Aging and developmental disabilities: demographic and policy issues affecting American families

Challenges of Developing a Mobile Game for Children with Down Syndrome to Test Gestural Interface

After a literature review published by Nascimento et. al. (2017), the research team noticed the lack of studies focused on game controllers’ accessibility during use by children with Down syndrome. In view of that, this research describes a mobile game development and its usability analyses, which were created to evaluate the accessibility of touchscreen gestural interfaces. The methodology was organized into three steps: bibliographic research and the definition of the project guidelines, the game development, and its evaluation. The guidelines used were based on a study made by Nascimento et. al. (2019) of the impairments that children can have, their game preferences found on Prena’s article (2014), games accessibility guidelines for people with intellectual deficiency from the Includification Book (2012), a manual of touchscreen gestural interfaces from Android and iOS and a game development framework from Schuytema (2008). Then, for the usability analyses, the team decided to first submit the game to a group of experts in order to make some improvements before submitting it to the audience. In this way, two evaluations were done, a heuristic test with usability specialists and a cognitive walkthrough with health professionals. The list of heuristics used on the tests was created by a mash up of the Breyer evaluation (2008) and the recommendations of the Able Games Association (2012) and the cognitive one followed the Preece, Sharp and Rogers (2007) recommendations. The results found reveal some challenges in the field and adjustments, mainly in the narrative, game goals and interface feedback, that should be addressed as soon as possible.

Translating the Chronic Disease Self-Management Program for Community-Dwelling Adults With Developmental Disabilities

Objective: The study was to test the feasibility of supplementary materials (DD-CDSMP) supporting people with developmental disabilities who are aging to participate in the Chronic Disease Self-Management Program (CDSMP). CDSMP is a six-session group intervention designed to increase self-management of chronic health conditions. Method: Supplementary materials were utilized within two CDSMP workshops. Each workshop involved seven to nine persons with developmental disabilities and five to seven staff. Supplementary materials to the existing intervention manual were reviewed using a framework for modifications and adaptions for evidence-based interventions. Process interviews with leaders and participants, pre- and posttests on self-management activity and satisfaction surveys assessed outcomes and feasibility. Results: Classes were successfully held with a 70% completer rate, and all materials proved useful. Discussion: People with developmental disabilities as they age tend to have more comorbid conditions than the general population. Developing and implementing materials and strategies to making self-management more accessible to people with developmental disabilities in mainstream rather than segregated settings will improve the quality of people's lives.

The Association between Education and Mortality for Adults with Intellectual Disability

Although the relationship between education and mortality is well documented in the general population, it has not been examined for adults with intellectual disability. Informed by fundamental cause theory, I explore the association between education and mortality in a sample of 4,241 adults with intellectual disability from the 1986-2009 National Health Interview Survey with Linked Mortality Files through 2011. Cox regression models were utilized to analyze the predictive effect of education on mortality risk while taking into account birth cohort differences. Increased education was associated with lower mortality risk for adults with intellectual disability, and this relationship strengthened in later birth cohorts who had greater access to the public education system. Comparison with a sample of 21,205 adults without intellectual disability demonstrates that the association between education and mortality risk was not as robust for adults with intellectual disability and highlights the ongoing socioeconomic challenges faced by this population.

End-of-Life Care Policies for People With an Intellectual Disability

It is estimated that more than 650,000 individuals with intellectual disabilities live with caregivers who are 60 or more years old. As they age, they face end- of- life issues in relation to their caregivers, as well as their own health care needs. This article examines some of the major issues concerning end- of- life care for people with an intellectual disability, presents findings of a recent national survey on end- of- life care vis-á-vis the policy implications, and describes some of the emerging strategies and innovations designed to promote improved end- of- life care.

Blood Pressure Screening, Control, and Treatment for Patients With Developmental Disabilities in General Medicine Practices

Background: Little is known about the adequacy of screening for and treatment of hypertension for people with developmental disabilities (DD). Pharmacists may assist in identifying and treating this special patient population. Objective: To characterize and compare the screening, treatment, and control of blood pressure (BP) in patients with DD to patients without DD. Methods: This retrospective study identified adult patients of primary care practices within a large academic health system who had DD (DD group) and a comparator group without DD (GenMed group). Outcomes assessed included percentage of patients screened, mean BP, percentage of patients with controlled BP, and antihypertensive medications prescribed. Results: The DD (n = 183) and GenMed groups (n = 497) were nearly all screened for BP. Mean systolic BP was significantly lower in the DD group (119.9 ± 14.6 mm Hg vs 122.8 ± 15.4 mm Hg GenMed, P = .03), while diastolic BP was no different ( P = .7). Stroke was documented significantly more often in the DD group (5.5% vs 1.4%, P = .005). Of patients with uncontrolled BP, the DD group had significantly higher systolic BP (155.8 ± 14.1 mm Hg vs 147.4 ± 9.5 mm Hg GenMed, P = .02). Hypertension was documented in 32% of DD group versus 38.5% of GenMed group, P = .15. Of this group, 88.1% of the DD group had controlled BP versus 78.0% of the GenMed group, P = .09. Antihypertensive prescribing was not different between the groups. Conclusion: DD group patients had similar outcomes for hypertension therapy compared to patients without DD. Those with uncontrolled BP in the DD group tended to have higher systolic BP. Significantly more DD patients had a history of stroke.

A comparison of reports of caregiver burden between foster family care providers and staff caregivers in other settings

There has been increasing concern about the impact of dementia symptoms on the lives and on the care being provided for persons with intellectual disability (ID) in out-of-home settings. One such setting that has received little attention is foster family care homes. These settings in the USA replicate family living and while some supports and resources are provided, they are not designed to meet intensive care needs. As a preliminary step in understanding family experiences and to expand the range of interest in Alzheimer’s disease (AD) in persons with ID beyond traditional out-of-home settings, a pilot study was initiated that included aging persons with ID and symptoms of AD who were living in foster family care settings in two regions of New York State as well as more traditional out-of-home care subjects. Comparisons of matched samples on subjective and objective burden measures suggest that there are few differences in experiences. The limitations of these findings are considered and recommendations made for future, related research.

Person-centered planning: evidence-based practice, challenges, and potential for the 21st century

Person-centered planning emerged in the 1990s as an innovative practice to assist persons with intellectual and developmental disabilities. The foundational purpose of person-centered planning is to assist the individual in developing service planning that reflects the needs and desires of the focal person with the disability. Despite its popularity with disability practitioners, advocates, and policy stakeholders, debate emerged at the beginning of the 21st century as to the viability of person-centered planning as an evidence-based practice. This article examines the historical development and evidence base, as well as the current challenges and potential of person-centered planning for adults with intellectual disabilities.

Older adults with intellectual disability

PURPOSE OF REVIEW

Improvements in health and social care for people with intellectual disability have led to a dramatic increase in the life expectancy of this population, resulting in a large and growing number of older adults with intellectual disability. They are at risk of age-related mental disorders such as dementia and continue to present with high rates of mental illness.

RECENT FINDINGS

Recent research with older adults with intellectual disability has included physical health issues that may affect mental well being, and biological and clinical features of dementia in people with Down syndrome. Two key clinical trials of memantine and antioxidants for dementia in Down syndrome showed that these treatment options were ineffective in the short term. Other research focussed on environmental and psychosocial issues (including carer issues) and end-of-life care.

SUMMARY

Improved mental well being requires effective management of mental illness and co-morbid physical health problems as well as consideration of environmental and social issues. Biological research has identified potential treatments for age-related decline, which has led to the development of medication trials. Despite disappointing results, two recent medication trials showed that randomized controlled trials are feasible in older people with intellectual disabilities - a group who are often excluded from trials.

Developing a Physical Activity Education Curriculum for Adults With Intellectual Disabilities

Adults with intellectual disabilities have high rates of physical inactivity and related chronic diseases. Researchers have called for an increase in the development and evaluation of health education programs adapted to the unique needs of this population. Formative and process evaluation strategies were applied to develop a physical activity education program. The first phase of formative evaluation included a comprehensive literature review to select educational strategies and curriculum content. The theory of planned behavior was selected as a guiding framework, and meetings with stakeholders were held to assess feasibility. The second phase of formative evaluation included an assessment of materials by an expert panel and the priority population, and pilot testing. Next, field testing was implemented, followed by process evaluation and an assessment of implementation fidelity. The final curriculum was developed as a result of the completion of the aforementioned steps and led to a successful physical activity intervention.

Access to respite breaks for families who have a relative with intellectual disabilities: a national survey

AIMS

This paper reports the findings of a national study of the variations in the provision and correlates of respite breaks to families. Background.  Internationally, respite breaks are a major support service to family carers, demand for which often exceeds supply for persons with an intellectual disability. Hence, the length of breaks available to families has to be rationed. Nurses are often involved in such decisions.

METHOD

National data on the use of respite breaks by over 4000 families in a full calendar year (2008) were analysed to examine the variation within the Republic of Ireland on two indicators: namely the proportion of carers who had any access to breaks and the median number of days they had received.

FINDINGS

Striking differences across health service areas were found on both indicators of usage. These were not solely attributable to the availability of provision but also reflected variations in the criteria local services used to allocate places. However, those persons with more severe disabilities were given priority, whereas carer characteristics were not a major influence. Contact with social workers and community nurses also increased the likelihood of carers receiving respite breaks.

CONCLUSION

Intra-country comparisons of service delivery should assist planners in creating more equitable access to respite breaks and the development of more explicit eligibility criteria for their use. Nurses are well placed to lead on this.

Perspectives on leadership in organizations providing services to people with disabilities: an exploratory study

As leaders from the Baby Boomer generation prepare for retirement over the next decade, emerging leaders must be identified and supported in anticipation of a major organizational transition. Authentic leadership is a construct that informs the development of values-driven leaders who will bring organizations into the future, just as the previous generation of leaders oversaw the movement of services away from state institutions and into networks of community-based service delivery organizations. The purpose of this exploratory study was to examine executive and emerging leaders' opinions about the unique leadership values, skills, and challenges in organizations that serve individuals with intellectual and developmental disabilities. Themes of defining, developing, and sustaining leaders emerged from the data and are explored through an authentic leadership framework.

Institutional care for people with disabilities in Taiwan: a national report between 2002 and 2007

The purposes of the present study were to describe the institutional care for people with disabilities included service types, service capacity and service utilization from 2002 through 2007 in Taiwan. Data were obtained from four ways of national data: (1) The condition of service institution for the physically and mentally disabled; (2) The physically and mentally disabled population by aged and grade; (3) The physically and mentally disabled population by cause; (4) Taiwan general population by age. We used percentage and overtime trend figures to examine the change in service capacity and the institutional care utilization of people with disabilities. The results revealed that the administrative prevalence of disabilities was increasing from 3.69% to 4.45% from 2002 to 2007 (increase rate 22.8%) in Taiwan. The number of disability institutions was increasing from 223 to 254 and yield an increasing rate 12.2%. The service capacity of institutional care was 16,664 persons in 2002, and it was increasing to 20,707 persons in 2007 (increase rate=24.3%). The cases admitted to institutional care were increasing from 12,611 in 2002 to 17,002 in 2007 (increase rate=34.8%). The male individuals with disabilities were more likely to admit to institutional care than the female cases. The data of the present study provided can be a basis for further discussion on the debate of institutional care or community care for people with disabilities in Taiwan community.

Health and Access to Health Care of Female Family Caregivers of Adults With Developmental Disabilities

The physical and mental health status of women providing care to adult relatives with developmental disabilities was compared with that of the general female population in the United States. There were no differences on physical health across four age groups. However, the mental health of midlife caregivers (45—54 years of age) and older caregivers (older than 65 years) was worse than national norms. This may be associated with two key periods: transitions to adulthood of individuals with disabilities and transitions when aging caregivers are no longer able to provide care. Greater unmet needs for services contributed to poorer mental health. Poorer access to health care also contributed to poorer mental and physical health. Unmet needs for services and out-of-pocket disability-related expenses appeared to pose difficulties for working age caregivers in affording the financial costs of health care for themselves.

The relationships among fundamental motor skills, health-related physical fitness, and body fatness in South Korean adolescents with mental retardation

The purpose of this study was to examine the following: (a) the relationships among the latent constructs of fundamental motor skills (FMS), health-related physical fitness (HRF), and observed body fatness in South Korean adolescents with mental retardation (MR); (b) the indirect effect of fundamental motor skills on body fatness when mediated by health-related fitness; and (c) whether the degree of MR and gender affects these relationships. Students ages 13 to 18 years (287 boys and 134 girls) were recruited for the study. Separate structural equation models were estimated based on gender and the level of disability: mild or moderate MR. Group differences in the model structure were not found, so the data were combined and a single model estimated. The results showed that FMS significantly contributed to HRF (standardized effects beta = .53), p < .01 and indirectly contributed to decreased body fatness mediated by HRF (-.27), p < .01. HRF directly contributed to decreased fatness (-.50), p < .01. The results from this study support the importance of both increased FMS and increased HRF in relation to decreased body fatness.

Longitudinal outcomes of a consumer-directed program supporting adults with developmental disabilities and their families

Longitudinal impacts of a consumer-directed support program that provides families with an individualized budget were studied at three points in time over a 9-year period: Time 1 (1991), Time 2 (1995), and Time 3 (2000). At Time 3, families in the program were also compared with families on the waiting list. Over time, families in the program experienced decreased unmet service needs, higher service satisfaction, increased community participation of individuals with disabilities, and decreased caregiver burden. At Time 3 families in the program had fewer unmet needs and higher service satisfaction than did families on the waiting list; there were no differences in community participation and caregiver burden.

Aging family caregivers: Policies and practices

This review examines later life family support for adults with developmental disabilities from a life course perspective that takes into account social trends and changes in service patterns and in attitudes of families. Key issues addressed include: (1) trends affecting family caregiving, (2) health and social outcomes of life-long caregiving, (3) support needs of families, (4) family support policies and practices, and (5) recommendations for a research and policy agenda. Research examining outcomes of life-long caregiving has shown that most families adapt well to having a family member with disabilities. However, some families are at risk for poorer physical and mental health outcomes. These include cultural minorities and families of adults with behavioral challenges. Caregiving does seem to have a negative impact on maternal employment and family income as mothers often give up or cut back on employment to care for a child with developmental disabilities, who is more likely to continue living in the family home throughout adulthood than other adult children. Federal and state initiatives are addressing issues of family support through both the developmental disabilities and aging service systems.

Young people with Down syndrome: a preliminary investigation of health knowledge and associated behaviours

BACKGROUND

Adults with intellectual disability have a range of significant health problems. If they are to live independently, they need to engage in behaviours that are health promoting, as well as avoiding behaviours that might directly lead to ill health. There is very little research about health-related knowledge and behaviour in this group.

METHOD

A group of 38 adolescents with Down syndrome (DS) and their families participated in this study. A semi-structured interview and a series of tasks were used to collect data on individuals' health knowledge and behaviour relating to 4 aspects of health: hygiene, substance use, exercise and healthy eating.

RESULTS

While the majority of young people demonstrated some awareness of basic hygiene, they were not yet at the level where these behaviours could be guaranteed to occur without parental support. Knowledge about substance use, exercise and healthy food was generally poor.

CONCLUSION

Knowledge of most aspects of health assessed in this study was poor and pointed to a gap in the preparation of these young people for independent living.

Supporting Aging Caregivers and Adults With Developmental Disabilities in Future Planning

A peer support intervention was developed to support aging caregivers and adults with developmental disabilities in planning for the future. The intervention consisted of a legal/financial training session followed by five additional small-group workshops. Pretest and 1-year follow-up surveys were conducted with 29 families participating in the intervention and 19 control families. Outcome measures included future planning activities, caregiving appraisals, discussion of plans with individuals who have developmental disabilities, and choice-making of individuals with developmental disabilities. The intervention significantly contributed to families completing a letter of intent, taking action on residential planning, and developing a special needs trust. Caregiving burden significantly decreased for families in the intervention and daily choice-making of individuals with disabilities increased.

Adult persons with intellectual disabilities on the island of Ireland

BACKGROUND

Information on the numbers of adult persons (aged 20 years and over) with intellectual disability (ID) is rarely collated at a national level. This is an impediment to service planning especially for a changing population.

METHODS

A database of all persons in receipt of ID services has been operating in the Republic of Ireland since 1995. In Northern Ireland, regional databases can be used to provide similar information.

RESULTS

A total of 25,134 persons were known to services in 2002; an overall prevalence for the island of 6.34 per 1,000. However this rate varied for different age groupings and across the two parts of the island. General population characteristics, as well as service factors, appear to account for this. Significantly more people lived with family carers in Northern Ireland. By 2021, it was estimated that the population would increase by over 20% with around one-third of persons aged over 50 years.

CONCLUSIONS

These data illustrate the variations that exist in the numbers of adult persons with ID known to services across and within regions of a country. Hence caution must be exercised in extrapolating prevalence rates derived in one area to another. The availability of comparative national data highlights issues around the equitable funding and delivery of services.

Cardiovascular disease prevalence and risk factors of persons with mental retardation

This paper reviews the recent literature on cardiovascular disease (CVD) prevalence, CVD-related mortality, physiological CVD risk factors, and behavioral CVD risk factors in adults with mental retardation (MR). The literature on the potential influences of modifiable behavioral CVD risk factors and the physiological CVD risk factors are also reviewed. Adults with mild to moderate MR residing in community settings appear to have an elevated disease prevalence, elevated CVD-related mortality, more adverse physiological CVD risk factors, and elevated behavioral risk compared to others with and without MR. Preliminary evidence supports the benefits of participating in the recommended physical activity levels and consuming the recommended diets to reduce the risk for CVD. The lack of large-scale longitudinal or experimental research indicates a gap in the research. The development of research-based, appropriate, primary prevention programs and intervention strategies aimed at lowering the risk for CVD is highly recommended. Programs should focus on educating individuals with MR along with direct care providers and family members on the importance of appropriate dietary concepts, physical activity habits, and regular health screenings by physicians. Programs should be individualized to regional and cultural issues.

Family Caregivers of Women with Physical Disabilities

Cross-sectional, correlational analyses of data from two separate studies were conducted to examine the correlates of adjustment among family caregivers of women with disabilities. Participants included 40 caregivers of women with spinal cord injuries in the first study and 53 caregivers of women with cerebral palsy, traumatic brain injury, and other neuromuscular disabilities in the second study. It was hypothesized that a negative problem-solving style would be associated with greater caregiver distress in both studies, and that caregiver adjustment would be associated with care recipient depression in the second study. As expected, results indicated that a higher negative orientation toward solving problems was associated with caregiver depression and lower well-being. However, in the second study, caregiver characteristics were not associated with care recipient depression. These data indicate that considerable variability exists in caregiver adjustment. Methodological limitations and the implications for research, service, and policy formation are! discussed.

Fair shares? Supporting families caring for adult persons with intellectual disabilities

BACKGROUND

Although the majority of adult persons with intellectual disabilities are cared for by their families, remarkably little is known of the characteristics of their carers, the support services they receive and their unmet needs. A particular concern is whether or not carers have equitable access to services.

METHOD

Information was gathered from service staff who knew best the person with the disability. A standard pro forma was used with a representative sample of over 1500 family carers in Northern Ireland (26% of the estimated population).

RESULTS

Nearly half of the people were being cared for by both parents, but around one third lived with lone carers and 20% with another relative. These subgroups of carers varied significantly in their personal characteristics and in terms of the person for whom they cared. However, Regression Analyses identified that their relative's higher dependency in person care was the only common variable that was predictive of carers' access to support services. A possible measure of unmet need for various support services was derived.

CONCLUSIONS

Services need to pay greater attention to the characteristics of family carers so as to overcome some of the present inequities in supports offered to them. Further areas for future research are identified.

State of the States in Developmental Disabilities: 2004

Public spending for MR/DD services grew rapidly during FYs 2000-2002. This rapid growth was followed by reductions in spending for MR/DD services as the nation's economy declined during 2002-2004. However, convergent factors stimulating future expansion of funding and services for persons with MR/DD include rapidly expanding cohorts of aging caregivers in the states, increasing longevity of persons with MR/DD, and extensive litigation in the states promoting access to services.

Family support in the United States: financing trends and emerging initiatives

Trends in family support spending and new programmatic initiatives across the country during the 1990s are summarized. Nationally, total spending for family support exceeded $1 billion in 2000. Between 1990 and 2000, spending for such services in the United States grew from 1.5% to 4% of total resources expended by state MR/DD agencies. However, we found considerable state variability in level of resources allocated to support families providing care to a member with developmental disabilities. Programmatic initiatives include trends toward family-directed services, targeted programs for special populations, such as ethnic minorities and aging caregivers, and the slow expansion of cash subsidies. Recommendations for the future course of policy in this area are provided.

Prevalence of physical inactivity and recommended physical activity in community-based adults with mental retardation

Little information has been reported on the leisure time physical activity (LTPA) habits of adults with mental retardation. Prevalence of physical inactivity and recommended LTPA of adults with mild to moderate mental retardation who live in community settings was described. Adults with mental retardation (76 men, 74 women) reported their physical activity habits. Overall, men and women who resided in community settings were similarly inactive, with 47% to 51% of individuals participating in little to no LTPA. Forty-two to 47% of them reported participation in moderate to vigorous LTPA five or more times per week. Limitations to quantifying physical activity through questionnaire process is discussed and development and implementation of programs designed to increase physical activity levels recommended.

For better or worse? Impact of residential placement on families

Postplacement adaptation was studied in 106 families with a member living in a residential facility. Respondents reported on three broad areas of functioning: involvement with the member in placement, well-being, and perception of placement advantages and disadvantages. Although respondents readily reported both pros and cons of placement, more than 90% concluded that, on balance, the living arrangement was an advantage for themselves, the child, and other family members. Families with children under age 15, contrasted with families of adolescents and adults, visited more often, reported the highest stress and caretaking burden, as well as the lowest marital adjustment and advantage to placement. Families of adults, for whom living away from the natural home is normative, seemed to have adapted well postplacement.

Quality of life of adults with mental retardation/developmental disabilities who live with family

In this paper, we review the literature related to the quality of life of adults with mental retardation/developmental disabilities (MR/DD) who live at home with their families. We examine the nature of the relationships between adults with MR/DD and their parents and siblings, the social worlds of adults with MR/DD, age-related functional and health issues that affect their quality of life, the range of services and supports provided to them, and familial efforts to plan for their continued well-being when parental care is no longer viable. Individual characteristics associated with these dimensions and/or more compromised quality of life profiles are identified. The paper concludes with recommendations for expanded research on the quality of life of adults with MR/DD who live in the parental home, a topic which has received markedly less attention than the quality of life of adults who live in publicly supported residential settings. MRDD Research Reviews 7:105-114, 2001.

Living circumstances of children and adults with mental retardation or developmental disabilities in the United States, Canada, England and Wales, and Australia

The purpose of this article was to collate evidence to describe where people with mental retardation or developmental disabilities live in five developed countries: United States, Canada, England, Wales, and Australia. Family homes are important dwelling places for people with mental retardation. They are the home of the great majority of children with mental retardation and a considerable proportion of adults with mental retardation. The likelihood of placement outside the family home increases with adulthood and progressively as people age. Adults with mental retardation live in a wide variety of settings, with formal residential provision frequently dependent on the arrangements that the authorities responsible for providing service support have chosen to make. There has been a considerable move away from accommodating people in large segregated and geographically isolated institutions in the countries considered. However, the current range of accommodation includes much with a distinctively different character to the homes where other citizens live. Many people still live in larger groups than would be ordinarily found in typical homes and this may necessitate departure from the architectural norm. In all of the countries considered, there has been a recent trend towards small community settings, compatible with typical housing architecture. This appears furthest advanced in the U.S. but is discernible elsewhere. Availability of residential services at a national level varies between 100 and 155 places per 100,000 total population. Regional variation within countries is even greater. In no case is the national availability considered adequate to meet the demand arising from changing need or expectations. MRDD Research Reviews 7:115-121, 2001. (c) 2001 Wiley-Liss, Inc.

Beyond sex and cooking: health education for individuals with intellectual disability

Issues of health education programming for people with intellectual disability are discussed. As environments in which such individuals live become more inclusive, and they are encouraged to make their own choices, the issue of whether current health education is sufficient to enable them to make healthy life choices is considered. More attention should be focused on programs in schools and the community to fulfill this need. Three aspects of health education programming are considered: physical activity, general health knowledge, and social supports for health. Continuity of information is viewed as important in policy development as well as in interprofessional coordination and cooperation to assure that these individuals are not further handicapped by poor health.

Personal characteristics and contextual factors associated with residential expenditures for individuals with mental retardation

A multivariate analysis was done to determine the relative importance of facility, resident, and community characteristics to expenditures. Facility factors associated with higher expenditures included ownership, facility size, facility services, and location. Individuals with a greater number of activity of daily living limitations, developmental disabilities, and more severe levels of mental retardation had higher expenses. Findings could improve our understanding of the costs of long-term residential care, assisting us to economically and effectively bring this population into the community. Data used are from the 1987 National Medical Expenditure Survey Institutional Population Component.