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Occasional LTC Policy Paper Series 1997 Duke LTC Resources

Local Taxes for Local Home Care: Evaluating the Hamilton County, Ohio, Elderly Services Program

Robert Applebaum, Ph.D., Jane Straker, Ph.D., Kathy McGrew, Ph.D. Scripps Gerontology Center, Miami University, Oxford, Ohio

Designed, financed and implemented with local funds, this new Ohio program provides one successful model for development of community based LTC.
This report describes the development and evaluation of a local home care project designed to expand in-home services in the Hamilton County (Cincinnati) area of Ohio. The program was designed, financed and implemented with local funds. Their experience and the accompanying evaluation represent one model for the development of community based long-term care. As is true for many counties in the U.S., Hamilton county (Ohio), has experienced a demographic revolution unprecedented prior to the 20th century. As a result of major public health, environmental, and medical advances, life expectancy has increased dramatically. With over 154,000 people over the age of 60, Hamilton county has one of the largest aging populations in the state of Ohio. About 38,000 older people in the county have a long-term disability, with about one-third of this group (13,000 people) classified as severely disabled (Mehdizadeh et al., 1996). Although extending life expectancy is viewed as a positive step, one negative side effect is the increasing number of older people who now need chronic care.

The existing state care program as targeted for older adults with extreme disability and lowest income.
Two major concerns have been directed toward the long-term care system in the United States. The costs of providing long-term care, particularly institutional care, have increased dramatically. In both Ohio and the nation long-term care has become a major component of the budget, with national public expenditures totaling $58 billion in 1996 (Burwell, 1996). About $2 billion of Ohio's budget is allocated to long-term care. Combined with high costs is a criticism that the system of long-term care is biased towards delivering care in the nursing home setting, despite older peoples' documented preferences for in-home services. To respond to this problem Ohio and other states have begun to increase the resources going to home care.

Despite continued increases in state funding, Ohio's Medicaid waiver program, PASSPORT, designed for older people in need of long-term care serves fewer than 13,000 people statewide, and fewer than 1,000 older people in Hamilton county. To be eligible for the state PASSPORT program recipients must meet the nursing home level of care criteria, and meet a strict income and asset test, which for example, requires a client to have less than $2,000 in assets excluding one's home and automobile. Thus, the PASSPORT program is targeted toward those older people with extreme levels of disability and the lowest income levels. This however, leaves a large number of disabled older people with low and moderate income with no governmentally financed in-home care.

Hamilton County's citizens, with a history of local tax levies for needed services and aware of similar services in Ohio, voted a local tax levy for LTC that generated $3.2 million per year for five years. Voters have recently reviewed their support of this community program.
Local Taxes for Local Services
The impetus for the in-home care program in Hamilton County mirrors the national concern about the lack of services available to older people requesting care outside the nursing home setting. The idea for a tax levy funded program had its roots in two phenomena--1) a community history of tax levies to fund children's services, mental health, health, and rehabilitative and long-term care services; and 2) a similar type of home care program that had been developed elsewhere in the state. In response to the home care challenge, the citizens of Hamilton County approved a five year tax levy allocating 13.2 million dollars per year to fund in- home services for people age 60 and above.

Local Administration of Services.
The Cincinnati Council on Aging administers the levy funds through a care management program (Elderly Services Program, or ESP) and carries an active caseload of over 5200 disabled older people. Council on Aging staff determines client eligibility, and arranges and monitors in-home services. ESP funds a range of in-home care including such services as personal care, homemaker, adult day care, home delivered meals, transportation, respite care, medical equipment, emergency response systems, and home modifications.

A Council on Aging administers funds through a case management program for over 5,200 disabled older adults.
This report, which is part of a larger evaluation of the Elderly Services Program (ESP), is funded by the Robert Wood Johnson Foundation. The Foundation found ESP to be a unique program and provided funds for the Scripps Gerontology Center at Miami University, and the Office of Geriatric Medicine at the University of Cincinnati to examine the program. Results would be used both by ESP for program improvement, and by the Foundation for its health systems promotion project being implemented throughout the United States. The objective of this study is to evaluate the effectiveness of the program. The evaluation addresses the following questions:
  • 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?
Study Methods
A management information system and a survey of participants are used to evaluate program effectiveness.
The study uses data from primary and secondary sources. Information on the characteristics of ESP clients comes from the program's management information system and a survey of ESP recipients, and includes data on individuals at enrollment and annually thereafter. The assessment of clinical practice comes from a review of a random sample of case records and interviews with ESP staff members involved in care delivery and supervision. Data on ESP consumer satisfaction comes from an in-person survey completed on a random sample of program clients.

This program is demonstrably serving the intended population of frail, lower income older adults.

The program includes an often neglected category of frail elderly: Those just above the poverty line. One third of participants have an income 150% of poverty and an additional 6% with an income of 250% of poverty contribute to the cost of care.
ESP Client characteristics: Frail, Lower Income Older Adults
A description of the 5,234 ESP clients currently enrolled is presented in Table 1. About one-third of the enrollees are between the ages of 60 and 74. Forty-three percent are between the ages of 75 and 84, and just under one-quarter are age 85 and above. As is common for those receiving long-term care, almost four-fifths of the clients are women. Unlike the typical nursing home resident, a sizeable proportion of clients (34%) are members of a minority group, most often African- American. ESP clients have relatively low incomes. Just under 30% of the clients have incomes that fall below the poverty threshold ($7,890 annually). An additional one-third of the enrollees have an income level between poverty and 150% of the poverty level. A small proportion of clients (5.7%) have incomes greater than 250% of poverty ($19, 725), and these individuals are required to contribute to the costs of their care. ESP was developed to serve older people who were experiencing a chronic disability requiring long-term care. The majority of ESP clients (62.3%) are classified as severely disabled. To be in this category an individual must have two or more impairments in activities of daily living. Activities of daily living include such tasks as bathing, dressing, and walking within one's home. Just over one- third of the clients are classified as moderately disabled, and thus experience one activity of daily living limitation or two or more instrumental activity of daily living limitations. Instrumental activities include such tasks as meal preparation, shopping, and housekeeping. A small proportion of clients (2.9%) have a mild disability, and these individuals typically receive transportation assistance associated with a specific health condition or treatment, such as dialysis.

Table 1
Characteristics of ESP Clients - 1997
Characteristic Percent
60-64 5.0
65-74 28.1
75-84 43.2
85-89 15.9
90+ 7.9
Female 78.2
Non-white 34.1
100% Poverty or below 29.1
100-150% Poverty 34.5
150-200% Poverty 21.3
200-250% Poverty 9.3
250% Above poverty 5.7
Single income clients 78.8
Disability Level
Mild disability (1 Instrumental Activity of Daily Living limitation) 2.9
Moderate Disability (1 Activity of Daily Living limitation or 2 or more Instrumental limitations) 34.9
Severe Disability (2 or more Activity of Daily Living limitations) 62.3
Family Support
Is there someone who could take care of you for a few days?  
Yes 65.8
Total Clients 5,234

The average program expenditure per client was $250 per month in contrast to the $600 spent by the community and home based medicare waiver program.

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.

Two thirds of program clients reported the availability of someone who could care for them for a few days.

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.

A single entry, triage case management strategy has been implemented.

Although states set different maximum expenditures per case, the usual cap for program services in Ohio is $350 per month. For those with severe need,the cap is $550

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.

Telephone monitoring has proved to be effective, faster, less expensive, and less intrusive.

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.

Clinic assessments and client surveys have conformed care adequacy and client satisfaction.

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).

A client survey covering choice, contact time, quantity and type of service, and overall satisfaction demonstrated over all satisfaction. Program quality was reported as good or excellent by 92% of the clients.

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.

Table 2
Consumer Satisfaction Survey for the Elderly Services Program
Consumer Survey Items
Response Category
To what extent did the choices of ESP services meet your needs? None of needs met
Only a few met
Most of needs met
Almost all needs met
How satisfied were you with the amount of time it took to begin ESP services? Very dissatisfied
Mostly dissatisfied
Mostly satisfied
Very satisfied
How satisfied are you with the amount of help received? Very dissatisfied
Mostly dissatisfied
Mostly satisfied
Very satisfied
Are you getting the kind of service you wanted? Definitely not
Not really
Yes, generally
Yes, definitely
Overall, how would you rate the quality of ESP? Poor
Client Response  
The people at ESP listen to my opinions. Strongly agree
Strongly Disagree
The People at ESP treated me with respect. Strongly Agree
Strongly Disagree

Summary and Conclusion

Highest praise for the Elderly Services Program: Voters renewed support by increasing support for renewal to 68% from 58% and increased the annual budget support by $2.5 million.

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


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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