Preference for long-term care arrangement and its correlates for older Korean Americans

OBJECTIVE: Care preference is important for both client's satisfaction and quality of life in long-term care. This study examines preference for long-term care arrangement and its correlates for older Korean Americans. METHODS: Data on two disability scenarios of hip fracture and stroke from a cross-section survey of 144 older Korean Americans were used to examine preferred care arrangement in terms of caregiver and care location, using multinomial logistic regression. RESULTS: Respondents expressed stronger preferences for "all informal" or "mixed" care arrangement for hip fracture scenario, but they preferred "all formal" care arrangement in the stroke scenario. Traditional value significantly decreased the odds of choosing "all formal" or "mixed" over "all informal" care arrangement. But Medicaid coverage and an independent decision-making style increased the odds of choosing "all formal" instead of "all informal" care arrangement. DISCUSSION: This study discusses the need for assessment of care preference and culturally appropriate long-term care services for minority elders.     

National and Regional Differences in Preparation for Future Care Needs: A Comparison of the United States and Germany

Planning for future care needs is likely to be influenced by both policy and culture. We compared attitudes regarding the usefulness of planning ahead for future care needs, processes of preparation for these needs (becoming aware of the risk of future care needs, gathering information about available options, deciding on preferences, concrete planning), and outcomes of preparation (e.g., knowledge about services) in 294 East German, 288 West German, and 590 American seniors. American respondents had higher preparation scores. Compared to the size of national differences, differences between East and West German seniors were generally smaller. East Germans made fewer decisions on preferences and engaged in less concrete planning. Most of the national and regional differences in preparation for future care needs were reduced or eliminated by controlling for differences in the perceived usefulness of planning.     

Elderly community residents' evaluative criteria and preferences for formal and informal in-home services.

This article focuses on the evaluative criteria of elderly community residents regarding their preferences in cases of long-term care decision-making. An overall picture of the evaluative criteria which the elderly use to evaluate various alternatives for long-term care are assessed. Furthermore, we determined which of these evaluative criteria may be considered as the most important by the elderly. A good relationship with informal carers appears almost pre-conditional to a preference for informal support. The desire not to burden acquaintances, as well as a positive previous experience with this type of care, are the most important reasons stated for choosing formal or private services. Insights into criteria that are used to evaluate different care arrangements clarify and refine our perspective on future developments.     

Preparation for future care needs: Styles of preparation used by older Eastern German, United States, and Canadian women

Many older persons have chronic conditions and limitations intheir everyday functioning. While some individuals prepare fortheir future care needs, many others do not. Usingsemi-structured, qualitative interviews, discourse about dealingwith the risk for needing help or care in the future wasinvestigated in 23 East German, 10 U.S., and 12 Canadian elderlycommunity-dwelling women (65 years). Eighty percent hadthought about future care needs; 64% had made general plans fortheir future care. Four preparation styles were identified inthe three social-structural contexts: Avoidance of preparation,thinking without planning, short-term planning, and long-termplanning. Individuals using these styles differed in theirsubjective assessment of preparation as well as in objectivepersonal conditions. More similarities than differences werefound between German, U.S. and Canadian women in the use of thesestyles. Results suggest that limited resources, systeminstability, and personal characteristics contribute to thechoice of planning style.     

Moving for care: findings from the US HIV Cost and Services Utilization Study

This paper examines sociodemographic and HIV-related factors associated with moving post-HIV diagnosis for non-care- and care-related reasons (versus never moving post-HIV diagnosis). Distinctions are made between those who move for informal care only, formal care only, or informal and formal care. Data come from the nationally representative US HIV Cost and Services Utilization Study (N=2,864). Overall, 31.8% moved at least once post-HIV diagnosis and 16.3% moved most recently for care. Among those who moved for care, 32.6% moved for informal care only, 26.8% for formal care only, and 40.6% moved for both. Post-HIV diagnosis moves for reasons unrelated to care were less likely among African Americans and older persons, and more likely among those with longer durations positive. Moves for care were less likely among African Americans, older persons, and persons with higher educational attainments, while they were more likely among those with an AIDS diagnosis and longer durations HIV-positive. Among those who moved for care, women and persons with higher incomes were less likely to move for formal or mixed care than informal care only. Given that moving for care may reflect disparities in access to care and unmet needs, additional analyses with more detailed data are warranted.     

Cultural Values and Caregiver Preference for Mexican-American and Non-Latino White Elders

This study examined caregiver preferences in the event of hip fracture between Mexican-American and non-Latino White elders. The differential effects of ethnicity and a cultural factor were also examined to elucidate the role of culture on caregiver preference.Data came from a cross-sectional survey of 89 Mexican-American and 30 non-Latino White elders. Hierarchical binary logistic regression was used to examine the differential impact of ethnicity and a cultural factor on caregiver preference. Fewer Mexican-American elders than non-Latino White elders preferred to rely on a formal/professional helper, and a greater proportion of Mexican-Americans than non-Latino Whites would turn to informal caregivers when faced with care needs following a hip fracture. The cultural factor significantly mediated the ethnic effect on caregiver preference. The need for culturally-relevant services based on caregiver preference for long-term care is discussed in addressing health disparities for ethnically diverse elders.     

Triply-diagnosed patients in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study: patterns of home care use

Although AIDS is a chronic illness, little is known about the patterns and correlates of long-term care use among triply diagnosed HIV patients. We examined nursing and home care use among 1,045 participants in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site study of HIV-positive patients with at least one mental health and one substance disorder. Patient interviews and medical record review data were used to examine the average monthly cost of nursing home, formal home and informal home care. Multinomial logit and two-part regression models were used to identify correlates of the use of formal and informal home care and the number of informal home care hours used. During the three months prior to baseline, 2, 7 and 23% of participants used nursing home, formal home and informal home care, respectively. Patients who were better-educated, had higher incomes, had Medicaid insurance (with or without Medicare coverage) and whose transmission mode was homosexual sex had higher regression-adjusted probabilities of receiving any formal home care; Latinos and physically healthier patients had lower probabilities. Women and patients who abused drugs or alcohol (but not both) were more likely to receive informal care only. Overall, patients who were female, better-educated, physically or mentally sicker or single-substance abusers were more likely to receive any home care (either formal or informal), while those contracting HIV through heterosexual sex were less likely. Women received 28 more monthly hours of informal care than men and married patients received 31 more hours than unmarried patients. We conclude that at least one mutable policy factor (Medicaid insurance) is strongly associated with formal home care use among triply diagnosed patients. Further research is needed to explore possible implications for access among this vulnerable subpopulation.     

Overwhelming odds: caregiving and the risk of institutionalization

In this study we explored whether informally or formally provided long-term care services reduce the risk of institutionalization among the impaired elderly and the nature of the relationship between support and risk. We relied principally on the 1982 National Long-Term Care Survey (NLTCS) with supplementary data from the 1984 NLTCS and the national American Housing Survey. Five specific types of effects were tested: direct effects of formal and informal care on institutional risk; buffering effects of support moderating risk factors; supplementation effects of formal support on the risk-reducing impact of informal care; facilitating effects of the housing environment in enabling support to continue; and intervening effects mediating the direct effects. The effects of each type of support differ substantially. The analyses do not confirm the notion that formal, paid care reduces institutional risk. In fact, the use of paid caregivers is associated with greater risk of institutionalization, other things equal. The results for informal care are more mixed. A general measure that accounts for all types of informal support has no effect on institutional risk in any of the formulations tested. But the marginally significant effects of quality and proximate support in the direct effects model are consistent with the hypothesis that caregiving reduces institutional risk. The findings also indicate that a small number of housing or locational features are facilitators of formal support and particular types of informal support.     

Developing a measure of older adults' preparation for future care needs.

We developed a measure of preparation for future care needs (PFCN) which consists of three parts: a) attitudes regarding the usefulness of planning for future care needs and toward the risk of needing help or care in the future; b) processes of preparation (becoming aware of future care needs, avoidance of preparation, gathering information, developing preferences, concrete planning); and c) contents of planning for short- and long-term care needs. Validity data of the questionnaire are reported based on 590 older adults (65-92 years). Engaging in preparation processes was associated with habitual decision styles, higher satisfaction with preparation, and greater knowledge of services. Greater vulnerability to needing future care was associated with higher expectations of needing care and more preparation. Internal consistency and stability of the measure based on 96 seniors was acceptable for almost all scales.     

Preferences for professional versus informal care at end of life amongst African-American drug users with HIV/AIDS

With the advent of antiretroviral therapies, persons living with HIV/AIDS (PLHIVs) are living longer but with increased impairment and care needs. The purpose of this study was to assess whether a vulnerable population of PLHIVs preferred informal versus professional care when unable to care for themselves, and individual and support network factors associated with preference for informal care. The findings have potential implications for facilitating the population's informal care at end of life. Data were from the BEACON study, which examined social factors associated with health outcomes among former or current drug-using PLHIVs in Baltimore, MD. Structural equation modeling was used to identify individual and support network characteristics associated with PLHIVs' preference for informal (family or friends) compared to professional care. The structural equation model indicated preference for informal care was associated with female sex, greater informal care receipt, reporting one's main partner (i.e., boy/girlfriend or spouse) as the primary source of informal care, and a support network comprised greater numbers of female kin and persons supportive of the participant's HIV treatment adherence. Not asking for needed help to avoid owing favors was associated with preferring professional care. Findings suggest that interventions to promote informal end of life care should bolster supportive others' resources and skills for care provision and treatment adherence support, and should address perceived norms of reciprocity. Such intervention will help ensure community caregiving in a population with high needs for long-term care.     

Frailty differences in older adults’ use of informal and formal care

ObjectivesThis study examines different combinations of informal and formal care use of older adults and investigates whether these combinations differ in terms of need for care (physical and psychological frailty) and enabling factors for informal and formal care use (social and environmental frailty).MethodsUsing cross-sectional data from the Belgian Ageing Studies (survey, N = 38,066 community-dwelling older adults), Latent Class Analysis (LCA) is used to identify combinations of informal and formal care use. Bivariate analyses are used to explore the relationship between the different combinations of care use and frailty.ResultsLatent Class Analysis (LCA) identified 8 different types of care use, which vary in combinations of informal and formal caregivers. Older adults who are more likely to combine care from family and care from all types of formal caregivers are more physically, psychologically and environmentally frail than expected. Older adults who are more likely to receive care only from nuclear family, or only from formal caregivers are more socially frail than expected.ConclusionsOlder adults with a higher need for care are more likely to receive care from different types of informal and formal caregivers. High environmental frailty and low social frailty are related with the use of care from different types of informal and formal caregivers. This study confirms that informal care can act as substitute for formal care. However, this substitute relationship becomes a complementary relationship in frail older adults. Policymakers should take into account that frailty in older adults affects the use of informal and formal care.     

Comparative costs of home care and residential care

PURPOSE: This paper reports on Canadian research that examined the cost effectiveness of home care for seniors as a substitute for long-term institutional services. DESIGN AND METHODS: Two Canadian cities were included in the research: Victoria, British Columbia, and Winnipeg, Manitoba. The research computes the costs of formal care and informal care in both settings and ensures comparable groups of clients in both settings by comparing individuals at the same level of care. RESULTS: The results reveal that costs were significantly lower for community clients than for facility clients, regardless of whether costs only to the government were taken into account or whether both formal and informal costs were taken into account. When informal caregiver time is valued at either minimum wage or replacement wage, there was a substantial jump in the average annual costs for both community and facility clients relative to when informal caregiver time was valued at zero. IMPLICATIONS: Nevertheless, the results reveal that home care is significantly less costly than residential care even when informal caregiver time is valued at replacement wage.     

How important is functional status as a predictor of service use by older people?

In studies of older people, it is often assumed that biophysical, or functional, status is the primary determinant of formal service use. This article reports baseline data from a longitudinal study of a community-based, linked random sample of frail elders (n = 635) and their informal caregivers (n = 429) to investigate the relative contribution of social circumstances to the use of community-based formal services. Elder respondents were categorized into three groups defined by their primary source of care: (a) informal only, (b) mixed help with predominantly informal care, (c) mixed help with predominantly formal services. Of the respondents, 79% received most of their help from informal caregivers, whereas 21% relied on formal services for most of their assistance. A series of logistic regression models were developed to identify variables that discriminated between major sources of care. The social factor of living alone is the consistent predictor of reliance on formal services. Only for those elders living alone does the physical factor of level of frailty predict reliance on formal services. Elders who live with a caregiver, particularly a spouse, are likely not to use any formal services regardless of their level of frailty. Finally, elders reliant on formal services receive much less care overall.     

Incorporating assistive devices into community-based long-term care: an analysis of the potential for substitution and supplementation

OBJECTIVES. This article examines the use of assistive devices as a part of the long-term care arrangements of community-dwelling older Americans. It examines the potential for assistive devices to substitute for and supplement personal care assistance. METHODS. Data from the Phase 2 Disability Supplements to the 1994-1995 National Health Interview Surveys are used to compare the use of personal care and equipment among persons reporting difficulty with a given activity of daily living. RESULTS. The capacity of equipment to substitute for or supplement personal care is highly task-specific and depends on the characteristics of the devices and the personal care providers. In general, those using simple devices are less likely to use informal care, whereas those using complex devices are more likely to use formal care services. DISCUSSION. Technology has the potential to confer quality of life enhancements for older persons and their caregivers and cost savings for payers.     

Retirement age caregivers and deprivation of area of residence in England and Wales

Many countries in Europe are beginning to acknowledge the essential contribution of informal caregivers, as policy changes leave more people with greater needs being cared for in the community. Carers who are themselves retired are a vulnerable group. Compared to caregivers in younger age groups, a higher proportion have pre-existing disease; they may be more vulnerable to the adverse effects of caregiving on health, and many survive on low incomes. This study investigated whether ill health amongst older carers and hours of caregiving were greater in disadvantaged areas of England and Wales. We also estimated the cost of replacing this care with formal services. Data were analysed from the 2001 UK census, relating to 9.2 million males and females of pensionable age living outside of communal establishments in England and Wales. Thirteen percent of people over retirement age (1.2 million) provided care for others, more than half of whom (742,182) reported poor health. Pensioners provided care in all areas; the proportion giving care was higher in low deprivation (advantaged) areas, but both the numbers and proportion of pensioners in poor health providing many hours of care were greater in disadvantaged areas. The annual cost of replacing all informal with formal social care was estimated to lie between 14.8 and 43.9 billion Euros. Older carers are an essential support to welfare systems. If demographic shifts require any substitution of formal for informal care, this will place a significant burden on all areas, with the greatest needs likely to be in the disadvantaged areas. Competing interests: all authors declare that they have no competing interests. Ethical permission was not required.     

Marital status, living arrangements, and the use of health services by elderly persons

Although marriage has been shown to have important health-protective consequences, it is not clear to what extent these effects are due to marriage per se or to the fact that married people are less likely to live alone. The social support literature suggests that living with others may reduce the need for use of formal and informal health care services independently of marital status because of (a) the substitution of home care, and/or (b) enhancement of physical and mental health. This study of elderly persons, based on data from the National Medical Care Expenditure Survey (NMCES), examined the substitution hypothesis. The impact of marital status and living arrangements on the use of formal health services among persons 65 years of age and older was examined using path analysis. These data confirm a substitution effect whereby persons living with others are more likely to stay in bed, but less likely to see a doctor, than are persons who live alone.     

The U.S. Long Term Care System: Development and Expansion of Naturally Occurring Retirement Communities as an Innovative Model for Aging in Place

The current U.S. health and long term care systems are inadequately prepared to meet the diverse and changing needs of the rapidly growing senior population. This paper describes the importance of naturally occurring retirement communities (NORCs) to promote the health and mental well being of older individuals through the collaborative efforts of formal and informal home and community based services and support. NORCs are considered a crucial model for aging in place since older adults prefer to remain in the comfort of their homes, and services can be provided in a much more efficient and cost effective manner. This paper examines the strengths, opportunities, and challenges of existing NORCs and discusses the need for the development and expansion of additional NORC programs as an innovative and viable solution for older adults aging in place.     

The impact of ethnic involvement and migration patterns on long-term care plans among retired sunbelt migrants: plans for nursing home placement

OBJECTIVES: We examine anticipated preferences for nursing home placement as a strategy for meeting possible future long-term care needs among a sample of community-dwelling elderly European Americans who migrated to Florida after retirement. We synthesize prior research on ethnicity in late life, retirement migration patterns, and informal networks of retired migrants. METHODS: We gathered data through structured personal interviews with 578 retired migrants identified through screening from telephone listings, supplemented with snowball sampling techniques. RESULTS: Lifetime migration patterns and current ethnic involvement are significant predictors of mentioning nursing home placement as a strategy for possible long-term care needs. DISCUSSION: We interpret these results within the framework of Rowles's emphasis on the permeability of community-nursing home boundaries.