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Ensuring a Qualified Long-Term Care Workforce: From Pre-Employment Screens to On-the-Job Monitoring

May 2006

DHHS, Office of the Assistant Secretary for Planning and Evaluation (ASPE)
Lewin contact: Lisa Alecxih

In an effort to improve the quality of care provided in long-term care settings, as well as ensure a committed and qualified long-term care workforce, the Office of the Assistant Secretary for Planning and Evaluation, within the U.S. Department of Health and Human Services, contracted with The Lewin Group to study the efficacy of various approaches to pre-employment screening and on-the-job monitoring of nurse assistants to prevent resident abuse in nursing homes. The two primary methods used for pre-employment screening include checking nurse aide registries and conducting criminal background checks. Federal guidelines require each state to establish and maintain a registry of nurse aides that includes certification information and substantiated findings of abuse, neglect, or financial exploitation in nursing homes. Previous studies have examined rates of abuse in nursing facilities, direct service worker capacity issues, and compliance of states to maintain nurse aide registries. This study looks across all of these issues, by examining the process states go through to collect and maintain information in their registries, state and employer mandated background check procedures, reporting and investigating policies/practices when abuse allegations are made, and the impact of such processes on the direct service workforce, employers and state agencies

Client Area: Federal Government
Expertise Area: Center on Aging and Disability


North Carolina Institutional Bias Study Combined Report

April 2006

North Carolina Department of Health and Human Services
Lewin contact: Lisa Alecxih

North Carolina offers an array of long term care (LTC) services for Medicaid beneficiaries. In 2004, House Bill 1414 directed the state’s Depart.ment of Health and Human Services to commission a study of whether an institutional bias exists in Medicaid-financed LTC services. In 2001, North Carolina’s Institute of Medicine presented a General Assembly-commissioned report  entitled “A Long Term Care Plan for North Carolina.”  The report outlined barriers in state LTC policy and practices and offered recommendations to the State on how to improve the LTC delivery system.  This study builds on those findings and recommendations and offers an updated look at North Carolina’s Medicaid LTC system

Client Area: State and Local Governments
Expertise Area: Center on Aging and Disability


The Future of Long Term Care Services in the Commonwealth of Pennsylvania

April 2006

Pennsylvania Health Care Association

The Pennsylvania Health care Association commissioned The Lewin Group to conduct a study that would help answer the following questions: What long-term care services will be needed and available over the next ten years? What is the current supply of long-term care services in the Commonwealth? What will the demand for long-term care services in the Commonwealth be over the next 10 years? Given the current supply of long-term care services and the estimated rate of growth in the demand for these services, what are the trade-offs between providing nursing home care versus providing home- and community-based services? This report is the second in a series of reports commissioned by the Pennsylvania Health Care Association. The first report provides information on the economic impact of nursing homes on the Commonwealth.

Client Area: Associations
Expertise Area: Center on Aging and Disability


Money Follows the Person Study

February 2006

Delaware Governor's Commission on Community-Based Alternatives for Individuals with Disabilities
Lewin contact Lisa Chimento

The Delaware Governor's Commission on Community-Based Alternatives for Individuals with Disabilities commissioned The Lewin Group to review and analyze the challenges and opportunities the State may face when undertaking a Money Follows the Person or “rebalancing” initiative. In essence, the study seeks to evaluate the manner in which Medicaid recipients access Medicaid benefits—either in institutions or in the community—and whether there exist policies or procedures that favor institutional placement over home and community-based services. It also reviews State initiatives on rebalancing and models the potential financial impact of Delaware’s adoption of a Money Follows the Person program.

Client Area: State and Local Governments
Expertise Area: Center on Aging and Disability, Medicaid and CHIP


Impact of SEA 493 Provisions on Indiana's Aged and Disabled Waiver

May 2005

Indiana Family and Social Services Administration

The Indiana Division of Disabilities, Aging, and Rehabilitative Services and the Office of Medicaid Policy and Planning contracted with The Lewin Group to study the impact of Senate Enrolled Act (SEA) 493, which makes significant changes in the State’s long term care (LTC) programs for individuals of advanced age and persons with disabilities. The study focused on the impact of changes to the State’s Section 1915(c) Aged and Disabled Medicaid Home and Community-Based Services Waiver.

Client Area: State and Local Governments
Expertise Area: Center on Aging and Disability, Medicaid and CHIP


The Economic Impact of Nursing Homes in the Commonwealth of Pennsylvania: Final Report

March 2005

Pennsylvania Health Care Association (PHCA)

Continued increases in longevity among the U.S. population, including those with chronic diseases or disabilities, are creating a demand for more LTC services of all types. Pennsylvania currently ranks second among the fifty states in the proportion of residents aged 65 and over. The Commonwealth’s fastest growing age group includes those aged 85 and over. Although occupancy levels in Pennsylvania nursing facilities have declined somewhat over the last few years, the rapidly growing aged 85 and over population necessitates a critical appraisal of the population's need for LTC services in the future and how these services should be coordinated. This appraisal has important implications for the Commonwealth's economy as well as the LTC community. With the current policy emphasis on HCBS LTC services, and the use of various provider taxes and intergovernmental transfers which may not be sustainable, there is a growing concern over the future financial viability of nursing homes. As such, various economic and healthcare delivery scenarios must be considered in future planning in order to assure an adequate supply of all types of LTC services to meet the complex needs of an aging population. Given these concerns, PHCA commissioned The Lewin Group, Inc. to conduct a study that would address two basic questions: What is the current economic impact of the nursing facility community on the Commonwealth? What LTC services will be needed and available over the next ten years? This report address the first of these two questions and contains information on the economic impact of nursing homes on the Commonwealth of Pennsylvania.

Client Area: Associations
Expertise Area: Center on Aging and Disability


Wisconsin Family Care Final Evaluation Report

July 2003

Wisconsin Legislative Audit Bureau
Lewin contact: Lisa Alecxih

The Lewin Group concluded its three year study of a managed long term care experiment in Wisconsin with the final of four reports summmarizing the implementation of the program and analyses of the initial access, cost and quality outcomes. The Family Care program combines county-run aging and disability resource centers to provide centralized outreach, information, referral and intake, with capitated care management organizations to coordinate the delivery of and payment for services. Unique features of the program include: a single point of entry for three target populations -- older frail adults, non-elderly adults with physical disabilities, and adults with developmental disabilities; a risk-adjusted capitated payment system for Medicaid long term care services; the institution of interdisciplinary care management teams that, in addition to long-term care, consider acute and primary care needs and strive to balance consumer preference and cost; and development of a quality assurance and improvement system that improves upon the traditional process measures by seeking direct input from members. Our independent study conducted for the Wisconsin Legislative Audit Bureau concluded that: The program substantially met the goals of: 1) increasing choice with a broader range of providers, more residential alternatives, and the option for members to direct their own care; 2) expanding access by eliminating waiting lists for services in the five counties piloting the full program; and 3) improving quality through a focus on social outcomes. The program has yet to demonstrate improved quality related to an individual's health using claims-based measures, in part due to the time period of our analyses, and the need for more time to fulfill the promise of better care management. Despite the potential for the capitated rate to inhibit spending, existing enrollees did not experience a decline in service levels during the first year of the program. It is too early to draw conclusions regarding the program's ability to create a cost-effective system for the future. Early evidence indicated that the Family Care counties had increases in spending similar to comparison areas and that spending on new enrollees offset savings associated with lower per capita spending increases and reduced use of institutions. The Wisconsin experience can provide valuable lessons related to single entry points, infrastructure, governance, information technology, care management, service integration, provider development, consumer direction and quality assurance/improvement for other states considering changes to their long term care systems.

Expertise Area: Center on Aging and Disability


Older Adults Waiver for Home and Community Based Services: Final Report

February 2003

University of Maryland, Baltimore County

The home and community-based Medicaid waiver that serves seniors in Maryland requires restructuring, in order to make services available to eligible seniors on a more expedited basis. In our report, we researched this waiver, known as the "Older Adults Waiver," and we made several recommendations to make the it more efficient. These recommendations include a sequence to develop a single point of entry, as well as tools to recruit, retain and pay providers, to ensure capacity in the community.

Client Area: State and Local Governments
Expertise Area: Center on Aging and Disability, Medicaid and CHIP


Update to Payer-Specific Financial Analysis of Nursing Facilities

January 2003

American Health Care Association

This study updates an earlier report by The Lewin Group released in March 2002. This study update provides the impact of Medicare and Medicaid payment shortfalls on nursing facilities in 2003 and 2004.

Client Area: Associations
Expertise Area: Center on Aging and Disability


National Family Caregiver Support Program Resource Guide

December 2002

DHHS, Administration on Aging

Intended for the staff of State Units on Aging, Area Agencies on Aging, Indian Tribal Organizations, and service providers, this Resource Guide offers practical information to help implement the new National Family Caregiver Support Program (NFCSP). As a Resource Guide—not a handbook of program policies or prescribed procedures—it features examples and resources to stimulate members of the aging network to pursue approaches that afford caregivers flexibility and assistance in meeting caregiver service needs. The information is based on established research and early practice experience and covers: roles of the aging network, profile of family caregivers, systems development, program effectiveness, working with families and other caregivers, NFCSP service components, designing the NFCSP in the context of diverse caregiver populations, and nontraditional approaches.

Client Area: Federal Government
Expertise Area: Center on Aging and Disability

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