Mental health services use by elderly adults in a primary care setting

This study examined the use of general health, mental health, and other medical specialty services by elderly persons 65 and older with mental disorders and compares them with adults 45 to 64 and 18 to 44. Data were collected at the Bunker Hill Health Center (BHHC), a Boston neighborhood health center providing a broad range of ambulatory medical and specialty mental health services. Results show that the 5-year rate of mental disorder diagnoses for elderly individuals is not significantly different from persons 45 to 64, although it is higher than the rate for young adults 18 to 44. Not only were elderly adults less likely to see a mental health specialist, but when they did, their use of mental health specialty services was usually lower.     

The use of health services by older adults

Using baseline data on the 5,151 respondents surveyed as part of the panel design of the Longitudinal Study on Aging (LSOA), this article estimates, cross-sectionally, the relationships hypothesized in the behavioral model of health services utilization. In addition to the traditional indicators of the predisposing, enabling, and need characteristics, the richness of the LSOA permits the inclusion of measures of multigenerational living arrangements, kin and nonkin social supports, health worries and the sense of health control, health insurance coverage, residential stability, and several multiple-item scales of functional limitations. Despite these innovations, the ability of the behavioral model to accurately predict the use of health services by older adults remains relatively unchanged. Important conceptual clarifications involving the hypothesized relationships, however, are identified and discussed.     

Assessing program fidelity in substance abuse health services research

This paper addresses how treatment fidelity and related constructs (e.g. program implementation) can be assessed in alcohol, drug abuse and mental health services research. First, it introduces definitions of fidelity and related concepts, and then describes various concepts and tools from program evaluation that have proven useful for assessing fidelity. Next, several of these are illustrated in detail through a case study of a multisite fidelity assessment in substance abuse services research: the process evaluation of the NIAAA Homeless Cooperative Agreement Program. This evaluation included analysis of implementation at the program- and participant-level, the development of scales from the individual services data to estimate intervention strength, fidelity, and leakage (i.e. the degree to which services intended exclusively for intervention groups were inadvertently delivered to comparison groups) and the methods with which these data were used to assess whether programs were implemented as planned.     

A package of primary health care services for comprehensive family-centred HIV/AIDS care and treatment programs in low-income settings

Particularly in resource-limited settings, HIV/AIDS is a family concern. Separate services for children and adults may make accessing care more difficult for families than services where family members can be cared for together. Implicit in comprehensive, family-centred approaches to care are the broader notions of longitudinal primary care and linkages to other services, including those based in communities. As highly-active antiretroviral therapy becomes more available, and the direct burden of HIV-associated morbidity diminishes, HIV-infected individuals require primary care that goes beyond exclusive management of HIV and related conditions, including preventive services and the management of common medical issues. The prevention of tuberculosis, diarrhoea, and, in endemic regions, malaria; the addressing of debilitating depression; cervical screening; and the management of chronic cardiovascular disease and its risk factors are all of benefit to patients accessing HIV/AIDS care. Packaging such services is an effective means both of standardizing care within a program and of ensuring patients receives a full roster of available interventions. As family-centred care models develop in resource-limited settings, the availability of evidence-based service packages such as presented here will help program designers prioritize available human and materiel resources toward those interventions that improve patients' global health and well being.     

Health literacy and use of outpatient physician services by medicare managed care enrollees

OBJECTIVE: To determine whether inadequate functional health literacy adversely affects use of physician outpatient services. DESIGN: Cohort study. SETTING: Community. PARTICIPANTS: New Medicare managed care enrollees age 65 or older in 4 U.S. cities (N = 3,260). MEASUREMENTS AND MAIN RESULTS: We measured functional health literacy using the Short Test of Functional Health Literacy in Adults. Administrative data were used to determine the time to first physician visit and the total number of visits during the 12 months after enrollment. The time until first visit, the proportion without any visit, and adjusted mean visits during the year after enrollment were unrelated to health literacy in crude and multivariate analyses. Participants with inadequate and marginal health literacy were more likely to have an emergency department (ED) visit than those with adequate health literacy (30.4%, 27.6%, and 21.8%, respectively; P =.01 and P <.001, respectively). In multivariate analysis, the adjusted relative risk of having 2 or more ED visits was 1.44 (95% confidence interval, 1.01 to 2.02) for enrollees with marginal health literacy and 1.34 (1.00 to 1.79) for those with inadequate health literacy compared to participants with adequate health literacy. CONCLUSIONS: Inadequate health literacy was not independently associated with the mean number of visits or the time to a first visit. This suggests that inadequate literacy is not a major barrier to accessing outpatient health care. Nevertheless, the higher rates of ED use by persons with low literacy may be caused by real or perceived barriers to using their usual source of outpatient care.     

Utilization of dental care services among low-income HIV-positive persons receiving primary care in South Florida

We investigated the use of dental care services among a population of low-income persons living with HIV/AIDS who had not seen a dental care provider during the 12 months prior to study enrollment. A total of 593 participants were recruited from five HIV primary care clinics in two South Florida counties and interviewed regarding past utilization of dental care services, HIV primary care service utilization, and barriers to care. Multivariate logistic regression analysis was used to determine correlates of oral care utilization within the preceding two years. One-third of respondents reported seeing a dentist in the preceding two years. The odds of having seen a dentist were greater for respondents with stable housing, more than a high school education, and who had received help in getting dental care; black respondents (compared to Hispanics and non-Hispanic whites) were less likely to have seen a dentist in the preceding two years. Despite the availability of dental services for low-income HIV-positive persons, utilization of dental care remains low. This study reinforces the need to provide assistance to HIV-positive persons in obtaining dental care. In particular, it indicates that such assistance should be targeted toward Black Americans, persons with low income and unstable housing situations, and those with limited help to navigate the health care system.     

Partnering managed care and community-based services for frail elders: the care advocate program

OBJECTIVES: To describe a demonstration program that uses master's-level care managers (care advocates) to link Medicare managed care enrollees to home- and community-based services, testing whether referrals to noninsured services can reduce service usage and increase member satisfaction and retention. DESIGN: Using an algorithm designed to target frail, high-cost users of Medicare insured healthcare services, the program partners PacifiCare's Secure Horizons and four of its medical groups with two social service organizations. SETTING: Three care advocates located in two community-based social services agencies using telephone interviews to interact with targeted elders living in the community. PARTICIPANTS: Three hundred ninety PacifiCare members aged 69 to 96 receiving care from four PacifiCare-contracted medical groups. INTERVENTION: The 12-month intervention provides telephone assessment, links to eight types of home- and community-based services, and monthly follow-up contacts. MEASUREMENTS: Sociodemographic characteristics of intervention participants, types of service referrals, and acceptance rates. RESULTS: Lessons learned included the importance of building a shared vision among partners, building on existing relationships between members and providers, and building trust without face-to-face interactions. CONCLUSION: The program builds on current insured case management services and offers a practical bridge to community-based services.     

Healthy patients who perceive poor health and their use of primary care services

Objective:To determine what proportion of patients who have poor health perceptions are physically healthy and to explore why some patients perceive a healthy state while others perceive illness. Design:A prospective consecutive series of office patients completed the Rand Corporation’s General Health Perceptions Questionnaire, and their physicians rated their physical health. Their use of health care services was determined for the following 12 months. Setting:A rural teaching office practice. Patients:Of 243 adult patients asked to complete the questionnaire, 32 were excluded, for dementia (8), illiteracy (4), illness (8), incomplete questionnaires (6), and other reasons (6). 208 patients (86%) formed the final study group. Measurements and main results:62 of 208 patients had poor health perception scores. 39 of the 62 were rated by physicians as physically healthy and were not statistically different in physical health ratings or numbers of prescribed medications from the 146 patients who had higher health perception scores. However, these 39 patients had significantly more health-related worry, acute pain, and depression than did the other 146 patients. They also made more office visits and telephone calls and had higher total primary care charges. Conclusions:This study suggests that 21% of adult primary care patients (39 of 208) have health perceptions lower than expected for their levels of physical health. These low health perceptions are correlated with increased emotional distress and higher utilization of health care resources. Strategies to identify these patients and interventions to improve their views of their health could reduce utilization.     

Five-year alcohol and drug treatment outcomes of older adults versus middle-aged and younger adults in a managed care program

AIMS: This study compared 5-year treatment outcomes of older adults to those of middle-aged and younger adults in a large managed care chemical dependency program. We examined age group differences in individual, treatment and extra-treatment factors, which may influence long-term outcome. DESIGN: Seventy-seven per cent of original study participants completed a telephone interview 5 years after out-patient chemical dependency treatment at Kaiser Permanente. This sample (N = 925) included 65 patients aged 55-77, 296 patients aged 40-54 and 564 patients aged 18-39 (age at baseline). MEASUREMENTS: Measures at follow-up included alcohol and drug use, Addiction Severity Index (ASI), Alcoholics Anonymous Affiliation Scale, social resource and self-reported health questions. Mortality data were obtained from contact with family members of patients as well as automated health plan records. FINDINGS: Older adults were less likely to be drug-dependent at baseline than younger and middle-aged adults, and had longer retention in treatment than younger adults. At 5 years, older adults were less likely than younger adults to have close family or friends who encouraged alcohol or drug use. Fifty-two per cent of older adults reported total abstinence from alcohol and drugs in the previous 30 days versus 40% of younger adults. Older women had higher 30-day abstinence than older men or younger women. Among participants dependent only on alcohol, there were no significant age differences in 30-day abstinence. In logistic regression analysis, age group was not significant. Variables associated with greater age that independently predicted 30-day abstinence in the logistic regression model included longer retention in treatment and having no close family or friends who encouraged alcohol or drug use at 5 years; female gender was also significant. CONCLUSIONS: Results indicate that older adults have favorable long-term outcome following treatment relative to younger adults, but these differences may be accounted for by variables associated with age such as type of substance dependence, treatment retention, social networks and gender. Age differences in these characteristics inform intervention strategies to support long-term recovery of older adults and provide direction for investigation of how age affects outcome.     

The impact of managed care on health care utilization among adults with asthma.

STUDY OBJECTIVES: To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings. DESIGN: Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population. MEASUREMENTS: Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. RESULTS: Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI -5.4, -0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = -16.5, 95% CI -27.8, -5.3). The two groups did not differ significantly in the proportion with asthma-related or nonasthma hospital admissions. CONCLUSIONS: Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in nonasthma care.     

Effectiveness of a video-based aging services technology education program for health care professionals

Health care professionals (HCPs) are a critical source of recommendations for older adults. Aging services technologies (ASTs), which include devices to support the health-care needs of older adults, are underutilized despite evidence for improving functional outcomes and safety and reducing caregiver burden and health costs. This study evaluated a video-based educational program aimed at improving HCP awareness of ASTs. Sixty-five HCPs viewed AST videos related to medication management, daily living, and memory. Following the program, participants’ objective and perceived AST knowledge improved, as did self-efficacy and anticipated AST engagement. About 95% of participants stated they were more likely to recommend ASTs postprogram. Participants benefitted equally regardless of years of experience or previous AST familiarity. Furthermore, change in self-efficacy and perceived knowledge were significant predictors of engagement change. Overall, the educational program was effective in improving HCPs’ awareness of ASTs and appeared to benefit all participants regardless of experience and prior knowledge.     

Perceived control as a buffer in the use of health care services.

Gerontologists are increasingly interested in the notion of perceived personal control because such perceptions can be threatened by age-related changes such as declining health and the loss of loved ones. Although a great deal is known about the central role of perceived control in healthy, successful aging, less is known about its potential role in specific contexts such as the use of health services. Our study examined the link between perceived control and patterns of health service use among older individuals with arthritis. We assessed perceived control during an interview, using both a domain-specific and a global measure, and considered health service use in the subsequent year. Even after statistically adjusting for age and morbidity, individuals who perceived low levels of control subsequently were found to use more health services than their high-control counterparts; they visited their physicians more often, had more laboratory tests, and stayed longer in the hospital. This was true, however, only for individuals who had also reported that their arthritis restricted the things they were able to do. Various interpretations are considered, including the possibility that patients with low perceived control are inefficient users of health services or that patients with high perceived control experience a deficiency in health care.     

An emergency medical services program to promote the health of older adults

OBJECTIVES: To evaluate the feasibility and effect of an emergency medical services (EMS) program that screened, educated, and referred older adults with unmet needs. DESIGN: A cluster sample design evaluation of an intervention conducted by EMS in one of two communities. SETTING: Two rural communities in upstate New York. PARTICIPANTS: Two hundred fifty-eight intervention-group and 143 control-group community-dwelling older adults receiving emergency care from participating EMS agencies between February 2004 and June 2005. INTERVENTION: EMS providers screened intervention group patients to identify those at risk for falls, influenza, and pneumococcal infections and provided patients educational materials. Patients' physicians were notified of screening results to provide interventions. Control group patients were provided usual care. MEASUREMENTS: Variables included patient demographic and clinical characteristics, the proportion of eligible patients screened, patient risk during EMS care and 14 days later, and patient recollection of receiving educational materials and conversations with physicians regarding needs. RESULTS: Follow-up was successful in 245 (61%) patients. Approximately 80% of intervention-group patients were successfully screened for each item. No differences were identified for characteristics collected at the time of EMS care, but a notable number of patients were at risk for each item. No differences existed between the control or intervention group for process measures such as recollection of receiving educational materials. For outcome measures, only an improvement in pneumococcal vaccination levels was found. CONCLUSION: EMS screening of older adults during emergency responses is feasible, but a simple intervention of providing educational materials to patients during emergency responses and faxing notifications to physicians appears insufficient to address patients' needs.     

Comparison of health services use by Chinese urban and rural older adults in Yunnan province

Background:   This article examines and compares the pattern of determinants of health services use between Chinese older adults residing in urban and rural areas of Yunnan province, China.
Methods:   Data from the Sample Survey on Aged Population in Urban/Rural China (SSAPUR) are used to compare the patterns of determinants for both physician visit and hospitalization between the urban and rural respondents. Andersen's health service utilization model was adopted as a conceptual framework.
Results:   Findings revealed that different patterns of determinants in physician visits and hospitalization existed among the two groups, implying that different barriers in health access are faced. The financial barrier was a prominent factor faced by urban elders in access to both physician visits and hospitalization, while rural elders encountered physical barriers in addition to financial difficulty when accessing health care.
Conclusion:   Study of the elderly population in Yunnan province helps to contrast the differences in health service use between urban and rural elders, which would shed light on possible focus in health policy-making and resource allocation to tackle the different health access barriers.     

The use of healthcare services for mental health problems by middle-aged and older adults

Although mental disorders occur commonly in later life, it has been reported that older adults are reluctant to seek help for their mental health problems. The purpose of this research study was to analyze the contact with healthcare professionals, self-perceived mental health problems and unmet needs, as reported by a nationally representative sample of community-dwelling adults. We report a cross-sectional analysis of all the respondents of the Australian National Survey of Mental Health and Wellbeing aged 55 years and older (N = 3178). Results indicated that 306 (9.6%) participants had a DSM-IV classifiable mental disorder based on self-identified symptoms over the preceding 12 months. Of these, 146 (48%) reported that they had not consulted a healthcare professional to deal with their mental health problems. Among those who consulted with a healthcare professional, the general practitioner was the main point of contact. Medication and psychotherapy/counseling were the most frequent form of help obtained. Informational and instrumental help, such as help to sort out practical problems and to look after oneself, were the most reported unmet needs. These results suggest a gap in the provision of healthcare services for mental health problems directed toward the specific needs of aging adults. The reported unmet needs might be met by increasing awareness amongst healthcare professionals regarding mental health problems in later stages of life and by improving the access of older people to the services commonly provided by multidisciplinary teams.     

Inequalities in health and health services delivery: a multilevel study of primary care and hypertension control

Delivery of health services is an important determinant of health. Restricted availability and access may result in health inequalities. To determine the extent of geographic variation in the delivery of health services and its effect on the health of community residents in terms of under-diagnosis and under-treatment of hypertension, we carried out a multilevel study of participants in the 1995 Nova Scotia Heart Health Survey (n = 3,094). We used individual level survey data and health status measurements linked to geographical level information to examine the importance of adequate delivery of health services to the diagnosis and treatment of hypertension in the universal health care setting of the province of Nova Scotia. The delivery of primary care services across Nova Scotia varied moderately with physician visit rates ranging from 3.3 to 5.5 visits per resident per year. There were neither substantial nor statistically significant differences in the diagnosis and treatment of hypertension among residents of communities varying in the delivery of health services. We concluded that a geographic variation in the delivery of primary care services is a public health concern that is not consistent with the objectives of universal coverage of health services; however, it was not confirmed to result in health inequalities.     

Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care

BACKGROUND: Osteoarthritis is the single most common cause of disability in older adults, and most patients with the condition will be managed in the community and primary care. AIM: To discuss case definition of knee osteoarthritis for primary care and to summarise the burden of the condition in the community and related use of primary health care in the United Kingdom. DESIGN: Narrative review. METHOD: A literature search identified studies of incidence and prevalence of knee pain, disability, and radiographic osteoarthritis in the general population, and data related to primary care consultations. Findings from UK studies were summarised with reference to European and international studies. RESULTS: During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled. CONCLUSION: Knee osteoarthritis sufficiently severe to consider joint replacement represents a minority of all knee pain and disability suffered by older people. Healthcare provision in primary care needs to focus on this broader group to impact on community levels of pain and disability.