Examining the efficiency of home care

The Influence of the End of Life on the Extent of Informal Help Received by Older Adults

This study examines the extent of informal help received in the home among the respondents to the Longitudinal Study on Aging. The focus is on the direct effects of health status on receiving informal help for activities of daily living (ADLs) and how receiving that informal help is influenced by proximity to death. The findings show that proximity to death is consistently related to receiving help from friends and relatives for those receiving help with basic and household ADLs. The findings also show how different dimensions of health status affect getting help. In addition to the effects of various dimensions of health status, some sociodemographic factors are important. The extent of informal help with basic and advanced ADLs increases with age, but socially isolated individuals (e.g., those living alone) receive substantially less help for all ADLs. Socioeconomic factors and race are for the most part unrelated to getting informal help.

What factors influence case managers' resource allocation decisions? A systematic review of the literature

OBJECTIVE

Case managers' decisions directly affect the amount and type of services individual clients receive, as well as overall home care program available resources. We know little about the resource allocation decision-making processes of case managers. The question guiding this review was, "What factors influence case managers' resource allocation decisions in home care?''

METHODS

The authors did a systematic literature review to answer the above question. After assessing the articles for inclusion, they assessed the quality (internal validity) of each included study. They described the characteristics of the studies and provided a synthesis of the findings of the primary studies.

RESULTS

Five qualitative and 6 quantitative articles met the inclusion criteria for this review. The findings of these studies are equivocal. Despite this, the authors were able to create a preliminary taxonomy of the factors that influence case manager resource allocation decisions. Despite evidence-based decision making receiving so much attention in contemporary health care literature, the authors found a near absence of reference to research use in the context of case manager decision making.

CONCLUSIONS

Currently, there are relatively few studies in the literature on the factors that influence, and how they are used in, case manager resource allocation decisions. Studies are often lacking in terms of conceptual clarity and theoretical framing. They are often not guided by theoretical frameworks and are not situated within the larger field of decision making or even within the clinical decision-making literature. These issues are impeding progress in this area.

The Relative Benefits and Cost of Medicaid Home- and Community-Based Services in Florida

PURPOSE

We compared inpatient days, nursing home days, and total Medicaid claims for five Medicaid-funded home- and community-based services (HCBS) programs for in-home and assisted living services in Florida.

DESIGN AND METHODS

We studied a single cohort of Medicaid enrollees in Florida aged 60 and older, who were enrolled for the first time in any of five Medicaid HCBS programs and who had at least one assessment (N=6,014). In this 3-year longitudinal study, we used a two-stage probit regression and ordinary least squares regression in order to test the independent effects of explanatory variables on outcomes and cost.

RESULTS

After controlling for differences in frailty, chronic health conditions, presence of dementia, and available caregiver, we found that Medicaid HCBS programs had a differential effect on hospital and nursing home utilization and cost.

IMPLICATIONS

Medicaid HCBS programs serve very impaired populations at a wide range of costs to Medicaid. The rates for Medicaid HCBS programs could be adjusted upward or downward in order to better reflect the level of need in each program. At the same time, providers could use titration techniques based on the relative costs of these needs in order to budget for the costs of meeting the needs of particular elders.

Assuring Quality Care: Exploring Strategies of Medicaid E&D Waiver Providers

Implementing quality assurance (QA) programs in unregulated non-institutional settings remains a challenge for home- and community-based service providers. A sample of 65 Elderly and Disabled (E&D) Waiver providers were presented with eight problem scenarios commonly found in homecare services. Each of the respondents was able to identify strategies they would use to recognize and address each problem. Findings suggest providers currently use multiple mechanisms as part of their overall QA program. Discussion focuses on the strengths of using multiple approaches and on increasing provider awareness of complementary QA strategies and reducing the reliance on staff report as a major QA strategy.

Practical considerations for maintaining independence among individuals with functional impairment

Social workers, gerontologists, and related health professionals must learn to recognize how aging, disability, and chronic illness affects individuals and their families' physical, psychological, and social functioning in order to develop effective interventions for their clients. This article discusses prevention strategies to help facilitate functional consequences of aging, including chronic illness and disease and offers suggestions for assisting clients to cope and manage the consequences of illness in frail elder adults.

Disability and home care dynamics among older unmarried Americans

OBJECTIVES

We describe how paid and unpaid home care hours received by older unmarried Americans change in response to disability dynamics. We test whether responses to disability declines and improvements are symmetric; that is, we test whether reductions in care hours that are due to disability improvements are of similar magnitude to increases in care hours that are due to disability declines.

METHODS

Using a national sample of older unmarried Americans, we examine changes in total hours, paid hours, and unpaid hours of care in response to declines and improvements in personal care (activities of daily living, or ADLs) and routine care (instrumental ADLs, or IADLs) disability. We model changes in the total hours of care received in the past month and jointly model changes in unpaid and paid hours, using Tobit models.

RESULTS

Changes in the total hours of care received respond to both increases and decreases in the count of ADL limitations and appear close to symmetric. In contrast, responses to IADL disability dynamics appear to be far less symmetric: Although increases in the count of IADL limitations are met with substantial increases in the total hours of care, decreases are not met with correspondingly large declines in care. The same general pattern is found for unpaid and paid care, and for Medicaid-funded home care.

DISCUSSION

Disability and care are not static constructs in old age. Older unmarried persons experience worsening, stabilizing, and recovery of function, and their care hours change accordingly. Evaluations of home care programs must be cognizant of such dynamic realities.

The family as provider of long-term care: efficiency, equity, and externalities

The passage of the baby-boom generation into old age raises the prospect of intense pressures on public programs benefiting the elderly, limiting any contemplated expansion of programs serving those needing sustained personal care. This necessitates consideration of comparative efficiency of alternative resources for elder care. I focus on two distinct aspects of such efficiency: productive--the relationship between inputs and outputs--and target--the coincidence of served and those viewed as needing services. I argue that for theoretical reasons family members, specifically children, may be more productive and efficient carers than paid helpers. Furthermore, even if no more efficient than formal providers, care provided by children reduces public expenditures on long-term care. In view of the value to society of children's caregiving activities, if a collective program of long-term care insurance were to be adopted, it should be configured to target its financing and benefits according to family composition.