Consumer-Directed Personal Care: Comparing Aged and Non-Aged Adult Recipient Health-Related Outcomes Among Those With Paid Family Versus Non-Relative Providers

Risk factors associated with the incidence of recipient injuries, bedsores and contractures, and health care use (i.e., emergency department and hospital use) among aged and non-aged adult personal care recipients are investigated. Data are from a statewide survey of aged and non-aged adult personal assistance service (PAS) recipients (n = 913) in California's In-Home Supportive Services (IHSS) program. This is a consumer-directed PAS program. Outcomes among recipients using relatives (other than spouses or parents) as paid providers are compared with those of recipients having non-relatives as providers. No differences were found by provider-recipient relationships. Non-aged recipients, those in poorer health, those with more than three activities of daily living (ADL) limitations, and those changing providers during the year were all at greater risk for adverse health outcomes. African American, Hispanic, and Asian recipients were at lower risk for injuries and hospital stays than were White recipients.     

Hospital Choice of Rural Medicare Beneficiaries: Patient, Hospital Attributes, and the Patient–Physician Relationship

Objective. To examine how patient and hospital attributes and the patient–physician relationship influence hospital choice of rural Medicare beneficiaries.
Data Sources. Medicare Current Beneficiary Survey (MCBS), Health Care Financing Administration (HCFA) Provider of Services (POS) file, American Hospital Association (AHA) Annual Survey, and Medicare Hospital Service Area (HSA) files for 1994 and 1995.
Study Design. The study sample consisted of 1,702 hospitalizations of rural Medicare beneficiaries. McFadden's conditional logit model was used to analyze hospital choices of rural Medicare beneficiaries. The model included independent variables to control for patients' and hospitals' attributes and the distance to hospital alternatives.
Principal Findings. The empirical results show strong preferences of aged patients for closer hospitals and those of greater scale and service capacity. Patients with complex acute medical conditions and those with more resources were more likely to bypass their closest rural hospitals. Beneficiaries were more likely to bypass their closest rural hospital if they had no regular physician, had a shorter patient–physician tie, were dissatisfied with the availability of health care, and had a longer travel time to their physician's office.
Conclusions. The significant influences of patients' socioeconomic, health, and functional status, their satisfaction with and access to primary care, and their strong preferences for certain hospital attributes should inform federal program initiatives about the likely impacts of policy changes on hospital bypassing behavior.     

Impact of a Disease Management-Health Promotion Nurse Intervention on Personal Assistance Use and Expenditures

The purpose of this study is to evaluate the effect of a primary care affiliated disease management-health promotion nurse intervention on paid personal assistance (PA) use and expenditures among Medicare beneficiaries with disabilities. We analyzed data on 570 community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Primary and Consumer-Directed Care Demonstration, a randomized controlled trial. We estimated a two-part model to test the effect of the nurse intervention on PA use and expenditures during the 2 years after study entry. Adjusting for covariates, average annual PA expenditures were $1,464 (29%) lower per person in the intervention group as compared to the control group. The findings of this study will help policy makers and practitioners understand the potential benefit of primary care affiliated nurse home visiting interventions on PA expenditures.     

Factors Associated with Inpatient Hospital (Re)admissions in Medicare Beneficiaries in Need of Food Assistance

Little is known about pathways underlying inpatient hospital (re)admissions in older adults unable to meet basic needs. This study examined the factors associated with (re)admissions in a sample of low-income older Medicare beneficiaries in need of food assistance in Georgia in 2008 (N = 892, mean age 75.4 ± 8.8 years, 30.3% Black, 68.5% female). About 35.3% of the sample experienced 1 + hospital (re)admissions. (Re)admissions were significantly more likely in individuals who requested Older Americans Act Nutrition Program Home Delivered Meals services (OR 2.3; 95% CI 1.4, 3.8), had more outpatient emergency room visits (1 visit: OR 2.1; 95% CI 1.4, 3.1; 2+ visits: OR 3.6; 95% CI 2.4, 5.4), and experienced greater multimorbidity (OR 1.6; 95% CI 1.4, 3.1). Support for home and community-based services may be critical in reducing potentially avoidable inpatient hospital (re)admissions.     

Job Stress and Job Satisfaction: Home Care Workers in a Consumer-Directed Model of Care

Objective. To investigate determinants of job satisfaction among home care workers in a consumer‐directed model. Data Sources/Setting. Analysis of data collected from telephone interviews with 1,614 Los Angeles home care workers on the state payroll in 2003. Data Collection and Analysis. Multivariate logistic regression analysis was used to determine the odds of job satisfaction using job stress model domains of demands, control, and support. Principal Findings. Abuse from consumers, unpaid overtime hours, and caring for more than one consumer as well as work‐health demands predict less satisfaction. Some physical and emotional demands of the dyadic care relationship are unexpectedly associated with greater job satisfaction. Social support and control, indicated by job security and union involvement, have a direct positive effect on job satisfaction. Conclusions. Policies that enhance the relational component of care may improve workers' ability to transform the demands of their job into dignified and satisfying labor. Adequate benefits and sufficient authorized hours of care can minimize the stress of unpaid overtime work, caring for multiple consumers, job insecurity, and the financial constraints to seeking health care. Results have implications for the structure of consumer‐directed models of care and efforts to retain long‐term care workers.     

A Public Celebration of a Personal Doctor

The life of a family doctor is engaged with the people, families, and community he or she serves. Caring changes lives. Yet, we seldom have the opportunity to hear the gratitude or to reflect upon the privilege. In this essay, two family doctors share the experience of seeing a community celebrate the life of their doctor. In these public reflections on their personal doctor, folks reveal how he saw their needs, understood their fears, and partnered with them to create futures. Their stories are compelling evidence that personal doctoring is alive and well and held deeply in the heart of America.     

Performance management: a qualitative study of relational boundaries in personal assistance

Personal assistance (PA) is a model of support where disabled people take control of recruiting, training and managing the people that support them. Personal assistance differs from other forms of care, such as domiciliary or informal care, because the disabled person is in control of how, when and by whom they are supported. With the advent of personal health budgets, PA is no longer limited to social care but is also central to future NHS services and funding arrangements. The aims of this study were to gain a deeper understanding of PA relationships, and to explore how both parties manage interpersonal challenges. We report on data from 58 qualitative interviews with disabled employers and personal assistants. Applying concepts from Goffman's (1959) scheme of impression management, we present an analysis of the relational dynamics that occur when two people cooperate in shared endeavours. Goffman's concepts of team members and non-persons, in addition to the themes of regions and information control, aid a more fundamental understanding of the relational dynamics that occur between disabled employers and their PAs.     

Geographic Differences in Use of Home Oxygen for Obstructive Lung Disease: A National Medicare Study

Rationale: Home oxygen is the most expensive equipment item that Medicare purchases ($1.7 billion/year). Objectives: To assess geographic differences in supplemental oxygen use. Methods: Retrospective cohort analysis of oxygen claims for a 20% random sample of Medicare patients hospitalized for obstructive lung disease in 1999 and alive at the end of 2000. Measurements and Main Results: While 33.7% of the 34,916 hospitalized patients used supplemental oxygen, there was more than a 4-fold difference between states and a greater than 6-fold difference between hospital referral regions with high/low utilization. Rocky Mountain States and Alaska had the highest utilization, while the District of Columbia and Louisiana had the lowest utilization. After adjusting for patient characteristics and elevation, high-utilization communities included low-lying areas in California, Florida, Michigan, Missouri, and Washington. Patients who were younger, male, white, and who had more comorbidities, more hospital admissions, and lived at higher altitudes and in areas of greater income also had higher odds of using supplemental oxygen. Residing in rural areas was associated with higher unadjusted oxygen use rates. After adjustment, patients living in large rural areas had higher odds of using oxygen than patients living in urban areas or in small rural areas. Conclusions: There is significant geographic variation in supplemental oxygen use, even after controlling for patient and contextual factors. The Centers for Medicare & Medicaid Services should examine these issues further and enact changes that ensure patient health and fiscal responsibility.     

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.     

HIV Prevention Services Received at Health Care and HIV Test Providers by Young Men who Have Sex with Men: An Examination of Racial Disparities

We investigated whether there were racial/ethnic differences among young men who have sex with men (MSM) in their use of, perceived importance of, receipt of, and satisfaction with HIV prevention services received at health care providers (HCP) and HIV test providers (HTP) that explain racial disparities in HIV prevalence. Young men, aged 23 to 29 years, were interviewed and tested for HIV at randomly sampled MSM-identified venues in six U.S. cities from 1998 through 2000. Analyses were restricted to five U.S. cities that enrolled 50 or more black or Hispanic MSM. Among the 2,424 MSM enrolled, 1,522 (63%) reported using a HCP, and 1,268 (52%) reported having had an HIV test in the year prior to our interview. No racial/ethnic differences were found in using a HCP or testing for HIV. Compared with white MSM, black and Hispanic MSM were more likely to believe that HIV prevention services are important [respectively, AOR, 95% confidence interval (CI): 3.0, 1.97 to 4.51 and AOR, 95% CI: 2.7, 1.89 to 3.79], and were more likely to receive prevention services at their HCP (AOR, 95% CI: 2.5, 1.72 to 3.71 and AOR, 95% CI: 1.7, 1.18 to 2.41) and as likely to receive counseling services at their HTP. Blacks were more likely to be satisfied with the prevention services received at their HCP (AOR, 95% CI: 1.7, 1.14 to 2.65). Compared to white MSM, black and Hispanic MSM had equal or greater use of, perceived importance of, receipt of, and satisfaction with HIV prevention services. Differential experience with HIV prevention services does not explain the higher HIV prevalence among black and Hispanic MSM. A complete list of the members of the Young Men’s Survey Study Group and cooperating organizations appears at the end of this article.     

Stakeholder Engagement in Designing Attributes for a Discrete Choice Experiment With Policy Implications: An Example of 2 Swiss Studies on Healthcare Delivery

ObjectivesThe use of discrete choice experiments (DCEs) has become increasingly popular in health policy development by involving and analyzing the preferences of target groups for different aspects of the policy intervention. In this article, we aim to contribute to the standardization of the process of attribute and attribute level development for DCEs with policy relevance. To do so, we propose and empirically illustrate a framework tool for the development and reporting of attributes and attribute levels, with the systematic engagement of relevant stakeholders.MethodsThe framework tool was kept general to allow its use as a standard reporting approach on the development process of a DCE, involving relevant stakeholders at each stage. The proposed 3-stage process consists of (1) collection, (2) selection, and (3) refinement of the DCE attributes and attribute levels. The application of the framework tool is illustrated by 2 projects, Health2040 and COCONUTS—both concerning the preferences of the Swiss population for the future organization of healthcare.ResultsBy engaging stakeholders, we identified and included attributes and attribute levels that would not have been identified solely through the existing literature. In addition, including multiple stakeholders from different professional backgrounds ensured that the selected attributes and attribute levels were policy relevant, were applicable in practice, and reflected the opinions of multiple actors in healthcare.ConclusionThe proposed framework helps to strengthen the standardization of the reporting on attribute and attribute level development with stakeholder engagement and to guide future research teams designing a DCE with policy implications.     

Using smart card technology to monitor the eating habits of children in a school cafeteria: 2. The nutrient contents of all meals chosen by a group of 8- to 11-year-old boys over 78 days

OBJECTIVE: The aim of the study was to test the abilities of the newly created smart card system to track the nutrient contents of foods chosen over several months by individual diners in a school cafeteria. METHODS: From the food choice and composition of food data sets, an Access database was created encompassing 30 diners (aged 8-11 years), 78 days and eight nutrients. Data were available for a total of 1909 meals. RESULTS: Based upon population mean values the cohort were clearly choosing meals containing higher than the recommended maximum amounts for sugar and lower than the recommended minimum amounts of fibre, iron and vitamin A. Protein and vitamin C contents of meals chosen were well above minimum requirements. Over the 1909 meals, nutrient requirements were met 41% of the time. CONCLUSIONS: The system created was very effective at continually monitoring food choices of individual diners over limitless time. The data generated raised questions on the common practice of presenting nutrient intakes as population mean values calculated over a few days. The impact of heavily fortified foods on such studies in general is discussed.