Meeting the Need for Personal Care among the Elderly: Does Medicaid Home Care Spending Matter?

Objective. To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care.
Data Sources. Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample ( n =6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs).
Study Design. Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates.
Principal Findings. Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods.
Conclusion. These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.     

Home Care of the Frail Elderly in the United Kingdom:

The paper reports the essential featurcs and evaluation of a scheme to improve the cffcctiveness of home care for the frail elderly. Decisions about resource allocation were devolved to front line social work staff, giving them greater autonomy within clear expenditure parameters. More imaginative responses were noted in the management of a number of difficult problems and the results of the evaluation were generally positive. It appeared that the scheme was most cost-effective for the extremely mentally and physically frail living with others and also for the less frail, socially isolated, depressed elderly person.     

Examining the Need Assessment Process by Identifying the Need Profiles of Elderly Care Recipients in the Ten-Year Long-Term Care Project (TLTCP) of Taiwan

ObjectiveTo deal with the increasing long-term care (LTC) needs of elderly people in Taiwan, the government launched the Ten-year Long-term Care Project (TLTCP) in 2007, and through the care management system, care plans for those in need were distributed and implemented by care managers according to the single assessment process. Based on the emphasis of linking the right need assessment to the care plan, this study aimed to explore the need profiles of LTC recipients with regard to their health indicators to serve as a validity check on the identified dependency levels and care plans in the current care management system.DesignA model based on latent class analysis (LCA) was used for dealing with the issue of health heterogeneity. LCA provides an empirical method that examines the interrelationships among health indicators and characterizes the underlying set of mutually exclusive latent classes that account for the observed indicators. The analysis included a total of 2901 elderly care recipients in the LTC dataset from a southern city, 1 of the 5 major metropolitan areas in Taiwan. The identified dependency levels of the samples and their care plans in need assessment were compared and discussed.ResultsFour need profiles were explored in the LTC dataset. Apart from the low (LD) (32.95%) and moderate dependent groups (MD) (17.48%), there were 2 groups identified among the high-dependency levels, including the severe physical and psychological dependency (SPP) (26.37%) and the comorbidities and severe dependency (CSD) groups (23.20%), which in sum were approximately identified as high dependency (HD) by care managers in the LTC dataset. In addition, the CSD group currently costs more for their care plans on average in LTC services (NT. 277,081.15, approximately 9200 USD) than the SPP group (NT. 244,084.21) and the other groups.ConclusionNeed assessment is a key to success in care management in LTC. The results of this study showed the importance of focusing on multifacet indicators, especially the mental and social health indicators in need assessments by improving the unified assessment process to sensitively detect those with various needs and then link them to the right care plan.     

Diabetes-Associated Factors as Predictors of Nursing Home Admission and Costs in the Elderly Across Europe

Objective

To identify the main factors associated with the use of nursing home facilities and to calculate their costs among older people with diabetes in Europe.

Impact of Home Care Management on the Involvement of Informal Caregivers by Formal Caregivers

This study explores the link between management characteristics of home care agencies and the involvement of informal caregivers in caregiving. Based on a study of policy documents of two agencies and semi-structured interviews with five team managers and 31 formal caregivers, we conclude that, although the importance of involving informal caregivers is emphasized in official documentation, actual contact with informal caregivers is often lacking. Comparison of the work processes of the two agencies shows that contact with informal caregivers and their potential involvement are enhanced by smaller teams, less task division, and clarity about the responsibilities of formal caregivers.     

Home Care Nurses' Experience of Job Stress and Considerations for the Work Environment

Home care nurses report increased stress in their jobs due to work environment characteristics that impact professional practice. Stressors and characteristics of the professional practice environment that moderate nurses' experience of job stress were examined in this embedded multiple case study. Real life experiences within a complex environment were drawn from interviews and observations with 29 participants across two home care agencies from one eastern U.S. state. Findings suggest that role overload, role conflict, and lack of control can be moderated in agencies where there are meaningful opportunities for shared decision making and the nurse-patient relationship is supported.     

There's a Problem With the Problem List: Incongruence of Patient Problem Information Across the Home Care Admission

ObjectivesIllustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer.DesignObservational field study.Setting and ParticipantsThree diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total).MethodsResearchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient).ResultsEach pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones.Conclusions and ImplicationsDiagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.     

Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States

ObjectiveHome health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their urban counterparts in delivering care (eg, longer distances to travel to patient homes leading to higher fuel/travel costs and fewer number of visits in a day, impacting the quality of home health care for rural beneficiaries). We review evidence on differences in care outcomes provided by urban and rural HHAs.DesignSystematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the Newcastle-Ottawa Scale (NOS) for quality appraisal.SettingCare provided by urban and rural HHAs.MethodsWe conducted a systematic search for English-language peer-reviewed articles after 2010 on differences in urban and rural care provided by U.S. HHAs. We screened 876 studies, conducted full-text abstraction and NOS quality review on 36 articles and excluded 2 for poor study quality.ResultsTwelve studies were included; 7 focused on patient-level analyses and 5 were HHA-level. Nine studies were cross-sectional and 3 used cohorts. Urban and rural differences were measured primarily using a binary variable. All studies controlled for agency-level characteristics, and two-thirds also controlled for patient characteristics. Rural beneficiaries, compared with urban, had lower home health care utilization (4 of 5 studies) and fewer visits for physical therapy and/or rehabilitation (3 of 5 studies). Rural agencies had lower quality of HHA services (3 of 4 studies). Rural patients, compared with urban, visited the emergency room more often (2 of 2 studies) and were more likely to be hospitalized (2 of 2 studies), whereas urban patients with heart failure were more likely to have 30-day preventable hospitalizations (1 study).Conclusion and ImplicationsThis review highlights similar urban/rural disparities in home health care quality and utilization as identified in previous decades. Variables used to measure the access to and quality of care by HHAs varied, so consensus was limited. Articles that used more granular measures of rurality (rather than binary measures) revealed additional differences. These findings point to the need for consistent and refined measures of rurality in studies examining urban and rural differences in care from HHAs.     

居家医疗护理服务现状及发展路径分析

目前,我国居家医疗护理服务尚处于起步发展阶段,虽然各地进行了多种实践,但居家医疗护理服务仍存在不少问题与瓶颈,如服务内容有待拓展、服务人员紧缺、相关法律法规不健全等。为此,可依托长期护理保险和家庭医生签约服务,推动以需求为导向的居家医疗护理服务的发展。     

人口老龄化背景下西部城市社区居家养老现状及养老服务需求的调查分析

目的：了解西部城市老年居民的养老现状及养老服务需求,为政府进行合理的服务供给提供参考依据。方法：对重庆市渝中区6个社区180名老人进行问卷调查。结果：社区目前所提供的养老服务与老人实际需要的服务项目在供需之间存在着一定差距,老年人对社区养老服务的整体满意度不高。结论：政府及相关部门应加大经费投入和统筹规划、加大宣传力度,同时不断完善和丰富养老服务内容,以促进社区居家养老模式的良性发展。     

医疗之家及其对我国卫生管理的借鉴意义

扩大基本卫生服务是改善群体健康、减低医疗花费的重要举措.介绍了美国当前被广泛推崇的—种基本卫生服务理念——医疗之家（patient centered medical home,PCMH）,详细分析了其特点及实施过程,并探讨了PCMH在我国基本卫生管理中的应用前景.     

Mortality of Care Home Residents and Community-Dwelling Controls During the COVID-19 Pandemic in 2020: Matched Cohort Study

ObjectiveThis study aimed to estimate and compare mortality of care home residents, and matched community-dwelling controls, during the COVID-19 pandemic from primary care electronic health records in England.DesignMatched cohort study.Setting and ParticipantsFamily practices in England in the Clinical Practice Research Datalink Aurum database. There were 83,627 care home residents in 2020, with 26,923 deaths; 80,730 (97%) were matched on age, sex, and family practice with 300,445 community-dwelling adults.MethodsAll-cause mortality was evaluated and adjusted rate ratios by negative binomial regression were adjusted for age, sex, number of long-term conditions, frailty category, region, calendar month or week, and clustering by family practice.ResultsUnderlying mortality of care home residents was higher than community controls (adjusted rate ratio 5.59, 95% confidence interval 5.23?5.99, P < .001). During April 2020, there was a net increase in mortality of care home residents over that of controls. The mortality rate of care home residents was 27.2 deaths per 1000 patients per week, compared with 2.31 per 1000 for controls. Excess deaths for care home residents, above that predicted from pre-pandemic years, peaked between April 13 and 19 (men, 27.7, 95% confidence interval 25.1?30.3; women, 17.4, 15.9?18.8 per 1000 per week). Compared with care home residents, long-term conditions and frailty were differentially associated with greater mortality in community-dwelling controls.Conclusions and ImplicationsIndividual-patient data from primary care electronic health records may be used to estimate mortality in care home residents. Mortality is substantially higher than for community-dwelling comparators and showed a disproportionate increase in the first wave of the COVID-19 pandemic. Care home residents require particular protection during periods of high infectious disease transmission.     

Housing Options and Choices for the Elderly

It is now generally recognised in industrialised countries, that one of the most urgent health and social problems is the provision of adequate yet appropriate accommodation, plus supporting services, for the rapidly increasing aged population. In addition, it is a widely held view that in the recent past provision of care for this population has been unduly focused on institutional solutions. Housing policy has a vital part to play in supporting the development of domiciliary services in assisting those aged who wish, to remain in the community. Studies have revealed that people typically have little idea of the options and choices open to them regarding accommodation in later life, nor how to obtain appropriate advice on which to plan. This paper considers the actual and potential contribution of sheltered housing within the overall continuum of supportive living alternatives. Variations of the basic sheltered housing concept are explored, the point being stressed that different types of sheltered (and other) housing provide important life-style choices for the elderly. The paper concludes that there is considerable scope for expanding what little sheltered housing currently exists in many Western countries.     

家庭医疗干预对改善老年慢性病患者心理社会功能的影响

目的 以经济条件相对落后的中小城市社区为现场,实施家庭医疗干预试验,探索社区卫生服务对老年慢性疾病患者身心康复的影响。方法 以老年慢性疾病患者为对象,实施家庭医疗护理干预;以同期、同类住院病人作对照,采用多元逐步线性顺归方法分析了两组病人的心理健康恢复情况及影响因素。结果 社区病人与住院病人在症状、体征等生理机能方面的恢复,差异无统计学意义,但社区病人心理功能与社会功能的康复略优于住院病人。结论 家庭医疗护理对病人的心理社会功能恢复更有利,因此,开展家庭医疗护理干预是解决老年慢性病患者就医难、住院更难的有效手段之一。     

The Patterns of Health Care Utilization by Elderly Europeans: Frailty and Its Implications for Health Systems

Objective

To examine the patterns of health care utilization by the elderly and test the influence of functional decline.

Data Source and Study Design

We used the three regular waves of the SHARE survey to estimate the influence of frailty on health care utilization in 10 European countries. We controlled for the main correlates of frailty and unobserved individual effects.

Results

The frail elderly increase their primary and hospital care utilization before the onset of disability. Multimorbidity moderates the effect of frailty on care utilization.

Conclusions

The prevalence of frailty is high in most countries and is expected to increase. This renders frailty prevention and remediation efforts imperative for two complementary reasons: to promote healthier aging and to reduce the burden on health systems.     

The Cost Efficiency and Clinical Quality of Institutional Long-Term Care for the Elderly

This study applied the stochastic frontier cost function with inefficiency effects to estimate the association between quality of care and cost efficiency in institutional long-term care wards for the elderly in Finland. We used several clinical quality indicators for indicating adverse care processes and outcomes, based on the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS). Average cost inefficiency among the wards was 22%. We found an association between the clinical quality indicators and cost inefficiency. Higher prevalence of pressure ulcers was associated with higher costs, whereas the higher prevalence of use of depressants and hypnotics increased inefficiency.     

Government Policay and the Living Arrangements of the Elderly

Although the courts and lawmakers have been reluctant to intervene in relationships between adult children and their aging parents, many examples of such intrusions can be found. Changes in the country's demographics, women's work roles, and the nature of the family have increased the importance of identifying the effects of government policy on family cohesion and living arrangement decisions. This paper represents one component of a larger empirical study on the contemporary extended family in America. The paper reviews the perliminary results of legislative history of the effects on living arrangement decisions of the elderly by Medicare, Medicaid, and filial support legislation.     

Changes in Regional Variation of Medicare Home Health Care Utilization and Service Mix for Patients Undergoing Major Orthopedic Procedures in Response to Changes in Reimbursement Policy

Background. Significant variation in regional utilization of home health (HH) services has been documented. Under Medicare's Home Health Interim and Prospective Payment Systems, reimbursement policies designed to curb expenditure growth and reduce regional variation were instituted.
Objective. To examine the impact of Medicare reimbursement policy on regional variation in HH care utilization and type of HH services delivered.
Research Design. We postulated that the reimbursement changes would reduce regional variation in HH services and that HH agencies would respond by reducing less skilled HH aide visits disproportionately compared with physical therapy or nursing visits. An interrupted time-series analysis was conducted to examine regional variation in the month-to-month probability of HH selection, and the number of and type of visits among HH users.
Subjects. A 100 percent sample of all Medicare recipients undergoing either elective joint replacement (1.6 million hospital discharges) or surgical management of hip fracture (1.2 million hospital discharges) between January 1996 and December 2001 was selected.
Results. Before the reimbursement changes, there was great variability in the probability of HH selection and the number of HH visits provided across regions. In response to the reimbursement changes, though there was little change in the variation of probability of HH utilization, there were marked reductions in the number and variation of HH visits, with greatest reductions in regions with highest baseline utilization. HH aide visits were the source of the baseline variation and accounted for the majority of the reductions in utilization after implementation.
Conclusions. The HH interim and prospective payment policies were effective in reducing regional variation in HH utilization.     

Measuring quality and level of care provided by family caregivers of persons with dementia: protocol for a systematic review of validated instruments

BackgroundChanges in the quality-of-life (QoL) of family caregivers as they care for their loved ones with dementia over time may affect the quality or level of care that these caregivers provide. We do not know if validated instruments exist to directly measure this quality or level of care. The purpose of this systematic review is to identify validated instruments for measuring the quality or level of care provided by family caregivers of persons with dementia.MethodsWe will include articles containing a validated instrument or questionnaire designed to measure quality or level of care provided by the aforementioned group of caregivers. The included articles may utilize the tools in primary or secondary data analyses, or evaluate the tools'' psychometric properties. The following electronic databases will be searched from inception date to the present: Medline, CINAHL Complete, Cochrane Central, and PsycINFO. We will also search the gray literature, the reference lists of included articles, and contact experts in the field to help identify relevant instruments. Included articles will be required to report on an instrument measuring at least one of the following outcomes: quality of care, level of care, appropriateness of care, amount of time spent providing care, and caregiver performance. Two reviewers will independently screen retrieved citations, extract data, and assess the methodological quality of each included article. A narrative synthesis method will be used to describe the findings.DiscussionResults of this systematic review will show whether validated instruments exist to measure the quality or level of care provided by family caregivers of persons living with dementia. This will make it possible to develop initiatives that are targeted towards improving the quality or level of care provided by family caregivers.