Long-Term Care for the Elderly in the District of Columbia: Issues and Prospects

JOSHUAM. WIENER ANDDAVIDG. STEVENSONLONG-TERMCARE FOR THEELDERLY IN THEDISTRICT OFCOLUMBIAIssues and Prospects Joshua M. WienerDavid G. StevensonTHE URBAN INSTITUTELONG-TERMCARE FOR THEELDERLY IN THEDISTRICT OFCOLUMBIAIssues and Prospects Copyright ©1999. The Urban Institute. All rights reserved. Except for shortquotes, no part of this book may be reproduced or utilized in any form or byany means, electronic or mechanical, including photocopying, recording, orby information storage or retrieval system, without written permission fromthe Urban Institute Press. AcknowledgmentsSupport for this paper was provided by the Robert Wood JohnsonFoundation and the Urban Institute.The authors would like to thank the many District government officials,providers, and consumer advocates who generously spent much of their timeanswering our questions and in reviewing earlier drafts. We would especiallylike to thank Elizabeth Stewart Fox, co-chair of the Long-Term Care, Elderly,and Adult Protective Services Subcommittee of the Human Services ActionGroup of the Anthony Williams ‘98 Transition. Helpful comments were alsoprovided by John Holahan, Barbara Ormond, and Randall Bovbjerg. ContentsBackground . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5D.C. Office on Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Medical Assistance Administration of the Department of Health . . . . . 7State Health Planning and Development Agency of theDepartment of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Licensing Regulation Administration of the Department of Health . . 8Adult Protective Services of the Department of Human Services. . . . . 8Policy Development and Implementation . . . . . . . . . . . . . . . . . . . . . . . . 9Home- and Community-Based Services. . . . . . . . . . . . . . . . . . . . . . . . . 11District-Funded Home Care Services . . . . . . . . . . . . . . . . . . . . . . . 11Home Health, Personal Care, and Adult Day Care . . . . . . . . . . . . . 12Medicaid Home- and Community-Based Services Waiver . . . . . . . . . 14Case Management/Level-of-Care Determination. . . . . . . . . . . . . . . 16Nonmedical Residential Care Facilities . . . . . . . . . . . . . . . . . . . . . . 18Nursing Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Nursing Home Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Certificate of Need and the Supply of Long-Term Care Providers . . . 23Quality of Care in Community Residence Facilities and NursingHomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Other Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28D.C. Office on Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Adult Protective Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29The Road Not Taken: Other Possible Initiatives . . . . . . . . . . . . . . . . . . . 30Maximizing Private Contributions for Long-Term Care . . . . . . . . . . 30Medicare Maximization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Integrating Acute and Long-Term Care through Managed Care . . . . 31Challenges for the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31List of People Interviewed or Who Provided Information . . . . . . . . . . . 39About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 LLong-Term Care forthe Elderly in theDistrict of Columbia:Issues and Prospectsike the rest of the United States, the District of Columbia spends a substan-tial portion—nearly a fifth—of its Medicaid budget on long-term care for theelderly. Compared with the 50 states, however, the District faces special chal-lenges in meeting the needs of the disabled elderly. The District’s older pop-ulation has a higher proportion of low-income people and African Americansthan the older population of the 50 states. The District is not quite a state—it lacks the size, geographic diversity, and broad fiscal base characteristic ofmost states—and it is also distinct from other cities in the governmentalresponsibilities that it assumes. In addition, decisionmaking in the District, asthe nation’s capital, has always been complicated, in part because of theinvolvement of Congress and the federal executive branch. The transfer ofmost government functions in 1995 from the mayor and the city council to afederally appointed control board has made policy development and imple-mentation even more complex. Although the context of long-term care policy in the District of Columbiais unique, local policymakers must address the sam