Policy makers, legislators, and the citizens of North Carolina are becoming aware of something that many elderly individuals and their families have known for some time. People who need community-based health and social services with the onset of chronic illness and disability in later years often find barriers to appropriate, affordable, and accessible care. They are often met by a confusing, unplanned, and unorganized "nonsystem" of long-term care services.

Decisions as to appropriate care are often made on the basis of available services or places for care rather than on the basis of objective criteria obtained through the application of a comprehensive, standardized assessment. Issues of affordability are complicated by an array of semiautonomous funding sources with conflicting eligibility criteria. Still other individuals who need long-term care services are found to be neither poor enough to qualify for the limited resources offered through public programs nor rich enough to pay for the cost of care completely on their own. Finally, if appropriate care is identified and money is not a serious barrier, elderly people may find that the kind of services most needed are in short supply or are unavailable in their communities. Case management is one mechanism that has been developed to assist those with long-term care needs in overcoming these barriers. It is through case management that the complex health and social service system is "managed" on behalf of the individual. It should be emphasized that it is the health and social service system which requires management, not elderly individuals or their families.

This position paper outlines issues, options, and principles associated with implementing a coordinated, case-managed system of community-based long-term care in North Carolina. This paper is organized into four sections. First, the research method we employed is described. Second, drawing on nearly three decades of research on home and community care, we identify models, goals, and outcomes associated with that care in order to present a framework for discussing the issues associated with and options for devising a system of coordinated home and community care in North Carolina. Third, we present a description of the practice of case management itself, along with a discussion of standards for the training of professional case managers who can serve as the linchpin for helping elderly North Carolinians gain access to affordable and appropriate care within the context of a larger, organized system. Finally, in light of recent state legislative initiatives and the prior discussion of options and issues in this area, we identify specific principles of policy and practice to guide the development of a case-managed system of home and community care for the elderly in North Carolina.

This background position paper and the principles identified in it serve as the foundation for more specific recommendations for developing a program of case-managed home and community care. This paper and a second paper outlining specific programmatic recommendations have been prepared by the North Carolina Institute of Medicine with the assistance of the Center for Aging Research and Educational Services.