• Is ESP serving an appropriate target population?
• Is ESP performing the clinical functions of case management in an appropriate manner?
• Are the clients of ESP satisfied with the care they receive?

Low-Cost Appropriate Services
Service expenditures for ESP clients averaged about $250 per month. Reflecting the fact that the program serves older people who experience a range of disabilities, ESP expenditures were substantially lower than the Medicaid home and community-based waiver program which spends about $600 per month. As is typical for programs of this nature, personal care and homemaker are the two most widely used services, with over 80% of clients receiving such care. Almost half of the clients receive medical transport, and about one-fifth receive a home delivered meal. Approximately one fifth of the enrollees receive medical equipment and about 10% have an emergency response system provided through the program. Adult day care, respite, and supportive services round out the key services delivered. A little over one-third of ESP clients receive one service, and just over one-third receive three or more services.

Informal Support Still Requested and Available
The availability of informal supports has been identified as a critical component of the long-term care system. Research studies continually find that for the majority of older people informal caregivers, usually a spouse or an adult child, provide about three-quarters of the long-term care needed (Mehdizadeh & Atchley, 1992). Changes in societal demographic trends, a more mobile society, and a shifting workforce continues to place more and more strain on family caregivers. When asked if there was someone who could take care of them for a few days two-thirds of the ESP clients surveyed in our study reported yes. Of those with caregivers, almost half were adult children, highlighting the importance of intergenerational communications.

The Targeted Population is Being Served
These data indicate that ESP is serving an at-risk group of older people. The vast majority of clients (97.1%) are classified as either moderately of severely disabled. The clients served are typically women living on incomes of 150% of poverty or below. ESP serves a high proportion of minority group members. ESP clients in a majority of instances report limited family support. Although the characteristics of those served is only one indicator of program performance, these data indicate that ESP is serving its intended target population.

Assessing ESP Clinical Effectiveness
A single entry, triage case-management strategy. The ESP home care intervention is based on a single entry point system in which older people with a disability can call one number to receive needed services. The program uses a triage system in which program applicants are assigned to a service category depending on their level of disability and amount of informal support. As noted, individuals with moderate needs are placed into an ongoing case management category. ESP clients in this category have a limit of $350 per month on the amount of in-home services funded by the program. Additionally, these individuals typically receive care management, assessment, and monitoring via the telephone. The majority of ESP clients (81%) are in the ongoing case management category. Individuals with severe needs are placed in a category that allocates up to $550 per month for services. These clients typically receive care management assessment and monitoring through an in-person process.

Case management by telephone is low cost and effective. The high use of the ongoing case management category varies from traditional community-based case management, which relies extensively on in- person case management. The advantages of an ongoing telephone approach is that clients can receive services faster, and such an approach has been shown to be less expensive and less intrusive. Ongoing case management was estimated to be about $40 per month per client, compared to about $80 for the intensive case management group. The potential disadvantage of this approach is that the telephone assessment and service monitoring process would be less effective, resulting in a less appropriate service plan for the consumer.

Did services match needs? To assess the effectiveness of this process, clinical researchers at Scripps completed a review of the telephone and face to face care management process. The study's objective was to understand the benefits and limitations of the ESP clinical practice model in regard to an appropriate match between the client's needs and services received. To conduct the study a nurse and social worker research team completed a clinical review of 40 ongoing case management clients selected at random. Data were gathered through in-person interviews completed in the home of the client. To evaluate the accuracy of the telephone assessments, research interviews completed a re- administration of the telephone assessment instrument. The research interview was then compared to the telephone assessment, the plan of care, and the services that had actually been received. All interviews were completed 5 weeks after entry into the program, to ensure that the in-home services were already in place. The service package was considered to be appropriate if the client was able to remain at home comfortably and if the client was satisfied that the service package met his/her needs.

Researchers found that accurate and relevant data can be gathered and an appropriate care plan can be established by telephone. In general, clients were satisfied with the package of services that had been arranged for them, although several identified a desire for additional services. A few clients expressed a desire to be more involved in selecting services; however, most were happy that someone else was addressing their service needs. Overall, researchers reported that telephone assessment and care planning can be effective in contributing to an appropriate service package while preserving consumer autonomy. The capacity of the telephone assessment to elicit accurate information was also affirmed in the study. The clinical researchers found that overall clients were being appropriately served and expressed satisfaction with the services arranged.

Consumer Satisfaction Survey
In order to assess satisfaction with ESP services a consumer survey was developed by researchers at Scripps. To complete the survey a random sample of active ESP clients was selected for an in-person visit. Interviews, conducted by Scripps research staff, took about 30 minutes to complete and focused on consumer health and functional status and consumer satisfaction with ESP services. One hundred and fifty-nine ESP clients completed the survey (a 68% response rate).

The consumer satisfaction component of the survey focused on two areas, service satisfaction and client respect. As presented in Table 2, service satisfaction focused on five key areas: 1) choice, 2) amount of time to receive care, 3) satisfaction with amount and 4) type of services, and 5)overall satisfaction. In general ESP clients reported high levels of service satisfaction. For example, over 91% of the respondents felt that ESP met almost all or most of their ser-vice needs. Over 92% reported getting the kind of services that they desired. Eighty-nine percent were satisfied with the amount of time it took to arrange services. These lower satisfaction rates may be attributable to the waiting period for services that has been required because of high demand for the program. On the overall satisfaction measure over 92% of the respondents reported the quality of ESP as good or excellent.

The survey also asked two questions about how clients were treated by ESP. Over 99% of the respondents reported that ESP staff treated the client with respect. The vast majority (92.2%) reported that ESP listened to their opinions. Other studies of consumer satisfaction suggest that being treated with respect and dignity is a critical satisfaction indicator for long-term care recipients.

Summary and Conclusion

This study reviewed the ESP project during the third and fourth years of operation. Three areas of ESP were examined; client characteristics and circumstances, clinical practice of agency, and consumer satisfaction. Findings indicated that ESP clients appeared to be a vulnerable group of people. The majority of clients were low income women who experienced severe levels of disability. A majority had limited family support. A clinical review of care management practice indicated that the program had implemented a cost saving client assessment and care management process that appeared to be effective. Finally, consumer survey data indicate a high level of satisfaction with ESP services. Along a range of survey items program respondents were consistent in their attitudes toward the program. Although such data need to be compared over time in order to develop benchmarks of quality, these data suggest that ESP is on target with consumers.

Based on this implementation experience ESP returned to the voters for a the five year levy renewal. With a large number of older people in the community using the service, positive implementation experience, and favorable support from the local media, 68% of the voters approved the levy. This was an increase in the proportion of affirmative voters (up from 58%) and included an increased dollar amount for operations, rising from 13 to 15.5 million dollars. In an era in which tax payers are carefully scrutinizing public expenditures, the levy success represents an interesting model of community efforts to take on a policy issue at the local level. Ultimately the ongoing success of this program will involve consumer and community perception of program effectiveness

References

Applebaum, R., Mehdizadeh, S., Straker, J. K., Pepe, C. (1995). Evaluating Long-Term Care Initiatives in Ohio. Scripps Gerontology Center, Miami University.

Burwell, B. (1996). "Medicaid Long Term Care Expenditures." Systemics. Lexington, MA. January.

Mehdizadeh, S. A. and Atchley, R. C. (1992). The Economics of Long-Term Care in Ohio. Scripps Gerontology Center, Miami University.

Mehdizadeh, S. A., Kunkel, S. R., and Applebaum, R. A. (1996). Projections of Ohio's Older Disabled Population. Scripps Gerontology Center, Miami University.

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