| 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
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.
Designed, financed and implemented with local funds, this
new Ohio program provides one successful model for development
of community based LTC.
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.
|The existing state care program as
targeted for older adults with extreme disability and
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.
Local Taxes for Local Services
|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.
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.
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:
|A Council on Aging administers funds
through a case management program for over 5,200 disabled
- 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?
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
A management information system and a survey of participants
are used to evaluate program effectiveness.
ESP Client characteristics: Frail, Lower
Income Older Adults
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.
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
|Characteristics of ESP
Clients - 1997
|100% Poverty or below
|250% Above poverty
|Single income clients
|Mild disability (1 Instrumental
Activity of Daily Living limitation)
|Moderate Disability (1
Activity of Daily Living limitation or 2 or more Instrumental
|Severe Disability (2 or
more Activity of Daily Living limitations)
|Is there someone who could
take care of you for a few days?
|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
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
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.
Satisfaction Survey for the Elderly Services Program
|Consumer Survey Items
|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?
|How satisfied are you
with the amount of help received?
|Are you getting the kind
of service you wanted?
|Overall, how would you
rate the quality of ESP?
|The people at ESP listen
to my opinions.
|The People at ESP treated
me with respect.
| 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
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
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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