Clinicians' predictions of nursing home placement for hospitalized patients.

Identifying patients who will need long-term care may improve the efficiency and effectiveness of acute hospital care. This prospective study evaluated clinicians' ability to identify patients requiring nursing home care. The study had two principal objectives. The first objective was to measure whether registered nurses, physicians, and social workers made similar estimates of the probability of nursing home placement early in an acute care hospitalization. The second objective was to identify the clinical characteristics of patients for whom the clinicians incorrectly predicted that they would return home. The study subjects were 342 patients older than age 55 who were admitted to the medicine, surgery, and neurology services of two university-affiliated Veterans Affairs hospitals. Fifteen percent were discharged to nursing homes. The nurses, physicians, and social workers had high agreement in their estimates of the probability of nursing home placement for each patient. However, each of the provider groups assigned low probability estimates to more than 20% of the patients discharged to nursing homes. Examination of the characteristics of patients assigned low probability estimates revealed that mental impairment and functional disability were higher in those patients who ultimately were discharged to nursing homes than in those patients who returned to their homes. These findings suggest that better assessment and interpretation of patient characteristics early in the hospital stay may improve discharge planning. Some clinicians appear to underestimate mental and functional impairment as risk factors for long-term care needs.     

Uncovering the care setting–turnover intention relationship of geriatric nurses

In times of global demographic changes, strategies are needed for improving nursing staff retention. We examined the association of care setting (nursing homes and home care) with geriatric nurses’ intention to leave their job and their profession. Thus far, it is unclear why nurses’ turnover intention and behaviour do not differ between care settings, although working conditions tend to be better in home care. We used the Job Demands-Resources model to explain indirect and buffering effects by job demands (time pressure, social conflicts) and resources (task identity, supervisor support, and co-worker support) via nurses’ perceived health and job satisfaction on nurses’ leaving intentions. The present cross-sectional questionnaire study was conducted with a sample of N = 278 registered nurses and nursing aides in German geriatric care. As expected, there was no direct relationship between care setting and leaving attitudes. Demands and resources predicted the intention to leave with job satisfaction as mediator. We found more demands in nursing homes but no differences in resources. Serial mediation effects of care setting on intentions to leave via demands/resources and health/job satisfaction as mediators were found only for time pressure and social conflicts. Unexpectedly, there were no clear differences between intention to leave the job and the profession. As hypotheses were only partly confirmed, other buffering and detrimental effects on leaving intentions are discussed. The present data suggest that detailed concepts for personnel and career planning in geriatric care are needed.     

Who recommends long-term care matters

PURPOSE: Making good consumer decisions requires having good information. This study compared long-term-care recommendations among various types of health professionals. DESIGN AND METHODS: We gave randomly varied scenarios to a convenience national sample of 211 professionals from varying disciplines and work locations. For each scenario, we asked the professional to recommend the appropriate forms of long-term care. RESULTS: Although the professional respondents used the full spectrum of options offered to them, some professionals tended to favor the sector they worked in. Advanced practice nurses recommended day care and homemaking more and adult foster care less. Gerontologists used skilled nursing-facility placement more actively and rehabilitation, homemaking, and home health care less actively. Geriatricians and primary care physicians both favored rehabilitation and skilled nursing-facility care and were both less enthusiastic about assisted living, homemaking, and informal care, but the geriatricians favored day care more than did the primary care physicians. Registered nurses were highly supportive of assisted living, adult foster care, homemaking, and home health care, and they opposed skilled nursing-facility care. Social workers were less likely than other participants to endorse rehabilitation and adult foster care. IMPLICATIONS: Because consumer preference should be a major factor in making long-term-care decisions, many consumers need information about what options may best fit their situation. In the absence of empirical data on which types of long-term care work best for whom, consumers have to rely on expert judgment-but that judgment varies. Clients should be aware that an expert's background (as defined by discipline and work situation) may affect his or her recommendations. Each discipline appears to have its own set of experiences and beliefs that may influence recommendations.     

The accuracy of prognostic judgments of elderly long-term care patients

Health care professionals' ability to make accurate prognostic judgments for long-term care patients was tested in a study employing quarterly assessments and prognoses for more than 700 patients. Prognoses were made for patients to ‘improve’, ‘decline’, or ‘remain the same’, in physical functioning ability for the next 90 days, after which reassessments took place.Despite substantial information on their patients, these teams of physicians, nurses, physical therapists, and social workers were not very accurate in making prognoses. They were right only about half the time. In general, they tended to be too optimistic.The study has profound implications for policy makers considering reimbursement on the basis of performance related to patient outcome goals. The goals are not likely to have much validity. Health care professionals may also be disturbed by the poor rate of correct guesses about patients' future courses of recovery.     

Inquiry into the ideal function of the pharmacy in home care*

Background: The aim of this study is to analyze why home‐care services provided by pharmacists have not been effectively utilized. Method: Questionnaires were submitted to home‐care service users, physicians, visiting nurses and home‐helpers and pharmacy directors. We studied whether gaps existed between users’ needs, physicians’ expectations of pharmacy services and pharmacists’ awareness of the importance of pharmacy services. We also investigated whether a failure to recognize the importance of cooperation with pharmacists in home‐care provision existed among physicians and nurses/home‐helpers. Results: Users and physicians expect pharmacists to be more involved in counseling about home care and welfare services than home‐visiting services. Pharmacists recognize home visiting services as being of greater importance than counseling about home care and welfare services. The results indicated that gaps existed between users’ needs, the physicians’ expectations and pharmacists’ awareness of the importance of pharmacy services. In terms of cooperation with pharmacists, study results implied that: (i) nurses/home‐helpers’ awareness of pharmacists’ home‐visiting service is lower than that of physicians; (ii) physicians’ expectations regarding pharmacists’ participation in home care services is lower than that of nurses/home‐helpers; (iii) over 70% of both groups recognize the necessity of pharmacists’ home‐visiting service. Conclusions: Pharmacists need to get more involved in counseling users about home care and welfare. Also, there should be a special focus on heightening nurses/home‐helpers’ awareness of pharmacists’ home‐visiting service and on raising physicians’ expectations for pharmacists’ participation in home care services to develop home‐care related pharmacy services in Japan.     

Long-term care preferences of hospitalized persons with AIDS

Objective:To determine in a cohort of hospitalized persons with AIDS: 1) their preferences for various postdischarge long-term care settings, 2) the postdischarge settings recommended by primary care providers (doctors, nurses, and social workers), and 3) the impact of these views on the resulting discharge dispositions. Design:Prospective cohort study. Setting:Medical wards of five Seattle tertiary care hospitals. Participants:120 consecutive hospitalized persons with AIDS and their primary care providers. Measurements and main results:Although 70 (58%) of the patients found care in an AIDS long-term care facility acceptable, 87 (73%) preferred home care. Thirty-eight (32%) of the cohort were appropriate for long-term care after hospitalization, according to primary care providers. Eleven of the 38 patients deemed appropriate for long-term care were discharged to long-term care settings; among these, three had preferred home care. Likelihood of discharge to long-term care settings increased if patients found it acceptable (OR=7.1; 95% CI=3.2, 15.5), if they did not prefer home care (OR=7.7; 95% CI=4.7, 13.5), and if providers judged them to be appropriate for long-term care (OR=29; 95% CI=13, 64). In unstructured interviews, availability of emotional and medical support and privacy emerged as important factors to persons with AIDS considering long-term care. Conclusions:Hospitalized persons with AIDS willingly express their desires for various postdischarge care settings. A majority find long-term care in AIDS facilities acceptable, although they generally prefer home care. Discharge disposition is associated with acceptability, preference, and appropriateness for long-term care. Presented in part at the Vth International Conference on AIDS, Montreal, Quebec, Canada, June 5, 1989. Also presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. Supported in part by the Northwest Health Services Research and Development Field Program (Seattle VA Medical Center) and the Seattle/King County Department of Public Health, AIDS Prevention Project. Dr. McCormick was a fellow in the Robert Wood Johnson Clinical Scholars Program during this project. The opinions stated herein are those of the authors and may not represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Place of death and associated gender difference in Korea 2006–2014: Evidence from exit interviews of the Korean Longitudinal Study of Ageing

Previous research has revealed that many people wish to die at home; however, most die in healthcare institutions. This study explored factors related to the place of death and gender differences in this regard among older adults in South Korea. Participants included older adults from the Korean Longitudinal Study of Ageing. Multinomial logistic regression was used to examine relationships between place of death and relevant factors. Most older adults died in hospitals, followed by at home and in assisted living residences. Hospital and assisted living residence deaths increased while home deaths decreased. In both men and women, higher daily living dependency increased the probability of dying in an assisted living residence. Women were more likely to die in assisted living residences than men, and for persons living in urban areas, there was a decreased likelihood of home death only in women. Findings support that end-of-life care is performed mostly by institutions in Korea and there are gendered patterns. To achieve aging in place, the place of death and community-based terminal care should be more considered when implementing long-term care policies.     

Social integrations related to institutionalized and noninstitutionalized forms of care of elderly people

This is a report about a research project analyzing costs and effectiveness of institutionalized and ambulatory care of older people. For this analysis economic factors as well as social factors are considered. On the sociological part multiple objective conditions (e.g. state health, financial situation and family relations) were correlated with subjective factors as feelings of well-being and various personal attitudes. To this purpose approximately 900 elderly persons (3 samples: 1. inhabitants of homes of the aged, 2. ambulant served (meals on wheels, home help and community nurses), 3. random sample of persons living at their own home. The 3 samples were taken in an urban, semiurban and rural area. Some remarkable differences between the 3 samples could be shown referring to the general physical and mental status and rate of impairment, in the state of care, familiar situation, social integration and subjective attitude (e.g. demonstrating that the inhabitants of homes for the aged were less socially integrated and less satisfied.     

Behavior sequences of long-term care residents and their social partners

OBJECTIVES: This study examines similarities and differences in social interactions of residents of an assisted living facility and those of a nursing home. Given increasingly popular alternative models of long-term care such as assisted living, the study seeks to identify how these long-term care settings differentially promote dependence and independence among their residents. METHODS: Data were collected during 256 observations of 64 residents and their social partners at meal times in public areas. Sequences of antecedent and response behaviors relating to independence and dependence in the two different long-term care settings were examined. RESULTS: Social partners responded consistently to behavior of long-term care residents, and the behavior of residents was consistently affected by that of their social partners. These sequential interactions were not affected by setting. DISCUSSION: Differences in the nursing home and assisted living facilities' stated philosophies of care were not manifested in the interactions of their staff and residents.     

The longitudinal relationship between the use of long-term care and depressive symptoms in older adults

PURPOSE: The aim of this study was to estimate the longitudinal relationship between transitions in the use of long-term care and older adults' depressive symptoms and to investigate whether this relationship could be explained by markers of older adults' underlying health, or other variables including demographics, personality, and partner status. DESIGN AND METHODS: Data were from the Longitudinal Aging Study Amsterdam, which consists of a random, community-based sample of 3,107 older Dutch people (55-85 years of age) stratified by age and gender. The use of informal care, professional home care, and institutional care was recorded, and respondents were screened on depressive symptoms. Follow-up measurements took place at 3 and 6 years. RESULTS: Longitudinal analyses showed significant associations between the enduring use of professional long-term care and an increase in depressive symptoms. Transitions to professional home care or institutional care were also associated with considerably more depressive symptoms after 3 years, whereas transitions from professional home care or institutional care to no care or informal care only were not associated with a change in depressive symptoms. Most of the associations remained significant after indicators of underlying health and other covariates were adjusted for, and also after the data were reanalyzed for respondents with and without functional limitations. IMPLICATIONS: This study does not involve a controlled experiment of professional long-term care among older adults. However, the findings suggest the possibility that receiving professional long-term care could introduce new stressors and increase the risk of depressive symptoms. Our analyses illuminate the concerns of elders regarding their use of professional long-term care and may help in planning for more effective delivery of this type of care.     

An evaluation of an alternative to long-stay hospital care for frail elderly patients: I. The model of care.

Recent UK government policy has advocated the development of case management to provide more coordinated care at home for vulnerable people. This paper describes a service model whereby case managers, with devolved budgets, employed by the social services department, were located in a geriatric multidisciplinary team to provide an alternative for patients requiring long-stay hospital care. As well as co-ordinating packages of care, case managers were responsible for deploying the time of home care assistants, multi-purpose workers who assisted health care staff and undertook home help tasks. The role of case managers within the multidisciplinary team is explained and the tasks undertaken by home care assistants are identified. Home care assistants undertook a wider range of activities than either home helps or nurses, covering both personal and domestic care tasks.     

Cost-effectiveness of long-term care services in South Korea

This study examines the economic validity of home health-care and nursing-home care with the aim of providing guidelines for efficient use of limited health-care resources. Data collection took place over 8 months in 2001 (from May to December) at six institutions: two home health-care service providers and four nursing homes. A total of 99 stroke patients (49 from home health-care service providers and 50 from nursing homes) participated in the study. The findings indicate that patients with a lower level of physical/cognitive dependency (activities of daily living (ADL) >or= 9.3, cognitive performance scale (CPS) >or= 3.3) tend to benefit more from home health-care service, while those with a high dependency level (ADL < 9.3, CPS < 3.3) receive more suitable care at nursing homes. The study confirms that the economic value of health-care providers varies with the level of physical/cognitive function of the patients. That is, higher efficiency is achieved when those with a lower and higher levels of dependency are provided with home health-care services and nursing-home care, respectively. When assigning long-term care services, it is suggested that the level of physical/cognitive function of patients should be taken into consideration.     

Racial differences in skilled nursing care and home health use: the mediating effects of family structure and social class

OBJECTIVES: This study investigates whether utilization of skilled nursing facility (SNF) care and Medicare home health differ by race. It then seeks to understand the extent to which family structure and social class explain any differences observed. METHODS: Linking measures from the 1989 National Long-Term Care Survey with Medicare claims data, we model SNF care and home health use as competing risks using a Cox proportional hazards model. Age at first use is the outcome measure, consistent with the analysis of long-term care use as a life-course transition. RESULTS: Blacks postpone both home health and SNF care until later ages than Whites, and both children and grandchildren play a part in deferring their use until even later ages. When formal assistance is needed, Blacks are more apt than Whites to use home health over SNF care. The race difference in SNF use is even greater than that previously reported for all types of nursing home use combined. Social class has little influence on the risk differential. DISCUSSION: Contrary to expectations, Black elders are not counterbalancing their lower rate of SNF use with a higher rate of home health use. This suggests that there are differences in need, preference, or access that are yet to be identified. Future research should consider the relationship between family structure and informal caregiving, variation in physician referral patterns by race, and the availability of long-term care in traditionally African American communities.     

Changing policies, changing patterns of care: Danish and Swedish home care at the crossroads

Despite pursuing the policy of ageing in place, the two Nordic countries of Denmark and Sweden have taken diverse roads in regard to the provision of formal, public tax-financed home care for older people. Whilst Sweden has cut down home care and targeted services for the most needy, Denmark has continued the generous provision of home care. This article focuses on the implication of such diverse policies for the provision and combination of formal and informal care resources for older people. Using data from Level of Living surveys (based on interviews with a total of 1,158 individuals aged 67–87 in need of practical help), the article investigates the consequences of the two policy approaches for older people of different needs and socio-economic backgrounds and evaluates how the development corresponds with ideals of universalism in the Nordic welfare model. Our findings show that in both countries tax-funded home care is used across social groups but targeting of resources at the most needy in Sweden creates other inequalities: Older people with shorter education are left with no one to resort to but the family, whilst those with higher education purchase help from market providers. Not only does this leave some older people more at risk, it also questions the degree of de-familialisation which is otherwise often proclaimed to be a main characteristic of the Nordic welfare model.     

Abuse of patients in nursing homes: findings from a survey of staff

Despite persistent allegations that abuse of nursing home residents is widespread, the topic has received only limited research attention. Data are presented from a survey of a random sample of 577 nurses and nursing aides working in long-term care facilities. Rates of abuse based on staff self-reports are presented, and subgroups of staff who are more likely to engage in abusive behaviors are identified.     

The effect of testosterone and a nutritional supplement on hospital admissions in under-nourished, older people

Background

Dementia is one of the most common causes of death among old people in Finland and other countries with high life expectancies. Dementing illnesses are the most important disease group behind the need for long-term care and therefore place a considerable burden on the health and social care system. The aim of this study was to assess the effects of dementia and year of death (1998-2003) on health and social service use in the last two years of life among old people.

Methods

The data were derived from multiple national registers in Finland and comprise all those who died in 1998, 2002 or 2003 and 40% of those who died in 1999-2001 at the age of 70 or over (n = 145 944). We studied the use of hospitals, long-term care and home care in the last two years of life. Statistics were performed using binary logistic regression analyses and negative binomial regression analyses, adjusting for age, gender and comorbidity.

Results

The proportion of study participants with a dementia diagnosis was 23.5%. People with dementia diagnosis used long-term care more often (OR 9.30, 95% CI 8.60, 10.06) but hospital (OR 0.33, 95% CI 0.31, 0.35) and home care (OR 0.50, 95% CI 0.46, 0.54) less often than people without dementia. The likelihood of using university hospital and long-term care increased during the eight-year study period, while the number of days spent in university and general hospital among the users decreased. Differences in service use between people with and without dementia decreased during the study period.

Conclusions

Old people with dementia used long-term care to a much greater extent and hospital and home care to a lesser extent than those without dementia. This difference persisted even when controlling for age, gender and comorbidity. It is important that greater attention is paid to ensuring that old people with dementia have equitable access to care.     

Community-based specialist nurses for older people with long-term conditions in England

Community matrons, specialist nurses trained in the management of long-term conditions working alongside primary care teams and social service staff, have played an important role in the new enhanced approach to community services (care closer to home) in England. The underpinning proposition is that timely proactive care inputs might prevent some acute exacerbations or reduce the severity of the acute exacerbation, and proper community-based interventions are expected to reduce 5% of acute bed days. The community matrons intervention aims to increase patient and carer knowledge of their condition, increase patient confidence in their ability to manage their own health, and work with patients and carers to ensure they have an emergency plan that identifies impending deterioration and initiates a planned course of action or treatment to prevent a health crisis and thereby reduce emergency admissions to hospital. To encourage a systematic approach to case selection, the “Patient At Risk of Rehospitalization” or PARR tool has been developed and is recommended in national policy guidance. During 2003, the Department of Health in England established pilot sites in nine primary care organizations for the North American Evercare model, which showed no significant effect on rates of emergency admission, emergency bed days used or mortality, although patient experience of the service was positive and satisfaction levels high. Although the empirical evidence for the application of a case management approach to patients with long-term conditions is weak, the policy concept of strengthening community care for this large group of people has been compelling. The PARR tool may be fundamentally flawed because patients classified at risk of readmission may not necessarily benefit from case management. Further work is required to investigate the issue of optimum patient selection for case management, perhaps based on the potentially more clinically relevant construct of frailty.