Family Care History - Long Term Care Redesign Guiding Principles

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 consumer outcomes.
    • 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 access.
  • 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 support goal.
  • 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 needed.


  • 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 fulfillment possible.
  • Promote and treat people with respect, dignity, and trust.
  • Make available to the general public understandable information on long term care and support.
  • Provide supports that facilitate, promote, encourage, and reward personal responsibility.
  • Ensure individual access to a range of flexible services and supports.
  • Support transitions throughout a person’'s life.
  • Promote hope and recovery--rather than disability and hopelessness.


  • Have the capacity to obtain ongoing and comprehensive knowledge of each person’'s 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 consumer'’s preferences to design service plan.
  • Authorize public support based on information gathered in the individual’s assessment.
  • 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 consumer'’s needs and preferences.
  • Treat individuals equitably with respect to access to public support, regardless of the individual’s location in the state or method of entering the long term care and support system.
  • 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 consumer’'s own financial resources including private insurance coverage to the extent it doesn’t impoverish other family members or provide a disincentive to employment or further independence, and remove barriers to family financial contributions.
  • 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 funding.
Last Revised: December 1, 2014