May 1999

Approximately 23,000 elderly and disabled Wisconsin residents receive long-term care that allows them to live in their own homes or in non-medical residential facilities rather than in nursing homes. The State’s original community long-term care program, the Community Options Program (COP-R), was created in 1981 in response to a rapid expansion of nursing home use. The Department of Health and Family Services now administers seven community long-term care programs, which are locally managed by the 72 counties and by one tribe. In 1997, reported service expenditures for 15,699 participants in three of these programs—the original COP-R and two other programs that serve primarily elderly and physically disabled individuals—were $120,893,900.

The three programs we examined, which are funded by state general purpose revenue (GPR) and federal funds made available under waivers of Medical Assistance program regulations, reimburse local providers for services that include daily personal care, home-delivered meals, and other in-home support; care in community-based residential facilities and adult and family group homes; day care; support services such as specialized transportation; and other program services. Funding for these programs has more than doubled since fiscal year (FY) 1991-92; however, demand for services has consistently exceeded available funds.

 Waiting Times Vary Among Counties and Disability Groups

As of June 1998, approximately 11,000 individuals were waiting to receive community long-term care services. Although 11 counties reported no waiting lists in December 1997, 12 counties had waiting lists of more than 100 individuals. The two largest counties, Milwaukee and Dane, had the largest waiting lists: 3,225 and 1,344, respectively. When the number of individuals waiting for community long-term care was compared to each county’s entire elderly and disabled population, the county with the largest waiting list was Menominee, with 52.8 individuals reported to be waiting for every 1,000 elderly and disabled residents. Statewide, 11.8 individuals were reported to be waiting for community long-term care for every 1,000 elderly and disabled state residents.

Local policies and practices and a statutory requirement that programs serve specific proportions of elderly, physically disabled, and other participant groups contribute to variations in the size of local waiting lists and to the amount of time eligible individuals must wait for program services. Statewide, median waiting times among counties with waiting lists were 2 years for developmentally disabled individuals, 1.5 years for physically disabled individuals, and 8 months for elderly individuals. The maximum wait for developmentally disabled individuals was nine years; for elderly individuals, it was four years.

 Services Vary Among Local Programs

We found considerable variation in the range of services offered by local providers, as well as in the service expenditures they report. Statewide, reported service expenditures for 1997 averaged $7,701 per participant. However, Pepin County reported average expenditures of $3,394 per participant, whereas the Oneida Tribe reported an average of $17,195 per participant, and Ozaukee County reported an average of $13,890 per participant. Such variations are caused, in part, by differences in individual participants’ needs; differences in local service costs and reporting practices; differences in reliance on other funding sources; and differences in the level of services provided.

More populous counties generally provided more services, but there was also significant variation in the number of services provided by counties of similar size. Statewide, the median number of services provided in 1997 by the three programs we reviewed was 14. The actual number of services provided ranged from a high of 24 in Milwaukee County to a low of 6 in Florence County.

Some of the variation results from differing approaches to service delivery. For example, the use of participants’ family members as paid service providers varies widely among local programs, as does the use of community-based residential facilities. These facilities, which provide treatment and services but only limited nursing care, have raised concerns because they accounted for $23.5 million, or nearly 20 percent, of reported 1997 program expenditures.

 The Family Care Proposal Would Restructure Community Long-term Care

In the 1999-2001 biennial budget bill, the Governor proposes pilot projects to test elements of a comprehensive restructuring of the entire long-term care system, including community long-term care. The restructured system, known as Family Care, would provide both community and institutional long-term care through a system with three significant components: all individuals seeking care in a nursing home or alternative residential setting would use a single point of entry; services could be arranged or provided by Care Management Organizations (CMOs), which would provide either institutional or community long-term care; and payments to CMOs would be based upon capitated monthly rates established by the Department, rather than on a fee-for-service basis.

Structuring Family Care as an entitlement program for individuals who meet criteria specified in statutes and administrative rule could eliminate many local variations in service delivery. However, problems such as a shortage of service providers for overnight and personal care and a lack of sufficient service capacity, which were identified by staff in many existing programs, could continue under Family Care.