An analysis of types and costs of health care services provided to an elderly inner-city population

Patterns of Health and Social Services Utilization

Utilization of an array of health and social services from formal and informal sources is studied here 1) to identify profiles of services utilization and 2) to predict the location of elderly in these profiles by a set of independent variables such as the sociodemographic characteristics of the elderly, their physical and mental health status and the density of their social support network. Two samples of non-institutionalized elderly living in two middle-sized towns were drawn from the universal old-age Canadian pension scheme. Their utilization of hospital, medical and pharmaceutical services was assessed, and their use of services for help with adivities of daily living was measured by a set of six indicators. A cluster analysis was run to identify profites of services utilization, and a discriminant analysis used the profiles as the criterion to be predicted by a set of variables. Five profiles of utilization were obtained; four of them identified elderly with very few experiences of services utilization and a fifth, a low number of elderly with utilization of all of the services listed in this study. Most of the elderly were users of a small subset of medical and social services. The location of elderly in the profiles was predicted by physical health status, coresidence and income. These results show that health and social services from both formal and informal sources are utilized by elderly. It is suggested that new types of formal agencies which consider the simultaneous delivery of social and health services will succeed inasmuch as they have the ability to interact with a system of informal care.

When the patient cannot come to the doctor: a medical housecalls program

OBJECTIVES

To describe a medical housecalls program and to assess its ability to meet the medical needs of homebound patients. PROGRAM STRUCTURE: The housecalls program is part of a larger ambulatory practice situated in a senior center staffed by geriatricians and nurse practitioners. The practice serves as the major teaching site of outpatient geriatrics for a medical residency program. Scheduled visits are made every 3 to 4 months, and unscheduled visits are made weekday days for acute problems.

PARTICIPANTS

Patients are eligible for the housecalls program if they live within a 15- minute drive of the center and are unable to leave their home.

PROGRAM EVALUATION

The majority of the 71 patients in the housecalls program between 1993 and 1995 were female (81%), aged 85 years or older (52%), and dependent in one or more activities of daily living: 65% were dependent in bathing and 42% in dressing. A substantial minority (16%) had severe cognitive impairment. Patients received a mean of 5.0 visits per patient-year. The majority of patients (59%) were treated at home for an acute illness or symptom ranging from upper respiratory tract infections to pneumonia and congestive heart failure. Approximately one-quarter of the patients or their proxies elected to avoid hospitalization; several of these patients had complex illnesses managed in their homes.

CONCLUSIONS

A wide range of medical problems can be addressed in patients' homes. Because our patients could not leave their homes easily, or at all, it is probable they would not have received routine medical care and would have used the emergency room for evaluation of acute problems if the housecalls program were not available. Despite their potential value in the care of frail older patients, housecalls will likely not become a widespread practice until barriers to their performance cited by physicians are addressed.

Predictors of formal home health care use in elderly patients after hospitalization

OBJECTIVE

To prospectively study the incidence of and risk factors for home health care (HHC) use in a cohort of elderly medical and surgical patients discharged from acute care. Although HHC is commonly received by patients in this group, its predictors have not been well studied.

DESIGN

Prospective cohort study.

SETTING

Medical and surgical wards at a university teaching hospital, followed by 23 Medicare-certified HHC agencies in the study catchment area.

PATIENTS

226 medical and surgical patients aged 70 years and older immediately after discharge from acute care.

MEASUREMENTS

HHC initiated within 14 days after hospital discharge, measured by direct review of HHC agency records.

RESULTS

The incidence of HHC initiated within 2 weeks post-discharge was 75/226 (34%). The median duration of service was 30 days (range 3-483) with a median of 3 visits per week. Four independent predictors of HHC were identified through multivariate analysis: educational level < or = 12 years (relative risk (RR) 3.3; 95% confidence interval (CI) 1.6 to 6.6); less accessible social support (RR, 1.7; CI 0.9 to 3.1); impairment in at least one instrumental activity of daily living (RR, 1.9; CI, 1.0, 3.4); and prior HHC use (RR, 2.1; CI, 1.2 to 3.6). Risk strata were created by adding one point for each risk factor present: with 0-1 risk factors, 8% used HHC; with two risk factors, 28%; with three risk factors, 45%, with four risk factors, 76%. This trend was statistically significant (P < 0.001).

CONCLUSIONS

HHC use is common among elderly patients after discharge from acute care. A simple predictive model based on four risk factors can be used on admission to predict HHC use. This model may be useful for discharge planning and health care utilization planning for the elderly population.

The impact of new technologies in primary health care

This article surveys the gradual diffusion of diagnostic technologies into homes in Sweden. The author speculates on the advantages and prospective problems of home care. In addition, the article proposes some general guides to assure that new technologies provide genuine benefits for the patient.

Evaluation research in long-term care. Scope and methodology

Several policy issues pertaining to long-term care (LTC) were assessed, and they include (1) What are the cost-effective alternatives in long-term care? (2) What are the major societal and individual factors that are amenable to program interventions for reducing unnecessary and inappropriate institutionalization of the chronically ill? (3) What are the critical elements of a successful evaluation research design in long-term care? (4) How can LTC research findings be transmitted into policy relevant guides for program planning and development? The strengths and weaknesses of a variety of evaluation designs in long-term care research were discussed.

Freedom, dependency, and the care of the very old

Difficulties exist in making treatment decisions for the very old and dependent patient. In the years to come, these difficulties will increase. It is argued that such persons should not be abandoned to their "rights" as autonomous persons; yet quality of life judgments should also be avoided except in limited circumstances. Since aging is a process of becoming more dependent, the author proposes a dependency rule, by which greater responsibility for treatment decisions falls on care-givers as a person's dependency increases. In place of quality of life judgments he suggests a medical indications policy, if the latter includes restoration of some affective function. Five kinds of freedom are proposed, of which only some are lost in chronic illness and old age. Finally, it is suggested that life itself involves greater interdependence than the autonomy criterion itself can allow. The author focuses on the problem of dependency in the aged and the role an increase in this dependency plays, with corresponding loss of personal autonomy, in quality of life judgments. These, in turn, form the basis for treatment decisions.

Hospital use by the extremely elderly (nonagenarians): a two-year study

Eighty-seven community-dwelling nonagenarians provided with extensive medical and social services as needed were followed for two years. Fifty-one subjects were admitted to an acute care hospital at least once. Total durations of hospitalization for those who required it averaged 44 days per individual over the two years. This represents about 13 hospital days per year per nonagenarian . Since it is likely that few, if any, hospitalizations would have been preventable by additional services, these data suggest that at a minimum one hospital bed would be continuously occupied for every 28 persons of this age and of this degree of infirmity . In these times of fiscal restraint it is especially important that the government and third-party payers determine the level of funding for expensive services such as acute hospitalization by assessing the needs of those who use them.