Cost comparisons between family-based care and nursing home care for dementia

A prospective study was carried out in Taiwan to measure the family cost of caregiving at home for 289 patients newly diagnosed with dementia (106 with senile-type dementia, 171 with vascular-type dementia). Their families were first interviewed in the outpatient department and then followed for 1 month after the dementia diagnosis was made. Simultaneously, the costs for providing nursing home care to patients with dementia were calculated using accounting data reported from six nursing homes. Comparisons were made between the amount and type of cost encountered by families and by nursing homes to determine whether family-based care was cheaper and more appropriate than nursing home care for dementia patients with different functional levels. The results showed that higher costs were encountered for caregiving at home when the patients had severe dependence. This tendency was more evident for patients with senile dementia than for patients with vascular-type dementia. The cost of labour was an important expense for families caring for patients at home (at least 85% of family costs). Our findings suggest that, when family labour cost is considered, nursing home care is less expensive than family-based care for long-term care, especially for dementia patients with severe or moderate dependence. Nursing home care is also a better choice when patients have great need for multiple health services.     

Predictors of nursing home placement and home nursing services utilization by elderly patients after hospital discharge in Taiwan

BACKGROUND: Providing appropriate follow-up health/long-term care services after hospital discharge for elderly persons is important to enhance health and quality of life. Therefore, identifying factors that affect follow-up service utilization has become an important concern. Most studies of predictors of follow-up service utilization for elderly persons after discharge were conducted in the United States of America (USA). Taiwan differs substantially from the USA in health care system, clinical practice, case-mix, culture, and social organization; thus the findings from the USA need to be validated in Taiwan to ensure appropriate discharge referrals. AIM: To investigate pre-discharge predictors of follow-up care including home nursing services and nursing home placement for elderly patients, discharged from hospitals in Taiwan. METHODS: A prospective study with a case-control design was used. FINDINGS: The strongest predictors of institutionalization in a nursing home at 1, 3 and 6 months after discharge were the elderly person's pre-admission institutionalization (0.33 to 0.48) and the caregiver's preference for institutional displacement (0.23 to 0.85). The strongest predictors of use of home nursing services were the elder's self-care ability (0.69 to 0.76), conscious level (0.51 to 0.73), and tubes remaining before discharge (0.58 to 0.79). These predictors were stable at 1, 3 and 6 months after discharge and could correctly classify 60-89% of sample. CONCLUSIONS: When taking nursing home and home nursing utilization into considerations at the same time, the elderly person's pre-admission institutionalization and the caregiver's preference for institutional displacement strongly predicted nursing home utilization after hospital discharge. The elder's self-care ability, conscious level, and tubes remaining before discharge strongly predicted the use of home nursing services after discharge.     

A cost-effectiveness analysis of home care and community-based nursing homes for stroke patients and their families

A prospective study designed for 336 hospitalized patients with stroke and their families, who were followed from the discharge day to the third month after being discharged, was carried out in order to compare the costs and effectiveness of home care with the community-based nursing homes for stroke patients with different physical function disabilities in terms of ADL scores and their families. The ADL scores of the patients with severe physical function disability did not improve with or without long-term care; however, the patients with moderate physical function disability were significantly improved at the end of the third month, even without interventions from long-term care. The family costs of the patients in nursing homes were substantially lower than the costs for the patients who stayed at home, and the relationship of the family costs of the patients cared for in their own homes was proportional to the patients'physical function status. The labour input from family caregiving accounted for at least 60% of the total family costs of the patients who stayed at home, and the paid for long-term care services accounted for at least 60% of total family costs when the patients stayed in nursing homes. The multiple linear regression demonstrated that the degree of caregiving from families was a predictor of the amount of the costs families incurred for patients with severe physical function disability; as a result the ADL scored on discharge significantly influenced the average total family costs for the patients cared for in their own homes.     

Development and testing of the Family Caregiving Consequences Inventory for home nursing assessment in Taiwan

This paper describes the development and psychometric testing of the Family Caregiving Consequences Inventory (FCCI). Data were collected from a convenience sample of 97 families in Taiwan to examine the validity and reliability of the three FCCI scales: frail elder outcomes, caregiver outcomes and family outcomes. Acceptable test-retest and internal consistency reliabilities were found, though inter-rater reliability was unsatisfactory. Criterion-related validity was demonstrated by congruence with home nursing specialists' assessment of family caregiving outcomes. Confirmatory factor analysis with a good overall model fit supported the construct validity of FCCI. However, a poor fit of the internal measurement structure was found for the frail elder outcomes scale and the family outcome scale. Studies with larger samples are needed to further verify the measurement models used here. Nevertheless, in its current form, the FCCI can be used to increase the sensitivity of home care nurses to family caregiving situations and provide an instrument for studies of family caregiving in Taiwan and other countries with similar home care needs.     

Maintaining family connectedness in long-term care. An advanced practice approach to family-centered nursing homes

The decision to place a relative in a long-term care institution is one of the most difficult processes families can go through. Family members often experience conflicting feelings of stress, shock, anxiety, fear, resistance, and guilt. In addition, many individuals, regardless of the amount of previous nursing home experiences, possess misconceptions about nursing home care (Grove, 1997; Mastrian & Dellasega, 1996; Tickle & Hull, 1995). Even after the family realizes the necessity of nursing home placement, achieving a level of comfort with such a decision and maintaining family relationships is a difficult challenge. Unfortunately, family-centered nursing care in long-term care settings is hindered by multiple barriers, including resistance to institutional change, family members' fear and hesitation, institutional rules and protocols, lack of institutional encouragement of family involvement, insufficient programs and activities addressing the social and emotional needs of the family, and ineffective communication between the staff and families. To remedy these barriers, it is suggested the family advanced practice nurse (APN) view the families as clients and initiate family-centered policies to encourage family involvement in the caregiving experience. Ultimately, this will promote individualized care of elderly adults and encourage family processes within the walls of the nursing home.     

Comparison of resource utilization for Medicaid dementia patients using nursing homes versus home and community based waivers for long-term care

BACKGROUND: Medicaid waiver home and community-based long-term care services (HCBS) may provide a partial solution to the escalating costs of long-term care. Persons with dementia can have complex caregiving needs; it is unknown whether their expenditures and resource utilization differ between community-based versus institutional settings. OBJECTIVE: To compare expenditures and resource utilization for Medicaid recipients with dementia who received long-term care through a nursing home versus HCBS waivers. DESIGN: Twelve-month cohort study. SETTING: Indiana Medicaid administrative data from 2001 through 2004. PARTICIPANTS: Medicaid recipients with dementia who lived in the community 6 months before receiving long-term care through nursing homes (N = 1534) or HCBS waivers (N = 174). MEASUREMENTS: Monthly inpatient and emergency department rates and total expenditures adjusted for prior use, demographics, insurance status, and comorbidities. RESULTS: Adjusted rates of inpatient use were stable for nursing home patients (0.06) but significantly increased over 12 months for HCBS recipients (0.07-0.12; P = 0.048). Adjusted total expenditures increased over 12 months from $1419 to $2002 for HCBS recipients (P < 0.001), but remained stable for those in nursing homes ($3413-$3336). Long-term care expenditures were on average $1688 per month higher for those in nursing homes. CONCLUSIONS: The escalation in inpatient use for HCBS waiver recipients suggests that future development of HCBS programs should consider the unique needs of persons with dementia so as to optimize their health outcomes. Despite increasing inpatient use among HCBS recipients, their overall expenditures remained significantly lower than those of nursing home patients.     

Cost analyses of home care and nursing home services in the southern Taiwan area

This study compares the cost of long-term care provided at patient homes with that of long-term care provided in nursing homes in southern Taiwan. Caring for a patient with a high degree of dependence at home is more expensive than caring for a patient in a nursing home facility when family costs and provider costs are considered together. This phenomenon is not demonstrated for patients with medium degrees of dependence. To be cost-effective, home care services should target patients with medium physical disability, and nursing home care should focus on patients with high levels of dependence.     

Seizing possibilities for positive family caregiving in nursing homes

Aims. This paper explores the ways family members reconstruct meaning through seizing possibilities for positive caregiving in nursing homes. Background. The importance of the ability of family caregivers to adapt and accommodate has been well documented in international family caregiving research. Through engagement in caregiving activities, families learn to modify, adapt and accommodate to changes in their situation and relationships. The support family caregivers experience in learning to accommodate change is crucial in enabling them to reconstruct positive aspects of caregiving in a long‐term aged care context. Method. In this study, a hermeneutic phenomenological approach was adopted informed by the philosophical world views of Heidegger and Gadamer. Data collected by in‐depth interviews and participant observations, from a purposeful sample of 14 family caregivers, underwent hermeneutic analysis. Results. Five shared meanings associated with seizing possibilities for positive caregiving were revealed: accommodating new and different ways of caring; feeling a part of the nursing home community; seeing the whole picture; learning to care in stress‐reducing ways and learning to seize possibilities for self. Conclusion. This paper illustrates how families, through caregiving experience in nursing homes, learn to become active managers, negotiating, accommodating and redeveloping a sense of future viewed with hope, strength and positive anticipation. Relevance to clinical practice. By highlighting what is attributed significance by families, a critical examination of the difficult issues which obstruct the development of meaningful partnerships among nurses, family and their relatives is facilitated. In particular, an examination of tensions at an ideological level supports the need for future research to focus its efforts on examining the ways of implementing nursing care that facilitates partnerships that incorporate and build upon positive and equal relations among staff, families and residents in the context of the nursing home setting.     

Comparisons of the cost-effectiveness among hospital chronic care, nursing home placement, home nursing care and family care for severe stroke patients

AIM: This study compared the cost and effectiveness of long-term institutional care and home care for stroke patients with severe physical disabilities. BACKGROUND: Whether home care is more economical or effective than institutional care for patients with chronic illnesses remains controversial when the cost of family labour is considered. Thus, decisions concerning the appropriate type of care setting for patients with severe chronic illness remain difficult. METHODS: From November 1995 to March 1996, 313 hospitalized stroke patients with severe physical disabilities treated at one of five hospitals in the Taipei metropolitan area were followed from the day of hospital discharge until the third month after discharge. These 313 patients were divided into four groups as follows: (1) 106 who were admitted to a chronic care unit in a hospital, (2) 60 who were admitted to nursing homes, (3) 60 who received professional home nursing care and (4) 87 who returned home without receiving professional care. The change of physical functional status in the patient was examined as the difference between activities of daily living (ADL) scores measured at discharge and at the end of the third month after discharge. RESULTS: Information on family costs for caregiving, including pay for long-term services utilized, labour costs for caregiving and out-of-pocket expenditures for miscellaneous materials was obtained during a weekly telephone interview. The results indicated that caring for patients in their own homes was not only more expensive but was also less effective in improving ADL scores than caring for patients in nursing homes and in chronic care units of hospitals. CONCLUSIONS: The results suggest that caring for patients with severe physical disabilities in institutions is more appropriate than caring of them at home.     

Around-the-Clock Nursing Care for the Elderly in Japan

Purpose: To describe the first phase of creating a Japanese model of community-based long-term care, called around-the-clock care (ACQ, by operationally defining the components of ACC, identifying those eligible for the program, clarifying methods of planning and organization, and exploring outcomes.
Design: Exploratory evaluation for the population of frail elderly Japanese citizens living at home. A convenience sample of 44 patients receiving care from four visiting-nurse-service stations during 3 months in 1994 was used.
Methods: Needs assessments; record reviews of patient encounters; evaluations by patients, families, and visiting nurses; and reviews of administrative data.
Findings: Nurses perceived that ACC stabilized medical status, reduced the emotional and physical burden of treatment, and improved hygiene. It also reduced family caregiving burdens and the stress of family caregivers' employment responsibilities. The highest rating of ACC by patient and families was for those with the most complex physical needs. Skilled nursing at home permitted early identification and treatment of problems before they became crises or required hospitalization.
Conclusions: Early findings suggest 24-hour nurse-home helper teamwork may bean effective system of community-based long-term care and should be considered a key element of future Japanese health policy.     

Selecting whether to die at home or in a hospital setting

Abstract

Data from a 1978 health care study in rural North Carolina were analyzed to investigate whether people prefer to die at home rather than in a hospital setting and the reasons for their preference. Medical, financial, personal and family-related reasons were investigated as possible explanations for selecting a preferred site of death. Differences between respondents in demographic, socioeconomic, and health-related variables were analyzed to determine their possible effects on where an individual preferred to die.

The results indicate that financial reasons were most likely to be given for preferring to die at home followed closely by individual reasons and then by family and health considerations. Statistically significant differences indicated that those who preferred to die at home were younger, white, more educated, were not satisfied with the quality of medical services, considered their health as excellent and were afraid of hospitals. The implications of these results were considered.     

Factors associated with nursing home entry for older people in Taiwan,Republic of China

Taiwan is facing a rapid change in the composition of its population. As the population ages, a greater demand for long-term care services and, in particular, nursing homes is expected. Before deciding who really needs nursing home care, it is important for policy makers to understand the current pattern of utilisation and what factors are associated with entry. This research assesses the relative importance of predisposing, enabling and need factors that lie behind this. It is based on a survey of elderly people in registered nursing homes, a comparison with a national sample of elderly people in their own homes and interviews with the lucid elderly patients (i.e. could communicate with no problems) and their carers. It was found that nursing home entry was associated with advanced age, gender, educational level and dependency levels of elderly people. After controlling for age, need factors have the greatest impact on admission. Specific medical problems such as cardiovascular, neurological and skeletal muscular diseases were also major contributors. Although most elderly people in Taiwan are cared for in their own homes by their families, under certain circumstances entry to a nursing home seemed inevitable. Decisions about nursing home entry were mainly taken within a family context with adult children being the main players while professionals played a relatively minimal role.     

Selecting whether to die at home or in a hospital setting

Data from a 1978 health care study in rural North Carolina were analyzed to investigate whether people prefer to die at home rather than in a hospital setting and the reasons for their preference. Medical, financial, personal and family-related reasons were investigated as possible explanations for selecting a preferred site of death. Differences between respondents in demographic, socioeconomic, and health-related variables were analyzed to determine their possible effects on where an individual preferred to die.

The results indicate that financial reasons were most likely to be given for preferring to die at home followed closely by individual reasons and then by family and health considerations. Statistically significant differences indicated that those who preferred to die at home were younger, white, more educated, were not satisfied with the quality of medical services, considered their health as excellent and were afraid of hospitals. The implications of these results were considered.     

Psychometric properties of the Caregiving Burden Scale for Family Caregivers with Relatives in Nursing Homes: Scale development

Aim: Most family caregivers continue their caregiving for frail relatives after admitting them to long‐term care facilities. The characteristics of this caregiving differ from those related to caregiving in home‐care settings. Thus, a new tool to evaluate the burden of family caregivers in institutional settings is needed. The aim of this study was to develop a new scale, the Caregiving Burden Scale for Family Caregivers with Relatives in Nursing Homes, and to confirm its validity and reliability. Methods: We conducted two cross‐sectional questionnaire surveys. The participants were a convenience sample of family members of residents in seven nursing homes for the validation study and in three nursing homes for the test‐retest study in Japan. Statistical analyses examined exploratory/confirmatory factor analyses, internal consistency, concurrent/discriminate validity, and test‐retest reliability. Results: A four‐factor solution with 16 items was selected as the most interpretable questionnaire. In the confirmatory factor analysis, the indices of fitness highly supported these results. The Cronbach's alpha coefficient for the total score was 0.86 and varied between 0.77 and 0.87 in the four domains. The scale showed moderate correlation with the Nursing Home Hassles Scale, suggesting its concurrent validity. The four domains had only a medium correlation with each other, indicating discriminate validity. Conclusions: The developed scale has acceptable validity and reliability for measuring the caregiving burden of family members with relatives in Japanese nursing homes. Future studies using the scale might lead to the improvement of care for family members with relatives in a long‐term care setting.     

Perspectives from family caregivers receiving home nursing support: findings from a qualitative study of home care patients with heart failure

Many heart failure (HF) patients depend on a family caregiver and many families need additional home care nursing support. This qualitative study identified perspectives of being a HF caregiver for families receiving home care nursing. Eleven caregivers of homebound HF patients were interviewed on what helps them the most, their own health, obstacles in caregiving, and greatest needs overall. Eight themes emerged and will be discussed in this article. The findings articulate the positive influence nurses can have on HF families to guide future practice and research.     

Determinants of hospice home care use among terminally ill cancer patients

BACKGROUND: Despite the widespread availability of hospice services for more than two decades in the United States, currently many terminally ill cancer patients who may benefit from hospice care do not receive it. PURPOSE: To identify determinants of the use of hospice home care services for terminally ill cancer patients during their final days of life. METHODS: Secondary analysis of data from 127 terminally ill cancer patients who participated in a prospective and exploratory study aimed at identifying determinants of congruence between the preferred and actual place of death. Multivariate logistic regression analysis was conducted to identify determinants of hospice home care use. RESULTS: Sixty-four (50.4%) out of the 127 participants had used hospice home care services before death. Important determinants of hospice home care use included: (a) longer length of survival (odds ratio [OR] 1.02; 95% confidence interval [CI]: 1.01-1.03); (b) perceived greater family ability to achieve preferred place of death (OR: 1.85; 95% CI: 1.30-2.62); (c) home as the realistic preferred place of death (OR: 5.58; 95% CI: 1.95-16.03); (d) being female (OR: 5.37; 95% CI: 1.81-15.95); (e) lower levels of functional dependency (OR: 0.94; 95% CI: 0.89-0.99); and (f) use of emergency care during the final days of life (OR: 4.03; 95% CI: 1.26-12.94). CONCLUSIONS: The results of this study identified several groups of terminally ill cancer patients who were at a disadvantage to use hospice home care, including those without sufficient family resources but who required intensive nursing care. Providing nursing care that enables family care-taking at home may facilitate hospice home care use for patients.     

Development of use and cost measures in a nursing intervention for family caregivers and frail elderly patients

The purpose of this pilot study was to refine and evaluate methods of measuring costs of an innovative home-health nursing intervention designed to support frail, older persons and their family caregivers. We evaluated a multifaceted strategy to collect a detailed utilization profile from 22 caregiver/care receiver dyads for hospital, ambulatory, home health, nursing home, and community services. The strategy was feasible for most participants, maximized accuracy of cost data, and minimized research burden on study participants. Lower overall costs were found in the intervention group, but the difference was not significant. Approaches to the measurement of costs in this study can serve as models for evaluating other innovations in nursing, home care, and long-term care. © 1996 John Wiley & Sons, Inc.     

Outcomes of family involvement in care intervention for caregivers of individuals with dementia

BACKGROUND: Despite the increasing number of individuals with dementia relocated from caregiving at home to a nursing home, there is only a small body of literature examining the influence of institutional family-oriented practices on family member perceptions of care and family-staff relationships. OBJECTIVE: The study tested the effects of the Family Involvement in Care partnership intervention on family members' perceptions of their caregiving role, relationships with staff, and satisfaction with the care of relatives with dementia residing in special care units as well as the effects on staff attitudes toward families and staff satisfaction with a caregiving role. METHODS: A quasi-experimental design with nonequivalent groups and repeated pretest and posttest measures was used to examine the effects of the Family Involvement in Care intervention. The study recruited 14 Midwestern nursing home special dementia care units, matched by aegis and staff turnover, and randomized from matched pairs to experimental and control conditions. The samples included 185 family members and 895 staff. The Family Involvement in Care intervention is a protocol for family and staff negotiation of a written partnership agreement. Family caregiver outcomes were measured using instruments pretested for reliability and validity. Data were analyzed using hierarchical linear modeling. RESULTS: With adjustment for multiple tests, statistically significant beneficial intervention effects were found in three areas of family caregiver outcomes (emotional reactions to the caregiving role, perceptions of relationships with staff, and perceptions of care for relatives) and in one of three areas of staff outcomes (staff perceptions of the family caregiving role). For family members, effects were found for the measures assessing loss, captivity, staff disregard, resident activities, and physical care. Some of the intervention effects for family members were found only for caregivers of the same generation as the resident. For staff, effects were found for measures of dominion, disruption by family, and irrelevance of family. CONCLUSIONS: The results of the study indicate that the Family Involvement in Care intervention improves the caregiving experience of family members in nursing homes as well as nursing home staff attitudes toward family members. The intervention did not influence the perceived conflict with staff on the part of family caregivers or the perception of a partnership with family caregivers on the part of staff.     

Meaning-making for family carers in nursing homes

Kellett UM. International Journal of Nursing Practice 1998; 4: 113–119 Meaning-making for family carers in nursing homes This ontological hermeneutic study highlights the importance of understanding the human experience of family caring. In contrast to much family caregiving research which focuses upon the home care situation, this study involved in-depth audiotaped conversational interviews and observations with 14 family carers who continue to care within a nursing home context. Thematic analysis of the transcribed interviews/field notes uncovered a number of common themes of meaning which highlight the nature of family caring experience in nursing homes. Discussion of such findings will challenge practitioners to reconceptualise the nurse–resident–family carer relationship, appreciate the many ways in which a family member’s involvement in care provides meaning and significance in their lives, and understand family carers through a process of human relating which fosters families’ meaningful involvement in caring within a nursing home context.