Inconsistency in level of care assignment decisions in skilled nursing facilities

In Arizona, a non-Medicaid state, we investigated the extent to which unregulated level of care assignments in Skilled Nursing Facilities consistently reflect level and nature of patient impairment. Using Multiple Discriminant Analysis (MDA) to develop optimal prediction functions, approximately 70 per cent of patients could be correctly classified. Factors identified by MDA as discriminating among patients at different levels of care are an Activities of Daily Living (ADL) impairment factor, and a factor defined by confusion, transitory contact with the social environment, and propensity to wander. Results are compared with those of studies using MDA to replicate Multidisciplinary Review Team (MRT) or other expert level of care assignments intended to develop patient classification functions for clinical use. MRT assignments appear to reflect patient impairment characteristics only slightly better than do unregulated institutional assignments, suggesting that such utilization review efforts may result in minimal net gains in appropriateness of placement.     

Effects of Copayment in Long-Term Care Insurance on Long-Term Care and Medical Care Expenditure

ObjectiveThis study aimed to clarify the difference in (1) long-term care (LTC) usage and expenditure and (2) medical care service usage and expenditure before and after the change in the copayment limit for qualifying individuals from 10% to 20%.Setting and ParticipantsThis quasi-experimental longitudinal design used the database from 1 prefecture of Japan that included 570,434 person-month records of 23,879 insured individuals (in August 2014) who used LTC services between August 2014 and July 2015 and were aged 65 years and older on August 1, 2014.MethodsWe conducted difference-in-difference estimations to compare “before” and “after” outcome differences between insured individuals whose LTC copayment increased to 20% and those whose copayment remained at 10%. Sex, age, Care Needs Level, subsidy, and public assistance were adjusted in the models, along with robustness checks.ResultsDifferences in both insurer's payment and insured's copayment indicated statistical significance between those whose copayment increased and those whose copayment did not increase. We found no significant difference in the number of minutes of home care service use, days of facility care service use, and LTC expenditures among those with copayment increases as well as those with no increase in copayment following the insured's copayment increase policy implementation. In contrast, the policy implementation caused significant differences in the number of days of hospitalization, medical care expenditures, and total expenditures.Conclusions and ImplicationsThe increase in insured individuals' copayment decreased LTC insurer's payment. However, total LTC expenditure increased over time although the increase trend slowed down in the treatment group after the copayment increase policy implemented. Besides, medical care expenditure increased consistently among insured individuals whose copayment increased. As there appears to be a “balloon effect” between LTC and medical care services, it is important to discuss the medical care system while considering the LTC insurance system comprehensively.     

Health care decisions at the household level: results of a rural health survey in Kenya

The observed visits to health care providers are an outcome of patients' health care decision-making process. Unlike the visits, this process is not observable. The paper first outlines this process, and then presents patterns of patients' visits to health care providers in a particular rural area in Kenya. The visit patterns are shown to vary greatly according to type of illness and to the stage of the illness. The paper has two main results. The first result is that in the study area, the majority of the patients sought medical treatment outside the 'free' government health care system. The other finding is that for a given illness episode, there is a very high likelihood of a patient consulting more than one provider for advice or treatment.     

Physician participation in a Medicaid managed care program, the Kansas Primary Care Network

This study was designed to identify the factors that enhance and impede physician participation in a Medicaid managed care program, the Kansas Primary Care Network (PCN). The data for the study were collected in the summer of 1993 through a mail survey of primary care physicians in the PCN service area. Logistic regression and cross tabular analytic techniques were employed for data analysis. The results indicate that physicians who are not receptive to capitation-based reimbursement practices, those who practice in the higher per capita income counties, those who do not compare the PCN reimbursement rates favorably with private insurance rates, and physicians who think that untimely payment and the requirement to document patient referrals for specialty treatment pose problems for them are less likely to participate in the PCN program. Further, the study shows that institutional physicians have larger Medicaid caseloads than solo practitioners, who have larger Medicaid caseloads than single-specialty and multi-specialty group practitioners. Since most of the variables that attain statistical significance in explaining physician participation in the PCN program have to do with money, the study reaffirms the two market theory of the United States' health care delivery system.     

Long-Term Care in San Mateo

This California county coordinates the “fourth stage of medicine” through a Medical Evaluation and Placement Team that includes medical social workers and public health nurses. As a result, says Dr. Salmon, it is well prepared to meet the demand for long-term services expected under Medicare and Medicaid.     

Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents’ nutrition and well-being is required.     

Long-Term Care Insurance in Japan

In response to an increase in the number of elderly people and increasing medical costs, the Japanese government implemented the Long-Term Care Insurance (LTCI) system for the elderly in April 2000. Three years have passed since the LTCI was initiated. The purpose of this paper is to describe the framework, current situation and issues of this system, and the challenges and roles of the LTCI in the future.The numbers of service agencies, institutions, and LTCI service users have been steadily increasing. The waiting list for institutions has also increased, and only half of the users have reached the upper cost limit. Most users were satisfied with the LTCI services. However, the decisions made by the elderly on the types of services to use within the LTCI system are sometimes influenced by their families. The system has some problems regarding the lack of support that is provided to the elderly with respect to their access, choice and use of the LTCI services. Often, care managers cannot devote enough time to the care management process. As a result, important elements of care management, such as conducting home visits to assess users’ conditions, monitoring the care that is received by users, and meeting with other service providers to discuss adequacy of care, are sometimes lacking. Private companies have promoted the quality and efficiency of the home care and long-term care market. The total amount of yearly medical expenses for elderly people in Japan has decreased following the implementation of the LTCI system, compared with that prior to the initiation of the system. LTCI premiums differ among municipalities. The questionnaire that has been used to assess the care requirements of the elderly was deficient in some areas of health. However, in 2003, some amendments were made to this questionnaire in an attempt to address these deficiencies. Furthermore, the LTCI system should have relieved some of the burden on the elderly patient’s family; however, since the implementation of the LTCI, its impact on the burden on the family has not been addressed sufficiently.Although there have been amendments to the system, several challenges of the LTCI system must be considered: (i) ensuring the future financing of LTCI services is met; (ii) providing countermeasures to promote the use of home-care services and to alleviate the care burden to family caregivers; (iii) providing adequate support and advocacy of rights and decision-making for the elderly; (iv) providing educational activities to disseminate knowledge about LTCI programs; and (v) ensuring the availability of activities to promote health for the elderly and to prevent them from becoming bedridden.     

Prevalence of Undernutrition in a Long-Term Care Facility in Qatar

This study assessed the nutritional status of 130 Qatari patients aged 65 to 90 years who were residing in a long-term care facility for six months. Admission weight was not measured for 49.2% of the subjects. Of those whose weight was measured at admission, assessment at six months indicated that 21.3% had lost more than 10% of their admission weight, 38.9% were under the fifth percentile of body mass index (BMI), 39.8% had a BMI less than 21, 27.1% had albumin level below 34 g/L, and 18.6% had total cholesterol below (140 mg/dl). The study showed a high prevalence of undernutrition among these long-term care residents and indicated that appropriate nutritional assessment and nutrition care were not fully implemented during their stay in the facility.     

武汉市部分老年人长期照护需求研究

介绍了老年人长期照护需求的意义和国内外概况,对老年人对社会性长期照护服务需求的总体情况进行了详细分析,并进行了讨论,提出了政策性建议。     

Care of cancer patients in a home-based hospice program: a comparison of oncologists and primary care physicians.

BACKGROUND. The purpose of this study was to describe a group of patients cared for in a home-based hospice program and to determine if there was a difference in patients' experiences dependent on whether the attending physician was a primary care physician or an oncologist. METHODS. Information about cancer patients admitted to the Burlington Visiting Nurse Association (VNA) Hospice program from January 1986 to December 1990 was reviewed to compare the experiences of the patients of the oncologists with those of the patients of the primary care physicians. RESULTS. There was no difference in average length of stay or overall ambulatory status between the patient groups. The patient group cared for by oncologists had more hospitalizations than the group cared for by primary care physicians though there was not a significant difference in the percentage of hospital vs home deaths. There was a significant difference between the groups in the use of controlled-release morphine, with oncologists using this approach more often than primary care physicians. Oncologists also had more patients on continuous parenteral morphine infusions during hospice care. CONCLUSIONS. Primary care physicians as well as oncologists provide effective cancer care and pain control in this home-based hospice program. The hospice interdisciplinary team can be a valuable resource for physicians in supplying information on appropriate narcotics dosages and routes of administration for their dying patients.     

Kangaroo Mother Care: the role of health care services and family networks in a successful program

Kangaroo Mother Care (KMC) provides many benefits to low birth-weight babies. The family's early and active participation in the care of these infants helps create and strengthen bonding. This study was intended to increase the knowledge on the effect of hospital and family conditions on the method's implementation. Fourteen women and seven men taking part in KMC in the Itapecerica da Serra General Hospital (S?o Paulo State) answered in-depth interviews. The respondents' statements are focused on the decision-making process in the method's implementation, which depends not only on the mother's desire and willingness, but also on the support provided by the family network and empathetic health care teams. Although mothers realize the importance of KMC for their infants' recovery, personal and family problems may prevent them from taking active part in the program. Interaction of such factors as history of perinatal death, presence of other children in the household, involvement of the father and other family members, and household management can establish patterns that may or may not be favorable when choosing and implementing KMC.