Relevance of readmission of elderly patients discharged from a geriatric unit

Eight percent of the elderly patients discharged from a geriatric unit in one year were readmitted within three months. Forty-six percent had been living alone and nearly all of these had received full community support at the time of discharge. Recurrent problems were the reason for readmission in 59% of cases, mainly due to falls, incontinence, and confusion. Only 54% of the readmitted patients were discharged home again--those with new additional problems tended to die in hospital, whereas those with recurrent problems often required institutional long-term care. It is concluded that even with careful discharge planning, a proportion of patients will require readmission, some of which will also require long-term institutional care. This number is quite small in terms of the total number of patients discharged from a geriatric unit and should not be a reason for seeking nursing home care at an early stage.     

Managed long-term care: care integration through care coordination

The New York State managed long-term care demonstration program combines traditional home, community, and institutional long-term care services with other benefits integral to maximizing overall well-being for a frail elderly population. A distinguishing feature of the model is the responsibility to coordinate both covered and noncovered services. This article, a case study of VNS CHOICE, a managed long-term care plan that serves 2,500 New York City residents, describes the program's operating structure, service delivery model, and care management strategies. By providing a capitated Medicaid long-term care benefit, VNS CHOICE can utilize a broad array of services, offer significant flexibility to care management staff, and support member and family involvement in care planning. Its broad care coordination responsibility allows it to achieve integrated care without integrated financing.     

The Effects of Dementia and Long-Term Care Services on the Deterioration of Care-needs Levels of the Elderly in Japan

To investigate the associations between dementia, the use of long-term care (LTC) services, and the deterioration of care-needs levels of elderly persons in Japan.Using a retrospective cohort study, we analyzed 50,268 insurance beneficiaries aged 65 years and older who had utilized LTC services between 2010 and 2011 in Kyoto prefecture, Japan. Logistic regression analyses were used to identify predictors of care-needs level deterioration.Dementia, facility care services, the male sex, older age, and lower baseline care-needs levels were associated with care-needs level deterioration. The disparity between odds ratios of home care services, dementia diagnoses, and facility care services on care-needs level deterioration diminished with increasing baseline care-needs levels. The other risk factors of care-needs level deterioration showed stronger associations as care-needs levels and age increased.The effects of baseline care-needs levels and dementia should be considered when developing LTC policies.     

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.     

Factors that influence home return from health care facilities for the elderly--related to the attitude of family caregivers

AIM: The number of users of long-term care insurance has been increasing rapidly since it started in 2000. The number of those who want to enter the long-term care insurance facilities has increased. Although the basic philosophy of long-term care insurance is independence support and self-decision, to enter a facility or home return from facilities is likely to be decided by family caregivers, not by the elderly themselves. Moreover, the number of elderly who return home from welfare facilities is decreasing. We investigated the intension of caregivers who are willing to accept the institutionalized elderly at home and analyzed the factors affecting the acceptance of caregivers. METHODS: Subjects were elderly who were in long-term care insurance facility in June 2004, and their caregivers. The study was conducted between June 2004 and September 2004 in Ibaraki Prefecture in Japan. A face-to-face interview based on a questionnaire was conducted for the institutionalized elderly and by the mail for the caregivers. RESULTS: The caregivers of 34.6% of the elderly who hoped to return home intended to accept them home. There were differences between the plans of the elderly and caregivers. The risk factors (OR, 95% CI) to make the intention of the caregivers to accept the institutionalized elderly home difficult were level of cooperation with other family members to take care of elderly (OR 15.37, 2.05-115.24), dementia behavior disturbance category with more than one (OR 8.34, 1.02-68.05), time spending in bed of a day (OR 1.31, 1.01-1.71), few knowledge of long-term care insurance system of caregivers (OR 3.65,0.81-16.38). CONCLUSION: It has been suggested that more physical activities in the facility, establishment of a care-system for the demented elderly living in the community and an educational campaign by the long-term care insurance system are necessary to increase the willingness of caregivers to accept home return of institutionalized elderly.     

Formal service provision and the care of the elderly at home in Ireland

Social and demographic trends in Ireland pose the need to develop our system of care for the elderly at home. Currently informal care is the principal source of care for dependent elderly people with institutional care acting as the main alternative, particularly when levels of dependency are high or where informal caring relationships break down or are not possible. Although the past two decades have witnessed the growth of formal community care services for the elderly there is still considerable scope for extending and refining these services and, in particular, for making them more relevant to heavily burdened informal carers. Substitutionality appears to be the governing principle with formal and institutional services tending to step in only when the informal system breaks down. The achievement of greater complementarity between the formal and informal caring systems and the re-focusing of institutional services to provide support for the community care system as a whole are the suggested priorities.     

Effects of supporting community-living demented patients and their caregivers: a randomized trial

OBJECTIVES: To determine whether community care of demented patients can be prolonged by means of a 2-year support program based on nurse case management. DESIGN: Randomized controlled intervention study with 2-year follow-up. SETTING: Demented patients entitled to payments from the Social Insurance Institution for community care, in five municipalities in eastern Finland. PARTICIPANTS: One hundred demented patients, age 65 and older, living at home with the primary support of informal caregivers, allocated at random to the intervention (n = 53) or control group (n = 47). INTERVENTION: Intervention patients and their caregivers were provided with a 2-year intervention program of systematic, comprehensive support by a dementia family care coordinator. MEASUREMENTS: Time to institutionalization (period in community care) from enrollment of patients in the study to their placement in long-term institutional care. RESULTS: During the first months, the rate of institutionalization was significantly lower in the intervention group than in the control group (P = .042), but the benefit of the intervention decreased with time (P = .028). Estimated probability of staying in community care up to 6, 12, and 24 months was 0.98, 0.92, and 0.63 in the intervention group and 0.91, 0.81, and 0.68 in the control group, respectively. Results also suggest that the intervention used in the study might be especially beneficial to patients with severe dementia and those with problems threatening the continuity of community care. CONCLUSIONS: The placement of demented patients in long-term institutional care can be deferred with the support of a dementia family care coordinator. However, by the end of the 2-year intervention, the number of patients institutionalized was similar in the intervention and control group. It seems to be beneficial to direct this type of intensive support at severely demented patients and their caregivers. On the basis of our experiences, we suggest that intervention by a dementia family care coordinator should be targeted especially at patients with problems threatening the continuity of community care.     

Nursing home care in the USA

Nursing home care in the USA is part of the costliest health-care system in the world, and is a heavily regulated industry still struggling to maintain quality care across the country. The modern nursing home dates back to the 1930s and the passage of the Social Security Act, with continued growth of the industry after the 1960s, when the Medicare and Medicaid programs were created. As in other industrialized countries, the elderly population in the USA is growing, and the highest growth is occurring among those older than 85. This is the group with the highest health-care costs and rates of nursing home utilization. There are two major types of care provided in US nursing homes: long-term and subacute care. In the 1980s, quality of care became an important concern, which led to major reform and passage of new regulations under the law known as OBRA-87. During this time, the Minimum Data Set (MDS), which is a comprehensive assessment tool, was introduced. It continues to be a vital tool for both payment and research. Reform also ushered in the state survey process, which scrutinizes nursing homes yearly and assesses financial penalties for substandard care. The aging of the American population will provide challenges for financing nursing home care in the future. The use of private long-term care insurance is growing, and may be an important source of payment for this type of care in the decades to come.     

Pain management at home.

The management of chronic pain should be a priority in geriatric home care. Pain is a common problem that has tremendous potential to influence the physical function and quality of life of elderly people during their remaining years. The experience of pain and its management at home are not analogous to institutional settings. Family and caregivers have important influences on pain management and may require education and support for the long-term management of chronic pain patients. Existing pain management strategies should be tailored to meet the special needs of geriatric patients and be sensitive to caregiver concerns. Implications, indications, and applications for high-tech pain management strategies need to be clarified for the management of older people at home.     

Coordinating services across the continuum of health,housing, and supportive services

This article describes trends in three areas of state long-term care policy for elderly low-income Medicaid beneficiaries--providing home care services to residents in subsidized housing and assisted living; offering nursing home residents opportunities to relocate to community settings; and integrating acute and long-term care services for beneficiaries who are dually eligible for Medicare and Medicaid. The information was obtained from reports and studies on state policy, site visits, and interviews with state officials. Multiple initiatives responding to consumer preferences and fragmentation of the delivery systems were identified. Key components were consumer demand; the availability of nursing facility alternatives; and state priorities for controlling expenditure growth. States use Medicaid to develop broad service menus that include in-home, community, residential, and institutional services. Several states are conducting demonstration programs that improve coordinating or integration of long-term care with the acute care system.     

Recent development in Chinese elder homes: A reconciliation of traditional culture

This paper examines recent developments in elder care homes and changing attitudes toward institutional care in the Tianjin area of China. Based on research conducted at 12 sites, this study compares two types of elder care homes which are competing in the growing Chinese market for institutional elder care: ones characterized as government-owned and others described as “non-government-owned.” Findings suggest that, despite rapid growth in the elder care home industry in China, the market is tilted toward the former government-owned elder care homes that still enjoy institutional and bureaucratic advantages in funding, staffing, and insurance. The research also examines the changing connotations of cultural norm in parent care. Traditional attitudes against placing parents in elder care homes are changing; some adult children as well as elders are starting to express acceptance of institutional elder care. The authors argue that institutional care for aging parents is likely to become a major option for parent care as adult children become increasingly unavailable due to the one-child policy, the need to work, and perhaps distant residence. Her recent research and publications mainly focus on familial and institutional elder care in China. She has also conducted research on religiosity and health behavior among Chinese immigrant elders in America. Dr. Zhan teaches courses in aging, gender, family, and aging and family policies in global perspectives at both undergraduate and graduate levels. Guangya Liu was one of the researchers conducting surveys and interviews about institutional care in Tianjin, China in 2003. She is currently a graduate student in the department of sociology and research assistant in the Gerontology Institute at Georgia State University. She is working for a project titled “Satisfaction and Retention of Direct-Care Staff in Assisted Living” funded by National Institute of Aging (NIA). Her interests include aging, long-term care, and China studies. He teaches research methodology, social indicator, and sociology of aging at both undergraduate and graduate levels. His research interests include sociology of aging, long-term care, and research methods.     

The combination of "Careworks" insurance plan integrated with medical and long-term care insurance

The social security system in Japan was greatly revolutionized when the long-term care insurance plan began in April 2000. Thus, Japan began the 21st century with two great social insurance plans, that is, medical care insurance and long-term care insurance. Each delivery system is divided: the medical care insurance plan is for the acute stage, and the long-term care is for the chronic stage. Both systems can be intended to cooperate to provide continuous care throughout life. The public health and welfare system has been trying hard to efficiently integrate the medical and long-term care insurance plans. However, it is necessary to establish a new insurance plan for ensuring the integrated adequacy of both insurance systems. One's life is destined to shift from medical care to long-term care at some point. As one ages or becomes disabled, it becomes difficult to lead an independent life with self-decision, and social support become necessary from third parties, instead of from the family or from one's own means. The society imposes the responsibility of payment of the medical and long-term care plan premiums on the individual throughout life. However, the structure of these insurance foundations should be combined under an integrated system, "Careworks", in order to also combine the concepts of length of life from the medicine and the respect of living from the long-term case to improve the social security of the life.     

Targeting and quality of nursing home care. A five-nation study.

The objective of this study was to demonstrate that appropriate targeting and quality monitoring of institutional care of the elderly is possible using person-based information on residents of nursing homes. This cross-sectional study used Minimum Data Set (MDS) assessments of nursing home residents in 6 US states, Copenhagen, Reykjavik, and selected locations in Italy and Japan. The outcome measures were life expectancy at age 65, population over 65, percentage over 65's in nursing homes, and clinical characteristics of nursing home residents from a multinational database of RAI/MDS assessments. We found that Japan has the highest life expectancy, and the second lowest expenditure on health care. The United States has the highest expenditure on health care and intermediate life expectancy. Italy has the highest proportion of population over 65 and the lowest proportion of over 65's in nursing homes. Iceland, a relatively young country, has the highest proportion of over 65's in nursing homes. Residents in Italy and the United States had the most severe physical, cognitive and clinical characteristics, those in Iceland the least. There was wide variation in markers of quality of care, with no country either uniformly good or bad across multiple measures. In conclusion, headline statistics comparing nations' percentage of Gross Domestic Product (GDP) spent on health care, age structure of the population, percentage of over 65's in nursing homes and clinical characteristics bear no consistent relationship. Local policy and practice also affect quality of care. Standardized assessment enables comparisons at local, national and international levels making possible further research on targeting and the appropriate use of institutional care, thus permitting a range of efficiency measures to be developed to inform policy.     

Care utilisation in the last years of life in relation to age and time to death: results from a Swedish urban population of the oldest old

The majority of older people experience progressive disability at the end of their lives and require long-term care as a result. This study analysed patterns of care utilisation during the 5 years prior to death, particularly the effects of age and time to death in relation to the use of public elder care (i.e. home help services and institutional care) and hospital care. A longitudinal study provided data on care utilisation among participants (aged 83+) who died between 1995 and 2004 (n = 567). Almost everyone received some kind of care in the last 5 years, 91% in the last year and 88% in the last 3 months preceding death. The number of days of elder care outnumbered the number of days in hospital by ten to one. Increasing chronological age was important for receipt of home help, whereas time to death was important for admission to hospital; there was a sharp increase in the proportion treated in hospital in the last 9 months before death. The proportion residing in institutional care facilities with around-the-clock care increased steadily with a sharper gradient 6 months before death. Both age and time to death had an effect on use of institutional care, but time to death had twice the effect of increasing age. In conclusion, age and time to death have different effects depending on the type of care studied, and individual-based longitudinal data gives a very different picture of care utilisation among the oldest old compared to cross-sectional data.     

Japan's universal long-term care system reform of 2005: containing costs and realizing a vision

Japan implemented a mandatory social long-term care insurance (LTCI) system in 2000, making long-term care services a universal entitlement for every senior. Although this system has grown rapidly, reflecting its popularity among seniors and their families, it faces several challenges, including skyrocketing costs. This article describes the recent reform initiated by the Japanese government to simultaneously contain costs and realize a long-term vision of creating a community-based, prevention-oriented long-term care system. The reform involves introduction of two major elements: "hotel" and meal charges for nursing home residents and new preventive benefits. They were intended to reduce economic incentives for institutionalization, dampen provider-induced demand, and prevent seniors from being dependent by intervening while their need levels are still low. The ongoing LTCI reform should be critically evaluated against the government's policy intentions as well as its effect on seniors, their families, and society. The story of this reform is instructive for other countries striving to develop coherent, politically acceptable long-term care policies.     

Bowel incontinence is related to improvement in basic activities of daily living in residents of long-term health care facilities for the elderly in Japan

Background:   The purpose of the present study is to clarify the target criteria for care in long-term health care facilities for the elderly in Japan and to investigate the relationship between changes in basic activities of daily living (BADL) over 1 year and the comprehensive geriatric assessment (CGA) scale.
Methods:   An observational study was conducted in a facility in Nagoya, Japan. The participants consisted of 54 residents. The following four scales of comprehensive geriatric assessment were administered to the residents in both 2000 and 2001: Barthel index (BI), Lawton scale, mini-mental state examination and geriatric depression scale 15.
Results:   The Barthel index was significantly improved in 2001 compared with 2000 ( P = 0.007). The Lawton scale was significantly lower in 2001 ( P = 0.029). Neither the mini-mental state examination nor geriatric depression scale 15 scores changed significantly. To determine the factors that influenced the change in BADL, logistic regression analyses were performed using the above four scales as independent variables and the BI change as a dependent variable. In multivariate analysis, a BI score of less than 75 approached significance for improvement in BADL ( P  = 0.094, odds ratio = 2.79). Other logistic regression analyses were also performed using each ADL task in BI as an independent variable and the change in BI as a dependent variable. In multivariate analysis, bowel incontinence was a significant independent variable ( P  = 0.006, odds ratio = 10.9).
Conclusion:   As bridging facilities between acute-care hospitals and home, long-term health care facilities are a reasonable choice for the elderly with bowel incontinence.     

Effects of a care protocol on care outcomes in older nursing home patients with chronic obstructive pulmonary disease

OBJECTIVES: To evaluate the effects of a care protocol used by community nurses to support nursing home staff in the care of patients with chronic obstructive pulmonary disease (COPD). DESIGN: Matched, randomized case-control trial. SETTING: Forty-five nursing homes of the New Territories South (NTS) cluster of Hong Kong. PARTICIPANTS: Eighty-nine older people (> or =65, present resident of a nursing home in the NTS region, main diagnosis of COPD, at least one hospital admission in previous 6 months) discharged to the nursing homes from the geriatric units of two hospitals. INTERVENTION: Using a care protocol, community nurses followed up older patients in the experimental group for 6 months after their discharge from the hospitals to the nursing homes. MEASUREMENTS: Data on functional, respiratory, and psychological parameters were collected at entry to study and 6 months later with standard measures. Data on hospital service utilization, nursing home staff, and patient satisfaction were also collected at 6 months. RESULTS: Experimental group participants had significant (P =.008) improvements in psychological well-being. Nursing home staff and experimental group patients were highly satisfied with the use of the protocol. There was no significant difference between the two groups in functional and respiratory outcomes or hospital service utilization. CONCLUSION: Psychological well-being as an important factor in rehabilitation in chronic illness has been much neglected in the literature. Supporting nursing home staff in the care of COPD patients through community nursing visits can enhance older residents' psychological well-being. Psychological aspects of care should be emphasized and incorporated into the delivery of regular nursing home care.     

Vergleich von Pflegeverlauf und Sterblichkeit von Pflegebedürftigen mit und ohne medizinische Rehabilitation

Background and objective

Empirical data, representative of the total population, are necessary for medico-actuarial risk calculations. Our study compares mortalities of long-term care (LTC) patients who are covered by statutory health insurance with regard to age and distribution of care levels when in home or institutional care with a special focus on whether rehabilitative care was performed.

Methods

The data of 88,575 LTC patients were analyzed longitudinally for 10 years, using routine data analyses on the files of the German Federal Health Insurance fund (average observation period 2.5 years, a total of 221,625 observation years). The numbers of LTC patients and their care levels while in home or institutional care were calculated, as were any changes to another care level or discontinuation of LTC benefits (as a result of the need for care falling below the eligibility criteria for care leveI or to death) during 1–10 years after the onset of LTC, always with respect to whether rehabilitative care had taken place or not. For the evaluation of care factors an indicator was developed.

Results

Total mortality was found to decline and reactivation to increase considerably for LTC patients after rehabilitation, basically irrespective of their age or care level and in home or institutional care settings as well. Ten years after the onset of care, 30.7?% of the patients with rehabilitation were still in nursing care, 9.8?% were reactivated and 59.5?% deceased. In contrast, only 9.2?% were still in nursing care, 3.7?% reactivated and 87.1?% deceased without rehabilitation. These results are irrespective of age distribution, care level, and residence in home or institutional care settings. The care status of patients, measured by the percentage in reactivation, care level I–III, and death, substantially depends on age at onset and care level and in addition on rehabilitative procedures. Hypotheses for further research are outlined.

Conclusion

Rehabilitation has a clear-cut potential for life extension as well as reducing or detaining long-term care if applied to (LTC) patients. The group of rehabilitated LTC patients has a comparatively higher degree of reducing or resolving LTC up to a complete reactivation or prolonging of life in spite of care needed. A successful rehabilitative effect occurs over all age groups and all care levels during home care considerably as well as during institutional care to a lower extent. Differentiation between the age at onset of LTC, care level, and first year and follow-up mortalities is recommended as well as between rehabilitated and nonrehabilitated care patients when undertaking medico-actuarial calculations.     

Retention and survival of hostel residents – a 12 year study

Abstract Background: The admission of a proportion of disabled people to hostels is inevitably followed by their transfer to nursing homes. Our hypothesis was that such admissions are justified in terms of quality of life and the cost to the community, notwithstanding the necessity of subsequent transfer. Aims: To test this hypothesis by measuring the retention and survival times of residents in hostel and in nursing home; to consider the relevance of these factors to the future policy of the two institutions. Methods: A retrospective study was made of 159 residents admitted over a period of 12 years to a hostel with 32 places. Times spent in the hostel and in the nursing home were recorded. Probabilities of survival in hostel and in nursing home were calculated according to the Kaplan-Meier method. Comparison with the expected survival of a matched cohort of the total population was determined. Estimation was made, using the SAS software package, of the likely number of places needed in nursing homes for residents following transfer. Results: Although the majority of hostel residents eventually needed nursing home care, a worthwhile proportion of their total institutional time (approximately two-thirds) was spent in the hostel. Ongoing support from the personnel in a geriatric service is likely to increase retention time in the hostel. Because of the ultimate outcome for the majority of residents, planning for hostel care should include consideration of places needed in nursing homes.