The small group home: needed option for the poor elderly.

This paper covers the possibilities of organizing community services and obtaining funding to make small group homes available to the poor. Statistics show that many frail elderly in nursing homes could function well in less protected environments if transition options for housing and services were available, such as the small group home, which fosters self-direction and "mainstreaming" of older persons in an age-integrated community. It fills a major gap in the continuum of health services at about 2/3 the cost of nursing home care. Only a few states are experimenting with alternative Medicaid regulations which permit payment for health related services, maintenance, homemaking and ADL assistance. None are known to be testing the small group home concept. Thus many older persons requiring some services must be institutionalized, although there may be no need for intensive nursing care or 24-hour supervision. The poor older person's choice, in particular, is restricted by Medicaid regulations. Demonstration small group homes are proving both cost and care effective. Home Care Research in Frederick, Maryland has several such homes. Such alternative "family style" living, with health related services, should be made available to all persons who qualify, regardless of income.     

Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

Experience of a Medicaid nursing home entry cohort.

Long-term care cost-containment policies have focused on reducing the numbers of persons entering nursing homes. To provide insight and background for such efforts, the authors studied the experience of Medicaid nursing home entry cohorts in three individual States. They found substantial interstate variation in rates of nursing home entry and subsequent patterns of discharge, suggesting the operation of fundamentally different policies for provision of Medicaid nursing home services. Analysis of the cost effectiveness and quality of care implications of these policies may provide guidance for future cost-containment efforts.     

Nursing homes in China

China will face a dramatic transition from a young to an aged society in the coming 30 to 40 years. In 2000, there were 88,110,000 persons aged 65 years and older, which represented 7% of the population. This percentage is projected to increase to 23% in 2050. Regarding health and long-term care for older adults, the current challenge is to build a comprehensive system of care for older adults. Nursing home care is an inevitable care model for frail older adults in China, which is largely sponsored by the government of China with contributions from some nongovernment organizations and private investors. China is a large country. Within the country, long-term care varies greatly between rural and urban areas, and among the different economic developing areas. In urban and better-developed areas, the range of services exists; however, in rural and less-developed areas, the range of services is limited. The "Star Light Program" and "Beloved Care Engineering" were recent government initiatives to improve aged care. They were launched in 2001 and have dramatically increased the number of both senior centers and nursing homes for older adults. While the quantity of nursing homes is still inadequate with an additional mismatch problem between the supply and demand, the quality of care in most nursing homes is suboptimal. At present, most administrative and frontline workers in nursing homes have received little training in elder care. There is a need for good-quality structured training in long-term care for all types of staff. Moreover, quality standard for care, including standard setting, assessment, and monitoring, is an important issue and needs substantial improvement for nursing homes in China. Currently, 1.5% of older people live in nursing homes and apartments for older people. Because of the peculiar 4-2-1 family structure in China, we expect the prevalence of nursing home placement of older adults will increase in the coming years. The government of China has realized that it is financially not sustainable to expand in this area using only the government's resources. The current policy is to encourage private and foreign investors to participate in the nursing home business in China.     

Estimating patient-level nursing home costs.

This article presents a methodology developed to estimate patient-level nursing home costs. Such estimates are difficult to obtain because most cost data for nursing homes are available from Medicare or Medicaid cost reports, which provide only average values per patient-day across all patients (or all of a particular payer's patients). The methodology presented in this article yields "resource consumption" (RC) measures of the variable cost of nursing staff care incurred in treating individual nursing home patients. Results from the application of the methodology are presented, using data collected in 1980 on a sample of 961 nursing home patients in 74 Colorado nursing homes. This type of approach could be used to link nursing home payments to the care needs of individual patients, thus improving the overall equity of the payment system and possibly reducing the access barriers facing especially Medicaid patients with high-cost care needs.     

Senile dementia: public policy and adequate institutional care

Increasing costs of institutional care for the aged have occasioned a variety of government cost containment measures. People with senile dementia of the Alzheimer's type (SDAT) will be the principal group to suffer from cutbacks. SDAT patients are usually eligible for Intermediate Care Facilities (ICFs), rather than Skilled Nursing Facilities (SNFs) and therefore for lower reimbursement. Because such patients require heavy care and are the ones most likely to be Medicaid-dependent, nursing homes are being provided with incentives to prevent admissions. At the same time, community services to aid overburdened caregivers are grossly inadequate. Costs to other parts of the health systems are increased by backups in acute hospitals when nursing home beds cannot be found. SDAT and Medicaid eligibility are the principal causes of such "administratively necessary" backup days, but in the main Diagnostic Related Groups (DRGs) may close even that temporary resource. Thus, virtually all avenues of care are shrinking for those who need them most.     

Medicaid enrollment among elderly medicare beneficiaries: individual determinants,effects of state policy,and impact on service use

OBJECTIVE: To better understand factors associated with Medicaid enrollment among low-income, community-dwelling elderly persons and to examine the effect of Medicaid enrollment on the use of health care services by elderly persons, taking into account selection in program participation. DATA SOURCES: 1996 Medicare Current Beneficiary Survey (MCBS) Access to Care and Cost and Use files. METHODS: Individual-level predictions of the probability of dual enrollment are obtained from equations that estimate jointly the residential status of Medicare beneficiaries (community versus institution) and the probability of Medicaid enrollment among community-dwelling eligible beneficiaries. Predicted values are then substituted into the service use equations, which are estimated via two-part models. PRINCIPAL FINDINGS: Less than half of all community-dwelling elderly persons with incomes at or below 100 percent of the Federal Poverty Level (FPL) were enrolled in Medicaid in 1996. Once selective enrollment was accounted for, there was limited evidence of a dual enrollment effect on service use. Although there were no effects of state Medicaid policy variables on the probability that beneficiaries lived in the community (as opposed to nursing homes), the effects of state's Medicaid generosity in home and community-based services had a sizeable and statistically significant effect on influencing the likelihood that eligible elderly persons enrolled in Medicaid. CONCLUSIONS: Our results provide compelling evidence that Medicaid participation can be influenced by state policy. The observation that "policy matters" provides new insights into how existing programs might reach a larger proportion of potentially eligible beneficiaries.     

Essential but Excluded: Building Disaster Preparedness Capacity for Home Health Care Workers and Home Care Agencies

COVID-19 has demonstrated the essential role of home care services in supporting community-dwelling older and disabled individuals through a public health emergency. As the pandemic overwhelmed hospitals and nursing homes, home care helped individuals remain in the community and recover from COVID-19 at home. Yet unlike many institutional providers, home care agencies were often disconnected from broader public health disaster planning efforts and struggled to access basic resources, jeopardizing the workers who provide this care and the medically complex and often marginalized patients they support. The exclusion of home care from the broader COVID-19 emergency response underscores how the home care industry operates apart from the traditional health care infrastructure, even as its workers provide essential long-term care services. This special article (1) describes the experiences of home health care workers and their agencies during COVID-19 by summarizing existing empiric research; (2) reflects on how these experiences were shaped and exacerbated by longstanding challenges in the home care industry; and (3) identifies implications for future disaster preparedness policies and practice to better serve this workforce, the home care industry, and those for whom they care.     

Elderly care. Armchair theatre

The government's plan to free beds in the acute sector by discharging elderly people from hospital into private nursing homes are ill-thought out and a poor response to a complex problem. Older people may come to fear admission to hospital, seeing it as a prelude to being put in a home. Greater investment in community services would be the best hope of appropriate care for many older people. The government should have the need for hospital-based services for older people in the next three years and aim for a corresponding increase in good community services.     

Penny wise, pound wise: a comparison of Medicaid expenditures for home and community-based services versus nursing facility care for older adults

Kansas Medicaid offers home and community-based services through the Frail and Elderly (FE) program as an alternative for older adults who are eligible for nursing home (NH) care but wish to stay in the community. We determined demographic and clinical characteristics of enrollees receiving FE or NH services, examined their relative health care utilization patterns, and estimated the difference in Medicaid's expenditures for FE versus NH care. After adjusting for key demographic and clinical variables, mean monthly expenditures were $1,281 lower for the FE cohort. Since NH and FE populations are dissimilar, these care options may not be easily interchangeable at the individual level.     

Results of the assessment of Kentucky's Medicaid home- and community-based services waiver

In states where a Home- and Community-based Services Waiver is operating under the Medicaid program, HCFA requires an independent assessment of the program. This paper reports on two assessments of the costs and use of services under Kentucky's HCBS waiver: one comparing waiver clients to a matched control group of regular Medicaid home health clients, and the other comparing elderly female waiver clients to a matched control group from nursing homes. Analyses of costs and use of home health services, hospital care, physician services, nursing home admission, and other services showed little difference between waiver clients and control groups. Waiver clients used more home health, but used other services at the same rate. Their costs were lower overall.     

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.     

The Care Span: Medicaid savings resulted when community health workers matched those with needs to home and community care

The Affordable Care Act of 2010 builds on earlier efforts to expand home and community-based alternatives to institutional long-term care. Identifying people living in the community who have unmet long-term care needs and who may be at risk for entering nursing homes may be crucial to these efforts. The Arkansas Community Connector Program used specially trained community health workers to identify such people in three disadvantaged counties and connect them to Medicaid home and community-based services. The result was a 23.8?percent average reduction in annual Medicaid spending per participant during the period 2005-08. Net three-year savings to the Arkansas Medicaid program equaled $2.619?million. Similar interventions may help other localities achieve cost-saving and equitable access to publicly funded long-term care options other than institutional care.     

Are community health workers more effective in identifying persons in need of home and community-based long-term services than standard-passive approaches

Consumers prefer home and community-based long-term care (LTC) services (HCBS) but lack information on those services. We examined the use of community health workers (CHWs) to find and help Medicaid beneficiaries with unmet LTC needs access HCBS compared to standard HCBS outreach approaches. We found that CHWs were very effective at finding persons with greater needs and were better able to help them access a greater range of HCBS services. We also found that five times fewer HCBS beneficiaries helped by CHWs had to use nursing home care services than those not helped by the CHWs despite the fact that their health status was poorer than those not helped by the CHWs. Our study provides evidence of the effectiveness of CHWs for HCBS service awareness and navigation.     

Disability and Care Needs Among Older Americans

Context

The cost of late-life dependency is projected to grow rapidly as the number of older adults in the United States increases in the coming decades. To provide a context for framing relevant policy discussions, we investigated activity limitations and assistance, care resources, and unmet need for a national sample of older adults.

Methods

We analyzed the 2011 National Health and Aging Trends Study, a new national panel study of more than 8,000 Medicare enrollees.

Findings

Nearly one-half of older adults, or 18 million people, had difficulty or received help in the last month with daily activities. Altogether, 1 in 4 older adults receiving help lived in either a supportive care (15%) or a nursing home (10%) setting. Nearly 3 million received assistance with 3 or more self-care or mobility activities in settings other than nursing homes, and a disproportionate share of persons at this level had low incomes. Nearly all older adults in settings other than nursing homes had at least 1 potential informal care network member (family or household member or close friend), and the average number of network members was 4. Levels of informal assistance, primarily from family caregivers, were substantial for older adults receiving help in the community (164 hours/month) and living in supportive care settings (50 hours/month). Nearly all of those getting help received informal care, and about 3 in 10 received paid care. Of those who had difficulty or received help in settings other than nursing homes, 32% had an adverse consequence in the last month related to an unmet need; for community residents with a paid caregiver, the figure was nearly 60%.

Conclusions

The older population—especially those with few economic resources—has substantial late-life care needs. Policies to improve long-term services and supports and reduce unmet need could benefit both older adults and those who care for them.     

COVID-19 en residencias de mayores: factores estructurales y experiencias que avalan un cambio de modelo en España

The effects of COVID-19 pandemic on older people living in care homes have been devastating. In Spain approximately 3% of the cases and 40% of the deaths have occurred in this group. In addition, due to measures taken to control the crisis, the incidence of geriatric syndromes has increased, and residents’ fundamental rights have been violated. In this article we describe structural factors of care homes and their relationship with public health services that have influenced the impact of the pandemic. We suggest different types of group homes, and models of provision/coordination with public health services that have given excellent results protecting nursing homes residents from COVID-19, as alternative models to conventional residences and to the regular provision of health care services. We recommend that these successful experiences are taken into account in the transformation of the social-health model (to one integrated and focused on people) that has begun to be implemented in some Autonomous Communities of Spain.     

A Research and Policy Agenda for Transitions from Nursing Homes to Home

SUMMARY

More than 1 million adults make the transition from nursing homes to the community every year, often using formal health services including Medicare Part A skilled home health care. Although the need for discharge planning is well described, and the risks associated with care transitions are increasingly recognized, there is very limited information about the process and outcomes as patients move from nursing home to home. This paper reviews pertinent published data and health services research as background information and outlines a research agenda for studying these important transitions.     

Outcomes of Medicaid home- and community-based long-term services relative to nursing home care among dual eligibles

ObjectiveTo provide the first plausibly causal national estimates of health outcomes for older dual‐eligible recipients of Medicaid HCBS relative to nursing home care and to explore possible mechanisms for the effect.Data SourcesWe use 2005 and 2012 Medicaid Analytic eXtract (MAX), a national compilation of Medicaid claims, merged with Medicare claims to identify hospital admissions, our main outcome variable.Study DesignWe model the effects of HCBS using a longitudinal instrumental variables framework. To address the endogeneity of HCBS receipt, we instrument for it using the county percentage of nonelderly long‐term care users who receive HCBS. The percentage of nonelderly users is highly predictive of HCBS use for an elderly beneficiary, but because the instrument was derived from a separate population, the exclusion restriction is unlikely to be violated.Population Studied1,312,498 older adults (65+) dually enrolled in Medicaid and Medicare and are using long‐term care. We also examine heterogeneity of effects by race/ethnicity and the presence of dementia.Principal FindingsHCBS users have 10 percentage points higher (P < .01) annual rates of hospitalization than their nursing home counterparts when selection bias is addressed; rates of potentially avoidable hospitalizations are 3 percentage points higher (P < .01). These differences persist across races, dementia status, and intensity of HCBS spending.ConclusionsShifting Medicaid long‐term care funding for older adults from nursing homes to HCBS, while well‐motivated, results in the unintended consequence of substantially higher hospitalization rates for older dual eligibles. The quality and/or quantity of services may be inadequate for some HCBS recipients. Hospitalizations are costly to Medicare but also to the HCBS recipient in terms of stress and risks. Although consumer preferences to remain at home may outweigh poor outcomes of HCBS, the full costs and benefits need to be considered. HCBS outcomes—not just expansion—need more attention.     

The dually entitled elderly Medicare and Medicaid population living in the community.

This study shows that the elderly living in the community and covered by Medicare and Medicaid have a higher proportion of older persons, of minority races, and of women and are in poorer health than other aged persons covered only by Medicare. The noninstitutionalized poor elderly population use more health care services (especially inpatient hospital care) and have much higher per capita health care expenses compared to those covered by Medicaid. There were also large disparities in education and income. The study indicates that the Medicare program provides substantially more financial protection for all elderly persons living in the community than for the total elderly population.     

The use of acute hospital services by elderly residents of nursing and residential care homes

The objective of this study was to compare hospitalisation rates by cause of admission, hospital death rates and length of stay for residents from nursing and residential care homes with those in the community. This is a retrospective study of acute hospital emergency admissions in one health district, Merton, Sutton and Wandsworth between April 1996 and March 1997. Data linkage and manual look up were used to derive emergency hospital admissions for residents of care homes aged 65 and over. Admission rates were calculated for cause, length of stay and hospital death for residents of care homes and in the community with relative risks. The relative risk of emergency admission from a care home compared with the community was 1.39 for all diagnoses, 2.68 for all injuries, and 3.96 for fracture of neck of femur. The relative risk of dying in hospital for care home residents was 2.58 overall, and 3.64 in the first 48 hours of a hospital stay (all P-values <0.0001). Admission rates were higher from residential than from nursing homes. There was some increase in admissions from homes during holiday periods and over Christmas. In conclusion, there are major difficulties in monitoring admissions from nursing and residential care homes due to poor quality recording and inaccuracies in NHS coding. This was compounded by an absence of data on the age and sex profile and healthcare needs of the resident population in care homes. Prospective studies are required to ascertain when admission is avoidable and when it is appropriate. The information strategy needs to ensure that routine data sources are capable of monitoring the use of hospital services by residents of care homes.