Use of Home-Based Clinical Care and Long-Term Services and Supports Among Homebound Older Adults

ObjectivesDescribe use of home-based clinical care and home-based long-term services and supports (LTSS) using a nationally representative sample of homebound older Medicare beneficiaries.DesignCross-sectional study.Setting and ParticipantsHomebound, community-dwelling fee-for-service Medicare beneficiaries participating in the 2015 National Health and Aging Trends Study (n = 974).MethodsUse of home-based clinical care [ie, home-based medical care, skilled home health services, other home-based care (eg, podiatry)] was identified using Medicare claims. Use of home-based LTSS (ie, assistive devices, home modification, paid care, ≥40 hours/wk of family caregiving, transportation assistance, senior housing, home-delivered meals) was identified via self or proxy report. Latent class analysis was used to characterize patterns of use of home-based clinical care and LTSS.ResultsApproximately 30% of homebound participants received any home-based clinical care and about 80% received any home-based LTSS. Latent class analysis identified 3 distinct patterns of service use: class 1, High Clinical with LTSS (8.9%); class 2, Home Health Only with LTSS (44.5%); and class 3, Low Care and Services (46.6% homebound). Class 1 received extensive home-based clinical care, but their use of LTSS did not meaningfully differ from class 2. Class 3 received little home-based care of any kind.Conclusions and ImplicationsAlthough home-based clinical care and LTSS utilization was common among the homebound, no single group received high levels of all care types. Many who likely need and could benefit from such services do not receive home-based support. Additional work focused on better understanding potential barriers to accessing these services and integrating home-based clinical care services with LTSS is needed.     

长期护理保险对居家社区护理需求的规范与引导：国际经验及启示

为贯彻“以人为中心”的服务理念、增强长护服务体系的可持续性,世界各国纷纷在配置使用公共长护资金时,有侧重地进行待遇设计,以规范、引导长期护理需求,发展居家社区护理。本文基于服务购买理论,将典型国家的长期护理保障待遇模式总结为“机构待遇资格限定型”与“居家待遇水平倾斜型”两类,并介绍了其待遇设计。我国长期护理保险正处于起步阶段,应通过公共保险购买机制优化服务利用结构、引导资源合理配置,有机结合待遇资格限定、差异化待遇水平、额外支持等多元待遇设计,建立健全以居家为基础、社区为依托的多层次长护服务体系。     

Delivering Person-Centered Care: Important Preferences for Recipients of Long-term Services and Supports

Objectives

Although assessing individual consumer preferences are an important first step in providing person-centered care, the purpose of this study was to identify the top 10 shared preferences that are important to a majority of consumers receiving long-term services and supports.

Dying at home in rural residential aged care: A mixed‐methods study in the Snowy Monaro region,Australia

Residential aged care (RAC) is a significant provider of end‐of‐life care for people aged 65 years and older. Rural residents perceive themselves as different to their urban counterparts. Most studies describing place of death (PoD) in RAC are quantitative and reflect an urban voice. Using a mixed‐methods design, this paper examines the PoD of 80 RAC residents (15 short‐stay residents who died in RAC during respite or during an attempted step‐down transition from hospital to home, and 65 permanent residents), within the rural Snowy Monaro region, Australia, who died between 1 February 2015 and 31 May 2016. Death data were collected from local funeral directors, RAC facilities, one multi‐purpose heath service and obituary notices in the local media. The outcome variable was PoD: RAC, local hospital or out‐of‐region tertiary hospital. For the permanent RAC residents, the outcome of interest was dying in RAC or dying in hospital. Cross tabulations by PoD and key demographic data were performed. Pearson Chi squared tests and exact p‐values were used to determine if any of the independent variables were associated with PoD. Using an ethnographic approach, data were collected from 12 face‐to‐face, open‐ended interviews with four RAC residents, with a life expectancy of ≤6 months, and six family caregivers. Interviews were audio‐recorded, transcribed and analysed thematically. Fifty‐one (78.5%) of the permanent residents died in RAC; 21.5% died in hospital. Home was the initial preferred POD for most interviewed participants; most eventually accepted the transfer to RAC. Long‐term residents considered RAC to be their “home”—a familiar place, and an important part of their rural community. The participants did not consider a transfer to hospital to be necessary for end‐of‐life care. Further work is required to explore further the perspectives of rural RAC residents and their families, and if transfers to hospital are avoidable.     

Use of Home-Based Formal Services by Adult Day Care Clients with Alzheimer's Disease

OBJECTIVES: To explore the association between adult day care (ADC) attendance and utilization of home-based formal services among people with Alzheimer's Disease (AD). METHODS: Data for this secondary analysis came from a longitudinal parent study of 457 subjects from 16 ADC programs and an Alzheimer's diagnostic center in metropolitan Chicago. We used the method of Generalized Estimating Equations to model the use of home-based formal services over time. RESULTS: Adjusting for relevant covariates, more days of ADC use at each follow-up was associated with decreased use of home-based formal services (coefficient = ?.25, p < .0001). Older, unmarried caregivers who are children of the care recipients had lower use of home-based services. DISCUSSION: Results suggest that ADC services may substitute for specific types of home-based formal services. The projected increase in AD prevalence over the next several decades warrants a clearer understanding of how people with AD use formal services.     

Trajectories of Long-Term Residential Care Needs Among Older Australian Women: A Cohort Study Using Linked Data

ObjectiveOlder women are more likely than men to enter residential aged care (RAC) and generally stay longer. We aimed to identify and examine their trajectories of care needs over time in RAC across 3 fundamental care needs domains, including activities of daily living (ADL), behavior, and complex health care.DesignPopulation-based longitudinal cohort study.SettingRAC facilities in Australia.ParticipantsA total of 3519 participants from the 1921-1926 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), who used permanent RAC between 2008 and 2014.MethodsWe used data from the Aged Care Funding Instrument, National Death Index, and linked ALSWH survey. Participants’ care needs in the 3 domains were followed every 6 months up to 60 months from the date of admission to RAC. Trajectories of care needs over time were identified using group-based multitrajectory modeling.ResultsFive distinct trajectory groups were identified, with large variation in the combinations of levels of care needs over time. Approximately 28% of residents belonged to the “high dependent–behavioral and complex need” group, which had high care needs in all 3 domains over time, whereas around one-third of residents (31%) were included in 2 trajectory groups (“less dependent–low need” and “less dependent–increasing need”), which had low or low to medium care needs over time. More than two-fifths of residents (41%) comprised 2 trajectory groups (“high dependent–complex need” and “high dependent–behavioral need”), which had medium to high care needs in 2 domains. Higher age at admission to RAC and multiple morbidities were associated with increased odds of being a member of the high dependent–complex need group than the less dependent–increasing need group.Conclusions and ImplicationsIdentification of the differential trajectories of care needs among older women in RAC will help to better understand the circumstances of their changing care needs over time. This will facilitate appropriate care planning and service delivery for RAC residents, who are mostly older women.     

The Compliance of End-of-Life Care Preferences Among Older Adults and Its Facilitators and Barriers: A Scoping Review

ObjectivesTo explore the compliance of end-of-life (EOL) care preferences, and the facilitators and barriers of promoting quality of EOL care among older adults.DesignA scoping review was used to identify key themes in the compliance of EOL care preferences among older adults.Setting and participantsStudies published between 2009 and 2020 were identified from the Medline and Cochrane libraries. Eligible articles containing components related to the compliance of EOL care preferences among older adults were selected.MeasuresThe eligible articles were thematically synthesized. Factors that affected the compliance of EOL care preferences among older adults were identified from the key components.ResultsIn total, 35 articles were included to identify the key components in the compliance of EOL care preferences: (1) supportive policy, (2) supportive environment, (3) cultural characteristics, (4) advance care planning (ACP), (5) the concordance of EOL care preferences between patients and surrogate decision makers, (6) prognosis awareness, and (7) patient's health status and the type of disease. Facilitators for the compliance of EOL care preferences included enactment of relevant policy, sufficient care institutions, the utilization of ACP, and poor health status. Barriers included lack of supportive policy, different culture, and low utilization of ACP.Conclusions/ImplicationsThe compliance of EOL care preferences was low among older adults. The compliance of EOL care preferences can be improved through relevant policy development and the utilization of ACP.     

A Recommended Package of Long-Term Care Services to Promote Healthy Ageing Based on a WHO Global Expert Consensus Study

ObjectivesTo reach consensus on a minimum list of long-term care (LTC) interventions to be included in a service package delivered through universal health coverage (UHC).DesignA multistep expert consensus process.Setting and ParticipantsMultinational and multidisciplinary experts in LTC and ageing.MethodsThe consensus process was composed of 3 stages: (1) a preconsultation round that built on an initial list of LTC interventions generated by a previous scoping review; (2) 2-round surveys to reach consensus on important, acceptable, and feasible interventions for LTC; (3) a panel meeting to finalize the consensus.ResultsThe preconsultation round generated an initial list of 117 interventions. In round 1, 194 experts were contacted and 92 (47%) completed the survey. In round 2, the same experts contacted for round 1 were invited, and 115 (59%) completed the survey. Of the 115 respondents in round 2, 80 participated in round 1. Experts representing various disciplines (eg, geriatricians, family doctors, nurses, mental health, and rehabilitation professionals) participated in round 2, representing 42 countries. In round 1, 81 interventions achieved the predetermined threshold for importance, and in round 2, 41 interventions achieved the predetermined threshold for acceptability and feasibility. Nine conflicting interventions between rounds 1 and 2 were discussed in the panel meeting. The recommended list composed of 50 interventions were from 6 domains: unpaid and paid carers' support and training, person-centered assessment and care planning, prevention and management of intrinsic capacity decline, optimization of functional ability, interventions needing focused attention, and palliative care.Conclusions and ImplicationsAn international discussion and consensus process generated a minimum list of LTC interventions to be included in a service package for UHC. This package will enable actions toward a more robust framework for integrated services for older people in need of LTC across the continuum of care.     

Outcomes of Medicaid home- and community-based long-term services relative to nursing home care among dual eligibles

ObjectiveTo provide the first plausibly causal national estimates of health outcomes for older dual‐eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect.Data SourcesWe use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable.Study DesignWe model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long‐term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated.Population Studied1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long‐term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia.Principal FindingsHCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending.ConclusionsShifting Medicaid long‐term care funding for older adults from nursing homes to HCBS, while well‐motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes—not just expansion—need more attention.     

The last 3 months of life: care, transitions and the place of death of older people

Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.     

Reduced mortality: the unexpected impact of a telephone-based care management intervention for older adults in managed care

OBJECTIVE: This analysis evaluated mortality over 24 months for Medicare managed care members who participated in the Care Advocate Program (CA Program) designed to link those with high health care utilization to home- and community-based services. DATA SOURCE: Secondary data from the CA Program, part of the California HealthCare Foundation's Elders in Managed Care Initiative. STUDY DESIGN: Randomized-control trial in which participants (N=781) were randomly assigned to intent-to-treat (ITT) and control groups. ITT group received telephonic social care management and 12 months of follow-up. Various multivariate analyses were used to evaluate mortality risk throughout multiple study periods controlling for sociodemographic characteristics, health status, and health care utilization. POPULATION STUDIED: Older adults (65+) enrolled in a Medicare managed care plan who had high health care utilization in the previous year. PRINCIPAL FINDINGS: ITT group had a significantly lower odds of mortality throughout the study (OR=0.55; p=.005) and during the care management intervention (OR=0.45; p=.006), whereas differential risk in the postintervention period was not statistically significant. Other significant predictors of mortality were age, gender, three chronic conditions (cancer, heart disease, and kidney disease), and emergency room utilization. CONCLUSIONS: Findings suggest that the care advocate model of social care management affected mortality while the program was in progress, but not after completion of the intervention phase. Key model elements accounted for the findings, which include individualized targeting, assessment, and monitoring; consumer choice, control, and participant self-management; and bridging medical and social service delivery systems through direct linkages and communication.     

Training of Healthcare Personnel to Improve Performance of Community-Based Antenatal Care Program

Background: The present study was performed to evaluate the effectiveness of a training course designed to improve the knowledge, skills, and attitudes of healthcare personnel to allow them to provide a comprehensive community-based antenatal care (ANC) program in rural Paraguay. Methods: Sixty-eight of 110 healthcare personnel in the Caazapa Region of Paraguay participated in a nine-day training course between November 1997 and March 1998. The knowledge of the participants related to maternal healthcare services was assessed both before and after the training course, and enrollment rates of pregnant women in ANC before and after the training were compared as a measure of patient satisfaction. The participants were also asked to evaluate the appropriateness of each individual method used in the training course. Results: The average scores of the participants’ knowledge increased significantly from 41.0 before to 60.1 after training (p<0.001). The enrollment rates of pregnant women in ANC increased from 2.2 times per pregnancy in 1996 to 3.4 times in 1998 (p<0.001). The participants reported that role-playing, demonstrations using visual information, and hands-on practice at a hospital were useful training methods. Conclusions: Continuous training for healthcare personnel in rural Paraguay contributes to an increase in their capacity to carry out community-based ANC program. The participants reported that learning through peer-educators, interactive communications, role-playing, and supervision provided in actual community services were beneficial. Continuous supervision should be provided to enable healthcare personnel to maintain the knowledge and skills acquired in the training.     

Elderly People Facing Urban Renewal and Problems of Relocation

No abstract available for this article.     

Determinants of Private Long‐Term Care Insurance Purchase in Response to the Partnership Program

Objective

To assess three possible determinants of individuals'' response in their private insurance purchases to the availability of the Partnership for Long‐Term Care (PLTC) insurance program: bequest motives, financial literacy, and program awareness.

Data Sources

The health and retirement study (HRS) merged with data on states'' implementation of the PLTC program.

Study Design

Individual‐level decision on private long‐term care insurance is regressed on whether the PLTC program is being implemented for a given state‐year, asset dummies, policy determinant variable, two‐way and three‐way interactions of these variables, and other controls, using fixed effects panel regression.

Data Extraction Methods

Analysis used a sample between 50 and 69 years of age from 2002 to 2010, resulting in 12,695 unique individuals with a total of 39,151 observations.

Principal Findings

We find mild evidence that intent to bequest influences individual purchase of insurance. We also find that program awareness is necessary for response, while financial literacy notably increases responsiveness.

Conclusions

Increasing response to the PLTC program among the middle class (the stated target group) requires increased efforts to create awareness of the program''s existence and increased education about the program''s benefits, and more generally, about long‐term care risks and needs.     

A Portrait of Older Californians With Disabilities Who Rely on Public Services to Remain Independent

Low-income older adults with disabilities in California depend on a variety of public programs to help them remain in their own homes. The availability of those services has been in flux since 2009 because of cuts caused by the recession. This article reports on a qualitative study of 33 California seniors who depend on fragile arrangements of paid and unpaid assistance. Thematic analyses of in-depth interviews conducted with these older adults and their caregivers indicate that the disability needs of these individuals are often unstable, with both physical and mental health status sometimes changing day to day. Most have nowhere else to turn for help if their public services are cut. All share the common goal of staying at home and maintaining their independence. Public services serve as a crucial link in the support networks of these individuals.     

Ten Years after the Creation of the Portuguese National Network for Long-Term Care in 2006: Achievements and Challenges

The Portuguese National Network for Long-term Integrated Care (Rede Nacional de Cuidados Continuados, RNCCI) was created in 2006 as a partnership between the Ministry of Health and the Ministry of Labour and Social Solidarity. The formal provision of care within the RNCCI is made up of non-profit and non-public institutions called Private Institutions of Social Solidarity, public institutions belonging to the National Health Service and for-profit-institutions. These institutions are organized by type of care in two main settings: (i) Home and Community-Based Services and (ii) four types of Nursing Homes to account for different care needs. This is the first study that assess the RNCCI reform in Portugal since 2006 and takes into account several core dimensions: coordination, ownership, organizational structure, financing system and main features, as well as the challenges ahead. Evidence suggests that despite providing universal access, Portuguese policy-makers face the following challenges: multiple sources of financing, the existence of several care settings and the sustained increase of admissions at the RNCCI, the dominance of institutionalization, the existence of waiting lists, regional asymmetries, the absence of a financing model based on dependence levels, or the difficulty to use the instrument of needs assessment for international comparison.     

Development of a Professional Identity for the Child Care Worker

The movement toward professionalization of the child care field confronts serious and complex problems of conceptualization and practical organization of roles, programs, and personnel. This article describes and analyzes these issues in the context of current practice and the emerging professionalization of the field.     

A Multicenter Study to Identify Clinician Barriers to Participating in Goals of Care Discussions in Long-Term Care

ObjectivesLong-term care (LTC) is an important setting for goals of care (GoC) discussions. Understanding clinician barriers to GoC discussions could identify opportunities for LTC-specific interventions to improve quantity and quality of GoC discussions in the context of serious illness.DesignA multicenter, cross-sectional survey study.Setting and Participants1184 LTC clinicians from 34 Ontario LTC homes were invited to participate.MeasuresThe questionnaire assessed (1) clinician barriers related to the LTC resident power of attorney (POA), the health care provider, and the health care system; (2) willingness to engage in GoC discussions; and (3) suggestions to address identified barriers. Responses were rated on a 7-point scale (1 = extremely unimportant/unwilling, 7 = extremely important/willing). A linear mixed-effects model determined significance between mean importance ratings for each barrier and the willingness to engage in GoC discussion between physicians and nurses. A simple content analysis was performed on written suggestions to address GoC discussion barriers.ResultsThe overall response rate was 49% (581/1184). The top 3 rated barriers were (1) POA's difficulty accepting their loved one's poor prognosis, (2) POA's difficulty understanding the limitations and complications of life-sustaining therapies, and (3) lack of adequate documentation of prior discussions with LTC resident or POA. Barriers related to the health care provider, and the health care system, were deemed statistically more important by nurses. LTC physicians were more willing to exchange information, be a decision coach, and participate in the final decision than nurses. Suggestions to improve GoC discussions include a dedicated team to have these conversations in LTC, and updating policies to mandate and standardize these conversations at all family meetings.Conclusions and ImplicationsThis study has identified key LTC clinician–identified barriers to GoC discussions. Developing targeted interventions to these barriers could be the foundation for developing new interventions that support high-quality GoC discussions.     

Comparing Patient and Provider Perceptions of Home- and Community-Based Services: Social Network Analysis as a Service Integration Metric

Integrated home- and community-based services (HCBS) for frail seniors require a unique style of teamwork and collaboration. In four case studies, patient perceptions of teamwork and collaboration among their HCBS care providers are compared with those of the providers themselves using network analysis. The degree of coherence between these perceived networks are examined using network analytics, and network visualizations are discussed. The value of network analysis in research on HCBS is considered.