A multivariate analysis of the predictors of long-term care placement

Impact of long-term care insurance on the health status of middle-aged and older adults

With the increase of aging population, long-term care insurance (LTCI) systems have become important for improving individuals' health. However, the effect of LTCI on health is unclear, especially in developing countries, owing to the lack of random policy shocks and comprehensive databases. This study investigates the Chinese LTCI pilot program, using four waves of the China Health and Retirement Longitudinal Study database (sample aged ≥45 years) from 2011 to 2018. The recent difference-in-differences approaches for staggered design, which are capable of dealing with the negative weights issue, are used to investigate changes in health status, measured by self-rated health (SRH), (instrumental) activities of daily living, self-rated depression, and cognition, in pilot and non-pilot cities before and after LTCI implementation. Long-term care insurance has a significant average effect on SRH improvement and a long-term positive effect on cognition for middle-aged and older populations. This study provides the first evaluation of LTCI policy on health outcomes using the recent difference-in-differences approaches. It provides evidence for the overall health improvement achieved through the LTCI and offers positive reinforcement and potential areas for improvement in establishing LTCI worldwide.

The disruption of the care chain: why do Lithuanian migrant home care workers return to their home country?

This study examined reasons for return migration among Lithuanian migrant home care workers who provided care to older adults abroad. In total, 13 interviews were conducted with a diverse sample of returnees. Using constant comparison, three major themes were identified. The first theme described the undocumented nature of the job as a reason to return. The emotional consequences of the job as well as its physically demanding aspects also were portrayed. The third theme addressed the increased awareness to possible losses and care needs brought by the job. Our findings stress the importance of the job characteristics of the worker as a push factor that results in the return of migrant workers to their home. The importance of the documentation status of the job and its precarious nature are discussed.

The prevalence of dementia: The confusion of numbers

The prevalence of dementia in American society is an important statistic. In order to allocate public dollars to both research and service programs designed for cognitively impaired persons and their families, and to aid policy makers at the community level in planning for services and facilities to meet the needs of their populations, accurate estimates of persons with dementia are critical. Inaccurate figures can lead to inefficiency in allocating resources at both the national and local levels, underutilization of resources resulting from overestimated demand, or barriers to access arising from excess demand for insufficient services.

Women's Views of Institutional Versus Community-Based Long-Term Care

Young, middle-age, and old women (N = 434) read factual descriptions of institutional and community-based care, and then made long-term care choices for elderly female targets with varying degrees of functional impairment, cognitive impairment, and informal support. Respondents also indicated what they would prefer in the target's situation. Results indicated that (1) community care was more positively perceived than institutional care, (2) only one-third had negative feelings about institutional care, (3) the greater the level of impairment the more likely institutional care was the preferred alternative, and (4) the less informal support a woman had the more likely that institutional care was the preferred care alternative. It was concluded that women's views of institutional care are not strongly negative, and that the availability of informal support is an even stronger predictor of long-term care choice for others or for the imagined self than is level of impairment. The implications of these findings for public policy are discussed.

Social Support Networks, Patient Status, and Institutionalization

The purpose of this research is to identify the relationship of social support to patients' functional status and institutionalization. Social support networks are considered as buffers between declines in physical functioning and risks of being institutionalized. Various dimensions of social support networks are investigated to determine if there are differential effects on the use of skilled nursing facilities. Multivariate analyses of data obtained from an experimental study of geriatric day care and homemaker services were performed. Findings show that social support plays an important role in mitigating the effects of deteriorative health status, and thus reduces the risk of being institutionalized. Furthermore, those who were most likely to improve in physical and mental functioning had stronger social support networks.

Adult Day Care and the Nursing Home

Adult day-care clients are compared with nursing home applicants who were reviewed and recommended for community or institution-based care. Social, health, and service-use characteristics are contrasted in order to identify factors that distinguish adult day care from nursing home care as an appropriate placement. Socioeconomic status, severity of physical disability, living arrangement, sensory impairment, use of in-home services, and days in the hospital tend to distinguish the groups. The groups are quite similar in demographic characteristics, mental status, frequency of out-patient physician visits, and number and types of diseases. The authors outline criteria that might be used to determine appropriate placement. They also point out the need for future research in order to draw comparisons among different types of adult day-care programs and to develop predictive models for service use and continuity of participation in adult day care.

Preferences for Care

This study investigates which care provider an elderly person living independently and aged 65 and older would prefer most should he or she be in need of such care. Four (hypothetical) care-need situations were distinguished, and respondents were requested to state their preference in each situation. In addition, the influence on these preferences of both individual and social characteristics of the elders and their previous experience with care was examined. A preference for informal care declines when the expected duration of care is extended and/or the person requires personal care. Previous experience with either formal or informal care increased the likelihood that that type of care would be preferred. Other predictive factors were age, gender, socioeconomic status, and the level of well-being. More research on the preferences of the older persons would enable health care professionals and government to adjust their policies to accommodate the wishes of the elders.

Getting Better and Getting Worse

This article examines change over 2 years in ability to perform 21 specific functions among Americans 70 years of age and over. Health change in old age is two-directional. Ability to perform specific functions improves for some and deteriorates for others. In addition, many individuals experience both types of functioning change at the same time—improvement in the ability to perform some functions and deterioration in ability to perform others. The covariates of functional improvement differ from those of functional loss. The return to functioning is most likely to occur when the overall functional status of the individual is higher, when the loss has been recent, and when the impairment is not severe. Decline in ability to perform specific functions is more likely when general health and functioning levels are lower and when a person has had a stroke, has arthritis, or has visual or auditory impairment. Age, race, and sex are related to the likelihood that functioning will deteriorate, but they have little effect on the likelihood of improvement.

Cognitive Impairment and Problem Behaviors as Risk Factors for Institutionalization

Data from the 1982 and 1984 National Long-Term Care Surveys are used to develop a predictive model for nursing home institutionalization that includes cognitive functioning and problem behaviors in addition to more commonly studied indicators such as disability. As expected, cognitive impairment is a risk factor for institutionalization, controlling for other characteristics such as age, living arrangement, and use of paid inhome care. Four problem behaviors were investigated, but only one, Wanders/Gets Lost, contributed to the model. Among cognitively impaired persons, those who wander/get lost had a twofold risk of institutionalization. The findings suggest the need to differentiate among difficult or problem behaviors and to further investigate those that arouse concerns about safety and require extensive supervision as risk factors for institutionalization.

Predictors of the Level of Care assigned to New Nursing Home Residents

Admission data from 159 residents of four Saskatchewan nursing homes were analysed in order to identify predictors of level of care. Multiple regression analyses showed that a high level of care was assigned to those who were unable to perform various activities of daily living, those who had behavioral problems, and those who had recently experienced a stressful life event; with these variables and a nursing home variable explaining 47.2% of the variance. Appropriately, the most important predictor is activities of daily living. The other major predictor is behavioral problems which, the results suggest, are caused by either an organic psychotic disorder or a high level of stress. It is recommended that, following admission, new residents with behavioral problems caused by stress should be the recipients of programs designed to help them cope with this stress and mitigate their behavioral problems. Then, they should be reassessed and, where appropriate, reassigned to a lower level of care.

Do social networks affect the use of residential aged care among older Australians?

Background

Older people's social networks with family and friends can affect residential aged care use. It remains unclear if there are differences in the effects of specific (with children, other relatives, friends and confidants) and total social networks upon use of low-level residential care and nursing homes.

Methods

Data were drawn from the Australian Longitudinal Study of Ageing. Six waves of data from 1477 people aged ≥ 70 collected over nine years of follow-up were used. Multinomial logistic regressions of the effects of specific and total social networks on residential care use were carried out. Propensity scores were used in the analyses to adjust for differences in participant's health, demographic and lifestyle characteristics with respect to social networks.

Results

Higher scores for confidant networks were protective against nursing home use (odds ratio [OR] upper versus lower tertile of confidant networks = 0.50; 95%CI 0.33–0.75). Similarly, a significant effect of upper versus lower total network tertile on nursing home use was observed (OR = 0.62; 95%CI 0.43–0.90). Evidence of an effect of children networks on nursing home use was equivocal. Nursing home use was not predicted by other relatives or friends social networks. Use of lower-level residential care was unrelated to social networks of any type. Social networks of any type did not have a significant effect upon low-level residential care use.

Discussion

Better confidant and total social networks predict nursing home use in a large cohort of older Australians. Policy needs to reflect the importance of these particular relationships in considering where older people want to live in the later years of life.

Characteristics predicting nursing home admission in the program of all-inclusive care for elderly people

PURPOSE

This study determined overall risk and predictors of long-term nursing home admission within the Program of All-Inclusive Care for the Elderly (PACE).

DESIGN AND METHODS

DataPACE records for 4,646 participants aged 55 years or older who were enrolled in 12 Medicare- and Medicaid-capitated PACE programs during the period from June 1, 1990, to June 30, 1998, were obtained. Participants were enrolled for at least 30 days and had baseline evaluations within 30 days of enrollment. Cox proportional hazard models predicting an outcome of nursing home admission of 30 days or longer were estimated.

RESULTS

The cumulative risk of admission to nursing homes for 30 days or longer was 14.9% within 3 years. Individuals enrolled from a nursing home were at very high risk for future admission, with a relative risk of 5.20 when compared with those living alone. Among individuals enrolled in PACE from the community, age, instrumental activity of daily living dependence, and bowel incontinence were predictive of subsequent nursing home admission. Asians and Blacks had a lower risk of institutionalization than Whites. However, other characteristics were not independently predictive of institutionalization, namely poor cognitive status, number of chronic conditions, activity of daily living deficits, urinary incontinence, several behavioral disturbances, and duration of program operation. Before adjusting for other variables, there was substantial site variability in risk of nursing home admission; this decreased considerably after other characteristics were adjusted for.

IMPLICATIONS

Despite the fact that 100% of the PACE participants were nursing home certifiable, the risk of being admitted to a nursing home long term following enrollment from the community is low. The presence of some reversible risk factors may have implications for early intervention to reduce risk further, although the effect of these interventions is likely to be modest. Individuals who received long-term care in a nursing home prior to enrollment in PACE remain at high risk of readmission, despite the availability of comprehensive services.

Caregiving and institutionalization of cognitively impaired older people: utilizing dynamic predictors of change

PURPOSE

The purpose of this study was to identify reliable predictors of nursing home entry over a 3-year period in a sample of 3,944 persons with dementia who resided in a home setting at baseline. Strengths of the analysis include a multiregional recruitment strategy, incorporation of salient caregiver characteristics, and a 3-year prospective design that allows for the modeling of change in important variables (e.g., care recipient functional status or caregiving indicators) when time to institutionalization is predicted.

DESIGN AND METHODS

Data were derived from the control sample of the Medicare Alzheimer's Disease Demonstration Evaluation (MADDE). A Cox proportional hazards model was used to predict time to institutionalization among individuals with dementia (baseline was enrollment into MADDE). Predictors included care recipient demographics, caregiver demographics, and time-varying measurements of care recipient functional status, caregiving indicators, and service utilization. Indicators of change were also incorporated to capitalize on the prospective data available.

RESULTS

Although several results were consistent with prior findings, caregiving indicators (i.e., burden and self-rated health) and community-based service use were significant predictors of earlier placement. Change in caregiver instrumental activities of daily living and care recipient activities of daily living were also related to expedited institutionalization.

IMPLICATIONS

The findings emphasize the importance of incorporating both care recipient and caregiver function and service use patterns when targeting programs designed to prevent or delay institutionalization for people with dementia.

Predictors of institutionalization of cognitively impaired elders: family help and the timing of placement

Although predictors of nursing home placement have attracted a good deal of attention in gerontological research, the type and amount of family assistance offered to caregivers prior to institutionalization has not been extensively examined. This study analyzed the impact of family help on the timing of placement among cognitively impaired care recipients. Using longitudinal data from the Adult Day Care Collaborative Study, an event-history analysis was performed to determine the effects of family help after sociodemographic characteristics, caregiving stressors, and indicators of caregiver well-being were taken into account. Results showed that caregivers were far less likely to institutionalize their relatives when family members provided overnight help and assisted with activities of daily living care. These findings suggest that specific types of family help play an important role in delaying nursing home placement among older adults suffering from dementia.

Socioeconomic and demographic predictors of mortality and institutional residence among middle aged and older people: results from the Longitudinal Study

STUDY OBJECTIVES

To identify socioeconomic and demographic predictors of long term mortality and institutional residence in old age, taking into account changes in socioeconomic and demographic circumstances between the 1971 and 1981 censuses.

DESIGN

Multivariate logistic regression modelling of outcomes for 10 year age cohorts of each gender. The outcomes were death by 31 December 1992; being in an institution in 1991.

SETTING

Members of the Longitudinal Study (a 1% sample of the British Census): 43,092 men and 50,839 women aged 55-74 in 1971.

MAIN RESULTS

Being in rented accommodation and in a household without access to a car carried 35-45% higher mortality rate over 21 years and similar excess risk of being in an institution in 1991. Marital status and living arrangements were weaker predictors of death but being single was a major predictor of moving to an institution for men. Losing household access to a car was a strong factor for mortality for men and for institutionalisation for men aged 55-64 in 1971. The effects were weaker for women. Moving into rented accommodation was a predictor of both outcomes for women and of death for the younger cohort of men. People who started to live alone in the inter-census period were at reduced risk of dying.

CONCLUSIONS

These results demonstrate persistence of inequalities in health related outcomes throughout old age, both in those with unfavourable circumstances in mid-life and in those who, in later life, have lost earlier advantages.

The effect of certificate of need and moratoria policy on change in nursing home beds in the United States

OBJECTIVES

This study examined the effects of state certificate of need and/or moratorium requirements on the change in nursing home bed growth in states over a 13-year period.

METHODS

Data were collected from five telephone surveys of state officials about state certificate of need and moratorium policies, state Medicaid nursing home reimbursement rates, and the licensed nursing home beds in each state for the 1979 through 1993 period. Two-stage least squares regression analysis treated certificate of need and/or moratorium and Medicaid reimbursement rates as endogenous variables in predicting the change in nursing home beds per aged population in states.

RESULTS

States that had a certificate of need and/or moratorium did have significant reductions in the growth in nursing home beds but Medicaid nursing home reimbursement rates were not related to change in bed stock. The percentage of the population living in a metropolitan area, the personal income per 1,000 population, the percent unemployed, a state's tax effort, and time were positively associated with change in nursing home beds. The ratio of nursing home beds per 1,000 aged population in the previous year was a negative predictor of change in bed stock in a given year.

CONCLUSIONS

State regulatory policies have an effect on bed growth in contrast to reimbursement policies.

Deinstitutionalization of the elderly in Finland, 1981-91

The success of Finnish deinstitutionalization policy among the elderly in 1981-1991 was evaluated in terms of institutionalization rates and case-mix. Censuses of institutionalized people in all public and private residential homes and health centre hospitals (or nursing homes) were performed in 1981, 1986 and 1991. Data on demographic factors, diagnoses and dependency level were gathered. Censuses from the closest years of psychiatric patients were also used to obtain a comprehensive view of institutionalization. The eligibility criteria for the study were (1) age 65 years or more (2) currently in long-term care. In both men and women the overall relative reduction was 33%, and largest in psychiatric care, at over 67%. In residential home care the relative reduction was about 40%. In health centre hospitals a slight increase was seen, about 10%. Length of stay shortened in residential homes but increased in health centre wards. Dependency level increased among the elderly people in long-term institutional care during ten years. In conclusion, the deinstitutionalization rate was substantial among the elderly in Finland. However, because of rapid demographic change the absolute number of elderly in long-term care remained almost constant. The case-mix has become more demanding and the proportion of elderly in constant need of extensive help has risen.

Caregiver role appraisal and caregiver tasks as factors in ending caregiving

This study focuses on factors related to why people with primary responsibility for providing care to ADL-impaired elderly persons ended their caregiving roles. Data are from the 1982 National Long-Term Care Survey and the Informal Caregiver Survey. Variables reflecting characteristics of care recipients and caregivers, caregiver role responsibilities, and appraisal of the caregiver role are investigated. Of particular interest is the influence of role responsibilities, such as number of ADL tasks, relative to appraisal of the caregiving role. The results indicate that factors other than role responsibilities are important in understanding who ends caregiving, and that risk factor profiles may prove a useful means of targeting caregivers at greatest risk of ending caregiving.

The geriatric "medical and public health" imperative revisited

Attempts to reduce the future demand for institutional care through community services are likely to have limited success. For this reason, health professionals must focus on preventing or ameliorating functional decline in older persons. To focus attention on this aspect of the geriatric imperative, we use an epidemiologic model to estimate the potential impact of existing or potential medical and public health interventions that might decrease the incidence of functional decline. For at least three major causes (stroke, hip fracture, and incontinence) of disability, the potential exists for reducing the incidence and burden of functional disability by a number of mechanisms. For example, treating just half of adults age 65-74 with currently untreated diastolic or isolated systolic hypertension would reduce the incidence of stroke by 2.77% in this age group (or 1,500 fewer cases of stroke annually). The estimates presented indicate the need (1) to better implement those interventions that are known to be efficacious, and (2) to identify and to test new interventions for conditions contributing to functional impairment in the elderly.

Developing a model of discharge planning based on patient characteristics

Previous research using hypothetical case scenarios has suggested a model of decision making in discharge planning involving at least two steps. The first is to assess the availability of a caregiver, and the second is to examine the complexity of the patient's situation regarding follow-up care needs, physical functioning, and compliance. The combination of these factors then influences the choice of discharge option. The present study attempted to validate and extend the model using actual cases in a retrospective chart review. The four variables of the original model correctly classified 68% of patients by discharge type and accounted for 29% of the variance. An expanded model that included chore assistance, living situation, caregiver availability, medical need, and patient age was able to account for an additional 19% of the variance in the discharge plan.

Living with others as an alternative to nursing home use

The authors studied a synthetic sample combining information on nonmarried women from surveys of community-resident elderly and nursing home residents to identify factors affecting the probability of observing individuals in one of three situations: living alone, living with others, and residing in a nursing home. Increasing income increased slightly the probability of living alone and had a positive effect on the probability of residing in a nursing home for most income levels within the sample range. As expected, disability and increasing age were very important in distinguishing those in the nursing home from those residing in the community, and also increased the probability of living with others, other things remaining constant. Whites were slightly more likely to live alone and less likely to reside in a nursing home, other things remaining constant. Residing in a warmer climate decreased the probability of being a nursing home resident. The analysis indicates that factors distinguishing nursing home residents from community residents are also at least somewhat useful in distinguishing those who live alone from those who live with others, supporting the inclusion of shared community living arrangements with the nursing home as part of a continuum of supportive living arrangements.

Assessing the impacts of community-based health care policies and programs for older adults

This article presents a framework for evaluating long-term care policies and programs to determine how well community-based programs benefit the older adult population. Equity, accessibility, quality, and efficiency are identified as core criteria for implementing and evaluating long-term care policy. Special problems with conducting process and/or outcome evaluation of community-based programs are noted, and findings of evaluation research on community-based health care programs are reviewed. Most previous research indicates that community-based health programs for older adults are not a substitute for institutional care and do not reduce either informal caregiving or ambulatory medical services. The article concludes with policy implications.

Race/sex comparisons of elderly living arrangements. Factors influencing the institutionalized of the unmarried

This article describes recent trends in the total institutionalization rates among unmarried Black and White populations, by sex. In addition, an analysis is provided that evaluates the individual attributes associated with the probability of institutionalization for these same groups in 1980. To accomplish these goals, U.S. Census data from the 1960, 1970, and 1980 Public Use Samples are employed. The evidence suggests convergence over time in age-standardized rates across both race and sex groups. Also, there is considerable consistency among the groups in the factors that predict the likelihood of being in a formal long-term care situation. Although the Black population continues to access formal institutions less frequently than does the White population, the findings suggest that forecasters and planners need to take into account the increasing rate of elderly Black institutionalization along with the individual characteristics that influence these rates.

Differences in oral health status between institutionalized and non-institutionalized older adults

Differences in oral health status between independent and institutionalized adults have been difficult to interpret because the latter population is typically older and has a higher proportion of women, confounding any association between institutionalization and disease levels. We undertook an analysis of oral disease amongst institutionalized (n = 149) and non-institutionalized (n = 246) samples of older adults randomly selected from the population in East York, Ontario. When the confounding effects of age and gender were controlled by constructing 67 matched pairs, institutionalized people were more than twice as likely to be edentulous (OR = 2.17, 95% CI = 1.09-4.29). This association was confirmed using data from all subjects in a logistic regression model. Analysis of covariance of data from dentate subjects revealed that the institutionalized seniors had fewer filled teeth (P less than 0.05, controlling for age and sex), but there were no statistically significant differences in the number of teeth which were missing, decayed, or requiring extraction. These findings suggest that antecedent, sociodemographic factors prior to institutionalization are responsible for the higher probability of oral disease in this group of older adults.

Predicting elderly nursing home admissions. Results from the 1982-1984 National Long-Term Care Survey

Predictors of elderly nursing home admissions were identified using the 1982-1984 National Long-Term Care Survey. The authors found age and health factors were important predictors. Gender was not a significant predictor for disabled elderly admissions when controlling for other variables, even though women constitute the vast majority of nursing home residents. Three of four measures of informal support availability and use were not significantly related to nursing home admission by the disabled. Income and asset wealth were also nonsignificant predictors of institutionalization by the disabled community population.

An analysis of decision making in discharge planning

A repeated-measures design was used to examine medical professionals' discharge planning strategies. Physicians, residents, nurses, and social workers were presented with 16 hypothetical case scenarios and asked to: (1) rate the appropriateness of four discharge options (nursing home, community nursing, adult day, and outpatient clinic care), and (2) select the most appropriate discharge plan for each case. Four within-group variables were included in the scenarios: physical impairment, caregiver availability, follow-up required, and patient compliance. Decisions were greatly influenced by caregiver availability. When a caregiver was available, respondents preferred community-based options (i.e., community nursing care or outpatient clinic); if the case involved complications (i.e., severe physical impairment, heavy follow-up, noncompliant patient), they considered community nursing care more appropriate than outpatient clinic. When a caregiver was unavailable, respondents preferred institution-based options (i.e., nursing home or adult daycare); if there were complications, they considered nursing home more appropriate than adult daycare.

Acute and custodial care among impaired aged

The authors surveyed a community-based population of 628 persons who were 65 and over and who lived either in a rural Maryland county or in Baltimore. For each subject, the number of different medical problems, the subject's capacity to perform physical tasks, and the ability to function were assessed. The number and type of medical problems tended to be the best predictors of whether or not hospital or physician's office care were used, and of the volume of physician's office visits for subjects who sought outpatient care. The subject's ability to function was the best predictor of whether or not the subject used a paid home aide and the volume of family caregiving. Implications for research on association between need and use of long-term care are discussed.

Do nursing diagnoses affect functional status?

1. Nurses in this study often made diagnoses pertaining to physiological or physical problems rather than psychosocial problems. One diagnostic category, "impaired home maintenance management," was consistently used incorrectly, suggesting a need for careful clinical training of nursing staff in diagnostic reasoning. 2. Patients who had a greater number of nursing diagnoses had greater improvements in function during the hospital stay. One explanation is that more nursing diagnoses may lead to more independent nursing actions, resulting in improvements in functional abilities. 3. Functional status on admission measured by the Katz ADL was the most powerful predictor of functional status at discharge. The scale can readily be used by nurses to document basic functioning and to quickly identify patients needing or coordinated discharge planning. 4. Institutionalized had a higher mean number of nursing diagnoses than those who were discharged to their own homes. The most powerful predictor of institutionalization was the Katz ADL score.

Data for long-term care planning. Application of a synthetic estimation technique

To provide state-level estimates for long-term care planning, synthetic estimation techniques were used to generate estimates of dependency in activities of daily living (ADL) and mobility among each state's population. Dependency is regressed on demographic predictor variables in a data set created by combining the 1977 National Health Interview Survey and 1977 National Nursing Home Survey. Coefficients were then applied to 1980 U.S. Bureau of the Census state prevalence estimates for these predictors. The results are state estimates that vary from 7.2% of the aged population ADL dependent in Alaska to 10.4% in Iowa and Nebraska. An alternative model regresses dependency on state mortality rates and produces similar but generally lower estimates.

Identifying factors associated with health care use: a hospital-based risk screening index

The purpose of the current study was to identify variables near hospital admission that could effectively discriminate patients at risk for nursing home placement, long hospital stay, or readmission. Risk factors reported in the literature were used to predict hospital outcome for 532 admissions. Factors that discriminated type of outcome included: two or more chronic medical conditions, living alone or being admitted from a nursing home, dependent ambulation, poor mental status, psychiatric comorbidity, prior admission, age over 75, and being unmarried. Using these criteria, an index was developed to determine risk for placement, readmission, or lengthy stay. Use of cumulative risk scores can result in accurate prediction of outcome and may be useful in targeting patients for intervention. Performance characteristics of the risk index are discussed.

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.

The transition from family in-home care to institutional care. Focus on health and attitudinal issues as predisposing factors

This research examines the correlates of institutional placement among families living with and caring for an older relative. Data are provided for 589 families who were part of a larger study of the effects of caregiving on spouse and adult-child caregivers concluded in Cleveland, Ohio, in 1982. The findings suggest that caregivers' attitudes concerning institutional care are at least as important as elders' physical and emotional health and caregivers' stress in determining which elders are placed in a nursing home subsequent to an elder health crisis.

The immediate and subsequent outcomes of nursing home care

To determine the relationship between admission status and subsequent outcomes, 563 patients discharged during 1980 from 24 nursing homes were followed through 1982. Only 28 per cent of patients were discharged to their homes. Reconstructed life histories of 529 discharges for the two-year follow-up revealed only 38 persons (7.2 per cent) were alive and at home; of these, 36 had been initially discharged to their homes. Four hundred and one persons (75.8 per cent) were dead. Mental orientation, urinary continence, functional status, hip fracture, and diagnoses associated with dementia were found to be significant predictors of outcome status after discharge and at follow-up. Social support had only a modest effect on the former outcomes.

Targeting community services to high-risk elders: toward preventing long-term care institutionalization

Data from a probability sample of 1,625 elderly participants in the Massachusetts Health Care Panel Study were used to identify elders at high risk of long-term care (LTC) institutionalization. Advancing age, living alone, using assistance to perform basic and instrumental ADL, using an ambulation aid, and mental disorientation were significant predictors of entering a LTC facility during the six-year study period. A comparison of selected characteristics from the Massachusetts sample with a random sample of Massachusetts' Home Care Corporation recipients showed that the statewide approach to delivering home care successfully targeted services to high-risk elders. Future research should examine the extent to which targeting services to high-risk elders actually prevents or delays LTC institutionalization.

A prospective study of long-term care institutionalization among the aged

A statewide probability sample of 1,625 elders living in Massachusetts are studied prospectively to identify key determinants of long-term care (LTC) institutionalization. One-hundred forty-seven elders, 9 per cent of the original cohort, entered a LTC institution during the six-year investigation. Using logistic multiple regression, we examine the predictive power of 19 independent variables grouped into six categories: demographic characteristics, attitude, social context, long-term care needs, physical disability, and mental/emotional disability. Five variables are significantly related to institutionalization: advancing age, using ambulatory aids, mental disorientation, living alone, and using assistance to perform "instrumental" ADL (activities of daily living). These results may be helpful to those trying to target non-institutional services to elders for use as substitutes for institutional long-term care. They may also help explain why recent experimental tests of substituting non-institutional care for institutional services have been less than successful.