Concurrent and long-term predictors of older adults' use of community-based long-term care services: the Caregiver Health Effects Study

Exploring barriers to and facilitators of the implementation of home rehabilitation care for older adults with disabilities using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

With global aging on the rise, the number of older adults with disabilities was also increasing exponentially. There has been growing international interest in home rehabilitation care as a new method for older adults with disabilities.

METHOD

The current study is a descriptive qualitative study. Guided by the Consolidated Framework for Implementation Research (CFIR), semistructured face-to-face interviews were performed to collect data. The interview data were analyzed using a qualitative content analysis method.

RESULT

Sixteen nurses with different characteristics from 16 cities participated in the interviews. The findings highlighted 29 implementation determinants of home-based rehabilitation care for older adults with disabilities, including 16 barriers, and 13 facilitators. These influencing factors aligned with all four CFIR domains that were used to guide the analysis and 15 of the 26 CFIR constructs. More barriers were identified in the CFIR domain of characteristics of individuals, intervention characteristics, and the outer setting, while fewer barriers were identified in the inner setting.

CONCLUSION

Nurses from the rehabilitation department reported many barriers related to the implementation of home rehabilitation care. They reported facilitators to the implementation of home rehabilitation care despite the barriers, which provided practical recommendations for directions to be explored by researchers in China and elsewhere.

Predictors of health service use by family caregivers of persons with multimorbidity

BACKGROUND

Informal caregivers of patients with multiple chronic conditions are socially good, promoting the sustainability of a large part of home care provision. However, this very demanding activity causes health problems that increase their own need for health services. This study analyses the use of health services by informal carers, comparing it with the use made by the general population with similar characteristics.

METHODOLOGY

Cross-sectional analytical study carried out in the Malaga-Valle Guadalhorce Primary Health Care District (Spain). Healthcare demand and perceived health were measured in the family caregivers, compared to the general population. Strobe Statement for observational studies has been used to strength the report of the results.

RESULTS

Final sample consisted of 314 family caregivers together with a subsample of 2.290 non-caregivers taken from data of the National Health Survey. This subsample was paired by gender with our sample. Formal caregivers make fewer annual visits to the health services, with respect to the general population, regardless of the perceived level of health. The difference of the means between those who perceive their health as very poor was 0.11 (95% CI: 0.01 to 0.20) consultations with the family doctor, 0.21 (95% CI: 0.15 to 0.26) consultations with medical specialists and 1.70 (95% CI: 1.52 to 1.87) emergency room attention. Three independent factors were identified that predispose to the increased use of health services: background of greater education achievement (OR 8.13, 95% CI: 1.30 to 50.68), non-cohabitation with the care recipient (OR 3.57, 95% CI: 1.16 to 11.11) and a more positive physical quality of life component (OR 1.06; 95% CI: 1.03 to 1.09).

DISCUSSION AND IMPLICATIONS

Intrinsic components of the caregiver reveal their independent relationship with the provision of informal care and the use of health services. A broader vision is needed for the factors that influence the health of these caregivers to develop multipurpose interventions and improve the consistency and effectiveness of the health services offered to the caregiver.

Evaluation of Reablement Home Care: Effects on Care Attendants, Care Recipients, and Family Caregivers

Background: The traditional home care model entails caring “for” people with disabilities, not “with” them. Reablement care has been applied to long-term care, but the evidence for care attendants, home care recipients, and family caregivers simultaneously is limited. Methods: First, a survey was conducted to explore the needs of home care recipients and family caregivers to achieve independence at home to develop the reablement home care model for home care. Then, an intervention with two groups was implemented. The experimental group included a total of 86 people who participated in the reablement home care model. The control group included 100 people and received usual home care. The self-reliance concept, job satisfaction, and sense of achievement for care attendants; quality of life for home care users; and caregiving burden for family caregivers were assessed. Results: The reablement home care model improved the job satisfaction and achievement of home care attendants, improved mutual support and independence in the self-reliance concept and quality of life among the users, and reduced the stress of the users and family caregivers. Conclusion: The reablement home care model improved the outcomes for providers, care recipients, and family caregivers. Reablement home care is suggested in long-term care policies.

Geriatric Assessment Predicts Hospitalization Frequency and Long-Term Care Use in Older Adult Cancer Survivors

PURPOSE

The association between geriatric assessment (GA)-identified impairments and long-term health care use in older cancer survivors remains unknown. Our objective was to evaluate whether a GA performed at cancer diagnosis was predictive of hospitalizations and long-term care (LTC) use in older adult cancer survivors.

METHODS

Older adults with GA performed between 3 months before through 6 months after diagnosis were included (N = 125). Patients with Medicare Parts A and B coverage and no managed care were identified. Hospitalizations and LTC use (skilled nursing or assisted living) were assessed up to 5 years postdiagnosis. GA risk measures were evaluated in separate Poisson models estimating the relative risk (RR) for hospital and LTC visits, adjusting for age and Charlson comorbidity score.

RESULTS

The mean age of patients was 74 years, and the majority were female (80%) and white (90%). Breast cancer (64%) and early-stage disease (stages 0 to III, 77%) were common. Prefrail/frail status (RR, 2.5; P < .001), instrumental activities of daily living impairment (RR, 5.47; P < .001), and limitations in climbing stairs (RR, 2.94; P < .001) were associated with increased hospitalizations. Prefrail/frail status (RR, 1.86; P < .007), instrumental activities of daily living impairment (RR, 4.58; P < .001), presence of falls (RR, 6.73; P < .001), prolonged Timed Up and Go (RR, 5.45; P < .001), and limitations in climbing stairs (RR, 1.89; P < .005) were associated with LTC use.

CONCLUSION

GA-identified impairments were associated with increased hospitalizations and LTC use among older adults with cancer. GA-focused interventions should be targeted toward high-risk patients to reduce long-term adverse health care use in this vulnerable population.

Fall determinants and home modifications by occupational therapists to prevent falls: Facteurs déterminants des chutes et modifications du domicile effectuées par les ergothérapeutes pour prévenir les chutes

BACKGROUND

Approximately one third of older people over 65 years fall each year. Home modifications may decrease occurrence of falls.

PURPOSE

This study aims to determine the risk factors of falls for frail older persons and to evaluate the impact of home modifications by an occupational therapist on the occurrence of falls.

METHOD

We conducted a longitudinal study using a quasiexperimental design to examine occurrence of falls. All participants 65 years of age and older and were assessed at baseline and 6 months after the intervention. Bivariate analysis and logistic regression models were used to study the risk factors of falls and the effect of home modifications on the incidence of falls.

FINDINGS

The main predictors of falls were vision problems, distress of informal caregiver, and insufficient informal support. Home modifications provided by an occupational therapist showed a significant reduction of falls.

IMPLICATIONS

Informal caregivers and their health status had an impact on the fall risk of frail older persons. Home modifications by an occupational therapist reduced the fall risk of frail older persons at 6-months follow-up.

Burden and Quality of Life of Family Caregivers of Stroke Patients

The purpose of this study was to identify the level of burden and quality of life of family caregivers of stroke patients and to investigate the correlation between burden, quality of life (including physical, social, psychological, and environmental domains), age of caregivers, and the care period. A descriptive correlational cross-sectional study was performed, with a convenience sample of family caregivers (n = 30) of stroke patients in São Paulo, Brazil. Data were collected using a questionnaire on participants' characteristics, the Zarit Burden Interview Scale (ZBIS), and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) instrument. A descriptive analysis was performed, and correlations between variables were analyzed using Pearson's product-moment correlation coefficient. The average burden score on the ZBIS was 29.6, representing a moderate burden, and the average overall quality of life score on the WHOQOL-BREF was 62.06%, which indicates moderate quality of life. A significant weak negative correlation was observed between burden and environmental domains (r = -0.470; p =.009), quality of life (r = -0.414; p =.023), and physical domains (r = -0.394; p =.031). No significant correlations were found between burden and quality of life, and variables in the psychological and social domains, age of caregivers, or care period. Caregivers for stroke patients presented with moderate levels of burden and reduction in quality of life. Levels of burden correlated negatively with environmental domains, quality of life levels, and physical domains; however, these correlations were weak, indicating the possible interference of other factors.

Meeting the mental and physical healthcare needs of carers

The health of family carers may affect not only their own lives but also the lives of the people for whom they provide care. This article describes how the caring role can affect the health and well-being of a carer of a person who has a mental or physical disorder. Suggestions are made about how to recognise and ameliorate some of the detrimental effects of the caring role on the carer's own health.

Formal Alternative Transportation Options for Older Adults: An Assessment of Need

This study measured the need for formal alternative modes of transportation among older adults by applying traditional factors of the Behavioral Model. Survey participants who regularly drove were compared to those who could no longer drive. Race/ethnicity and self-reported health were significant predictors of perceived need for transportation services for both groups. However, income and service awareness were significant predictors only for drivers, while family proximity was a significant predictor only for non-drivers. Results suggest the importance of gaining a better understanding of the factors associated with need for senior-focused transportation services to more effectively plan such programs.

Trajectories of Community-Based Service Use: The Importance of Poverty and Living Arrangements

This study examined how older adults' living arrangements and poverty status affected their use of in-home health, functional, and out-of-home services over time. Using eight waves of data from the Korea Welfare Panel Study, we employed a logistic mixed-effect model to analyze how poverty and living arrangements affect community-based service use. Living-alone older adults and elder-only couples were more likely than co-residing households to use services. Elder-only couples, when poor, were more likely to use in-home and out-of-home services over time. Understanding predictors of community-based service use over time enables researchers and policymakers to better understand the process of aging-in-place.

A Influência das Características dos Prestadores e dos Utentes no Consumo de Recursos em Unidades de Cuidados Continuados

<b><i>Introdução:</i></b> O envelhecimento populacional, o aumento da prevalência de doenças crónicas e de multipatologia, são fenómenos que encontraram novas respostas com a criação da Rede Nacional de Cuidados Continuados Integrados (RNCCI) em Portugal, a partir de 2006. É esperado que esta estrutura adicional de oferta de cuidados permita contribuir para a criação de valor aos seus utentes. <b><i>Objetivo:</i></b> O presente estudo teve como objetivos estimar o consumo de recursos medido através da duração de internamento em unidades de internamento em cuidados continuados (UICC) em Portugal e analisar a associação com as características dos utentes e dos prestadores de cuidados. <b><i>Método:</i></b> Foi realizado um estudo transversal e retrospetivo, que utilizou informação da atividade das unidades da RNCCI entre 2010 e 2012. Recorreu-se a modelos de regressão lineares múlti­plos, utilizando a duração de internamento como variável dependente e, como preditores, variáveis representativas das características individuais dos utentes e dos prestadores. <b><i>Resultados:</i></b> Para os 30.090 episódios incluídos, a duração média de internamento foi de 34,2 dias nas unidades de convalescença, 84,1 dias nas unidades de média duração e reabilitação e 106 dias nas unidades de longa duração e manutenção. A dispersão da duração de internamento foi elevada em todas as tipologias e regiões. Isoladamente, as variáveis associadas às características dos utentes apresentaram capacidade preditiva muito reduzida. A inclusão das variáveis associadas à organização da oferta de cuidados aumentou a capacidade do modelo explicar a variabilidade do tempo de internamento dos utentes. <b><i>Conclusão:</i></b> Os resultados do modelo de regressão linear múltipla sugerem que são as características associadas à oferta de cuidados que apresentam maior relevância para explicar a variabilidade da duração de internamento em cuidados continuados. Sugere-se que futuros desenvolvimentos incluam melhorias nas práticas de registo e a implementação de um sistema de classificação de utentes específico, internacionalmente validado para a estratificação do risco em cuidados continuados.

Certified Nursing Assistants Balancing Family Caregiving Roles: Health Care Utilization Among Double- and Triple-Duty Caregivers

PURPOSE OF THE STUDY

This study examines how certified nursing assistants (CNAs) balancing family caregiving roles-child care (double-duty child caregivers), elder care (double-duty elder caregivers), and both child and elder care (triple-duty caregivers)-utilize health care services relative to nonfamily caregiving counterparts (formal-only caregivers).

DESIGN AND METHODS

A sample of 884 CNAs from the Work, Family and Health Study was drawn on to assess the number of acute care (i.e., emergency room or urgent care facility) and other health care (i.e., outpatient treatment or counseling) visits made during the past 6 months.

RESULTS

Double-duty elder and triple-duty caregivers had higher acute care utilization rates than formal-only caregivers. CNAs with and without family caregiving roles had similar rates of other health care visits.

IMPLICATIONS

CNAs providing informal care for older adults have higher acute care visit rates. Given the increasing need for family caregivers and the vital importance of the health of the nursing workforce for the health of others, future research on how double- and triple-duty caregivers maintain their health amidst constant caregiving should be a priority.

Community-Based Long-Term Care Services

Objective: This study examines the relationship between caregivers’ perception of community-based long-term care (CBLTC) services and the service use. Method: We used first two waves of the longitudinal data set of 1,416 dyads of care recipients and their caregivers in Singapore. Four perceived attributes of LTC services—service quality, convenience, social connectedness, and affordability—were measured on a 5-point scale. Results: Among the four perceived attributes, perceived affordability was significantly associated with future utilization for all types of CBLTC services. Perceived service quality and convenience was significantly associated with center-based LTC services use. Discussion: Caregivers are critically involved in the decision of using CBLTC services, and their perception of service characteristics is significantly associated with the uptake of CBLTC services. It is important to incorporate both care recipients’ and caregivers’ needs and preferences when designing and promoting integrated health care delivery models.

Individual and Contextual Determinants of Social Homecare Usage in Slovenia

THEORY

Social homecare is important for older people, as it enables them to remain in their own homes during worsening health, thus relieving the burden on institutional facilities such as homes for the elderly or nursing homes and hospitals.

METHOD

A representative survey of social homecare users was employed to assess determinants of the scope of social homecare in Slovenia. Multiple regression analysis was used to evaluate determinants defined by Andersen's behavioral model that affect the scope of social homecare.

RESULTS

As expected, need (Functional impairment B = .378, P = 0.000) was the most important explanatory component, followed by availability of informal care network (Lives alone B = -.136, P = 0.000; Has children B = - .142; P = 0.000) and other contextual factors such as total costs of the services (B = -.075; P = 0.003) and temporal availability of services (B=-.075, P=0.012). The model explained 18% of variability in the scope of social homecare.

CONCLUSION

This study showed that data on the individual level, as opposed to data on an aggregated level, show different determinants of social homecare utilization. Moreover, the results showed that social homecare is especially important in two circumstances: when older people have a high level of need and when they do not have access to informal care networks. Contextual factors had a moderate effect on the scope of social homecare, which shows universal access to the latter at the individual level.

Use of health and social care services in a cohort of Italian dementia patients

The aim of this study, conducted in the Region of Lazio, Italy, in 2008-2010, was to describe the use, over a one-year period, of health and social care services in a cohort of 712 patients with a diagnosis of dementia. These patients had never previously used such services. We evaluated the association between the patients' sociodemographic and clinical characteristics and their use of services. Sociodemographic and clinical data were collected at baseline using validated instruments, while the use of services was investigated at the end of the one-year follow-up through a structured (questionnaire-based) interview with the caregiver. We found that 11.9% of patients used health or social care services. The most frequent diagnoses were: Alzheimer's disease (72.1%), mixed dementia (20.5%), and vascular dementia (9.7%). A higher probability of use of services was observed in patients with: more than five years of schooling (OR=1.79; 95%CI:1.08-2.96); one or more comorbidity (OR=4.87; 95%CI:2.05- 11.57); severe (OR=4.78; 95%CI:1.75-13.06) or moderate dementia (OR=2.08; 95%CI:0.98-4.40). The low health and social care service use among dementia patients in this study could be explained by a lack of availability of services. Public health authorities should plan adequate networks of services, considering both patients and caregivers' needs.

Formal and informal support of family caregivers managing medications for patients who receive end-of-life care at home: a cross-sectional survey of caregivers

BACKGROUND

Managing medications is a complex responsibility of family caregivers caring for end-of-life patients. This study characterizes caregivers with and without formal/informal support managing medications for patients who receive end-of-life care at home.

AIM

To explore factors related to caregivers' support with managing medications for end-of-life home hospice patients.

DESIGN

A convenience-sampled, cross-sectional telephone survey.

SETTING/PARTICIPANTS

Computer-assisted telephone interviews were administered to 120 caregivers managing medications, who were referred by five Chicago-based home hospice services. We measured caregivers' additional formal (paid) and informal (unpaid) support with managing medications, and caregiver/patient socio-demographic, relational, and health characteristics.

RESULTS

While 47 (39%) had no additional support with managing medications, 27 (22.5%) had formal support, 37 (31%) informal, and 9 (7.5%) both. Seven caregivers (19%) with formal and 13 (31%) with informal support reported disagreements concerning treatment plans. Caregivers lacking formal support tended to be racial/ethnic minorities, live with the patient in their home, or report greater emotional burden. Caregivers with formal support tended to report higher education/income, lower mutuality, or care for a patient with over 6 months' hospice enrollment. Caregivers lacking informal support tended to be spousal caregivers, live with the patient, or have experience caring for another dying person.

CONCLUSION

Our study suggests that high proportions of caregivers may not have support managing medications for patients receiving hospice care at home. More research should examine whether the observed variations in obtaining support indicate disparities or unmet needs among caregivers. Disagreement about treatment with formal/informal support also warrants further investigation.

Identifying the Potential for Robotics to Assist Older Adults in Different Living Environments

As the older adult population grows and becomes more diverse, so will their needs and preferences for living environments. Many adults over 65 years of age require some assistance [1, 2]; yet it is important for their feelings of well-being that the assistance not restrict their autonomy [3]. Not only is autonomy correlated with quality of life [4], autonomy enhancement may improve functionality [2, 5]. The goal of this paper is to provide guidance for the development of technology to enhance autonomy and quality of life for older adults. We explore the potential for robotics to meet these needs. We evaluated older adults' diverse living situations and the predictors of residential moves to higher levels of care in the United States. We also examined older adults' needs for assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and medical conditions when living independently or in a long-term care residence. By providing support for older adults, mobile manipulator robots may reduce need-driven, undesired moves from residences with lower levels of care (i.e., private homes, assisted living) to those with higher levels of care (i.e., skilled nursing).

Systematic review of occupational engagement and health outcomes among community-dwelling older adults

We conducted this systematic review, one of four related to productive aging, to explore the existing evidence for the health benefits of engagement in occupations and activities among older adults. The review incorporates the breadth of areas of occupation in which older adults engage and the range of health benefits derived from that engagement. The results of this review demonstrate the multidisciplinary appreciation for occupational engagement and associated well-being and elucidate the health effects of engagement in a wide variety of occupations and activities. Additionally, the results of this systematic review support occupational therapy's historical ideologies and core philosophies linking occupational engagement to improved health and well-being. The findings suggest an increasing role for occupational therapy service delivery in community-based health promotion and prevention efforts to meet the everyday activity and health needs of the growing older adult population.

Factors influencing the resilience of carers of individuals with dementia

Most individuals with dementia live in the community, receiving care from family or lay carers. Carers’ wellbeing, and the quality of the care they provide, depends on their resilience in the face of the challenges associated with caring for someone with dementia. However, factors associated with carers’ resilience are not yet fully understood. The aim of this review is to present a narrative synthesis of factors, materials and resources associated with carers’ resilience. Electronic and hand searches identified relevant published literature, which was narratively synthesized. A framework consisting of three inter-related domains of factors influencing carers’ resilience emerged, encompassing: social and cultural factors; properties of the care relationship; and carers’ psychological factors. Holistic assessment based on this framework can help practitioners to identify vulnerable carers and to target help on factors that help to make them vulnerable but that are amenable to change.

Health care utilization among homebound elders: does caregiver burden play a role?

OBJECTIVE

To describe informal caregiver and patient characteristics associated with high caregiver burden in homebound elders and to examine associations between high caregiver burden and patient health care utilization at the practice level.

METHOD

We used a cross-sectional and prospective cohort design to study 214 caregiver-patient dyads in a home-based primary care program.

RESULTS

Informal caregivers with the highest burden were more likely to help with more activities of daily living and instrumental activities of daily living and spend >40 hr/week in caregiving. Patients whose caregivers experienced the highest burden were more likely to be non-White males without 24-hr paid homecare. There were no significant independent associations between high burden and high calls, high visits, or social work involvement.

DISCUSSION

In this medically complex and highly dependent population, further study of how families and other caregivers impact health care utilization is needed.

Utilization of long-term care services under the public long-term care insurance program in Korea: Implications of a subsidy policy

OBJECTIVES

South Korea introduced public long-term care insurance (LTCI) in 2008. This study examined the patterns of and factors associated with public long-term care (LTC) utilization among older LTCI beneficiaries in Korea, with special attention to the policy for subsidizing the co-payments of lower income populations.

METHODS

Using a 5% national representative sample of 280,290 older people aged 65 or older obtained from the 2010 national LTCI claims database, we examined socio-demographic and health factors associated with service utilization decisions, service type chosen, and the intensity of service use.

RESULTS

About 5.48% of older adults in 2010 utilized the LTC provided under the Korean public LTCI, among which about 26.1% received a subsidy. Compared to their counterparts, the subsidized users were more likely to be low-income, female, and living alone. They were more likely to choose institutionalized care and spend to their monthly benefit limit while paying a lower co-payment. The factors associated with pattern and intensity of LTC utilization were not the same between subsidized and non-subsidized users.

CONCLUSION

The findings imply the subsidy policy promotes equity of access to public LTC services. Further evaluation is necessary on the impact of the policy on the effectiveness of LTC utilization by socially marginalized populations.

Facilitators of home and community-based service use by urban African American elders

OBJECTIVE

To examine the factors associated with urban African American elders' utilization of home and community-based services and explore whether these factors differ by category of service.

METHODS

Data came from a representative sample of 1,099 African American older adults living in Detroit. Logistic regression models were used to explore the predisposing, enabling, and need factors associated with any service use and five categories of service use: in-home care, household services, functional care, out-of-home services, and financial/legal services.

RESULTS

Findings suggest that previous studies using the Andersen model may not be generalizable to an urban African American population. Service use was related primarily to enabling resources, particularly in terms of financial resources, not driving a car, and social resources and support. Future research should further examine the facilitators and barriers to service use by urban African Americans to improve their access to care.

Why do patients and their families not use services for dementia? Perspectives from a developed Asian country

BACKGROUND

Despite the need for community services to support the intensive levels of care provided by dementia family caregivers, findings consistently indicate low rates of service utilization. This study aims to explore the extent of service use and examine the factors that may influence the use of services in a sample of family caregivers of Persons With Dementia (PWD).

METHODS

Two hundred and seventy-two family caregivers completed a questionnaire assessing caregiver burden, knowledge and use of services, dementia severity, frequency of problem behaviors and socio-demographic characteristics.

RESULTS

The rate of service use was modest with 39.9% using any of the available services. Reasons for non-use included lack of time (26.2%), perceived lack of need (18.5%), and presence of domestic help (21%). Separate regression models were evaluated to identify factors associated with caregiver service use and PWD service-use. Caregiver employment status (OR = 0.53, CI = 0.30-0.94) and knowledge of available services (OR = 4.22, CI = 2.23-7.98) contributed significantly to the model distinguishing caregiver service users from non-users. Knowledge of available services (OR = 2.14, CI = 1.23-3.71) was the only significant predictor of service use targeted at the PWD.

CONCLUSIONS

Given that knowledge significantly increased the odds of service use, strategies should be designed to raise awareness about the availability of dementia support services in the community and provide a deeper understanding about the value of such services. Future research should employ larger sample sizes and explore factors not measured in this study that might potentially better explain use of services.

Is use of formal community services by older women related to changes in their informal care arrangements?

This paper examines how the relationships between the factors (predisposing, enabling and illness) of the 1973 Andersen framework and service use are influenced by changes in the caring role in older women of the 1921–26 cohort of the Australian Longitudinal Study on Women's Health. Outcome variables were the use of three formal community support services: (a) nursing or community health services, (b) home-making services and (c) home maintenance services. Predictor variables were survey wave and the following carer characteristics: level of education, country of birth, age, area of residence, ability to manage on income, need for care, sleep difficulty and changes in caring role. Carer changes were a significant predictor of formal service use. Their inclusion did not attenuate the relationship between the Andersen framework factors and service use, but instead provided a more complete representation of carers' situations. Women were more likely to have used support services if they had changed into or out of co-resident caring or continued to provide co-resident care for a frail, ill or disabled person, needed care themselves, and reported sleep difficulties compared with women who did not provide care. These findings are important because they indicate that support services are particularly relevant to women who are changing their caring role and who are themselves in need of care.

Social Support Networks and Expectations for Aging in Place and Moving

This study investigated the relationship of social support networks with expectations for aging in place and moving in a sample of relatively healthy, community-dwelling adults ( N = 4,611). Results indicated that those with aging in place expectation and those with moving expectation were comparable in sociodemographics, self-rated health, and social support networks. Knowledge of home- and community-based services (HCBS) availability was associated with respondents reporting an older age at which they expected regular help and moving. When compared with those who did not offer an age prediction, knowledge of HCBS availability, information sources for personal care, and social activity engagement were important in understanding the choices of age ranges at which respondents expected to age in place and to move. Findings point to the importance of expanding social support networks, providing opportunities for social activity, and strengthening information networks with the emphasis on targeting older adults and their caregivers.

Service use barriers differentiating care-givers' service use patterns

This study describes what types of service use barriers older adults' informal care-givers perceive and examines how these barriers differentiate care-giver service use patterns. Analysing the 2004 National Long-Term Care Survey and Informal Care-giver Data Set (N=1908) in the United States of America, this study reports the prevalence of service barriers for each type of service as well as for overall service use. Service barriers are measured in terms of availability, awareness, affordability, staff quality, privacy violation, complex bureaucracy, language barriers, qualification of each programme and no thought of service. Andersen's health behaviour model guides determinants related to care-giver service use patterns. As a main outcome, care-giver service use patterns (light service users, selective in-home users, and multiple service users) are examined in relation to service use barriers when other predisposing, enabling and need variables are controlled. Of the ten service use barriers defined in this study, awareness and no thought of service are the most prevalent barriers. Care-givers reporting service barriers of availability, awareness and affordability are more likely to be light service users compared to multiple service users and selective in-home service users. These findings highlight the significance of enhancing awareness of care-giver supportive services as well as increasing availability and financial support for service use.

Willingness to Use Mental Health Services Among Older Residents in Assisted Living

Examining the importance of mental health care in assisted living (AL) settings, the present study examines older AL residents’ willingness to use mental health services and its predictors. Data based on face-to-face interviews with 150 older residents from 17 AL settings in Florida are used in the analyses ( Mage = 82.8, SD = 9.4). Multivariate logistic regression is used to estimate the likelihood of willingness to use mental health services in relation to predisposing (demographics and physical health), mental health needs (depressive symptoms), and enabling variables (social network, instrumental support, emotional support, informational support, satisfaction with support, and previous use of mental health services). Willingness to use mental health services is predicted by younger age, unmarried status, lower levels of emotional support, and higher levels of informational support. The relationship of informational support to higher willingness to use mental health services suggests that AL residents could benefit from educational interventions on late life depression.

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.

Predicting In-Home Respite Utilization by Family Caregivers of Older Adults: Results of a Community Study

This longitudinal study applies the behavioral model of health services use (Andersen, 1995) to the prediction of in-home respite utilization within the naturalistic context of ongoing respite services. Participants ( N = 74) were family caregivers who provided informal care for a physically and/or cognitively impaired older adult. All participants resided in the Midwest and received in-home respite services managed by an Area Agency on Aging and funded through the National Family Caregiver Support Program. The primary significant predictor of 3-month in-home respite utilization was the caregiving dyad’s past in-home respite usage. Contrary to prior research, demographic predisposing variables (relationship type, household income) and objective need variables (behavioral dysfunction, functional impairment) were not associated with hours of respite use over 3 months, nor was level of caregiver depressive symptoms. Implications of these data for case management, the provision of in-home respite services, and future research are discussed.

Transportation Difficulty of Black and White Rural Older Adults

The purpose of this study was to understand self-reported transportation difficulty among rural older adults. We used data from the UAB Study of Aging (255 Black and 259 White), community-dwelling participants residing in rural areas. We examined the relationship of predisposing characteristics, enabling resources, and measures of need for care with self-reports of transportation difficulty. Blacks reported having more transportation difficulty than Whites (24.7% vs. 11.6%; p ≤ .05). When we introduced other variables, race differences disappeared, but there was a race by income interaction with transportation difficulty. Whites with lower incomes were more likely to have transportation difficulty than Whites with higher incomes. When data from Blacks and Whites were analyzed separately, income was the only variable associated with transportation difficulty among Whites. Among Blacks, income was not related to transportation difficulty but several variables other than income (age, gender, marital status, MMSE scores and depression) were.

Unmet needs and depressive symptoms among low--income older adults

Previous studies have found that declining health, decreased social interaction, and inadequate financial resources were significant risk factors for late-life depression, and social support from families and friends and religiosity were significant protective factors. In this study, we examined if low-income older adults' perceived unmet need for home- and community-based services for many aging-associated problems would be independently associated with their depressive symptoms, controlling for these known risk and protective factors. We interviewed a total of 213 community-residing older adults to assess their depressive symptoms, using the Geriatric Depression Scale (GDS), and unmet needs in the areas of personal assistance, instrumental and environmental support, emotional support, and other facilitative/enabling services. We found that the number of unmet needs was significantly positively associated with these older adults' depressive symptoms, although it explained only a small proportion of the variance of the GDS scores. Future research and practice implications are discussed.

Understanding patterns of service utilization among informal caregivers of community older adults

PURPOSE

The article seeks to identify patterns of service utilization among informal caregivers of frail older adults. In particular, the study examined determinants that explain heterogeneous variations in caregivers' service use patterns.

METHODS

Using a latent class analysis (LCA) on the 2004 National Long-Term Care Survey and Informal Caregiver data (n = 1,908), this study classifies overall patterns of caregiver service utilization: financial information, support group, respite service, day care or senior center, personal or nursing care, housework, meal delivery, transportation, house modification, and assistive devices. With an emphasis on caregivers' service use patterns and social network derived from the Network Episode Model, the modified Andersen model guides determinants of these patterns.

RESULTS

The LCA classified a hierarchical structure of service use patterns: multiple service users, selective in-home service users, and light service users. Caregivers' network compositions signified heterogeneity in service use patterns. Care recipient- and caregiver-related needs contributed to distinguishing service use patterns.

IMPLICATIONS

Differentiation of services may be important for meeting caregivers' needs and distributing program resources by identifying target populations for intervention. This typology process may tailor specific interventions to better support caregivers.

Family influence on caregiver resistance, efficacy, and use of services in family elder care

This research investigated how resistance to use of services attributed to family members and primary caregiver self-efficacy and resistance influenced actual use of services. Data were analyzed from questionnaires completed by 224 persons engaged in informal elder care in the community. Tests of 6 hypotheses revealed that family influence on caregivers had a consistent, important influence on behavior and views of caregivers. Family resistance to use of formal services framed caregivers' feelings, preferences, and decisions ranging from their own perceived self-efficacy to actual obtainment of help outside the family. Professionals must include family members in their dialogue with primary caregivers about their plans for elder care. Suggestions for interventions to better understand family and caregiver resistance are discussed.

The influences of gender and religiousness on Alzheimer disease caregivers' use of informal support and formal services

Objective. This study explored how male and female family caregivers of Alzheimer's disease (AD) patients differ in their use of formal services and informal support and how religiousness may affect such differences. Methods. Data were from a sample of 720 family caregivers of AD patients who participated in the Resources for Enhancing Alzheimer's Caregiver Heath (REACH I) study sites in Birmingham, Boston, Memphis, and Philadelphia. Results. Female caregivers were less likely to use in-home services than males (M = 0.83 vs. M = 1.06, p < .01) but reported more use of transportation services (21.6% vs. 12.7%, p < .01) and more use of informal support (M = 13.9 vs. M = 10.7, p < .01). Mediation tests suggested that three measures of religiousness helped explain the relationship between gender and use of formal services and informal support. Discussion. These findings highlight the necessity to assess AD caregivers' religiousness to better understand their circumstances.

Use of home-based formal services by adult day care clients with Alzheimer's disease

OBJECTIVES

To explore the association between adult day care (ADC) attendance and utilization of home-based formal services among people with Alzheimer's Disease (AD).

METHODS

Data for this secondary analysis came from a longitudinal parent study of 457 subjects from 16 ADC programs and an Alzheimer's diagnostic center in metropolitan Chicago. We used the method of Generalized Estimating Equations to model the use of home-based formal services over time.

RESULTS

Adjusting for relevant covariates, more days of ADC use at each follow-up was associated with decreased use of home-based formal services (coefficient = .25, p< .0001). Older, unmarried caregivers who are children of the care recipients had lower use of home-based services.

DISCUSSION

Results suggest that ADC services may substitute for specific types of home-based formal services. The projected increase in AD prevalence over the next several decades warrants a clearer understanding of how people with AD use formal services.

Program and Policy Issues Affecting Home and Community-Based Long-Term Care Use: Findings from a Qualitative Study

This paper describes a qualitative study of factors affecting decisions about use of Medicaid-funded long-term care (LTC) services in Arkansas for the elderly (aged 65+), non-elderly adults with physical disabilities (aged 21-64), and adults with developmental disabilities (aged 18+). From focus groups with LTC service providers and key informant interviews with consumers and other decision-makers, three themes for improving LTC services emerged: (1) Leveling the playing field for home and community-based services (HCBS) and institutional services; (2) information dissemination and counseling; and (3) expanding services to meet unmet needs. Policy recommendations are made to improve access to HCBS.