Association Between Disability Trajectory and Health Care Service Utilization Among Older Adults in China

ObjectivesThis study aimed to identify the heterogeneous disability trajectories among older Chinese adults and examine the association between disability trajectories and health care service utilization.DesignProspective cohort study.Setting and ParticipantsA community-based study including older adults aged ≥65 years from the Chinese Longitudinal Healthy Longevity Survey.MethodsDisability was assessed by the difficulties in activities of daily living and instrumental activities of daily living between 2002 and 2018. Health care utilization was measured by the expenditures on outpatient and inpatient services in 2018. Growth mixture modeling was conducted to estimate heterogeneous disability trajectories. A 2-part model was used to analyze the association of disability trajectories and health care utilization. Covariates were included based on Andersen's behavioral model.ResultsThree classes of disability trajectories were identified: the progressive (7.9%), late-onset (13.7%), and normal classes (78.4%). Older adults who followed the late-onset trajectory of disability were more likely to use inpatient services compared with the normal class (odds ratio = 1.47, P < .010), after controlling potential confounders. Compared with the normal class, the progressive class on average spent US$145.94 more annually (45.2% higher) on outpatient services (P < .010) and $738.99 more annually (72.6% higher) on inpatient services (P < .001); the late-onset class reported higher annual expenditures on outpatient and inpatient services of $215.94 (66.9% higher) and $1405.00 (138.0% higher), respectively (all P < .001).Conclusions and ImplicationsHeterogeneous disability trajectories exhibited distinct health care service utilization patterns among older Chinese adults. Older adults affected by late-onset disability incurred the highest health care needs. These findings provide valuable policy-relevant evidence for reducing health care burden among older adults.     

The Effects of Depressed Affect on Functional Disability Among Rural Older Adults

This study investigates functional disability among some of the nation's most vulnerable older adults: rural Medicaid recipients. Data were provided by 221 older adults (mean age = 75.9 years; 82% women) who were receiving community-based long-term care services through Medicaid. Participants self-reported functional ability involving the completion of six basic activities of daily living (BADLs), three cognitive instrumental activities of daily living (IADLS), and four physical IADLs. Self-reports of depressed affect and the number of physical health conditions were also obtained. Path analysis was used to examine all of the associations among age, gender, number of chronic health conditions, depressed affect and functional disability. The tested model was significant [chi2 (DF = 3, n = 221) = 5.052, p = 0.168; TLI = 0.945; CFI = 0.992; RMSEA = 0.056] and explained 45.1% of the variance in BADL disability. Depressed affect significantly predicted disability in cognitive IADLs and physical IADLs, which predicted disability in BADLs. Age and gender had indirect effects on BADL, through their association with cognitive IADLs and physical IADLs. The number of chronic health conditions exerted both indirect and direct effects on BADL disability. Results are discussed within the context of the growing literature that suggests the importance of psychological variables as predictors of functional disability. Moreover, we discuss whether community-based long-term care is appropriate for older adults with high levels of functional disability.     

Social Frailty Predicts Incident Disability and Mortality Among Community-Dwelling Japanese Older Adults

Objective

To determine the prevalence of social frailty and its relation to incident disability and mortality in community-dwelling Japanese older adults.

Walking the Line: Navigating Market and Gift Economies of Care in a Consumer‐Directed Home‐Based Care Program for Older Adults

Context

Paid caregivers of low-income older adults navigate their role at what Hochschild calls the “market frontier”: the fuzzy line between the “world of the market,” in which services are exchanged for monetary compensation, and the “world of the gift,” in which caregiving is uncompensated and motivated by emotional attachment. We examine how political and economic forces, including the reduction of long-term services and supports, shape the practice of “walking the line” among caregivers of older adults.

Methods

We used data from a longitudinal qualitative study with related and nonrelated caregivers (n = 33) paid through California’s In-Home Supportive Services (IHSS) program and consumers of IHSS care (n = 49). We analyzed the semistructured interviews (n = 330), completed between 2010 and 2014, using a constructivist grounded theory approach.

Findings

Related and nonrelated caregivers are often expected to “gift” hours of care above and beyond what is compensated by formal services. Cuts in formal services and lapses in pay push caregivers to further “walk the line” between market and gift economies of care. Both related and nonrelated caregivers who choose to stay on and provide more care without pay often face adverse economic and health consequences. Some, including related caregivers, opt out of caregiving altogether. While some consumers expect that caregivers would be willing to “walk the line” in order to meet their needs, most expressed sympathy for them and tried to alter their schedules or go without care in order to limit the caregivers’ burden.

Conclusions

Given economic and health constraints, caregivers cannot always compensate for cuts in formal supports by providing uncompensated time and resources. Similarly, low-income older adults are not competitive in the caregiving marketplace and, given the inadequacy of compensated hours, often depend on unpaid care. Policies that restrict formal long-term services and supports thus leave the needs of both caregivers and consumers unmet.     

Financing elderly people's long‐term care needs: Evidence from China

Confronted by accelerated population aging, China is establishing a long‐term care (LTC) system. This study discusses challenges and recommendations for financing China's LTC system. On the basis of the data on elderly people's self‐care ability from the Chinese Longitudinal Healthy Longevity Survey, we calculate the size of the elderly population that need LTC for the period from 2015 to 2030 and analyse the increasing tendency of LTC expenses by considering the impact of price increase. We also analyse the local governments' financial capacity for LTC support by comparing the expense level to the fiscal revenue. The study found that aging will double the LTC expenses by 2030. Therefore, this study suggests the establishment of an LTC insurance system that allocates LTC expenses, which are currently borne by individuals and families, more fairly among the government, individuals, and families. Moreover, with the current LTC reforms, implemented primarily by local governments in China, we believe that the central government should bear some of the fiscal responsibility by conducting fiscal transfers to partially support undeveloped regions that are establishing an LTC system.     

Long‐term Care Insurance and Carers' Labor Supply – A Structural Model

In Germany, individuals in need of long‐term care receive support through benefits of the long‐term care insurance. A central goal of the insurance is to support informal care provided by family members. Care recipients can choose between benefits in kind (formal home care services) and benefits in cash. From a budgetary perspective, family care is often considered a cost‐saving alternative to formal home care and to stationary nursing care. However, the opportunity costs resulting from reduced labor supply of the carer are often overlooked. We focus on the labor supply decision of family carers and the incentives set by the long‐term care insurance. We estimate a structural model of labor supply and the choice of benefits of family carers. We find that benefits in kind have small positive effects on labor supply. Labor supply elasticities of cash benefits are larger and negative. If both types of benefits increase, negative labor supply effects are offset to a large extent. However, the average effect is significantly negative. Copyright © 2015 John Wiley & Sons, Ltd.     

Gait Speed in Ambulant Older People in Long Term Care: A Systematic Review and Meta-Analysis

BackgroundGait speed, recently proposed as the sixth vital sign of geriatric assessment, is a strong predictor of adverse outcomes. Walking faster than 1.0 m/s is associated with better survival in community-dwelling older adults, and a recent meta-analysis of older adults in clinical settings estimated usual gait speed to be 0.58 m/s. Here, we aimed to review gait speed values for long term care residents.MethodsRelevant databases were systematically searched for original research studies published prior to December 2012. Inclusion criteria were participants living in long term care, mean age >70 years, and gait speed measured over a short distance. Meta-analysis determined gait speed data adjusting for covariates including age, sex, and cognition.ResultsFinal data included 2888 participants from 34 studies. The percentage of residents ineligible because of inability to mobilize was stated in only 1 study. Of the 34 studies, 22 reported cognitive status using the Mini-Mental State Examination. Usual pace and maximal pace gait speeds were determined separately using a random effects model. No association between gait speed and covariates was found. Usual pace gait speed was 0.475 m/s (95% confidence interval 0.396–0.554) and maximal pace was 0.672 m/s (95% confidence interval 0.532–0.811).ConclusionsIn ambulant older people in long term care, gait speed is slow but remains functional. However, since many residents are likely to have been ineligible to participate in assessments, these results cannot be generalized to the long term care population as a whole.     

Long‐Term Care Financing: Lessons From France

Context

An aging population leads to a growing demand for long-term services and supports (LTSS). In 2002, France introduced universal, income-adjusted, public long-term care coverage for adults 60 and older, whereas the United States funds means-tested benefits only. Both countries have private long-term care insurance (LTCI) markets: American policies create alternatives to out-of-pocket spending and protect purchasers from relying on Medicaid. Sales, however, have stagnated, and the market''s viability is uncertain. In France, private LTCI supplements public coverage, and sales are growing, although its potential to alleviate the long-term care financing problem is unclear. We explore whether France''s very different approach to structuring public and private financing for long-term care could inform the United States’ long-term care financing reform efforts.

Methods

We consulted insurance experts and conducted a detailed review of public reports, academic studies, and other documents to understand the public and private LTCI systems in France, their advantages and disadvantages, and the factors affecting their development.

Findings

France provides universal public coverage for paid assistance with functional dependency for people 60 and older. Benefits are steeply income adjusted and amounts are low. Nevertheless, expenditures have exceeded projections, burdening local governments. Private supplemental insurance covers 11% of French, mostly middle-income adults (versus 3% of Americans 18 and older). Whether policyholders will maintain employer-sponsored coverage after retirement is not known. The government''s interest in pursuing an explicit public/private partnership has waned under President François Hollande, a centrist socialist, in contrast to the previous center-right leader, President Nicolas Sarkozy, thereby reducing the prospects of a coordinated public/private strategy.

Conclusions

American private insurers are showing increasing interest in long-term care financing approaches that combine public and private elements. The French example shows how a simple, cheap, cash-based product can gain traction among middle-income individuals when offered by employers and combined with a steeply income-adjusted universal public program. The adequacy of such coverage, however, is a concern.     

Between older adults' needs and the law: The Israeli Long Term Care Insurance Law from the Perspectives of Service Users and Providers

The Israeli Long Term Care Insurance Law (LTCIL) was one of the first long term care insurances in the world to support older adults and their family members and allow them to stay in their homes for as long as possible. The present study aimed to evaluate the perspectives of older adults, their family members and home care workers regarding the LTCIL. Views of workers of the National Insurance Institute (NII), which is directly responsible for the enactment of the law, are also integrated. Interviews were conducted between June 2016 and June 2017. Thematic qualitative analysis is based on interviews with 15 NII workers, 31 older adults, 31 family members, and 6 paid home care workers. The present study stresses the tension between the LTCIL and older adults' perceived rights and needs. It also demonstrates how even though the NII workers are engaged with various stakeholders, they often lack direct contact with older adults, their family members and paid home care workers: those most directly influenced by the LTCIL. Policy considerations are discussed.     

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.     

Food Insecurity and Functional Disability Among Older Adults in Ghana: The Role of Sex and Physical Activity

ObjectivesWe examined the associations between food insecurity and functional disability among older adults in Ghana and, the roles of sex and physical activity on the relationship.DesignA cross-sectional study design was employed.Setting and participantsA total of 4446 older adults (50+ years of age) from the Study on Global Aging and Adult Health Ghana Wave 2, a countrywide study, was completed in 2015.MethodsLogistic regression models were used to examine the associations between measures of food insecurity and functional disability using data from Study on Global Aging and Adult Health Ghana Wave 2. Functional disability was assessed using World Health Organization Disability Assessment Schedule 2.0 composed of 12 items in 6 domains of cognition, mobility, self-care, getting along, life activities, and participation in society. Food insecurity was assessed from 12-month food sufficiency and experience of hunger over the last 12 months.ResultsApproximately 11% were identified as having functional disability. The prevalence of food insecurity was 23.8% for insufficient food intake and 18.3% for hunger. Adjusting for all variables, older adults who reported consuming insufficient food (OR 2.27; 95% CI 1.57, 3.28), and those who experienced hunger (OR 2.35; 95% CI 1.59, 3.46) had higher odds of functional disability, compared with those not reporting these issues. Sex differences modified the association between hunger and functional disability. Physical activity served as a protective factor (OR 0.60; 95% CI 0.38, 0.95) on the association implying that older adults who engaged in physical activity were 40% less likely to experience food insecurity-induced functional disability.Conclusions and ImplicationsFood insecurity is associated with functional disability among older adults. Results highlight the usefulness of tackling the social determinants of health and promoting financial/social security in older age in a changing Ghanaian society.     

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.     

Estimating Lifetime Costs of Social Care: A Bayesian Approach Using Linked Administrative Datasets from Three Geographical Areas

We estimated lifetime costs of publicly funded social care, covering services such as residential and nursing care homes, domiciliary care and meals. Like previous studies, we constructed microsimulation models. However, our transition probabilities were estimated from longitudinal, linked administrative health and social care datasets, rather than from survey data. Administrative data were obtained from three geographical areas of England, and we estimated transition probabilities in each of these sites flexibly using Bayesian methods. This allowed us to quantify regional variation as well as the impact of structural and parameter uncertainty regarding the transition probabilities. Expected lifetime costs at age 65 were £20,200–27,000 for men and £38,700–49,000 for women, depending on which of the three areas was used to calibrate the model. Thus, patterns of social care spending differed markedly between areas, with mean costs varying by almost £10,000 (25%) across the lifetime for people of the same age and gender. Allowing for structural and parameter uncertainty had little impact on expected lifetime costs, but slightly increased the risk of very high costs, which will have implications for insurance products for social care through increasing requirements for capital reserves. Copyright © 2014 John Wiley & Sons, Ltd.     

Implementing Diabetes Care Guidelines in Long Term Care

Objective

The objectives of this article are to (1) describe the outcomes of a diabetes care program in a long term care facility dedicated to diabetes excellence and (2) compare the relevant outcome variables of research published between 2007 and 2012 with the results found in the studied facility.

Design

Three-year retrospective chart review of the facility's residents with comparison to extant literature.

Participants

A total of 224 resident charts within the studied facility were reviewed. Residents with a diagnosis of diabetes, or who were on diabetes medications, or whose fasting blood sugars exceeded 126 mg/dL on 2 occasions, and whose length of stay exceeded 6 months, were tracked for adherence to diabetes guidelines (n = 48). Participant outcomes from relevant studies in the literature were compared to these 48 participants' outcomes.

Intervention

All levels of staff in the studied facility were educated in general diabetes care. A nurse practitioner was contracted to provide medical care for all diabetic residents (with primary care provider approval). A scorecard for adherence to diabetes guidelines was completed by the nurse practitioner. Over a 3-year period following the education program and scorecard implementation, a chart review of all residents was completed by a consulting diabetes educator/nurse practitioner/nurse faculty member and 6 undergraduate nursing students.

Results

In general, the nursing home in the present study compared favorably with other relevant studies, demonstrating lower A1C levels, tracking blood sugars more regularly, monitoring blood pressure and lipids more regularly, having a greater percentage of patients on lipid-lowering medications among those in need, more appropriate use of sliding scale insulin, greater adherence to recommendations regarding diet, and had more patients who fit criteria on preventive anticoagulation.

Discussion

The results for the studied facility were very similar, often better, when compared with the most current nursing home literature. Areas of weakness provided focused strategic planning for the facility. Regrettably, the research is sparse, and evidence supporting guideline adherence data is often missing, making data comparison difficult. This model of care, linking health care agencies with academia, could offer a supportive and affordable method for identifying responses to evidence-based care guidelines.

Conclusion

This narrative review points to the need for continued work in the application of evidence-based guidelines in long term care, specifically in the area of interventions that must be adjusted to the needs of the nursing home population, with increased awareness in maintaining or improving quality of life.     

The Mental Health Status and Long Term Care Needs of the Chinese Elderly in Hong Kong

ABSTRACT

This paper examines the mental health status of 945 Chinese older people who are in need of long term care services in Hong Kong. It was found that for those aged respondents who are already waiting for admission to infirmary, over 59.3% were already living in private aged homes, and only as few as 17.8% of these applicants were still living in their own homes. Besides, it was found that the mean SPMSQ score was lowest amongst those living in medical infirmary (1.52) and highest for those living in their own residences (5.99). Analysis of the relationship between GDS scores and residential types reveals that there were higher proportion of respondents residing in their own residences that fell into the highly depressed category. There is a need for the overall revamp of the planning, provision and financing for long term care and psychogeriatric services for Chinese older people in Hong Kong.     

Unmet long‐term care needs and depression: The double disadvantage of community‐dwelling older people in rural China

This study investigates the relationship between unmet long‐term care needs and depressive symptoms among community‐dwelling older people in China. The data come from a nationally representative sample of 1,324 disabled older people from the China Health and Retirement Longitudinal Survey (CHARLS) collected between 2013 and 2014. Regression analyses were conducted to examine the factors associated with unmet needs and the impacts of unmet needs on people’s depressive symptoms. We found that disabled older people living in rural communities have a higher level of unmet needs than those in urban communities. Unmet needs cause more severe depressive symptoms among rural older people, but they do not have a significant impact among urban older people. Depressive symptoms are also affected by people’s health conditions in rural China and by household income in urban China. We argue that older people living in rural communities face a double disadvantage. The first disadvantage relating to unmet needs reinforces the second one relating to mental health. These findings highlight the urgent need for more investment by the Chinese central government in formal social care services and support for carers in rural areas.     

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.     

Funding and planning for social care in later life: a deliberative focus group study

This study examined people's perceptions and behaviours in relation to planning for their social care needs, and their values and priorities concerning how social care should be funded. Eight deliberative focus groups were conducted in May 2018 with 53 participants, aged 25–82 years, in London, Manchester and rural locations near York and Sheffield. Multiple uncertainties created barriers to planning for social care needs including not knowing how much to save, not thinking it possible for an average person to save enough to meet significant needs, reluctance to plan for something potentially unnecessary, lack of suitable and secure ways of saving, and a perception of social care policy as unsettled. Participants also had significant concerns that they would not be able to obtain good‐quality care, regardless of resources. In addition, it was commonly thought unrealistic to expect families to provide more than low‐intensity, supplementary care, while use of housing assets to pay for care was considered unfair, both for home‐owners who could lose their assets and non‐home‐owners who were left reliant on the state although it was more acceptable where people were childless or had substantial assets. Participants thought any new arrangements should be inclusive, personally affordable, sustainable, transparent, good‐quality and honest. They preferred to contribute regularly rather than find considerable sums of money at times of crisis, and preferred to risk‐pool, with everyone obliged or heavily encouraged to contribute. Transparency was valued so those better at ‘working the system’ were not able to benefit unfairly  and participants wanted to know that, if they contributed, they would be assured of good‐quality care. Trust in Government and other institutions, however, was low. New funding arrangements should incorporate measures to increase transparency and trust, be clear about the responsibilities of individuals and the state, provide meaningful options to save, and place significant focus on improving actual and perceived care quality. For acceptability, proposals should be framed to emphasise their affective dimensions and positive values.