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...

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…