o r t a n c e for y o u of t h e C o n f e r e n c e w i t h r e s p e c t t o t h e f o l l o w i n g : St imaJ ated my interest in n ew areas Chance to observe met hods Brought together interesting group Provided a decent^ free lunch Loyalty to sponsors or investigators Opportunity to explain my program/agency OTHER:_____________________________________________________________ OTHER:_____________________________________________________________ To w h a t e x t e n t do y o u r e c o m m e n d t h a t o t h e r c o m m u n i t i e s r e p l i c a t e t h e " S t a y i n g at H o m e " C o n f e r e n c e m e t h o d for f a c t f i n d i n g and d i s s e m i n a t i o n ' A G R E A T D E A L S O M E V E R Y L I T T L E N O N E O v e r a l l , w h y d i d y o u c h o o s e t o p a r t i c i p a t e in t h e c o n f e r e n c e ? C O M M E N T S : A b o u t t h e C o n f e r e n c e , t h e R e p o r t a n d / o r o t h e r p h a s e s : A r e t h e r e any n e x t s t e p s t h a t you or yo u r o r g a n i z a t i o n i n t e n d to t a k e as a r e s u l t of y o u r p a r t i c i p a t i o n ? T h t s T ) k y u u / Reiurn envelope enclosed. Please ma;J by July 2 2 , 1985. HIGH MEDIUM LOW HIGH MEDIUM LOH HIGH MEDIUM LOH HIGH MEDIUM LOH HIGH MEDIUM LOH HIGH MEDIUM LOH HIGH MEDIUM LOH HIGH MEDIUM LOH

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Creator Koegler, Carolyn Vick (author)

Core Title The use of modified Delphi/Nominal Group Technique to set priorities for a system of long term care for the elderly

Degree Master of Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-407782

Unique identifier UC11658524

Identifier EP58918.pdf (filename),usctheses-c37-407782 (legacy record id)

Legacy Identifier EP58918.pdf

Dmrecord 407782

Document Type Thesis

Format application/pdf (imt)

Rights Koegler, Carolyn Vick

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA