Home and Community-Based Care Today,

Home and Community-Based Care Today, we face many challenges in society. Some of these relate to the costs of living, while others relate to political, social, educational, and a myriad of other issues. One major challenge facing society today, and for which we are somewhat ill prepared, is the increasing number of years an average human being might expect to live. Medical technology and greater attention to longevity-increasing lifestyle habits have created a major demographic shift towards what is referred to as an "aging" society.

This means that most people alive today face a situation in which they will probably reach extreme old age. This, in turn, means that many more people than in the past will be in need of long-term care, either at home or in an institutional setting. This challenge has created a great economic burden on states to fund such care for the citizens most in need. Although all states have systems in place to deal with the care needs of their citizens, few of these are uniform.

Some states, for example, emphasize institutional care in terms of their funding, while others have begun to place increasing emphasis on providing high-quality home and community-based long-term care for people who prefer those. In order to better address the needs of citizens in a truly person-driven way, states, professionals, and services users need to enter into partnerships to obtain solutions to funding challenges, as well as obtaining the best ways to provide the highest quality of care resources for citizens across the country.

Background: The Current Situation Today, the older, disabled, and otherwise in need of care person has a choice of two basic options: Receiving care in the home setting or receiving care in an institution. According to the AARP (2013), for example, today's person in need of services has the option of long-term services and supports (LTSS). These include assistance with routine daily activities such as bathing, eating, and shopping.

When a cognitive or chronic health condition affects daily life in the long-term, this is a type of long-term service that might interest a person. Long-term assistance might also include equipment such as wheelchairs or environmental modifications. The most-used health care systems in the United States today include Medicaid and Medicare. Currently, these systems provide support for people in need of both short- and long-term care. Long-term services and support listed for Medicaid fall under institutional or home and community-based services, as mentioned above (Medicaid.org, 2013).

While both options have their benefits and drawbacks, most people today, especially when facing age-related challenges, prefer to remain at home for as long as possible before being institutionalized. The ideal for home and community-based care, of course, is to provide the optimal quality of care a person might be able to expect. According to Medicaid, this would include several ideals in terms of long-term care in the home setting.

At the basis of this is the partnership paradigm, according to which service providers and institutions work in partnership with states, consumers, and advocates in order to promote an optimal level of care to individuals who need it. The specific effects of this paradigm aim to provide services that are person-driven.

This means that people in need of long-term care services should have choices regarding issues such as who would be involved in care, where the care setting should be, the level of participation and community life, and other general decisions relating to their care. Another ideal is inclusiveness, where all users are supported and encouraged to live where they wish while having access to all the services and professionals they need.

Effectiveness and accountability mean that a high quality of service is provided, while all partners involved ensure accountability and responsibility in terms of level of care and usage of funding, whether from private or public sources. Also in terms of costs, the system provided should be sustainable and efficient, where economy and efficiency are balanced by means of coordinated care provisions and payment.

He system should also be transparent, making effective use of tools such as information technology to provide consumers, providers, and tax payers with fully disclosed information regarding the application of funding. While these ideals look very good on paper, the reality is often that the system remains somewhat less than streamlined, especially as far as costs are concerned on a state level. This is not to say that services are not provided to a level that is promised.

The simple reality of the matter is, however, that today's health care system in the United States tends to be somewhat overwhelmed by the increasing needs, especially among the aging population, for services that were unforeseen mere decades ago. Today, an estimation device known as "Scorecard" serves towards stabilizing the current divide among states regarding the quality, amount, and costs of services provided. The current Scorecard focuses on state services provided for older people and adults suffering from physical disabilities.

The main purpose of the Scorecard, then, is to measure the ability of states to provide "high-performing" or "excellent" LTSS to individuals within that state. Various characteristics have been identified in terms of excellence for these services. The first of these is affordability and access. According to this requirement, long-term care services provided at the state level need to be both affordable and accessible to those who need it. It should be easy for consumers to both find and afford these services.

The second requirement is the choice of setting and provider. As mentioned, it is today an increasing choice among consumers to receive long-term care services in their homes. Hence, this requirement concerns the ability of states to provide consumers with a range of at-home and institutional settings to choose from when in need of long-term care. These serves also need to take a person-centered approach, regardless of setting, as well as offering consumers a choice of caregivers to provide services.

A third requirement is quality of life and quality of care. According to this requirement, services are required not only to offer maximum positive outcomes, but also include respect in the treatment of individuals. Whenever possible, personal preferences of care recipients should be respected. In many cases, family members act as caregivers, especially where the care of older people is concerned. In such a case, the needs of caregivers that are not in fact medical professionals should be taken into account by state services.

Concerns that need to be taken into account in this regard include the fact that family caregivers are in danger of being overburdened, especially where here are issues such as jobs and children involve. According to the Scorecard, states are also required to offer effective transitions and organization of care. This means that long-term care services need o be coordinated or integrated with other health services and social supports.

Where an older person already receives care from a social worker, for example, this person needs to be involved when the long-term care needs of the client changes. In this, the Scorecard offers a valuable tool in order to determine both the current level of services provided at the state level and to determine the needs still existing among clients in the state. In addition, the organization, delivery, and financing of these services can be streamlined much more effectively with the inclusion of the Scorecard or similar estimation devices.

This, however, is a major challenge, since services currently offered by states and policies to support them are widely divergent, as will be seen. The Role of the Registered Nurse One issue of great concern in the choice between home care and institutional care is he quality and type of care the individual would be able to obtain.

For this reason, advocates who promote increased home and community-based long-term care services have also promoted the ability of these individuals to enlist the services of professionals such as advanced practice registered nurses (APRNs) (Brassard, 2011, p. 4). According to Brassard (2011, p. 4), there are several benefits to allowing nursing practitioners to practice in the home setting. In addition to the professional service received at home, such a service will also allow the individual to receive institutional care once this becomes necessary.

Although a prolonged home setting for the long-term care of an aging, ill, or disabled person has become the increasing norm, and indeed the choice within many families, it is also a fact that this setting can become unviable in terms of the ability of the home setting to meet the needs of such an individual.

Involving a nursing practitioner has the advantage of helping patients and their family members make sound decisions regarding their health and he specific needs regarding their continued care in the home setting or in alternative care settings. Indeed, proposed legislation to allow advanced practice registered nurses to certify home health services also has the advantage of taking the burden from formal institutions by streamlining both the decision of certification and the provision of home services to long-term care patients.

Registered nurses are both qualified, educated, and certified to provide a high quality of various care services that an individual may need in a home setting or elsewhere. Hence, providing these practitioners with the power to certify and provide home care is a solution to an overwhelming problem that has plagued the health care environment in recent years. Nursing practitioners, as a result of the nature of their work, are closely connected to the needs of individual patients.

This means that they, more than many other health care providers and institutions, are able to assess the needs of individuals, their households, and the level of care they require. This places them in a position to accurately determine the need and/or of such individuals to obtain long-term home care and when such home care becomes unviable.

As such, registered nurses who serve individuals in the home setting are able to maintain not only a clear estimate of the needs of individuals, but also the prolonged maintenance of optimal dignity for them, especially in the case of terminal illness or extreme old age.

The ultimate result is that the phenomenon of home-care delays and preventable hospitalization will be avoided, as the availability of nurses working directly with patients and certifying home care is generally higher than that of physicians, who are more often than laden with heavy workloads. As such, the access of the public to home care will increase, while the costs of care will be reduced, since nursing practitioners are far more directly involved than external physicians in this decision.

As such, extra visits to physicians and the possible needs for ambulance services will be eliminated. Research and Funding Challenges In reviewing some research on the cost-effectiveness of home care services, Doty (2000) found a somewhat different situation than the ideal suggested by the Medicaid.org Website. One finding, for example, suggests that the costs incurred by providing greater access to long-term care supported in a home and community environment often, at best, would incur the same costs as an institutional setting, or worse, would create greater expenditures.

One significant reason for this is that the home-based care systems investigated often included formal home care for those who would not have been at high risk for institutionalization in the long-term, even without formal care at home. In other words, these individuals would have benefited from informal care provided by family or friends.

Doty (2000) therefore suggests that targeting of individuals in actual need of formal care and a higher availability of informal community supports to offset the costs of formal supports could provide a higher likelihood of budget neutrality for home-based care systems. However, constrained budgets also means a lower level of the services that is enabled within communities. This, in turn constrains the ability of people to make choices regarding their long-term care, which is not desirable, according to the "person-driven" requirement listed by Medicaid.

What happens in this case is therefore a difficult trade-off between the services provided and costs related to these services. Another challenge is the fact that these costs are by no means streamlined across the country. Some states, for example, focus their costs on encouraging individuals to make use of institutional care, while others focus on enhancing home-based and community services for their citizens. This creates a wide discrepancy among services and the quality of such services provided across states in the country.

There is, however, an encouraging trend towards providing more home care services funded by entities such as Medicaid. The main challenge is to streamline funding in such a way to make home and community-based services for those who prefer them at least as cost-effective as institutional care settings. Financing Solutions It has been seen that, while it is easy to debate for the benefits of encouraging home-based long-term care as opposed to institutionalized services, the challenges are significant. One major concern is financing.

This is no simple matter to resolve, since, as seen, there is a wide discrepancy among states regarding the amount of expenditure related to long-term care services for individuals who need it. Summer (2007, p. 1) mentions the historical trend towards generally financing institutional care. Generally, Medicaid has been responsible for the finance of such services. This could be one of the reasons for the wide discrepancy in funding among states, as well as the tendency towards lower cost-effectiveness in terms of less conventional home care systems.

Hence, the problem does not necessary relate to inherent cost deficiencies within such systems, although it does imply the necessity to apply costs and decisions in a more efficient way. Since there is a current trend towards preferring home-based services, this need should be addressed in a cost-effective way.

Summer (2007) notes that the general shift towards community-based services has been encouraged by cost containment goals within states (although, in light of the above, this is somewhat ironic) and pressure in the political arena to create a more inclusive society for people with disabilities. There is a wide variation among states, as mentioned, regarding the approach towards community-based services and the extent to which they are available.

As an example, Summer notes that, across the 50 states, Medicaid long-term service expenditures for people with disabilities and the elderly ranged from one to 54% of total state budgets. It is therefore clear that, in order to ensure that a sufficient quality of service is provided across the country, some streamlining, both in terms of approach and financing, is required. To address the challenges related to limited resources and growing service demands, Summer (2007, p. 4) suggests that states need to create a relatively uniform approach in determining eligibility for long-term care provisions.

Specifically, she suggests two sets of questions, relating to functional eligibility and the development of care plans, respectively. To determine "functional eligibility" or "level of care," Summer suggests that states need to determine factors such as the criteria to be used, whether the same process should be used to determine eligibility for all services, the levels of care to be provided, the professionals to be involved in the determination, and the training to be provided to these professionals.

To determine the way in which care plans should be developed, states need to focus on questions regarding the involvement of consumers and possible cost limits as applied to care plans. In terms of more specific suggestions, Summer (2007, p. 4) offers the idea that states need to make specific determinations regarding criteria for eligibility or level of care. These criteria should be explicitly described rather than simply indicating that a person qualifies for waiver services to avoid being institutionalized.

Clearer criteria would create a more uniform national system for making such determinations. Such criteria would also eliminate the possibility that some individuals in great need may not obtain access to the services they require. To do this, the various levels of criteria across states need to be streamlined. The only way to do this would be a significant policy change at a national level. Summer (2007, p. 5) notes that technology can greatly aid this process.

Various policymakers, health care professionals, and other stakeholders across the country can communicate to assist and streamline this process. Indeed, members of the public themselves can also take part in this process, since they will be directly affected by such policies. Long-term care and eligibility determinations for older people are especially important, since most people alive today will live to see a significant number of years, many of which will be spent in likely need of long-term care.

One example of an online tool used to determine the level of care required for individuals is the Wisconsin Family Care Program (Summer, 2007, p.6). Social workers and registered nurses can become certified screeners by passing an online training course and exam. This already creates a more effective way of screening more people in less time, hence saving on the cost of labor hours.

Better communication across states, among professionals and service users, as well as he increased use of technology can therefore go a long way towards not only providing more uniform long-term care across the country, but also to determine and lower the costs of these. Streamlining such services among states will go a long way towards not only better monitoring expenses, but also in determining how to cover these expenses and the best and fairest ways in which to raise the necessary revenues to cover them.

Towards such a solution, Lynch, Estes and Hernandez (2007) also offer the suggestion of effective partnerships among various stakeholders. According to the authors, one solution to the current long-term care challenges can be found in long-term care policy reform, in which consumers will be empowered while care coordination services should be established for chronic disease education and home and community-based services (abbreviated as HCBS).

As such, the proposal focuses on high risk Medicare beneficiaries and eligible Medicare/Medicaid beneficiaries who experience challenges regarding daily living limitations, either in terms of instrumental assistance or general activity assistance. The main aim of the authors' proposal is maximizing consumer choice and involvement, which are stated above as essential in terms of state-provided services.

Hence, an enhanced sense of choice will create, for these consumers, greater empowerment in a situation that tends to make them feel powerless, having lost or experiencing a perpetual loss of ability to take part in daily life on what is considered a "normal" level. The challenge is, however, that the services required by older or disabled individuals remaining at their homes rather than entering institutions are far from cheap.

Hence, streamlining expenses and budgets for such services not only at a state level but also at the national level is essential. Such a coordination of services and costs is the essence of the authors' proposal. The proposal is based upon several advances made in the investigation of offering cost-effective services for people receiving care at their homes. These include the following (Lynch, Estes, and Hernandez, 2007, p.

2): a) developments in chronic disease management; b) positive outcomes for disabled and elderly persons who control their own care; c) the need for flexibility in access to medical and home and community-based services. According to the authors, streamlining the cash flow and level of services provided to people who prefer to remain in their homes for as long as possible includes several benefits.

One such benefit is that there would be a flexible package allowing home and community-based care services for those proving eligible for Medicaid and Medicare-Medicaid services, as well as older people with daily activity needs. This would create benefits not only for the care recipients involved, but also for the states providing the are. Streamlining services and financing will create a platform for more cost-effective services while also liberating revenue that could be applied elsewhere.

As the authors mention, more liberal asset tests will also be available to people who qualify for the program, while a capped service budget can be established in a fair way, based upon the level of disability and needs involved. Such a program would then create a flexible, more cost-effective, and more generally effective level of service than the one-size-fits-all level of care that is the tendency in many states today.

In addition, those who do find themselves in need of residential services, such as those reaching extreme old age or such a level of disability or illness that they can no longer viably remain at home, can then enter institutionalized settings when they or their family members consider this necessary. According to the proposal, this will also be subject to the budgets and caps established when the individual initially begins to make use of the care service.

Of course, the greatest advantage of restructuring and streamlining state budgets for long-term care needs is the empowerment of consumers, as mentioned above. Feeling in control of one's life is important even within the best of conditions. It is particularly important to encourage this feeling of control in those who feel disempowered by their illness or condition. Particularly, this is important for older people who experience a gradual loss of their faculties with the advancement of the later stages of life.

To encourage as much well-being as possible in later life, a degree of choice and empowerment is vital. As such, this is one of the most important side-effects of creating better cost management for long-term care. In this light, the proposal created by Lynch, Estes, and Hernandez (2007, p. 3) provides options for both consumers who are covered by Medicaid and for those who are not eligible. For the latter market, the proposal offers a buy-in option.

As such, the proposal covers both beneficiaries and non-beneficiaries in such a way that their specific level of need is addressed without incurring unnecessary costs either from tax payers, consumers, or health care providers. Legislation It has always been at the heart of the United States Constitution that all citizens should expect a number of basic human rights. Included in this is the right to a healthy, happy life.

Hence, various types of legislation has been passed over the year relating to affordable health care, especially for those in society who are most vulnerable. One example of this is the Affordable Care Act (The White House, 2013). In order to help curb the costs this Act would create for states, the Deficit Reduction Act of 2005 (DRA) has been implemented (Summer, 2007, p. 3). The Act allows states to provide community-based waiver services as state plan services.

As part of this, states are also allowed to implement enrolment caps, waiting lists, and provide services in certain parts of a state only. Self-direction of services is also allowed, including a limitation of such options to certain parts of the state or to certain population groups. Again, the various provisions of the Act creates a platform for varying services across varying states. Communication and streamlining are necessary to create more streamlined services.

Indeed, the Centers for Medicare and Medicaid Services have not provided states with clear guidelines for the use of provisions under the Act. Summer (2007, p. 3) notes that, in the year of writing, only Iowa has received approval for community-based services, but was still awaiting guidance on accomplishing such implementations. There is, for example, uncertainty regarding the range of services to be provided under the plan. In addition, some of.