in 1980 the health care financing administration ( hcfa ) , in cooperation with the health policy center of brandeis university , began planning a demonstration program to provide and finance long - term care services .
this demonstration program uses a social health maintenance organization ( s / hmo ) to combine acute and long - term care services under a single prepaid health care plan for the elderly .
s / hmo benefits include all basic acute and ambulatory health care services covered by medicare as well as selected chronic care services .
these services are paid for by medicare on a capitated basis , along with a premium paid by the enrollee , or when applicable , medicaid .
the demonstration was designed to address the health care and health insurance needs of both a severely impaired and a well group of elderly .
beneficiaries meeting their state 's nursing - home - certifiable criteria at enrollment receive an adjusted medicare capitated rate , which is higher than the adjusted average per capita cost ( aapcc ) rate established for the well enrollees .
although all enrollees are eligible for basic medicare benefits , only those assessed as nursing home certifiable or " at risk " of nursing home placement are eligible for chronic care benefits .
the availability of long - term chronic care benefits , and the associated case management processes , distinguish an s / hmo from a health maintenance organization ( hmo ) ; these features plus the capitation payment distinguish an s / hmo from fee - for - service health care .
the demonstrations began in early 1985 and will continue for 7 years under the current terms of the program .
the four sites involved include : elderplan in brooklyn , new york , sponsored by metropolitan jewish geriatric center ; medicare plus ii in portland , oregon , sponsored by kaiser permanente center for health research ; seniors plus in minneapolis , minnesota , sponsored by group health inc . and ebenezer society ; and scan health plan in long beach , california , sponsored by senior care action network .
although under different organizational auspices , all s / hmo 's share the common purpose of testing the ability of these health plans to attract members and to provide an expanded array of acute and chronic care benefits within a capitated budget .
hcfa has commissioned a comprehensive evaluation of the s / hmo 's by a consortium of researchers .
the prime contractor is the institute for health & aging at the university of california ; others include berkeley planning associates , the center for demographic studies at duke university , and westat , inc .
it explores the cost effectiveness of each s / hmo demonstration model as well as internal operations and environmental factors affecting program outcomes .
the evaluation investigates nine major issues : selection bias in initial enrollment and in attrition .
public , third party , and out - of - pocket expenditures for acute and chronic care services .
marketing efforts , the market area , and environmental conditions affecting each site 's operations .
patterns of change in the organizational form , management , and financing at each site as the programs evolve . the effectiveness of case management in controlling chronic care service use and cost and assuring access to appropriate levels of care .
an interim evaluation report covers organizational and operational issues ( health care financing administration , 1988 ) .
current field work is gathering health status , health service utilization , and out - of - pocket expenditure data on s / hmo enrollees and the fee - for - service comparison group .
the focus of this article is on case management roles and activities across the four s / hmo demonstration sites .
the information presented is drawn from data gathered during site visits in 1986 and from progress reports during the first 2 years of operation of the s / hmo 's , which began enrollment in 1985 . throughout this article
, emphasis is placed on the 1986 data , which represent a more stable program period and are less susceptible to variations experienced during the initial startup period .
it is important to note that the s / hmo is an evolving form , and as such , there have been some important changes in case management and its activities since this article was prepared .
the information provided here describes s / hmo case management as it functioned at the close of the second year of the demonstration and does not reflect changes made as the plans assumed full financial risk .
at each s / hmo demonstration site , the case management component was given responsibility for managing the non - acute , long - term care services . in the s / hmo ,
the role and authority of the case manager was envisioned as much broader than in earlier long - term care demonstrations ( leutz et al . , 1985 ) .
in most earlier demonstrations , the case manager role focused primarily on screening and assessment and the coordination and/or authorization of community - based care ( austin , 1983 ; berkeley planning associates , 1985 ; health care financing administration , 1988 ; zawadski , 1984 ) . in the s / hmo ,
the case manager was to have primary responsibility for authorizing all long - term care services , responsibility for monitoring the chronic care services and budget , and final authority over chronic care resource allocation . beyond this
, it was hoped that the case management component would also be able to establish new norms of practice regarding linkages with other components of the health care system .
it was also hoped that these norms would lead to care of a consistently high quality that would simultaneously maintain chronic care costs at budgeted levels . within these broad goals and objectives ,
each demonstration plan was permitted flexibility in developing its case management model . as implemented , no two case management models were alike .
there were no restrictions placed on the plans by hcfa as to which members should be eligible to receive the expanded long - term care benefits . during the planning phase , there was debate about the advisability of limiting services to the severely impaired versus providing services to less impaired members as a preventive measure .
in addition , because the plans were reimbursed at a higher capitated rate for members assessed as meeting their state 's nursing home certification ( nhc ) criteria , it was decided to link eligibility for the chronic care services , at least in part , to nursing home status .
although each plan paralleled its state nhc form and guidelines to qualify a member for chronic care benefits ( and a higher reimbursement rate ) , the nhc criteria were different among the four demonstrations .
( forty - five variables were used for certification and only 11 were common to all plans . )
each plan also expanded eligibility criteria beyond nhc , allowing at least some services to members who were not nursing home certifiable ( henceforth referred to as  certifiable  ) , but who were considered to be  at risk  of future institutionalization by case management staff .
the final determination of eligibility for chronic care services and/or case management was determined by interrelated factors : the stringency of the state 's nursing home criteria and the plan 's application of these criteria ; the extent to which the plan permitted provision of chronic care services to less impaired members ; and the extent to which the plan provided case management services to members who did not qualify for chronic care services . the eligibility criteria of the four plans can be placed on a continuum ranging from the most restrictive to the least restrictive .
seniors plus and scan health plan were much less restrictive , electing to provide preventive services to moderately impaired members .
at all of the sites , the case management department was the single entry point into the chronic care service component of the s / hmo .
initially , every new enrollee received by mail a baseline health status form ( hsf ) . if this form , or a followup telephone screening to review hsf responses , indicated that the person might be impaired , a case manager conducted an in - person comprehensive health assessment .
telephone screenings and comprehensive assessments could also be triggered by referrals from s / hmo medical staff and other service providers .
following the comprehensive assessment , a final determination was made about eligibility for chronic care services .
given the differences in the eligibility criteria and processes at the four sites , it was not surprising to find that different proportions of the total membership were being permitted access to chronic care services . in table 1 one
can see the numbers and proportions of the s / hmo membership who were certifiable , of the members who were receiving chronic care services , and of the members who were receiving case management services only during the fourth quarter of 1986
. also shown , where available , are plan projections of case mix made during the planning stages of each s / hmo .
medicare plus ii projected that only 5 percent of its membership would be certifiable and only those enrollees would receive chronic care services . by the fourth quarter of 1986 ,
the s / hmo had 4,300 members ; 6.7 percent were certifiable , but only 4.5 percent ( 67 percent of the certifiable group ) were receiving chronic care services .
another 4 percent of members received case management services only ( i.e. , periodic monitoring ) .
the proportion of certifiable members was larger than the proportion of members receiving chronic care services for two reasons .
second , during the first 24 months of the demonstration , there was an anomaly in the state of oregon 's nhc criteria that resulted in several incontinent medicare plus ii members being evaluated as certifiable , although they did not actually need services . at elderplan ,
the actual number of functionally impaired persons receiving chronic care benefits was considerably lower than that projected in its demonstration protocol .
elderplan projected that 13.8 percent of its members would be impaired and using chronic care services at any given time .
of the four plans , elderplan had the highest projected use of chronic care benefits . by the fourth quarter 1986 , this s / hmo had 2,502 members ; 4.1 percent were certifiable , and only 2.9 percent were receiving chronic care services ( i.e. , approximately 71 percent of certifiable members were receiving chronic care services ) .
seniors plus projected that 4.3 percent of its members would be certifiable , but that 8.5 percent of enrollees would receive chronic care benefits .
this reflected this plan 's orientation toward using chronic care services as a form of third - level safeguard to forestall further deterioration of the condition of moderately or severely impaired members at risk of becoming certifiable . by the fourth quarter of 1986 , the s / hmo had 1,688 members ; 7.2 percent of enrollees were certifiable ; 11 percent of the members were receiving chronic care services ; and an additional 8.2 percent of members received case management services only .
scan health plan also followed the seniors plus strategy of preventive use of chronic care services and projected that a larger proportion of its membership would receive those services ( 10.0 percent ) than would be certifiable ( 4.0 percent ) . as was the case for seniors plus ,
the actual membership was more impaired than was anticipated . by the fourth quarter of 1986 ,
scan health plan had 2,061 members ; 5.5 percent were certifiable ; 12.1 percent were receiving chronic care services ; and 7.9 percent received case management monitoring only .
these data indicate that at the end of the second year of the demonstration , two of the plans were providing chronic care benefits ( either case management or chronic care services ) to a large proportion of the membership who were assessed by case managers as " at risk " of institutionalization but who did not meet their state 's nhc criteria . at scan health plan ,
only 28 percent of those receiving chronic care benefits were certifiable ; at seniors plus , the percentage was only slightly higher35 percent . in sharp contrast , at elderplan and medicare plan ii , at least three - fourths of the chronic care recipients were certifiable .
these differences are noteworthy because as the plans assumed full financial risk in year three , scan health plan , citing fiscal reasons , petitioned hcfa and changed its eligibility criteria , offering chronic care services only to members who were certifiable .
in large part , the roles , responsibilities , and authority given to the case management component of the demonstration plans were determined by their organizational model  whether the plan 's principal sponsor was an established hmo or a long - term care provider that created a newly formed hmo .
the organizational model was also a key determinant of case management department linkages to the larger s / hmo delivery system .
indeed , the organizational model often determined whether the case managers had direct control over a service or whether the case manager 's role was primarily that of coordinating with another health care provider . the major difference in case management practices between the established hmo and long - term care organization s / hmo models
is found in the degree of involvement of s / hmo case managers in monitoring acute care utilization .
the two s / hmo 's affiliated with established hmo 's ( medicare plus ii and seniors plus ) chose to leave primary responsibility and control over acute care utilization ( i.e. , hospital and post - hospital , skilled nursing home , and home health care ) to their respective hmo utilization review and discharge planning staff .
the s / hmo 's founded on preexisting long - term care organizations ( scan health plan and elderplan ) attempted to gain control over acute care utilization by assigning part of the utilization review and discharge planning responsibilities to the case management component of the s / hmo .
both plans experienced considerable difficulty with the original providers when they attempted to place case managers in these new roles .
for example , at one site the case manager role was a source of contention with the regular hospital utilization review and discharge planning staff , who maintained that the job could be done more efficiently and effectively in - house .
a more detailed discussion of organizational factors influencing hospital and nursing home utilization is presented in the interim congressional report ( health care financing administration , 1988 ) . other case managers ' roles were similar across all plans , reflecting traditional case management functions ( e.g. , assessment , care planning , and service arrangement ) . at all sites ,
the case managers were responsible for coordinating the fairly comprehensive array of institutional and community - based long - term care services that constituted the chronic care benefit package .
in addition , case managers routinely contacted non - s / hmo service providers to obtain information or refer members for services not covered by the s / hmo , such as legal help , social security assistance , shared housing , friendly visitors , and senior centers .
face - to - face meetings or telephone calls were conducted with caregivers to negotiate care plans , explain benefits and copayments , clarify client needs , help the family accept client disabilities , facilitate family interaction , identify tasks family members could reasonably perform , and support family caregiving efforts .
all plans had written guidelines specifying that no chronic care services could be authorized without first exploring the availability of potential help from informal caregivers . at each of the sites ,
in most cases this required the development of a long - term chronic care service utilization plan to prevent clients from exhausting their benefits .
additionally , the plans had somewhat different benefit periods and cost - sharing arrangements ( health care financing administration , 1988 ) .
it is important to place in perspective the actual dollar amount available for a case manager 's use in developing a chronic care plan .
for example , scan health plan offered a fairly generous $ 7,500 annual benefit , yielding an average monthly benefit of $ 625 .
if an elderly person with alzheimer 's disease needed day care 3 days a week ( at $ 27 per day ) and a home health aide to assist the family with the member 's personal care needs for 2 hours ( at $ 8.75 per hour ) on the days when day care was not attended , the weekly cost would be $ 151 , which would exceed the budget . for members with short - term or time - limited chronic care service needs
, benefit limits usually posed no problem . for a highly impaired person requiring services on an ongoing basis , services had to be carefully allocated to maximize member benefits . to date
, it appears that the case managers have been able to monitor and maximize benefits with considerable success .
for example , during the fourth quarter of 1986 , the plans reported that only a small number of members had exhausted their benefits 
by the end of the second year of the demonstration , plans varied considerably in the extent to which the acute and long - term services had been integrated to provide an effectively coordinated continuum of care for impaired elderly . in general , at medicare plus ii ,
s / hmo case mangement was a fairly insular unit functioning with a reasonable , although not a high , degree of coordination with the larger kaiser system .
most physicians and providers generally did not know whether a member was in the medicare plus ii program .
the larger kaiser system remained responsible for acute hospital care , medical care , and medicare - covered home or nursing home care .
the s / hmo case managers were only responsible for the expanded chronic care services and budget . at elderplan , there was little evidence of an integrated service system .
it appeared that the s / hmo could have benefited from stronger ties and coordination between the medical / hospital service components and the case management component responsible for long - term care .
a large number of medical specialists operating independently of the s / hmo were responsible for acute hospital care .
the primary care physician group was under contract to the s / hmo but was not closely linked to the case management component . in an attempt to gain control over hospital utilization , a case manager was assigned the utilization review and discharge planning functions , but did not have the power or authority to influence practice patterns .
further , working relationships between key personnel in the principal acute care hospital and the case managers were not strong .
long - term institutional and in - home care were the sole responsibility of the case managers , with little input from the medical component .
in contrast to elderplan , seniors plus appeared to effectively integrate the s / hmo case management department with two strong preexisting service providers  group health , inc . and ebenezer society .
at each level of health care  acute hospital , outpatient clinic , nursing home , community - based services , and in - home services  there were well defined , closely coordinated working relationships between the case managers and the other service providers . in turn
, the other service providers recognized that when a s / hmo client required chronic care services , the case managers then had control over chronic care service use and cost . continued coordination between the acute care and long - term care service teams was evidenced in the case conference meetings attended by the medical director , select physicians , the home care service director from ebenezer , the geriatric nurse practitioner who managed nursing home care , and the s / hmo case managers . in the scan health plan
, a large number of health care providers could be involved in a member 's plan of care .
even though the scan program had a number of years of experience working with many of the providers in the multipurpose senior services program ( mssp ) , the s / hmo case management department faced a tremendous challenge as it attempted to coordinate this diverse group of service providers ( more than 100 ) into a comprehensive continuum of care for the impaired s / hmo members .
each type of health care was provided by a different vendor under contract . with the assistance of the scan health plan medical director ,
the role of the case management department was to coordinate this array of service providers . at the end of the second year of the demonstration , based on service provider interviews
, it appeared that some of the linkages needed to be strengthened and better coordinated  especially between the s / hmo case managers and the primary care physicians , the medical specialists , and the hospital discharge planning unit .
a detailed description of the acute and long - term care service delivery systems at each site at the end of the second year of the demonstration is provided in the congressional report ( health care financing administration , 1988 ) .
this report also provides information on the health care environment and the market in which each of the plans was implemented .
this preliminary review of the case management component of the s / hmo demonstrations has identified a number of issues and questions to be examined in subsequent analyses . in addition , the ongoing research agenda contains specific questions about s / hmo members who are eligible for and are receiving chronic care benefits .
how do the health and functional limitations of members receiving chronic care services and case management vary across plans ? to what extent do plans provide case management to persons determined not to be nursing home certifiable ?
what are the implications of this for state nursing home criteria , plan resource allocation , and beneficiary satisfaction ? how do services differ between members assessed as nursing home certifiable and members assessed as " at risk " of institutionalization ? what is the potential impact on client case mix and program revenues of standardizing nursing home certification criteria ?
what are the quantitative and qualitative differences in each plan 's approach to case management for members with the same primary diagnosis ? what out - of - pocket costs are incurred for noncovered long - term care services ?
can case managers remain within chronic care budgets as the membership ages and frailty advances ? should case managers participate in hospital utilization review and discharge planning ?
what impact will multiple vendor agencies have on case management work load and member satisfaction ? will case managers be able to develop formal chronic care standards and protocols for issues such as normal usage , equity of service allocation , and quality of care ? what similarities and differences are evolving between case management in the s / hmo 's and earlier long - term care demonstrations ?
what aspects of the s / hmo case management approach are transferable to other prepaid health care settings ?
 in this article , case management departments and roles during the early years of the social health maintenance organization ( s / hmo ) demonstrations are compared . 
 these organizations provide acute and chronic care services under a prepaid plan for the elderly . 
 eligibility criteria for case management and chronic care services at each site are compared , followed by a description of the resultant case mix of members receiving chronic care benefits . 
 case managers principal activities are described , and a preliminary assessment is made about the strength of the linkages that have been developed between the case management component of these plans and the larger health care system . 
Introduction
Case management's mandate
Service eligibility criteria
Case mix
Primary case management roles
Service integration
Research agenda