Models for Integrating and Managing Acute and Long-Term Care Services in Rural Areas

EDITOR LARRY C. MULLINS, Auburn University Montgomery ASSISTANT EDITOR ALLISON BANNING, Auburn University Montgomery ASSOCIATE EDITOR, Demographic and Socioeconomic Issues CHARLES F. LONGINO, Wake Forest University ASSOCIATE EDITOR, Health and Health Care Issues RAYMOND T. COWARD, Pennsylvania State University ASSOCIATE EDITOR, Family and Caregiving Issues ROSEMARY BLIESZNER, Virginia Polytechnic Institute and State University ASSOCIATE EDITOR, Planning, Practice, and Policy Issues LISA P. GWYTHER, Duke University EDITORIAL BOARD REBECCA G. ADAMS, University of North Carolina at Greensboro TRUDY B. ANDERSON, Texas A&I, Kingsville LARS ANDERSSON, Stockholm Gerontological Research Center, Sweden GREGORY W. ARLING, University of Wisconsin–Madison GLENDA AVERY, Auburn University LORIN A. BAUMHOVER, Appalachian State University TIMOTHY H. BRUBAKER, Miami University–Ohio JAMES H. CARTER, Duke University NEENA L. CHAPPELL, University of Victoria, British Columbia, Canada ALEXANDER CHEN, University of Maryland at College Park STEPHEN GOLANT, University of Florida CAROLE HABER, University of Delaware ROMA HANKS, University of South Alabama CHARLENE A. HARRINGTON, University of California, San Francisco BETTY J. HAVENS, Department of Health, Province of Manitoba, Canada CAROL CLARKE HOGUE, University of North Carolina–Chapel Hill VIRA R. KIVETT, University of North Carolina at Greensboro JOHN A. KROUT, Ithaca College, New York JERSEY LIANG, University of Michigan GEORGE MADDOX, Duke University WILLIAM J. MCAULEY, University of North Carolina at Charlotte LINDA MOODY, University of South Florida RUDOLF MOOS, Stanford University and Department of Veterans Affairs Medical Center, Palo Alto F. ELLEN NETTING, Virginia Commonwealth University VICTOR REGNIER, University of Southern California KAREN ROBERTO, Virginia Polytechnic Institute and State University JULIA H. ROSE, Case Western Reserve University ROBERT RUBINSTEIN, University of Maryland, Baltimore County RICK J. SCHEIDT, Kansas State University ELEANOR PALO STOLLER, Case Western Reserve University GORDON F. STREIB, University of Florida PAMELA TEASTER, Virginia Polytechnic Institute and State University SHIRLEY S. TRAVIS, University of North Carolina at Charlotte ANTHONY M. WARNES, University of Sheffield, England FRANK WHITTINGTON, Georgia State University For Sage Publications: Kim Koren, Katinka Baltazar, and Michelle Stuckey Cover art: Judith Aymar; Typography: Tracy E. Miller Volume 20, Number 4, December 2001 Special Issue: Models of Integrated Long-Term Care: Rural Applications CONTENTS Current Research in Rural Models of Integrated Long-Term Care . Joyce Beaulieu Graham D. Rowles Linda C. Kuder 379 Models for Integrating and Managing Acute and Long-Term Care Services in Rural Areas . Andrew F. Coburn 386 Financing and Payment Issues in Rural Long-Term Care Integration. Paul Saucier Julie Fralich 409 Rural Long-Term Care Integration: Developing Service Capacity . Elise J. Bolda John W. Seavey 426 Case Management Issues in Rural Long-Term Care Models. Cheryl Schraeder Teri Britt 458 State and Local Initiatives and Research Questions for Rural Long-Term Care Models . Linda C. Kuder Joyce Beaulieu Graham D. Rowles 471 The Inaugural INVESCO Lecture on Retirement Income Security Divine Benefit Versus Divine Contribution Pensions: Approaches to Monitoring Improvements in American Retirement Income Security Over the Next Decade . Neal E. Cutler 480 Index . 508 JournalBeaulieu of et Applied al. / Research Gerontology in Rural Models of Care Current Research in Rural Models of Integrated Long-Term Care Joyce Beaulieu Graham D. Rowles Linda C. Kuder University of Kentucky This introductory article describes four commissioned articles in this issue that review the research on integrated models of long-term care and the rural implications of these models. Most models have been tested in urban areas or with urban population bases. Rural regions have both barriers and opportunities in implementing integrated long-term care. Although a full range of long-term care services may be failing to meet the needs of home and community-based care, rural areas may have better cooperation among acute and long-term care providers. Managed care penetration and experience are limited in most rural regions, but examples are given of Pro- gram for All-Inclusive Care of the Elderly programs, the Arizona long-term care system, the Carle Clinic demonstration, and developments in several states for serving rural long-term care populations with new models that integrate across providers, funders, and/or services. Rural long-term care has received little attention by researchers. During the 1990s, however, more studies were undertaken to explore how rural communities meet the needs of those who are elderly or disabled in ways that maintain the integrity of the local culture, improve local options for care, and value family and kin roles in caring for chronically ill family members. Two conferences were held during this time, one in 1994 and the other in 1999. Both conferences spotlighted current research in rural long-term care and sought to develop research agendas. The first conference was a systematic exploration of the unique roles of both formal institutions (hospitals, nursing homes, home- and community- AUTHORS’NOTE: The work presented here is the result of a research development and dissem- ination conference hosted by the University of Kentucky (UK) Center for Health Services Man- agement and Research, the Sanders-Brown Center on Aging, and the UK Center for Rural Health on Models of Integrated Long-Term Care: Rural Applications, September 16-17, 1999, in Lexington, Kentucky. The conference was funded by the Agency for Health Care Policy and Research Grant No. 1 R13 HS09850-01. Additional support was provided by the Federal Office of Rural Health Policy. The Journal of Applied Gerontology, Vol. 20 No. 4, December 2001 379-385 © 2001 The Southern Gerontological Society 379 380 Journal of Applied Gerontology based services and senior centers) and informal networks in the provision of rural long-term care (Rowles, Beaulieu, & Myers, 1996). The second conference focused on the utility of different models of long-term care currently being tested, issues in adapting these models for rural populations, and a review of findings from a few extant models that specifically serve rural clientele. The 1999 conference took as its starting point the findings of the 1994 rural long-term care conference on the roles of rural institutions and the need for further research and advocacy for specific programs. Specifically, the 1994 conference led to a statement of seven overriding principles for improving rural long-term care (Beaulieu, Rowles, & Myers, 1996; Rowles, Beaulieu, & Myers, 1995). Community locus of control. Communities need programs that respond to their unique characteristics and their environmental, demographic, economic, social, political, and cultural diversity. Nonlinear models of care. Long-term care needs of clients fluctuate rather than follow a linear pattern of improvement or decline. As a result, integration of services and providers is required across primary care, acute care, and long-term care. Client-centered philosophy of care. Program reimbursement policies that some- times pigeonhole clients into categories of eligibility do not meet the individual needs of rural elders. More flexible payment structures are needed to facilitate humane and cost-effective care. Family-centered decision making. Just as the community should be the unit of accountability to meet community needs, so should the client and her or his support system make decisions about individual services. Access to information. Contrary to the stereotypes of the strong communication networks of small communities, rural areas may have weak informal and formal networks of information sharing for long-term care services, including Internet capability. Consumers in rural areas need adequate information about services, and communities need to be able to access new information about long-term care models that work to make decisions for improving long-term care service availability and delivery. Cooperation among providers. To improve access to rural care, cooperative and collaborative relationships must be built across levels of care (acute and long-term care), among sites of care (inpatient, outpatient, and home and community services), and among professions (medicine, nursing, social service, rehabilitation therapy, and others). Redefinition of health professional roles. Greater access to long-term care may be achieved in rural areas by adding flexibility in insurance and public programs for the use and reimbursement of rehabilitation therapists or other profession- als who are in short supply. The following articles reiterate these principles within the theme of integrating services across levels of care and financing streams. Each article Beaulieu et al. / Research in Rural Models of Care 381 discusses the current research and models being tested. In many cases, research is scant, except in urban examples. The authors describe the programs, their goals, and their potential or actual implementation for rural clients. The first article defines and describes research and demonstrations for various modes of integration of financing mechanisms, providers, and services (Coburn, 2001 [this issue]). Dr. Coburn describes the principles of managed care that underpin demonstrations of Medicare/Medicaid programs and other

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