Community Technology Options Project (CTOP)

Final Report

The Community Technology Options Project (CTOP) was implemented as a response to the belief that there continue to be nursing home placements which could be avoided and/or substantially delayed through the use of assistive technology devices and services. Current Adult Services and Aging (ASA) programs provide for the provision of limited assistive technology devices, so this effort involved the provision of more extensive devices and services. Initial discussions involving Medicaid (Dave Christiansen), ASA (Gail Ferris) and DakotaLink subsequently lead to development of a pilot project. The pilot project covered four counties in the Yankton area and utilized local ASA, DakotaLink and Independent Living Center staff. DakotaLink met the costs associated with those necessary assistive devices and services which were/are not covered/allowable under existing state and federal programs.

The demonstration project had three (3) eligibility criteria:

1. The case had been referred to CTOP by an ASA worker because placement in a long term care facility appeared to be imminent if a solution to the barrier(s) to independence was not identified and the necessary assistive device(s) and service(s) provided.
2. Professionals at the local level agreed that there was a reasonable expectation that the assistive device(s) purchased would result in the consumer being able to remain independent for at least one year.
3. CTOP/DakotaLink was the “funding” source of last resort. In short, other state and federal programs did not view the assistive device(s) or services(s) as “medically necessary”, and the consumer did not have the personal resources necessary to purchase the device(s).

Of the fourteen cases referred, nine met these criteria. A brief summary of each follows:

1. Dennis S. - Fifty-three (53) year old with left side paralysis resulting from surgery to remove a brain tumor. Able to eat with some assistance, but dependent upon total assistance from his Mother in all other functional areas. Found to be in need of an electric wheelchair ($5,665), body lift and a harness ($1,000).
2. Alta H. - Eighty-two (82) year old with “dementia”. Good health with the exception of significant short-term memory issues. Family had considered long term care as a result of Alta forgetting to shut off her stove. Found to be in need of a stove shut-off timer ($400).
3. Sharon K. - Fifty-four (54) year old with severe cerebral palsy. Unable to get out of chair, sit down, or stand by self for any length of time. Found to be in need of lift chair ($400), lift device ($210) and sit-stand ($399).
4. Gloria T. - Seventy-five (75) year old with severe rheumatoid arthritis. Elderly spouse no longer able to assist her out of the entrance to their mobile home. Gloria unable to assist herself in these activities as a result of severe pain. A portable ramp would not work, as the height of the entrance to the home would require a thirty-three (33’) foot long ramp. A ramp of this length would extend beyond the boundaries of their lot. An assistive device (vertical wheelchair platform lift) met the need ($5,200).
5. Gloria S. - Forty-five (45) year old with a diagnosis of multiple sclerosis. Items which were determined to be necessary and unallowable under other programs included a ramp, threshold ramp and automatic medication dispenser. DakotaLink expended $852.
6. Charles W. - Fifty-seven (57) year old man with severe multiple sclerosis. It was determined that a lift chair was needed. Cost to the project was $387.
7. Victoria H. - Seventy-eight (78) year old woman with arthritis. A ramp was needed. Cost to the project was approximately $1,000.
8. Lillian H. - This elderly woman, with complications of diabetes, was determined to be in need of a walker with a basket, writing board, lift device, chair with arms, reacher, and riser. CTOP expenditures were $822. Five hundred fifteen dollars was expended by ASA and other local sources.
9. Curtis T. – A young man with traumatic brain injury. Staff determined this individual in need of a “Cheap Talk 4” at a cost of $133.

Case files on the five cases, which were referred but not approved under CTOP, are available for your review. For purposes of this memorandum, suffice to say that two of the individuals being considered died before a determination was made. One of the individuals being considered was found to have excessive resources--in short, staff believed he could afford to purchase the devices and services himself. One individual being considered decided that he did not want assistance, and the family of one client purchased the device needed.

Without question, the success of the State at preventing or delaying costly nursing home placements over the past several years has been noteworthy. Current statewide occupancy rates are probably the best measurement of this. However, what the CTOP demonstration has suggested is that emphasizing the provision of more significant assistive devices and services could add to what is occurring.

According to the Office of Adult Services and Aging, the average cost of a nursing facility is in the neighborhood of $34,000 per year. Keeping individuals independent for even one additional year, then, would provide a significant cost avoidance factor for the State. Although the system is often expending funds on these individuals while they are still “independent” (i.e., ASA programs), costs associated with these efforts are, of course, much less than Long Term Care. Considering the expense of a nursing home, the time it takes a consumer to expend his/her personal resources and transition to Title 19 is relatively brief.

What a review of the cases identified above will illustrate is the fact that the “assistive devices” and services that were needed were quite inexpensive and often associated with home modifications; and what is more often than not needed is a ramp and threshold ramp. These are fairly inexpensive items, but extremely important to an individual’s ability to remain independent. However, the Home Modification Program (funded by the Department of Human Services and administered by the Independent Living Centers) is quite limited. Funds in this program have traditionally been expended before mid-year and the waiting lists are long.

Total funds from all sources expended for assistive devices through the CTOP effort were under $28,000 for the nine individuals found eligible and the total cost for assistive technology services was $1,520.00. The nine individuals served have, to date, accumulated a total of 96 months of independence since provision of the assistive technology devices and services. Once again, the eligibility criteria for CTOP included a determination by an ASA worker that (1) placement appeared imminent if the device and service was not provided, and (2) there was a reasonable expectation that the consumer would remain independent for at least one year. CTOP was implemented as a response to the belief that nursing home placements could be avoided or substantially delayed through the use of assistive devices and services, and that the upshot of this would be a financial savings to government given the rapid movement from private-pay to Title 19.

Given the relatively few cases involved in CTOP it would, of course, be impossible to draw any statistically valid conclusions. Whether or not there is a value in involving assistive technology experts in the assessment of Title 19 clients/potential clients, or whether or not the use of assistive technology devices and services can avoid or substantially delay nursing home placements cannot be determined by fourteen referrals. The sense of DakotaLink and Independent Living Center staff in the Yankton area is that both have a positive impact, and that the nine individuals who were served would have needed a nursing facility had they not received the necessary device(s). The findings of one of the most conclusive research projects to date would support this position.

In an article entitled “Effectiveness of Assistive Technology and Environmental Interventions in Maintaining Independence and Reducing Home Care Costs for the Frail Elderly”, William C. Mann, OTR, PhD and others published their findings in the May/June 1999 issue of Rehabilitation Engineering Research Center on Aging. This publication is funded by the National Institute on Disability and Rehabilitation Research in the U.S. Department of Education. Dr. Mann’s research project was also supported by the Administration on Aging of the Department of Health and Human Services and the Andrus Foundation of the American Association of Retired Persons.

Essentially, Dr. Mann’s premise was that to offset the impact of impairments resulting from chronic conditions and the aging process, people who are elderly often rely on assistive devices such as canes, walkers and bath benches. Dr. Mann went on to add what he termed Environmental Interventions such as the addition of ramps, lowering of cabinets, etc. His observation was that few assistive devices, and even fewer Environmental Interventions were covered expenses by any third-party payers. Likewise, it was his observation that third-party payers did not pay for the assessment services of experts who could determine what the frail elderly individual needed.

The “context” of Dr. Mann’s study was founded in the conviction that home environmental interventions and assistive devices have the potential to increase independence for community-based frail elderly persons, but that their effectiveness had not yet been demonstrated. His objective was to evaluate a system of assistive devices and environmental interventions service provision designed to promote independence and reduce health care costs for physically frail elderly persons.

Participants totaled 104 home-based elderly persons. One group included 52 individuals who were a part of the so-called treatment group, and the other 52 individuals were a part of the control group. All participants underwent a comprehensive functional assessment and evaluation of their home environment by an expert in the field of assistive devices/environmental interventions. Participants in the treatment group received the necessary assistive devices and environmental interventions based on the results of the evaluation. The control group received what were termed usual services. In short, they did not receive the services/interventions identified in the evaluation.

The study lasted for eighteen months, and many of the conclusions were what one might expect. The frail elderly persons in the study (both groups) experienced functional decline over time. However, the rate of decline was less in the treatment group. In other words, they found that the rate of decline could be slowed, delaying placement. It is interesting to note that the control group required significantly more expenditures for institutional care once placed. It is perhaps more interesting to note that while in the home, there was no significant difference in total in-home costs; although the treatment group posed an expense for assistive devices and environmental interventions that the control group did not pose, the control group deteriorated more rapidly and presented significantly greater expenditures for nurse and case manager visits. Dr. Mann concluded that the rate of decline can be slowed, and institutional and certain in-home personnel costs reduced through a systematic approach to providing assistive devices and environmental interventions.

To summarize, we would recommend that the State consider increasing its financial commitment, particularly in the area of environmental interventions/home modifications. The CTOP demonstration program clearly identified this as a need in the Yankton area. There is reason, we believe, to expect that the same need exists throughout the state. Preventing or delaying placement in a nursing facility should more than pay for the effort. In addition, based upon what Dr. Mann found, the cost of care once a placement is finally made should be less. Since Social Services purchases care from a facility based on the consumer’s level of need, this should also impact the state.