Medicare and Medicaid Home Health and Medicaid Waiver Services for Dually Eligible Older Adults: Risk Factors for Use and Correlates of Expenditures

Risk Adjustment in Home and Community Based Services Outcome Measurement

The purpose of this study was to review and evaluate existing research that used risk adjusters in disability research. Risk adjustment controls for individual characteristics of persons when examining outcomes. We have conducted a systematic review and an evaluation of existing studies that included risk adjusters for outcomes of people with disabilities receiving services (home or community based). The process included coding each study according to the type(s) of risk adjusters employed and their relation to the specific population and outcomes within a framework. Panels were utilized to prioritize the risk adjusters. Findings indicate that four risk adjusters can be tentatively recommended as potential candidate risk adjusters: chronic conditions, functional disability, mental health status, and cognitive functioning. Holistic Health and Functioning far outweighed other outcomes studied to date. Further, there is a need for testing recommended risk adjusters across multiple outcomes and different populations of people with disabilities.

Clinical trial testing in-home multidisciplinary care management for older adults with cognitive vulnerability: Rationale and study design

Care management approaches are being widely tested in the Medicare-eligible population to manage chronic conditions, but few have focused on cognitive vulnerability as the pathway to optimizing independence in the community-dwelling older population. Cognitive vulnerability refers to living with dementia, depression, and/or a history of delirium. Many studies have shown that cognitive vulnerability is associated with poor health-related outcomes in community-dwelling older adults, raising the health policy importance of finding evidence-based approaches to improve outcomes for this target population. Moreover, very little is known about effects of care management approaches in the rapidly growing Medicare Advantage population. In response to these knowledge gaps, we are testing the efficacy of an in-home, nurse practitioner-led care management team for adults age ≥ 65 with cognitive vulnerability in a Medicare Advantage population. Older adults and family caregivers randomized either to this multidisciplinary care management team, or to a telephonic care management program routinely offered by our Medicare Advantage partner. The intervention period is 12 months and the primary outcome is any emergency department visit or hospitalization over the 12-month period. In this paper, we report on the rationale for testing a multidisciplinary care management intervention for this target population, and explain how a university-based research team collaborated with a Medicare Advantage insurer to conceptualize and implement the clinical trial. We also provide details on study design, and on components of the in-home and telephonic care management interventions. We conclude with a synopsis of recruitment progress along with selected baseline characteristics of the study cohort.

Healthcare costs for the elderly in Japan: Analysis of medical care and long-term care claim records

BACKGROUND

The population is aging rapidly in many developed countries. Such countries need to respond to the growing demand and expanding costs of healthcare (HC) for the elderly. Therefore, it is important to investigate the factors correlating such HC costs. In Japan, HC is composed of two sections, namely medical care (MC) and long-term care (LTC). While many studies have examined MC and LTC costs on their own, few studies have conducted comprehensive investigations of HC costs. The aim of this study is to examine the risk factors that influence HC costs for the elderly who enroll in the LTC insurance system in Japan.

METHODS

The inclusion criteria in the present study are as follows: being 65 years of age, or older; certified eligibility for, and use of services offered by the LTC insurance system at home or in an institutional setting in December 2009; and being covered by the National Health Insurance (NHI) system. MC and LTC insurance data were obtained from claim records for the elderly in July and December of 2007, 2008, and 2009 (i.e., a total of six survey points). Panel data, per subject, were constructed using MC and LTC claim records. The sample included 810 subjects and 4029 observations.

RESULTS

We estimated a regression equation with a censored dependent variable using a Tobit model. Significant associations between MC or LTC costs and interaction terms (household composition × seasonal effects) were investigated. MC costs significantly decreased and LTC costs significantly increased among subjects living alone during winter. Income level was also a positive determinant of MC costs, while eligibility level was a positive determinant of LTC costs.

CONCLUSIONS

We recommend that the health policy for the elderly focus more on seasonal effects, household composition, and income level, as well as on eligibility level.

Home and community-based service and other senior service use: Prevalence and characteristics in a national sample

We report on the use of home and community-based services (HCBS) and other senior services and factors affecting utilization of both among Americans over age 60 in the Health and Retirement Study (HRS). Those using HCBS were more likely to be older, single, Black, lower income, receiving Medicaid, and in worse health. Past use of less traditional senior services, such as exercise classes and help with tax preparation, were found to be associated with current use of HCBS. These findings suggest use of less traditional senior services may serve as a "gateway" to HCBS that can help keep older adults living in the community.

Translation of the Care of Persons with Dementia in their Environments (COPE) intervention in a publicly-funded home care context: Rationale and research design

BACKGROUND

Dementia is the leading cause of loss of independence in older adults worldwide. In the U.S., approximately 15 million family members provide care to relatives with dementia. This paper presents the rationale and design for a translational study in which an evidence-based, non-pharmacologic intervention for older adults with dementia and family caregivers (CGs) is incorporated into a publicly-funded home care program for older adults at risk for nursing home admission.

METHODS

The 4-month Care of Persons with Dementia in their Environments (COPE) intervention is designed to optimize older adults' functional independence, and to improve CG dementia management skills and health-related outcomes. COPE features 10 in-home occupational therapy visits, and 1 in-home visit and 1 telephone contact by an advanced practice nurse. COPE was deemed efficacious in a published randomized clinical trial. In the present study, older adults with dementia enrolled in the Connecticut Home Care Program for Elders (CHCPE) and their CGs are randomly assigned to receive COPE plus their ongoing CHCPE services, or to continue receiving CHCPE services only.

OUTCOMES

The primary outcome for older adults with dementia is functional independence; secondary outcomes are activity engagement, quality of life, and prevention or alleviation of neuropsychiatric symptoms. CG outcomes include perceived well-being and confidence in using activities to manage dementia symptoms. Translational outcomes include net financial benefit of COPE, and feasibility and acceptability of COPE implementation into the CHCPE. COPE has the potential to improve health-related outcomes while saving Medicaid waiver and state revenue-funded home care program costs nationwide.

2015 Alzheimer's disease facts and figures

This report discusses the public health impact of Alzheimer’s disease (AD), including incidence and prevalence, mortality rates, costs of care and the overall effect on caregivers and society. It also examines the challenges encountered by health care providers when disclosing an AD diagnosis to patients and caregivers. An estimated 5.3 million Americans have AD; 5.1 million are age 65 years, and approximately 200,000 are age <65 years and have younger onset AD. By mid-century, the number of people living with AD in the United States is projected to grow by nearly 10 million, fueled in large part by the aging baby boom generation. Today, someone in the country develops AD every 67 seconds. By 2050, one new case of AD is expected to develop every 33 seconds, resulting in nearly 1 million new cases per year, and the estimated prevalence is expected to range from 11 million to 16 million. In 2013, official death certificates recorded 84,767 deaths from AD, making AD the sixth leading cause of death in the United States and the fifth leading cause of death in Americans age 65 years. Between 2000 and 2013, deaths resulting from heart disease, stroke and prostate cancer decreased 14%, 23% and 11%, respectively, whereas deaths from AD increased 71%. The actual number of deaths to which AD contributes (or deaths with AD) is likely much larger than the number of deaths from AD recorded on death certificates. In 2015, an estimated 700,000 Americans age 65 years will die with AD, and many of them will die from complications caused by AD. In 2014, more than 15 million family members and other unpaid caregivers provided an estimated 17.9 billion hours of care to people with AD and other dementias, a contribution valued at more than $217 billion. Average per-person Medicare payments for services to beneficiaries age 65 years with AD and other dementias are more than two and a half times as great as payments for all beneficiaries without these conditions, and Medicaid payments are 19 times as great. Total payments in 2015 for health care, long-term care and hospice services for people age 65 years with dementia are expected to be $226 billion. Among people with a diagnosis of AD or another dementia, fewer than half report having been told of the diagnosis by their health care provider. Though the benefits of a prompt, clear and accurate disclosure of an AD diagnosis are recognized by the medical profession, improvements to the disclosure process are needed. These improvements may require stronger support systems for health care providers and their patients.

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities

The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA.

Who pays for home care? A study of nationally representative data on disabled older Americans

BACKGROUND

We examine who pays for services that support disabled older Americans at home. We consider both personal sources (e.g., out-of-pocket payment, family members) and publicly funded programs (e.g., Medicaid) as sources of payment for services. We examine how the funding mix for home care services is related to older people's economic resources, needs for care, and other socio-demographic characteristics.

METHODS

Our sample consists of 11,725 person-years from the 1989, 1994, 1999, and 2004 waves of the National Long-Term Care Survey. Two-part regression analyses were performed to model hours of care received from each payer. "Random effects" and "fixed effects" estimation yielded similar results.

RESULTS

About six in ten caregivers (63%) providing home care services are paid by personal sources alone. By contrast, 28% receive payment from publicly funded programs alone, and 9% from a combination of personal and public program sources. Older people with family incomes over 75,000 dollars per year receive 8.5 more hours of home care overall than those in the lowest income category (less than 15,000 dollars). While the funding mix for home care services is strongly related to older people's economic resources, in all income groups at least 65% of services are provided by caregivers paid in whole or in part from personal sources. In fact, almost all (97%) home care received by those with family incomes over 75,000 dollars per year are financed by personal sources alone.

CONCLUSIONS

We outline the implications that heavy reliance on personally financed services and economic disparities in overall services use has for disabled older Americans and their families.

2014 Alzheimer's disease facts and figures

This report discusses the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality rates, costs of care, and overall effect on caregivers and society. It also examines the impact of AD on women compared with men. An estimated 5.2 million Americans have AD. Approximately 200,000 people younger than 65 years with AD comprise the younger onset AD population; 5 million are age 65 years or older. By mid-century, fueled in large part by the baby boom generation, the number of people living with AD in the United States is projected to grow by about 9 million. Today, someone in the country develops AD every 67 seconds. By 2050, one new case of AD is expected to develop every 33 seconds, or nearly a million new cases per year, and the total estimated prevalence is expected to be 13.8 million. In 2010, official death certificates recorded 83,494 deaths from AD, making AD the sixth leading cause of death in the United States and the fifth leading cause of death in Americans aged 65 years or older. Between 2000 and 2010, the proportion of deaths resulting from heart disease, stroke, and prostate cancer decreased 16%, 23%, and 8%, respectively, whereas the proportion resulting from AD increased 68%. The actual number of deaths to which AD contributes (or deaths with AD) is likely much larger than the number of deaths from AD recorded on death certificates. In 2014, an estimated 700,000 older Americans will die with AD, and many of them will die from complications caused by AD. In 2013, more than 15 million family members and other unpaid caregivers provided an estimated 17.7 billion hours of care to people with AD and other dementias, a contribution valued at more than $220 billion. Average per-person Medicare payments for services to beneficiaries aged 65 years and older with AD and other dementias are more than two and a half times as great as payments for all beneficiaries without these conditions, and Medicaid payments are 19 times as great. Total payments in 2014 for health care, long-term care, and hospice services for people aged 65 years and older with dementia are expected to be $214 billion. AD takes a stronger toll on women than men. More women than men develop the disease, and women are more likely than men to be informal caregivers for someone with AD or another dementia. As caregiving responsibilities become more time consuming and burdensome or extend for prolonged durations, women assume an even greater share of the caregiving burden. For every man who spends 21 to more than 60 hours per week as a caregiver, there are 2.1 women. For every man who lives with the care recipient and provides around-the-clock care, there are 2.5 women. In addition, for every man who has provided caregiving assistance for more than 5 years, there are 2.3 women.

Environmental Predictors of Unmet Home-and Community-Based Service Needs of Older Adults

Home- and community-based services (HCBS) for many older adults are an essential component of aging-in-place. Andersen developed the contemporary model used to predict service use. Researchers have modified the model to examine need. Studies that attempt to predict unmet needs have explained only 10% to 15% of the variance. This study is based on the supposition that lack of accounting for environmental factors has resulted in such small explanatory power. Through the use of 2008 Southeastern Pennsylvania Household Health Survey data, this exploratory study modeled predictors of unmet HCBS needs. Findings reveal that lack of access to healthy foods and poor housing quality have a significant relationship to unmet HCBS needs. This model predicted 54% of the variance. Results reveal environmental questions to ask, a way to identify older adults with unmet HCBS needs and environmental barriers that if addressed may reduce older adults’ eventual need for health services and HCBS.

2012 Alzheimer's disease facts and figures

This report provides information to increase understanding of the public health impact of Alzheimer's disease (AD). Topics addressed include incidence, prevalence, mortality rates, health expenditures and costs of care, and effect on caregivers and society. The report also explores issues that arise when people with AD and other dementias live alone. The characteristics, risks, and unmet needs of this population are described. An estimated 5.4 million Americans have AD, including approximately 200,000 age <65 years who comprise the younger-onset AD population. Over the coming decades, the aging of the baby boom generation is projected to result in an additional 10 million people with AD. Today, someone in America develops AD every 68 seconds. By 2050, there is expected to be one new case of AD every 33 seconds, or nearly a million new cases per year, and AD prevalence is projected to be 11 million to 16 million. Dramatic increases in the number of "oldest-old" (those age ≥85 years) across all racial and ethnic groups are expected to contribute to the increased prevalence of AD. AD is the sixth leading cause of death in the United States and the fifth leading cause of death in Americans age ≥65 years. Although the proportions of deaths due to other major causes of death have decreased in the last several years, the proportion due to AD has risen significantly. Between 2000 and 2008, the proportion of deaths due to heart disease, stroke, and prostate cancer decreased by 13%, 20%, and 8%, respectively, whereas the proportion due to AD increased by 66%. In 2011, more than 15 million family members and other unpaid caregivers provided an estimated 17.4 billion hours of care to people with AD and other dementias, a contribution valued at more than $210 billion. Medicare payments for services to beneficiaries age ≥65 years with AD and other dementias are three times as great as payments for beneficiaries without these conditions, and Medicaid payments are 19 times as great. In 2012, payments for health care, long-term care, and hospice services for people age ≥65 years with AD and other dementias are expected to be $200 billion (not including the contributions of unpaid caregivers). An estimated 800,000 people with AD (one in seven) live alone, and up to half of them do not have an identifiable caregiver. People with dementia who live alone are exposed to risks that exceed the risks encountered by people with dementia who live with others, including inadequate self-care, malnutrition, untreated medical conditions, falls, wandering from home unattended, and accidental deaths.

Volume of home- and community-based services and time to nursing-home placement

OBJECTIVE

The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients' risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home.

DATA SOURCES

Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs.

STUDY DESIGN

Enrollees in Indiana Medicaid's Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk.

PRINCIPAL FINDINGS

Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77-0.99).

CONCLUSIONS

Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.

Home Health Care Nursing Visit Intensity and Heart Failure Patient Outcomes

This study is a secondary analysis of data for 107 home health care heart failure patients. The authors investigate the impact of patient characteristics and nursing visit intensity on change in activities of daily living (ADL) status and instrumental activities of daily living (IADL) status and improvement/stabilization of dyspnea. Prior hospital stay (β = .38, p = .001) and nursing visit intensity (β = -.39, p = .001) predict improvement in ADL status. The model for change in IADL status is not significant. Patients with more than two comorbidities (OR = 6.5, p = .04) and patients who received higher nursing visit intensity (OR = 7.0, p = .04) are more likely to have improved/stabilized dyspnea at home care discharge.

2011 Alzheimer's disease facts and figures

Alzheimer's disease (AD) is the sixth leading cause of all deaths in the United States and is the fifth leading cause of death in Americans aged ≥65 years. Although other major causes of death have been on the decrease, deaths because of AD have been rising dramatically. Between 2000 and 2008 (preliminary data), heart disease deaths decreased by 13%, stroke deaths by 20%, and prostate cancer-related deaths by 8%, whereas deaths because of AD increased by 66%. An estimated 5.4 million Americans have AD; approximately 200,000 people aged <65 years with AD comprise the younger-onset AD population. Every 69 seconds, someone in America develops AD; by 2050, the time is expected to accelerate to every 33 seconds. Over the coming decades, the baby boom population is projected to add 10 million people to these numbers. In 2050, the incidence of AD is expected to approach nearly a million people per year, with a total estimated prevalence of 11 to 16 million people. Dramatic increases in the numbers of "oldest-old" (those aged ≥85 years) across all racial and ethnic groups will also significantly affect the numbers of people living with AD. In 2010, nearly 15 million family and other unpaid caregivers provided an estimated 17 billion hours of care to people with AD and other dementias, a contribution valued at more than $202 billion. Medicare payments for services to beneficiaries aged ≥65 years with AD and other dementias are almost 3 times higher than for beneficiaries without these conditions. Total payments in 2011 for health care, long-term care, and hospice services for people aged ≥65years with AD and other dementias are expected to be $183 billion (not including the contributions of unpaid caregivers). This report provides information to increase understanding of the public health effect of AD, including incidence and prevalence, mortality, health expenditures and costs of care, and effect on caregivers and society in general. The report also examines the current state of AD detection and diagnosis, focusing on the benefits of early detection and the factors that present challenges to accurate diagnosis.

Home Health Care Nursing Visit Intensity and Heart Failure Patient Outcomes

This study is a secondary analysis of data for 107 home health care heart failure patients. The authors investigate the impact of patient characteristics and nursing visit intensity on change in activities of daily living (ADL) status and instrumental activities of daily living (IADL) status and improvement/stabilization of dyspnea. Prior hospital stay (β = .38, p = .001) and nursing visit intensity (β = -.39, p = .001) predict improvement in ADL status. The model for change in IADL status is not significant. Patients with more than two comorbidities (OR = 6.5, p = .04) and patients who received higher nursing visit intensity (OR = 7.0, p = .04) are more likely to have improved/stabilized dyspnea at home care discharge.

Integrating mental health parity for homebound older adults under the medicare home health care benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.

Unmet Needs for Home and Community-Based Services Among Frail Older Americans and Their Caregivers

Objective: This study examined unmet needs for home- and community-based services (HCBS) among frail older Americans. Method: Using population-based sample from the National Long-Term Care Survey, a hierarchical logistic regression analysis was conducted to examine the predictors of unmet needs for seven types of HCBS. Results: Lack of awareness, reluctance, unavailability, and affordability of services were the main reasons for unmet needs for HCBS. Factors that were associated with unmet needs included Black race/ethnicity, greater care needs (functional limitations and behavioral problems), and less informal support (substitute help and family agreement). Discussion: It is important to identify risk factors that may lead to older adults’ unmet needs for HCBS. The findings of this study charge researchers to look beyond service utilization and give more attention to service needs among those who did or could not access the services.

2010 Alzheimer's disease facts and figures

Alzheimer's disease (AD) is the seventh leading cause of all deaths in the United States and is virtually tied with the sixth leading cause of death-diabetes. AD is the fifth leading cause of death in Americans aged 65 and older. Although other major causes of death have been on the decrease, deaths because of AD have been rising dramatically. Between 2000 and 2006, heart disease deaths decreased 11.1%, stroke deaths decreased 18.2%, and prostate cancer-related deaths decreased 8.7%, whereas deaths because of AD increased 46.1%. Older African-Americans and Hispanics are more likely than older white Americans to have AD or other dementia. Current estimates are that African-Americans are about 2 times more likely, and Hispanics about 1.5 times more likely, than their white counterparts to have these conditions. However, the relationship of race and ethnicity to the development of AD and other dementias is complex and not fully understood. In 2009, nearly 11 million family and other unpaid caregivers provided an estimated 12.5 billion hours of care to persons with AD and other dementias; this care is valued at nearly $144 billion. Medicare payments for services to beneficiaries aged 65 years and older with AD and other dementias are three times higher than for beneficiaries without these conditions. Total payments for 2010 for health care and long-term care services for people aged 65 and older with AD and other dementias are expected to be $172 billion (not including the contributions of unpaid caregivers). An estimated 5.3 million Americans have AD; approximately 200,000 persons under age 65 with AD comprise the younger-onset AD population. Every 70 seconds, someone in America develops AD; by 2050 the time of every 70 seconds is expected to decrease to every 33 seconds. Over the coming decades, the baby boom population is projected to add 10 million people to these numbers. In 2050, the incidence of AD is expected to approach nearly a million people per year, with a total estimated prevalence of 11-16 million people. Dramatic increases in the numbers of "oldest old" (aged 85 years and older) across all racial and ethnic groups will also significantly affect the numbers of people living with AD. This report provides information to increase understanding of the public health effect of AD, including incidence and prevalence, mortality, costs of care, and effect on caregivers and society in general. This report also sets the stage for better understanding the relationship between race and ethnicity and the development of AD and other dementias.

Understanding factors that influence success of home- and community-based services in keeping older adults in community settings

OBJECTIVE

To understand factors that influence success of home- and community-based services in keeping older adults in community settings, we examined the causal relationships among older adults' personal factors, older adults' home- and community-based services use, and older adults' remaining in communities.

METHODS

Structural equation modeling was employed to test a home- and community-based services model based on Andersen's Health Behavioral Model. Data from 5,294 elders in a nationally representative dataset, the Second Longitudinal Study of Aging, were included for analysis.

RESULTS

Two significant supportive factors for older adults to remain in communities were use of paid instrumental activities of daily living (IADL) personal care services and awareness of unmet needs.

DISCUSSION

Our findings suggest the importance of encouraging older adults to acknowledge their unmet needs and to seek community-based support services early, rather than wait until they have developed more serious needs, such as difficulties in activities of daily living (ADL).

The effect of major and minor depression on Medicare home healthcare services use

OBJECTIVES

To examine the associations between major and minor depression and categories of Medicare home healthcare use.

DESIGN

Observational prospective study (1997-1999).

SETTING

Visiting nurse agency in suburban New York State. PARTCIPANTS: Five hundred thirty-nine new Medicare admissions aged 65 and older (mean age 78.4), 65.1% female, and 15.0% nonwhite. Approximately 13.5% were diagnosed with major depression and another 10.8% with minor depression.

MEASUREMENTS

Consensus "best estimate"Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses for major and minor depression assessed using Structured Clinical Interviews for DSM-IV (SCID) plus medical charts.

RESULTS

Major and minor depression appear to have little association with probability and amount of use of the types of Medicare home health care (skilled nurse, home health aide, therapist (physical, occupational, and speech), and medical social services). Overall, patients with minor depression appear to have utilization similar to that of patients with major depression.

CONCLUSION

It seems likely that any potential incremental depression effect on utilization is being offset by the transitional medical state of the patients that entered Medicare home healthcare directly from a hospital, nursing home, or rehabilitation facility, and the overall severity of disability and chronic illness present in long-term home healthcare patients. Further research is required to determine whether similar findings occur in other home healthcare agencies and whether these are present under the current Medicare Prospective Payment System reimbursement mechanism.

Psychosocial Care in Home Health Policy

As of summer 2008, health care reform has become an important part of the 2008 presidential election. However, long-term care has been absent in the discussion of health care reform by presidential candidates. This article examines policies that govern the payers of long-term care, specifically home health care (HHC). HHC is the fastest growing industry within long-term care, as there is a growing number of older adults in need of both skilled and unskilled home care. Medicare and Medicaid are the two major payers of HHC; yet these payers do not address the psychological and social needs of the patients. Furthermore, there is a long-term care disconnect between Medicare and Medicaid that creates even larger problems for older adults in need of long-term care.

Predicting change in functional status over quarterly intervals for older adults enrolled in the PACE community-based long-term care program

BACKGROUND AND AIMS

Many frail older adults experience multiple changes in activities of daily living (ADL) functioning over the course of a year. Accurate predictions of ADL status over quarterly intervals may improve the precision of care planning for older adults who seek long-term care in the community. The study sought to develop and validate a model that predicts older adults' ADL status over quarterly intervals.

METHODS

The study included 3127 enrollees from 11 Program of All Inclusive Care for the Elderly (PACE) sites. Nurses assessed ADL status quarterly. Potential predictors included baseline assessment of age, sex, race, and living situation and quarterly assessments of prior functioning, co-morbidities, prior hospitalizations, and mental status.

RESULTS

Change in level of functioning occurred for 30% of quarterly observations. Predictors of functioning at the end of a quarter were prior ADL change, prior hospitalization, living with others, impaired mental status, cancer, dementia, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease. When the model was applied to the validation observations, 93% of predictions were within one level and 72% of the predictions were the same level of ADL functioning observed at the end of the quarter.

CONCLUSIONS

In a sample of community-living ADL-disabled older adults, changes in functional status over a quarter were common and associated with functional and health status at the beginning of the quarter. Further validation of the model may result in an index that helps clinicians better predict future ADL needs of community-living older adults who need long-term care.

Home-care clients' need for help, and use and costs of services

The aims of the study were to describe (1) the need for help as well as the use and costs of services of home help and/or home nursing (home care) and (2) to identify the variables associated with the use and costs of health and social care services. A total of 721 Finnish home-care clients were interviewed in 2001. The need for help was assessed by basic and instrumental activities of daily Living (ADL) and in terms of pain and illness, rest and sleep, psychosocial well-being and social and environment variables. The Anderson-Newman model was used to study predictors of use of services, including visits of home-care personnel and visits to the doctor, nurse, physiotherapist, laboratory and hospital. Weekly costs of services were calculated. Data were analyzed using multivariate analyses. The clients had poor functional ability and they needed help at least once a week with, on average, 6 out of 15 ADL functions, and 5 out of 13 items relating to pain and illnesses, rest and sleep, psychosocial well-being and social and environment items. The enabling and need variables, particularly the variables "living alone" and "perceived need for help", were important predictors for the use of services. Social care constituted more than half of the average weekly costs of municipalities. The perceived need for help with basic ADL was associated with higher costs. To ensure the quality of life among home-care clients while keeping costs reasonable is a challenge for municipalities.

Comparison of resource utilization for Medicaid dementia patients using nursing homes versus home and community based waivers for long-term care

BACKGROUND

Medicaid waiver home and community-based long-term care services (HCBS) may provide a partial solution to the escalating costs of long-term care. Persons with dementia can have complex caregiving needs; it is unknown whether their expenditures and resource utilization differ between community-based versus institutional settings.

OBJECTIVE

To compare expenditures and resource utilization for Medicaid recipients with dementia who received long-term care through a nursing home versus HCBS waivers.

DESIGN

Twelve-month cohort study.

SETTING

Indiana Medicaid administrative data from 2001 through 2004.

PARTICIPANTS

Medicaid recipients with dementia who lived in the community 6 months before receiving long-term care through nursing homes (N = 1534) or HCBS waivers (N = 174).

MEASUREMENTS

Monthly inpatient and emergency department rates and total expenditures adjusted for prior use, demographics, insurance status, and comorbidities.

RESULTS

Adjusted rates of inpatient use were stable for nursing home patients (0.06) but significantly increased over 12 months for HCBS recipients (0.07-0.12; P = 0.048). Adjusted total expenditures increased over 12 months from $1419 to $2002 for HCBS recipients (P < 0.001), but remained stable for those in nursing homes ($3413-$3336). Long-term care expenditures were on average $1688 per month higher for those in nursing homes.

CONCLUSIONS

The escalation in inpatient use for HCBS waiver recipients suggests that future development of HCBS programs should consider the unique needs of persons with dementia so as to optimize their health outcomes. Despite increasing inpatient use among HCBS recipients, their overall expenditures remained significantly lower than those of nursing home patients.

The effects of integrated home care and discharge practice on functional ability and health-related quality of life: a cluster-randomised trial among home care patients

Objectives

The aim was to evaluate the effects of integrated home care and discharge practice on the functional ability (FA) and health-related quality of life (HRQoL) of home care patients.

Methods

A cluster randomised trial (CRT) with Finnish municipalities (n=22) as the units of randomisation. At baseline the sample included 669 patients aged 65 years or over. Data consisted of interviews (at discharge, and at 3-week and 6-month follow-up), medical records and care registers. The intervention was a generic prototype of care/case management-practice (IHCaD-practice) that was tailored to municipalities needs. The aim of the intervention was to standardize practices and make written agreements between hospitals and home care administrations, and also within home care and to name a care/case manager pair for each home care patient. The main outcomes were HRQoL—as measured by a combination of the Nottingham Health Profile (NHP) and the EQ-5D instrument for measuring health status—and also Activities of Daily Living (ADL). All analyses were based on intention-to-treat.

Results

At baseline over half of the patient population perceived their FA and HRQoL as poor. At the 6-month follow-up there were no improvements in FA or in EQ-5D scores, and no differences between groups. In energy, sleep, and pain the NHP improved significantly in both groups at the 3-week and at 6-month follow-up with no differences between groups. In the 3-week follow-up, physical mobility was higher in the trial group.

Conclusions

Although the effects of the new practice did not improve the patients' FA and HRQoL, except for physical mobility at the 3-week follow-up, the workers thought that the intervention worked in practice. The intervention standardised practices and helped to integrate services. The intervention was focused on staff activities and through the changed activities also had an effect on patients. It takes many years to achieve permanent changes in every worker's individual practice and it is also likely that changes in working practices would be visible before effects on patients. The use of other outcome measures, such as the use of services, may be clearer in showing a positive impact of the intervention rather than FA or HRQoL.

A qualitative analysis of the meaning of aging for women with disabilities with policy implications

This is a report of a hermeneutic phenomenological study of the meaning of aging for women with childhood-onset disabilities due to the effects of paralytic polio. Twenty-five women aged 55-65 years were interviewed 2 to 4 times regarding their life course experiences and the meaning they assigned to aging. Field notes, audiotaped interviews, life course charts, and demographics were used in thethematic analysis that produced 5 themes: Bodies Change, Disrupted Meaning, The Unpredictibility of Aging, Slowing Down, and Changing Perspective. Overall, the findings indicate that the experiences of disability due to the result of paralytic polio could not be separated from the experiences of aging, which ultimately led the author to question policies that distribute and fund benefits based on age and disability status without an understanding of the varied experiences of women with disabilities.