Purpose: There is inadequate knowledge about how to best design new programs to provide home and community based long-term care (HCLTC) supports to the increasing numbers of persons needing them. This research examines an innovative long-term care model entitled Family Care, being piloted in five Wisconsin counties, which uses a publicly-funded managed care approach to finance and provide both community-based and institutional long-term care services to frail older adults and adults with physical and developmental disabilities. We investigate how well Family Care has achieved its stated policy goals of promoting: choice, access, and quality of consumer's health and social outcomes, all while creating a cost-effective long-term care system for the future. We examine successes and challenges to implementing these goals by examining the perspectives of case managers working in the Family Care program.

Methods: Perspectives of Family Care care managers (CMs) are investigated using quantitative and qualitative data from a telephone survey of 133 social work and nurse CMs working in the five pilot Family Care counties (response rate=72%). We describe CMs' responses to closed-ended questions about organizational or structural barriers to HCLTC services related to stated policy goals of choice, access, quality, and cost-effectiveness. We also apply closed coding procedures to examine responses related to these policy goals in a number of open-ended questions.

Results: The stated goals of Family Care often compete, creating inevitable tensions in program implementation. Family Care CMs indicated that Family Care was successful at meeting the access goal by making Family Care an entitlement. They also indicated that Family Care was successful in achieving the goal of choice by providing consumers with more choices regarding program services and through creating a more flexible, responsive system that customizes services and supports to consumer needs. Care managers believed that they were somewhat successful at implementing “consumer centered” care, which supports the goals of both choice and quality. Similarly, reported successes with implementing an interdisciplinary team approach to case management are consonant with the goal of quality. However, CMs cited several barriers that prevented them from better meeting program goals of choice and quality. They reported that a lack of care providers in their communities negatively affected how well consumers were being served. They discussed an overemphasis on the goal of cost-effectiveness to the detriment of choice and quality goals. Other challenges to achieving these goals included: large caseloads, excess paperwork, too little time with consumers, and complicated, constantly-changing program guidelines.

Implications for Policy: Our results illustrate how the details of program implementation can support or hinder achievement of HCLTC program goals. New HCLTC programs must be designed and implemented in ways that balance policy and program outcomes related to choice, access, quality and cost-effectiveness. Recommendations of Family Care CMs suggest that equitable achievement of these program and policy outcomes might be facilitated by: clear communication of program goals, training and support that reinforce program goals, appropriate caseloads, efficient systems, and adequate funding levels.