DHS LTC &
Support System Redesign:
The new long term care and support system will:
- Maximize flexibility, effectiveness, innovation, practicality and creativity in funding
sources, services and resources.
- Be consumer centered and family focused, as appropriate, especially for families with
young children in need of ongoing support.
- Involve a care managed system with the following characteristics:
- Resources and funding follows the person.
- Provider has shared responsibility with consumer for positive clinical and personal
- Services are managed to provide continuity and quality care.
- Supports families in their care giving roles.
- Includes an array of available service and support choices.
- Whenever possible, individuals are supported to live in the community.
- Have the capacity to respond to urgent needs in a timely fashion in a variety of
settings, not just in institutional placements.
- Supports preventative efforts and planning.
- Be understandable, culturally competent, efficient, responsive, reliable and easy to
- Not be limited to existing systems, programs, and resources.
- Encourage collaboration among federal, state, county, tribal, private agencies, and
consumers in the design and provision of long term care and support.
- Maximize support to and from friends, family, neighbors and the community, recognizing
the importance of informal support.
- Make decisions ethically and consciously when situations arise involving conflicting
principles and/or ethical choices.
- Have coordinated funding and service policies that support the long term care and
- Provide useful data, including client satisfaction data, that can be used for long term
planning purposes and for quality assurance and regulatory functions.
- Provide a timely and affordable appeals process.
- Address labor force issues such as availability, salaries, benefits, and training
RELATIONSHIP TO CONSUMER
- Provide opportunities and support for people to sustain or create important
relationships and social roles, which may include education and employment; to be included
in the life of the community; to contribute to society; and to achieve the greatest
- Promote and treat people with respect, dignity, and trust.
- Make available to the general public understandable information on long term care and
- Provide supports that facilitate, promote, encourage, and reward personal
- Ensure individual access to a range of flexible services and supports.
- Support transitions throughout a persons life.
- Promote hope and recovery--rather than disability and hopelessness.
ASSESSMENT AND PLANNING
- Have the capacity to obtain ongoing and comprehensive knowledge of each persons
condition, resources, abilities, disabilities, support needs, and preferences with the
involvement of the consumer and her/his family or guardian as appropriate.
- Utilize the information from the assessment in conjunction with the consumers
preferences to design service plan.
- Authorize public support based on information gathered in the individuals
- Ensure that funding and service decisions are made in conjunction with the consumer, and
if appropriate, the family or other person(s) who is (are) closest to and most
knowledgeable about the consumers needs and preferences.
- Treat individuals equitably with respect to access to public support, regardless of the
individuals location in the state or method of entering the long term care and
- Monitor services so that they are provided according to care plan and according to the
quality and outcomes desired.
- Include a process to resolve differences in care planning and assessment including:
dispute resolution, grievance procedures and mediation.
- Take into consideration publicly-funded, privately-funded, and voluntary informal
supports, services, and resources.
- Seek to provide maximum service and/or support and quality for dollars spent.
- Have the ability to differentiate individuals functional and fiscal needs and
prioritize public resources equitably.
- When available use a consumers own financial resources including private insurance
coverage to the extent it doesnt impoverish other family members or provide a
disincentive to employment or further independence, and remove barriers to family
- Encourage and support family caregiving as much as possible, including supporting
changes in tax, estate and other state laws that would facilitate such caregiving.
- Authorize publicly-funded services, within the limits of state, county, and federal
Last Revised: December 27, 2010