Community Care

  There is no consistent state-level effort to encourage home and community-based care in lieu of institutionalization.

Adult Day Care and Adult Day Health Care programs provide local options for treatment but are limited because of lack of funding.

Family caregiver programs provide respite services and counseling, but waiting lists are long and resources are few.

Long-standing problems with the In-Home Supportive Services program continue to affect quality of care, but recent legislative changes hold out hope for improvement.

County-administered adult protective services program have proven an inadequate safety net because of lack of funding and statewide standards.






Community Care

Finding 2: The State's policies and programs do little to encourage the use of community-based services, and too small an effort is made to protect people from premature deterioration that can result in costly institutional placements.

In many areas of state concern, prevention is an investment that saves long-range costs -- but prevention rarely wins priority over reactive services when resources are limited. In the case of long-term care, the bulk of government dollars is spent on institutionalization, and preventive services that would keep people out of high-cost institutions are stretched thin. Statutes are in place that favor community-based care, and exemptions and waivers for licensing regulations provide limited tools to keep people in home-like environments. But by and large, the state bureaucracy blocks rather than enables community solutions, and policy makers provide little financial support for preventive programs. Programs that have proven their worth but that suffer from financial neglect include:

The imbalance between institutional and community-based care is difficult to tally accurately because of the fragmented nature of the State's programs. But California spends about $2 billion annually on long-term care in skilled nursing facilities, providing services to about 70,350 people. In comparison, about $850 million is spent on the In-Home Supportive Services program, which reaches almost 200,000 people, with another $200 million for a variety of services underwritten by the Department of Aging that reach thousands more consumers in their homes and communities. An additional $4 million is spent on Alzheimer's Centers and $5 million to support family caregivers of brain-damaged adults.

The California statistics are not out of line with the national experience. For instance, in 1991 the federal Medicaid program spent $20.7 billion on nursing home care or about 27 percent of all expenditures. The same year Medicaid expenditures on home health care were $4.1 billion, or about 5.3 percent of all Medicaid spending.(66)

A key difference between the State's financial support for institutional care and community-based care is the "unlimited" nature of institutional care from the consumer's perspective. A person who is eligible for skilled nursing care and who is poor will have the cost covered by Medi-Cal for all necessary services and for however long such care is needed. The In-Home Supportive Services program, while an "entitlement" that covers all eligible persons, nonetheless provides a limitation on the number of hours and the cost of services provided. Similarly, support for family caregivers is limited to the funding provided each year by policy makers and there are long waiting lists for services.

These budget allocations may make it appear that the State places a priority on institutional care. But actually the State's statutes regarding long-term care place heavy emphasis on home- and community-based care. This was true of both the original Older Californians Act and in its new version, which replaces the original effective January 1, 1997. The Older Californians Act, which places renewed emphasis on home- and community-based services, has several goals: to shift control of programs and funding from the State to local areas, to integrate social and medical services, to provide a single, easily accessible point of access to services and to provide effective case management. How these goals will take shape is still unknown, especially since there is no additional funding to make the changes.

Among other things, the Older Californians Act directs the State's Department of Aging to ensure "to the extent possible" that services provided by multiple state departments are coordinated and integrated. The Act continues, "That integration may include, but not be limited to, the reconfiguration of state departments into a coordinated unit that can provide for multiple services to the same consumers."

The Act defines the Department's mission as providing leadership to the area agencies on aging in developing systems of home- and community-based services that will maintain consumers in their own homes or in least-restrictive, home-like environments. The program standards the Department will adhere to and enforce include:

The call for integrated and community-based services in the new law is welcomed by consumer advocates. But the framework the law provides will need to be accompanied by substantial changes in the way the State does business if reform is to be effective. One area that many have targeted is the way the State licenses long-term care providers.

Licensing Categories

The lack of flexibility in California's approach to licensing programs may force a person to move to settings with higher levels of care before it is really necessary to do so. This is so even though the State has been responsive to the changing needs of long-term care consumers by adding exceptions and waivers to what are generally strictly regimented care options. But these innovations often lag behind growing need.

For instance, some terminal care is available to residents of Residential Care Facilities for the Elderly (RCFEs) through the secured-perimeter Alzheimer's program and the hospice program. But in general people who require medical care -- even at low levels that could be provided by home health agency personnel coming into an RCFE -- must move on to skilled nursing facilities.

This may mean that people with diabetes who can no longer do the finger prick test for blood sugar levels on their own must move to a full medical-model facility. Or someone who needs inhalant therapy several times a day but otherwise is capable of managing with minor assistance may not be allowed to remain in an RCFE.

Another example occurs when a person cannot arrange for a caregiver under the In-Home Supportive Services program. Multiple efforts to find someone reliable and well-trained to provide needed service may eventually frustrate relatives' ability to help keep a person in his own home. This, too, may lead to premature placement in a skilled nursing facility.

From the State's perspective, keeping people in settings that are not skilled nursing facilities as long as possible is at least partly driven by economics -- alternative settings are cheaper and usually not paid for by the government. But there is also a human component to this problem. It has long been recognized that relocating frail elderly or severely disabled people can have a negative impact on their ability to function and survive. Known as transfer trauma, this phenomenon has been studied with different results. Some studies have found increased morbidity and mortality; others have found positive outcomes if the move is handled well and living conditions improve. But in general, moving to an entirely new and unfamiliar environment is very difficult and often dangerously depressing for people who are ill.(67)

Rigid licensing categories not only directly impact consumers, they also affect the decisions made by care providers. The creativity that many community-based programs try to bring to long-term care is hampered by a state structure that requires them to deal with multiple licensing entities -- and the multiple reporting, tracking and auditing requirements that come with fragmented but rigid regulations.

For instance, the On Lok program, which offers a combined approach to caring for enrollees, has day health center licenses, primary medical care clinic licenses and a home health agency license. In addition, because it is paid for its enrollees on a capitated (per-person) basis, it must comply with Department of Corporations filing provisions that are designed for managed care health plans that typically cover thousands of enrollees -- rather than the 485 On Lok has. The result is that On Lok faces multiple and duplicative inspection processes and in some cases must set up separate bookkeeping mechanisms that add no value to On Lok's purposes other than satisfying regulatory requirements.(68)

Participants on the Little Hoover Commission's advisory committee who are long-term care service providers said that if dual licensing were not so difficult and expensive they would be able to fashion solutions that would allow residents to age in place for a longer period. For instance, large residential care facilities could also become adult day health care centers, providing a licensed source of medical care for residents who no longer can attend to their own medical needs but who are far short of needing round-the-clock medical assistance in a skilled nursing facility.

In addition to meeting the needs of the residents, such an arrangement would give the residential care facilities an additional source of revenue (from Medi-Cal reimbursement of adult day health care services) to underwrite better care. Such a dual arrangement would also limit the transportation costs and problems most adult day health care centers face.

But beyond wishing that licensing processes were more amenable to allowing providers to offer multiple types of service, the Commission's advisory committee members worried that any move to consolidate licensing would bring the medically oriented, arduous inspection process that affects skilled nursing facilities into play for residential care facilities. And while desiring more effective oversight for all types of long-term care services, consumer advocates on the advisory committee did not want to see the medical-orientation and what they perceive as anti-consumer due process entanglements of the skilled nursing oversight system imposed on community-based, home-like service providers. Any reform would have to be carefully constructed to focus on outcomes rather than processes, the advisory committee cautioned.

For the most part, service providers have focused on modifying their own licensing categories rather than finding an overall solution. For instance, the California Association of Adult Day Services advocates a "levels of care" approach to licensing that would allow adult day programs to offer only core services or to offer augmented and specialized services with different add-on licensing approvals. This would allow consumers to receive multiple types of services in a single setting. The association's "Levels of Care Initiative" document states:

A levels of care approach to service delivery is based on the notion that the needs of persons with chronic disabilities change over time. It may be subtle or dramatic. In response to the variety of needs among adults with chronic disabilities, adult day services programs have developed to provide a range of services from respite-only adult day care to adult day health programs in a community clinic setting.(69)

The desirability of integrating licensing for long-term care services is not a new concept. In 1986, the Senate Subcommittee on Aging conducted a hearing to explore licensing models that would provide a real continuum of long-term care services. Several service providers, including On Lok, testified about the problems with trying to offer integrated services. The executive director for the Jewish Homes for the Aged in Los Angeles told the subcommittee that the program offered only partial adult day care services and had set up a minimal assisted living housing arrangement separately from its main operations largely because of the demands of multiple licensing processes. He identified the disincentives for holding multiple licenses as:(70)

A representative for the California Association of Homes for the Aging echoed those concerns. He described continuing care retirement communities as a model that allows consumers to move from complete independence through assisted living to complete care without having to relocate. But licensing under separate state agencies is costly and duplicative. Saying that the pieces of a high-quality long-term care program exist and are individually well formulated, he concluded:

Will we continue on this same course of targeting to distinct sub-populations based on categorical funding programs, thus reinforcing the existing fragmented system and increasing the possibility of duplications in effort? Or can we adopt a generic model and pool resources to better serve disabled adults and their families? This is basically a call for this constellation of services and programs to be consolidated into a continuum; regulated and licensed by a single agency and funded through consolidated sources. The benefits are obvious: cost savings through reduced redundancy and duplication and efficient administration; caring for the state's frail elderly and their families in a humane and orderly manner.(71)

Most people testifying favored slow and well-studied reform that would lead to a more welcoming licensing structure. The executive director of On Lok said that such an effort should be ongoing as different models of care evolve over time.(72)

As a result of the hearing, the subcommittee made recommendations, including establishing a task force to review regulations, central coordination of all state programs and the development of multidisciplanary team licensing -- consolidating the process of granting, evaluating and renewing licenses rather than consolidating the licenses themselves.

Ten years later, people are still discussing such changes. Task forces meet to discuss the feasibility of a matrix -- or add-on model -- of licensing and to review regulations for overlap and obsolete requirements. But little progress has been made to make the licensing process friendlier to programs that want to provide an integrated array of social and medical services. The reasons are many: fear of change, departmental turf concerns and federal barriers, to name a few.

Adult Day Programs

Programs that are particularly affected by state licensing policies are the different types of adult day services, which is one reason the statewide association is pushing for reform (as described above). But a more pressing concern for most of these programs is financial viability.

Adult day care and adult support centers are licensed by the Department of Social Services to provide organized social services and protective supervision in a community setting. Adult day health care programs, on the other hand, are overseen by the Department of Aging under licensing requirements from the Department of Health Services. Alzheimer's Day Care Resource Centers provide respite to primary caregivers, training and education under the oversight of the Department of Aging.

These programs provide services that are intended to keep frail people healthy and at home. The highest level program can provide all of the care of a skilled nursing facility -- but the consumer goes home at night. The programs rely on an organized, comprehensive, team approach combining input from staff, the consumer and family. The statewide organization describes the approach:

The programs bridge medical and social services by viewing the person as a multidimensional person living within a larger community that includes both formal and informal support. Center staff work closely with participants, community resources, family members and other caregivers on an intensive, daily basis.(73)

Advocates for the programs say that statistics indicate that services from a day program may help delay institutionalization three years or longer.

The cost is comparatively low. For $54.30 a day, Medi-Cal requires programs to provide transportation to and from the consumer's home, skilled nursing services, meals, personal care and other activities for at least six hours. This compares to the $80 per day that Medi-Cal pays for skilled nursing home care.

Service providers say the reimbursement rate makes it difficult for programs to survive -- and almost impossible for new ones to be created. There are about 84 day health care programs, 110 day care centers and 16 specialized Alzheimer's programs, largely concentrated in the San Francisco Bay Area and Los Angeles area. Most people who could benefit from these services do not have access to them simply because of geography. Recently, rural programs have run into problems because of new tough requirements that all consumers in the service area be provided transportation to and from the program no matter how geographically remote. This means programs are faced with increased transportation costs or restricting service to areas where they can provide transportation.

Those connected with adult day care identified the following priorities during the Little Hoover Commission advisory committee meetings:

Advocates say these types of programs need to be promoted to both consumers and policy makers so that they are not overlooked as efficient, life-enhancing methods for coping with long-term care needs in non-institutional ways.

Family Caregiver Programs

California's Caregiver Resource Centers take a different tack from most long-term care programs. They focus on the people who provide care rather than on the consumer who needs care. Under a 1984 law, the State provides funding for a statewide program of assistance for those caring for adults with brain damage, regardless of cause. The program's target audience for information, supportive services and training are the families, unpaid caregivers and professionals who work with the patients.

Services at 11 nonprofit centers include:

The funding has held constant for the past few years, despite growing need and long waiting lists, at $5 million. Of that amount, $1.3 million is used to pay for in-home and out-of-home respite care. Experts say giving caregivers a break is critical to avoid burnout, depression, premature placement of patients in skilled nursing facilities, and -- far worse but not uncommon -- suicide. Respite care not only gives the caregiver time off, but it also provides the patient with a change, either in companionship with in-home respite care or in scenery with out-of-home respite care.

The resource centers are allowed to authorize up to $425 monthly for respite care, but most cap the service at $350 so that more people can be served. On average, caregivers who are covered receive about nine hours of respite time per week. Caregivers may be provided vouchers to receive respite care through established programs (such as day care centers) or they may be given funding directly to arrange their own respite care.(74)

Almost as important as respite care is the information the centers provide on such things as how to turn someone in bed, mood swings (both the patient's and the caregiver's), the disease process and how to find support groups.

The Family Caregiver Alliance, which is the research and consulting arm of the state-funded program, has conducted several studies to determine the characteristics and needs of brain-damaged adults and their caregivers. The results of one large, year-long study are summarized in the box on the previous page. Another smaller study of 284 caregivers in the Bay Area painted a picture that makes it clear why life is so difficult for these people:

Their patients range in age from 18 to 93, with the average 67. Many wander (48 percent), cannot be left alone (78 percent), awaken the caregiver at night (77 percent) and are stubborn or combative (84 percent). Two-thirds need help to bathe or take medications, three-fifths cannot dress themselves, half cannot go to the bathroom alone and one-third need help to eat.

They have been providing care an average of five years, 59 hours a week, with 28 hours paid help and less than two hours help from other kin outside the patient's household. Many feel tired (59 percent), are usually tense or anxious (42 percent) and feel quite burdened (46 percent). One-fifth had not had a vacation in five years.(75)

The biggest problem facing the program is financial constraints. In 1994-95, the program reached 9,235 caregivers with one or more services. The same year a total of 820 families received respite care. As of January 1, 1996, 3,000 families were on a waiting list for respite care -- a waiting list so lengthy that sometimes patients die or go to institutions before they get to the top of the list.(76)

Stressing the importance of the caregiver program, one advocate told the Little Hoover Commission:

Aging issues are family issues. Families, not institutions, are the major providers of long-term care in this country. Public policies must promote comprehensive, appropriate and affordable long-term care and support for family caregivers. Respite care is just one of a range of services that families need to keep them together at home and out of more costly institutional settings.(77)

In-Home Supportive Services

The In-Home Supportive Services program is a giant among the non-institutional long-term care programs, costing more than $845 million in direct services, with another $150 million for administration, and reaching almost 200,000 people a year. But despite its relative wealth, this program, too, faces severe fiscal limitations that directly impact the quality of care people receive.

The program, administered by counties under oversight from the Department of Social Services, provides the following types of services to people who are low-income and who have been assessed as needing assistance with activities of daily living:

The Little Hoover Commission reviewed this program in 1991, concluding that limited funding and inherent structural flaws prevented the program from providing effective services.(78) The report cited as key problems the fragmentation of responsibility, with all levels of government trying to escape the burden of being the employer of caregivers; the prevalence of relying on the disabled consumer to manage the care, in some cases inappropriately; and the low quality of care stemming from many factors, including lack of standards and training for workers, who are often low paid and transient.

After meeting with the Commission's advisory committee, consulting with state officials and hearing from many IHSS recipients, the Commission found that none of these problems have been resolved. There have, however, been several developments since 1991:

  • Medi-Cal funding for IHSS was obtained: In 1991, the IHSS program in California was completely funded with state General Funds. Other states, however, had made use of a Medicaid waiver to provide the same type of services with a combination of state and federal funds. The Little Hoover Commission's report recommended that California apply for a waiver as a means of stretching state dollars further, bringing in federal funding and improving services. As the Commission report was issued, policy makers enacted legislation requiring the Health and Welfare Agency to investigate the feasibility of obtaining a waiver.

    At about that same time, the State began to move programs to county control and funding responsibility under a process called realignment. Also at that time, the State's multi-year recession began to squeeze the resources available for all service programs.

    When the Medi-Cal waiver came through, the State had two separate IHSS programs: 1) The so-called IHSS Residual Program is funded 65 percent by the State and 35 percent by counties. 2) The Personal Care Services Program is funded 50.23 percent by the federal government, 32.35 percent by the State and 17.42 percent by the counties.(79) A primary difference in who uses each program is that the Residual Program allows payments to family members; in addition, it allows protective supervision services, which the Medi-Cal program does not. Today about 65 percent of IHSS recipients receive care through the Medi-Cal-funded program.

    While long-term care advocates are pleased with the implementation of the waiver program (after a shaky and expensive start when the program required intensive use of health care professionals even for personal care), they are less so with the fact that the expanded funding base allowed the State to cut back on its level of commitment to the program. Advocates had sought the dedication of the extra resources to improved and greater levels of service.

  • The Public Authority mechanism was created. The 1991 Commission report also encouraged the creation of non-profit entities to run controlled registries of screened and available workers, provide training and offer dispute resolution services. In 1992 this law was enacted but follow-up regulations made the public authorities liable as employers of the caregivers. The problems were resolved, consumer advocates believe, with budget language passed in the summer of 1996 that made it clear caregivers will continue to be paid through the State's payroll mechanism, that the public authority will face no increased tax liabilities and that recipients will maintain control of care provider selection.(80)

    The Public Authority mechanism, already existing in three San Francisco Bay Area counties, is embraced enthusiastically by IHSS consumers. Set up by counties at arms' length, the Public Authorities serve as umbrella organizations to engage in collective bargaining with caregivers (even through the caregivers are employed directly by the IHSS consumer), deal with consumer complaints and try to improve the availability and training of caregivers. Run by boards that are heavily populated with IHSS recipients, the Public Authorities have the practical goal of making the program work better for consumers. Like most components of the long-term care system, the major potential barrier to success will be the lack of funding to carry out the variety of necessary chores.

  • The controversial managed care mode became the Task Frequency mode of service. In its 1991 report, the Commission recommended that non-severely impaired, low-hour cases be handled by contract agency workers. The recommendation included the caveat that such arrangements must contain suitable safeguards to ensure consumer freedom of choice and high performance standards.

    From 1992 to 1995, the State authorized a demonstration project in Tulare County to assess the ability of a privatized managed care program to deliver services to IHSS recipients that met the needs of all clients at costs similar to existing services and with the same quality of care. The reviews of the project were decidedly mixed:

    The Legislature responded to the demonstration and to a ruling by the federal government that its funding could not be used for managed care IHSS by creating in mid-1996 the "task frequency" mode of service. The mode requires the county to provide case management services, allowsservice to be delivered on a task-frequency basis rather than an hourly basis and will rely on state formulated performance and quality standards.(83)

    The recent legislative changes, which have not had a chance yet to affect in any broad way IHSS service delivery, make it difficult to assess whether the IHSS program will need further reform to become an effective, quality component of the long-term care system. The Public Authority mechanism holds the hope of giving consumers an opportunity to find qualified, pre-screened workers. The Task Frequency mode, if embraced by counties, promises relief for IHSS recipients who do not desire or who are not able to act as employers, locating, hiring, training, managing and firing workers (and even the most ardent advocates for self-directed management of IHSS services conceded to the Commission that some 15 percent of recipients need assistance in obtaining and managing workers).

    One thing is clear: Responsibility for the program should not continue to pass from bureaucracy to bureaucracy like a hot potato that no one is willing to own. The Department of Social Services told the Little Hoover Commission that it must move cautiously in creating and imposing performance standards, worker screening and training for fear it will be ruled by courts to be the employer -- a designation the State wants to avoid at all costs since it would require increased worker wages, benefits and working conditions.(84) Similarly, counties do not want to be on the hook as the employer for fear of liability when accidents occur or workers abuse or injure consumers.

    The result of government's refusal to "own" the program is that, despite repeated criticisms in a variety of forums, IHSS continues to operate inefficiently and ineffectively with very little accountability. The Commission received multiple complaints from consumers in 1991, and much the same type of concerns were expressed during the course of this study. One San Francisco Bay Area woman wrote extensively about the poor quality of care she received under a managed care arrangement that further injured her health. Her complaints resulted in no care at all, with no assistance from county employees in locating replacement care providers and no assistance from the State in enforcing her entitlement to care under the program. Her tale is hardly unique.

    Other states, such as Oregon, appear able to provide consumers with enough choices to bring market forces to bear on the issues of quality and reliability. As the Public Authority and Task Frequency mechanisms develop in California, long-term care analysts should look for signs that they bring consumers actual, rather than illusory, freedom of choice and service that meets needs rather than hour or cost allowances.

    Adult Protective Services

    Federal law mandates that adults of any age and income be provided protective services when abuse, neglect or exploitation is occurring. In California, the service is provided by the counties with very little guidance or oversight by the State. The Little Hoover Commission's advisory committee identified the following problems with Adult Protective Services:

    Like the IHSS program, Adult Protective Services was reviewed by the Little Hoover Commission in 1991. The Commission found then that the program was overloaded, underfunded and not standardized.(86) The situation has not improved. State officials confirmed to the Commission that Adult Protective Services has suffered cutbacks and service limitations in the last few years at the hands of counties with diminishing resources. While a Senate subcommittee focused in 1996 on areas that need reform, funding was not increased and no one predicts that improvement is close at hand.

    Summary

    Home- and community-based services can maintain a person's ability to have some degree of independence, remain at home or in home-like settings and enjoy a quality of life that is not always possible in institutions. Services that allow this include:

    California has programs that provide these services, but like many states its policies and funding do not make them a priority -- despite the fact that there is widespread agreement that they should be. As one report summarized:

    Despite the fact that eight times as many people with disabilities live in the community as in nursing homes, the current financing system is heavily skewed toward institutional care. Spending for nursing homes in 1991 was about six times as great as spending for home care. Many people with disabilities can receive appropriate care at home. With home care services, their functional status, physical health, and mental and social well-being improve. Ninety-five percent of the elderly with chronic disabilities prefer home care to institutionalization.(87)

    Recommendations

    Recommendation 2-A: The Governor and the Legislature should revamp the present highly segmented licensing structure for long-term care service providers to allow a more seamless delivery of service, to allow aging in place whenever possible and to emphasize social models over medical models.

    Creating a unified licensing plan that would allow service providers to add-on optional services or provide various types of care in a single setting is a key requirement for moving long-term care toward integrated, consumer-focused service. Those who fear the consolidation of the existing separate licensing systems should have their concerns addressed by requiring any new system to be outcome-based, flexible in implementation, consistent in interpretation and supportive of social models of service delivery. Barriers raised by federal funding and oversight requirements for skilled nursing facilities should be addressed through waivers, demands for federal law reform or, if no other course is feasible, separation from other forms of long-term care licensing.

    Recommendation 2-B: The Governor and the Legislature should designate a point person to develop funding streams and provide technical support for adult day care and adult day health care programs.

    These programs can play a critical role in providing relief for caregivers and increasing the number of functionally impaired people who can remain at home and out of costly institutions. The State should provide leadership in securing Medicare reimbursement for services by pushing for changes in federal laws and waivers. In addition, the State should focus on educating the public about the services available and enhancing the opportunity for development of more programs.

    Recommendation 2-C: The Governor and the Legislature should increase funding for family caregiver respite and support services.

    For more than a decade, the Caregiver Resource Centers have documented their value in providing services that allow people with brain impairment to remain home and under the care of family and friends. But funding constraints have kept the waiting lists long, limiting this program's ability to serve as a safety net for the long-term service continuum of care. The California Senior Legislature, which has the responsibility of proposing laws to assist the State's seniors, is backing a statewide respite care program as one of its priorities for 1997. Expanding the existing program would meet their goals.

    Recommendation 2-D: The Governor and the Legislature should encourage counties, through funding and other incentives, to form Public Authorities to improve delivery of services under the In-Home Supportive Services program.

    The problems with the In-Home Supportive Services program have been well documented and widely acknowledged for years. Improvements have been non-existent, due to lack of funding and governmental abhorrence to becoming involved to a point of being named the employers of caregivers. The Public Authority mechanism, while largely untested, has the ardent support of consumers as a means of improving the quality of care. This mechanism should be given every opportunity to succeed.

    Recommendation 2-E: The Governor and the Legislature should require counties to provide multiple modes of services so In-Home Supportive Services recipients who do not want to act as employers have options, including care through agencies, that will meet their needs.

    While many IHSS recipients want to retain control over their service provider choices, others neither desire nor can handle the role of employer. Just as recipients who want to be employers should have that choice, recipients who need management assistance for their caregivers should not be left without a program to meet their needs.

    Recommendation 2-F: The Governor and the Legislature should increase funding and expand the state role in standardizing adult protective services throughout the state.

    Society needs an effective mechanism for protecting people who are functionally impaired and threatened with abuse, neglect or exploitation. The present county-administered programs are not uniform throughout the state and lack the resources to provide effective service. The California Senior Legislature has made increasing the funding and effectiveness of this program, as well as enhancing elder abuse prevention and treatment programs, as two of its top 10 priorities for 1997.

    Recommendation 2-G: The Governor and the Legislature should clarify mandated reporting laws to turn them into a more effective tool for protecting vulnerable citizens.

    Mandated reporting laws vary with regard to what should be reported, by whom, to whom and what resulting action is required. Providing uniformity to this system would make it more understandable both to those who are required to comply with the provisions and those who are seeking protection from them.





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