Occasional LTC Policy Paper Series © 1997 Duke LTC Resources
North Carolina's CAP/DA Population: Is CAP/DA On Target?
by Stuart Bratesman, Jr., MPP
Policy Analyst
Duke Long Term Care Resources
Overview
The N.C. CAP/DA program appears to be on target.
The Community Alternatives Program for Disabled Adults (CAP/DA),
North Carolina's Medicaid home and community-based waiver program, is
intended to provide alternatives to nursing home placement for the low-
income disabled adults. CAP/DA permits poor, frail older adults to age in
place. Available evidence indicates that this program does in fact serve
the intended population. This study uses a recent random sample of 425
N.C. CAP/DA clients to characterize the CAP/DA population and to
compare this group, when possible, to other populations of older adults.
The Problem
Is CAP/DA on target in reaching highly impaired clients?
This paper addresses the question of whether N.C. CAP/DA actually
targets a population characterized by low income, Medicaid-eligible and
nursing home-eligible persons with high levels of disability as measured
by impairments in Activities of Daily Living (ADL's).
Methodology
It is frequently impractical and expensive to analyze a program's
total population. In the 1994-95 program year, CAP/DA served
6,467 clients throughout North Carolina. Instead, this study
took advantage of the data available from existing sequential
random samples of CAP/DA clients. Sequential sampling, in the
tradition of the U.S. Census Bureau and Bureau of Labor Statistics'
Current Population Survey (CPS), was used to generate a CAP/DA
study sample for comparison with other populations of older
adults.
In this case, Medical Review of North Carolina (MRNC), under contract to
North Carolina's Medicaid agency, the Division of Medical Assistance
(DMA), takes a statewide monthly sample of 85 CAP/DA clients chosen at
random among the cases that were active that month, and examines their
assessment records for compliance with CAP/DA enrollment regulations.
To date, Duke LTC has contracted with MRNC for selected assessment
data for each of the 85 enrollees sampled monthly from March-through-
July of 1996. The Duke LTC Program also contracted with MRNC to
abstract information about the functional status and social characteristics
of enrollees. Over the first five months, the study accumulated a sample
reported here of 425 cases. These assessment data include age, gender,
ethnicity, living arrangements and various standard measures of disability
and impairment.
This information was used to profile the characteristics of the N.C.
CAP/DA population and compare it other populations of disabled adults.
To learn where the CAP/DA population is located within the universe of
other populations of older or disabled adults, we've chosen three other
groups for comparison:
- a national sample of non-institutionalized Medicare beneficiaries
from the 1992 Medicare Current Beneficiary Survey including
dual-eligibles and Medicare-only groups* as analyzed and
reported by the Center for Health Economics Research and
the Long-Term Care Data Institute (1);
- a statewide sample North Carolina's Adult Care Home residents
reported in 1995 by the Research Triangle Institute (RTI)(2); and
- the North Carolina and national nursing home populations
as reported by the N.C. Division of Facility Services for
the twelve months ending in April 1996 from their on-going
annual survey of all nursing home residents in the state.(3)
* "Dual-eligibles are low-income Medicare enrollees who
also qualify for Medicaid services.
Our comparisons, reported in the tables which follow, are
made on the basis of basic demographic characteristics and
measures of levels of impairment in ADL's, where available
from the other reports. ADL's - which measure the ability
of a person to bathe, dress, walk indoors, transfer in- and-out
of bed, use the toilet, or eat, on their own or with varying
levels of required assistance - are the recognized gold standard
for measuring and reporting disability.
Since the age ranges of comparison groups and the characteristics
being measured differ in published accounts from one comparison
population to another, it is important to pay close attention
to the description of the tables and graphs below to know
what is being compared in each case. Some tables compare populations
of adults age 18-and-up. Other reports restrict the comparisons
to older adults above age 64. Some compare the percentage
of clients requiring any level of assistance in an ADL. Other
tables compare the percentage of clients who are totally dependent
upon the assistance of others in the performance of an ADL.
It is always good practice to carefully read reports of comparisons
among older adult populations to assess their comparability.
Description of North Carolina's CAP/DA Program
North Carolina's CAP/DA program was begun in 1982 under the
authority of a federal Health Care Financing Administration
Medicaid waiver to provide a home and community-based services
alternative for the frail elderly and disabled adults facing
institutionalization in a nursing home. The program permits
low-income disabled adults to live in the least restrictive
setting given their level of impairment and the network of informal
support provided by family and friends.4
North Carolina CAP/DA serves Medicaid eligible adults age
18-and-over, certified by a physician to require care at the
intermediate care facility- level, or skilled nursing facility-level.
To qualify for CAP, a client must be able to be safely cared
for at home, given a set of services that remain within the
Medicaid cost limit.
CAP/DA Services
In the 1994-95 program year, the latest year for available figures,
North Carolina CAP/DA services cost $74,097,048.5 CAP/DA services,
listed in order of the 1994-95 annual program cost include the
percentage of program cost in parentheses:
- personal care services from an in-home aide (91%)
- case management (6%)
- home mobility aides and incontinence supplies (1%)
- in-home and institutional respite care (less than 1%)
- adult day health care (less than 1%)
- telephone alert (less than 1%)
- home delivered meals and nutritional supplements (less than 1%)6
Findings
North Carolina's CAP/DA population is older, more female, more
minority, and is more functionally impaired than most other
comparison groups.
North Carolina's CAP/DA population looks very much like what
one would expect in a poor, frail population of older adults.
Compared to other older populations, the N.C. CAP/DA sample
has a higher proportion of the "oldest old", a higher percentage
of women, a higher percentage of minorities, and a very high
incidence of impairment in Activities of Daily Living (ADL's).
Below, we will compare the N.C. CAP/DA population to other
groups, first by age distribution, then by gender, then by
ethnicity, and then by the incidence of ADL impairments.
Demographics (Age, Gender and Ethnicity)
N.C. CAP/DA serves a primarily older population. More than three-
quarters (78%) of CAP/DA participants are age-65-or above. Twenty-eight
percent of CAP/DA clients are 85-and-older (see table 1).
Table 1: Distribution by Age of North
Carolina CAP/DA Participants (March-July 1996, n=425)
| Age Group |
18-54 |
55-64 |
65-74 |
75-84 |
85+ |
Total |
% of CAP/DA
Participants |
13% |
10% |
19% |
30% |
28% |
100% |
The age distribution of North Carolina CAP/DA participants,
age 65-and- above, is older than that of the national age 65-and-above,
non- institutionalized Medicare population. This holds true
for both the Medicare-Medicaid dual-eligible and Medicare-only
components of the Medicare population (see Chart 1).7
Chart 1
The age distribution of N.C. CAP/DA clients in the 18-and-over
age range is also older than the age distribution of the 18-and-over
residents of the state's Adult Care Homes (see Chart 2).8 N.C.
CAP/DA has higher proportions of clients in the 65-to74, 75-to-84
and 85-plus age groups with greater differences between the
percentages of the oldest-old.
Chart 2
Gender and Race
CAP/DA is 84% female and 42% non-white
Overall, North Carolina CAP/DA clients are 84% female and
42% non- white. Within the over-65 age group, the CAP/DA population
has a higher proportion of women and racial minorities than
either the dual-eligible or Medicare-only components of the
national community-dwelling Medicare population (see Table 2).
Table 2: North Carolina's CAP/DA Clients
Compared to the National Community- Dwelling Medicare Population
by Gender and Race (all groups age-65-and-above)9
Client
Population |
Male |
Female |
White |
African - American |
Other Non - White |
| N.C. CAP/DA |
11% |
89% |
60% |
37% |
4% |
| Dual-Eligible |
22% |
78% |
62% |
28% |
7% |
| Medicare-Only |
41% |
59% |
89% |
7% |
1% |
When compared to Adult Care Home residents across ages 18-and-
above, North Carolina's CAP/DA program also serves higher percentages
of women (84% vs. 66%), and African-Americans (37% vs. 29%).10
Functional Impairment in Activities of Daily Living
Functional Status: 85% require hands-on
assistance for three-or-more ADL impairments
One of the more striking characteristics of the North Carolina
CAP/DA population is their high level of functional impairment.
Eighty-five percent of the state's CAP/DA clients require
hands-on assistance from another person in the performance
of three-or-more ADL's. Ninety-nine percent require hands-on
assistance with bathing, and 96% require hands-on assistance
to get dressed.
A North Carolina CAP/DA client above age 64 is four times
as likely to require assistance in bathing than a person in
the over-64 national sample of those eligible for both Medicare
and Medicaid, and fourteen times more likely than those in
the Medicare only sample (see Table 3).11
Table 3: North Carolina's CAP/DA Clients
Are Much More Likely to Require Some Kind of Assistance in Activities
of Daily Living than Community-Dwelling Medicare Beneficiaries
Across the U.S. (Includes only those age-65-and-above)
| ADL |
Bathing |
Dressing |
Walking |
Transferring |
Toileting |
Eating |
N.C.
CAP/DA |
99% |
96% |
77% |
71% |
69% |
40% |
| Dual Eligibles |
23% |
13% |
24% |
15% |
7% |
2% |
Medicare
Only |
7% |
5% |
8% |
5% |
2% |
1% |
CAP/DA recipients are also much more likely to be impaired
than the residents of North Carolina's Adult Care Homes (see
Table 4). CAP/DA clients are from one-and-a-half to almost
four times as likely as an Adult Care Home resident to require
assistance with a given ADL.
Table 4:
North Carolina's CAP/DA Clients Are More Likely to Require Some
Kind of Assistance in Activities of Daily Living than Residents
of N.C. Adult Care Homes. (All clients and residents age-18-and-above)
| ADL |
Bathing |
Dressing |
Walking |
Transferring |
Toileting |
Eating |
| N.C. CAP/DA |
99% |
95% |
80% |
73% |
70% |
41% |
| N.C. Adult Care Residents |
66% |
39% |
26% |
23% |
24% |
11% |
| Ratios CAP/DA - to-Adult Care |
1.5 |
2.4 |
3.1 |
3.2 |
2.9 |
3.7 |
N.C. CAP/DA clients are among the most
impaired.
There is also a much higher prevalence of multiple functional
impairments among CAP/DA clients than among Adult Care Home
residents. To make a direct comparison between the CAP/DA
sample and the RTI study of Adult Care Home residents we measured
the percentage of CAP/DA clients who required hands-on assistance
for no ADL's, 1-to-2 ADL's and 3-to-5 ADL's in dressing, walking,
toileting, transferring and eating. RTI excluded bathing from
their multiple impairment count since many Adult Care Homes
provide bathing assistance to all residents, regardless of
need, as a standard operating procedure. Therefore, for the
purposes of the following comparison, we also excluded bathing
from the multiple impairment measures for CAP/DA.
At the lowest end of the multiple impairment scale, 3% of
N.C. CAP/DA clients had no hands-on level ADL impairments,
while 59% of North Carolina Adult Care Home residents in the
RTI sample had no ADL's. In the middle range, 24% of the CAP/DA
group, and 21% of Adult Care Home residents, displayed one-to-two
hands-on level ADL's. At the high end of the multiple impairment
scale, over three-and-a-half times as many CAP/DA clients
(73%) as Adult Care Home residents (20%) had three-or- more
of five possible ADL's.
Not surprisingly, the population that appears most similar
to the CAP/DA group is the nursing home population. The most
recent N.C. Division of Facilities Services statistics on
ADL impairment among North Carolina nursing home residents
describe the percentage of residents who require hands-on
assistance or who are dependent on staff for bathing, dressing
transferring, toileting, and eating and they describe the
incidence of occasional-to-frequent bladder and bowel incontinence
(see Table 5). These reports also provide comparisons to the
nationwide nursing home resident population.
N.C. CAP/DA clients are about as likely as nursing home residents
to require assistance in bathing, dressing and transferring
or to be occasionally-to-frequently incontinent of bladder.
In fact, the N.C. CAP/DA population has a slightly higher
incidence of impairment in all those areas except transferring.
However, the incidence of impairment in toileting and eating,
and the incidence of bowel incontinence are all somewhat greater
in the nursing home setting. The differences in the incidence
of bowel incontinence are likely to account for some of the
differences in toileting impairments. In every case except
bathing, North Carolina nursing home residents are slightly
more likely to be impaired than the national nursing home
average.
Table 5: The Impairment Profile of North
Carolina CAP/DA Clients and Nursing Home Residents are Similar
for Bathing and Dressing and Bladder Incontinence. Nursing Home
Residents are More Likely Require Hands-On Assistance for Toileting
and More Likely to be Bowel Incontinent.12
| |
Percent of Persons Requiring
Hands-On Assistance in: |
Occas.to
Total
Incontinence |
| Bathing |
Dressing |
Transferring |
Toileting |
Eating |
Bladder |
Bowel |
| N.C. CAP/DA
Participants |
99% |
93% |
72% |
68% |
39% |
54% |
36% |
| N.C. Nursing
Home Residents |
92% |
88% |
76% |
80% |
50% |
53% |
50% |
| Nationwide Nursing
Home Residents |
93% |
85% |
72% |
76% |
47% |
52% |
45% |
| Ratios: N.C.
CAP/DA-to- N.C. Nursing Home |
1.07:1 |
1.06:1 |
0.94:1 |
0.84:1 |
0.78:1 |
1.03:1 |
0.72:1 |
| Ratios: N.C.
CAP/DA-to- National Nursing Home |
1.06:1 |
1.09:1 |
1.01:1 |
0.89:1 |
0.82:1 |
1.05:1 |
0.79:1 |
The N.C. CAP/DA population ranks roughly equal with the N.C.
Nursing Facility population as the most functionally impaired
among sub-groups of older adults.
These comparisons between groups show an increasing order
of the incidence of functional impairment:
| Least Impaired |
Older Adults in General |
| |
Older Adults / Medicare Only |
| Older Adults / Medicare & Medicaid |
| N.C. Adult Care Home Residents |
| N.C. CAP/DA Participants |
| Most Impaired |
N.C. Nursing Home Residents |
Indeed, the CAP/DA population is much more similar, across
all impairment measures, to the N.C. Nursing Home population
than it is to the Adult Care Home Population. This places
the CAP/DA population where one would expect, since the program's
medical need criteria are intended to target those persons
at greatest risk for admission to a nursing facility.
Conclusions
N.C. CAP/DA is on target, providing needed services for many
of North Carolina's most seriously impaired low-income older
adults.
North Carolina's CAP/DA program reaches seriously impaired
low-income older adults and provides them with a home and
community-based alternative to institutionalization. The random
sample of CAP/DA participants are one of the most functionally
impaired populations in the state, on par with North Carolina's
nursing home population and much more impaired than the state's
Adult Care Home and general Medicare populations.
Future analysis of the CAP/DA data set will explore the relationship
between the presence or absence of informal support and levels
of impairment, and examine the relationship between level
of functional impairment program costs at the individual level.
References
1. Walsh, Edith G., et.al., "The Community
Medicare Population: A Comparison of Characteristics, Medicare
Utilization and Costs of the Dually Eligible and Medicare Beneficiaries
without Medicaid," (Center for Health Economics Research: Waltham,
Mass.) hand-out accompanying a poster presentation at the 1996
Annual Meeting of the Gerontological Society of America, Washington,
D.C.)
2. Hawes, Catherine, et.al., "Study of North Carolina Domiciliary
Care Home Residents," Feb. 15, 1995, (Research Triangle Institute:
Research Triangle Park, N.C.)
3. N.C. Div. of Facility Services, computer print-out of a "Full
Facility Profile" for N.C. nursing facilities, (Raleigh, N.C.:
Jan. 14, 1997)
4. N.C. Div. of Medical Assistance - Community Alternatives
Programs Unit, Medicaid Community Alternatives Program for Disabled
Adults (CAP/DA) Manual, (Raleigh, N.C.: October 1994), Ch. 1,
p. 1.
5. "CAP/DA Annual Reports Summary," N.C. Div. of Medical Assistance,
(Raleigh, N.C.: Nov. 5, 1996), p.2.
6. Ibid.
7. Walsh.
8. Hawes, p. 17.
9. Walsh, Table 1.
10. Hawes, p. 17.
11. Walsh, Table 7.
12. N.C. Div. of Facilities Services, "Full Facility Profile"
Acknowledgements
I would like to thank the North Carolina Division of Medical
Assistance and Medical Review of North Carolina for their
kind assistance in providing the data on CAP/DA clients that
made this study possible. I would particularly like to thank
Annette Fulcher of MRNC for her assistance in making MRNC's
CAP/DA data easier to translate from their computer system
to ours. I also wish to extend particular thanks to Judy Walton
of N.C. DMA for answering our many questions about the proper
interpretation of information collected on the CAP/DA assessment
form and for providing additional data on CAP/DA program costs.
I could not have written this paper without the support, guidance,
assistance and advice of my colleagues at Duke LTC including
Jennifer Hoffmann, Sandra Crawford Leak, and especially Dr.
George Maddox, the Duke LTC Program Directory. Prof. Elise
Bolda of the Muskie Institute of Public Affairs at the University
of Southern Maine offered many constructive criticisms and
suggestions that were incorporated into the final work. However,
the sole responsibility for any and all mistakes of judgement,
analysis and interpretation is mine.
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