Designing Service Delivery Systems: Lessons from the Development of Community-Based Systems of Care for the Elderly

Abstract

Over the last 60 years, interest groups have played an increasingly important role in defining problems and providing solutions to pressing social issues. Through their activities, remarkable improvements have been made in health, welfare, housing, and education of those in need or for whom the mix of public and private services had been inadequate. The variety of services and benefits available to the elderly, in particular, suggests that age-based interest groups, and those who benefit from services to the elderly, have been effective in advancing their social policy agendas. As a result, numerous programs, agencies, and services with an age-based eligibility criterion have been developed. The expansion of services benefiting older adults, coupled with a dramatic rise in the number of the elderly, particularly the oldest of the old, and an increase in the intensity of care required, has resulted in the graying of the federal budget (Hudson, 1978). In health care, for example, expenditures for persons 65 years of age and older have grown significantly over the past two decades and are projected to increase even more dramatically as the baby boom cohort ages. Without major changes in the health status of older people, medical costs for the oldest are projected to increase more than six fold by the year 2040 (Schneider & Guralnik, 1990). The phenomenon of population aging is occurring in a context characterized by sluggish economic growth, concern over the fiscal health and financial capacity of government, and growing political mobilization by other social policy advocates. As a result, increased attention has been directed at ways to control the costs of aging services (Zedlewski, 1988). Although it is clear that present approaches to providing services to the elderly and other needy populations are inordinately costly, there is uncertainty about how to organize and deliver services in a cost-effective manner while minimizing the potential for unintended consequences for the elderly or those invested with their care. Rationalizing service delivery by consolidating services from different sectors into an integrated system is generally assumed to provide the most efficient structure to accommodate the variety of potential service users, including persons with diverse needs and different levels of resources. Such an approach is thought to minimize transaction costs, or costs of exchange, for providers and reduce transition costs, or the costs of transferring between services, for consumers. Yet the costs of coordination itself are rarely defined or measured, particularly within the current context of multiple stakeholders, competing interests, and long-term programmatic investments. With cost control as the sine qua non of service delivery (Greene, Loverly, & Ondrich, 1993), there has been a failure to recognize that problems confronting elders and other populations with complex service needs, may be exacerbated by the unintended consequences of cost-containment efforts (Brandon, 1992), including efforts to administratively streamline services provided to a given population. Increasingly complex, acute, institutional, community, and home-based delivery modalities, coupled with the blurring of traditional boundaries, add to the likelihood that attempts to improve one component of the delivery system will create inadvertent and perhaps dysfunctional changes in other components. As a result, policy initiatives designed to improve services provided to the elderly within an increasingly pluralistic, multi-institutional, and multi-system delivery network, must be guided by a better understanding of the impacts that these efforts have on well-established, highly complex, and interdependent inter-organizational interactions and institutional relationships. Otherwise, solutions that appear to be logical, rational, or intuitively obvious may result in changes that aggravate rather than address problems. …