Cash and Counseling: A Promising Option for Consumer Direction of Home- and CommunityBased Services and Supports

Examining Satisfaction and Quality in Home- and Community-Based Service Programs in the United States: A Scoping Review

BACKGROUND AND OBJECTIVES

Long-term services and supports in the United States are increasingly reliant on home- and community-based services (HCBS). Yet, little is known about the quality of HCBS. We conducted a scoping review of the peer-reviewed literature to summarize HCBS consumer, provider, and stakeholder satisfaction with services as a means of assessing quality.

RESEARCH DESIGN AND METHODS

We searched PubMed, OVID-MEDLINE, and SCOPUS to identify articles published from 2000 to 2021 that reported on studies describing a U.S.-based study population. Articles were grouped into 3 categories: drivers of positive consumer satisfaction, drivers of negative consumer satisfaction, and provider and stakeholder perspectives on satisfaction.

RESULTS

Our final sample included 27 articles. Positive perceptions of quality and reported satisfaction with services were driven by consistent, reliable, and respectful care providers, and adoption of person-centered models of service delivery. Mistreatment of consumers, staff turnover, training, service interruptions, and unmet functional needs were drivers of negative consumer perceptions of quality. Support for caregivers and emphasis on training were identified by providers and stakeholders as important for providing satisfactory services.

DISCUSSION AND IMPLICATIONS

Multiple data challenges limit the ability to systematically evaluate HCBS program quality; however, studies examining single programs found that HCBS consumers are more satisfied and associate higher quality with easy-to-navigate programs and professional staff. Efforts to expand HCBS should also include requirements to systematically evaluate quality outcomes.

"I'm just trying to cope for both of us": Challenges and supports of family caregivers in participant-directed programs

Recently, national attention has focused on the needs of family caregivers providing complex chronic care, noting the necessity to better understand the scope of challenges they encounter. Although a robust body of literature exists about the scope of family caregiving, little is known specifically about the experiences and perspectives of family caregivers who support participant directed (PD) participants, particularly across the caregiving trajectory. Therefore, the aim of this qualitative descriptive study was to describe what family caregivers of individuals with developmental disabilities, physical disabilities, aging, or chronic health conditions identify as the challenges they experience as complex, and their perceptions of the effectiveness and gaps in family support resources in PD. Semi-structured interviews were audio-recorded with a purposive sample of caregivers. Transcribed interviews were analyzed using conventional content analysis. Fifty-four caregivers of individuals with a range of disabilities participated (age 34-78, M 59.9 ± 8.8; male 19%; spouse 17%, parent 61%). Six categories emerged from the analysis: contextualizing complexity, complexity in transitions, coping with complexity: advocacy & isolation, supportive support, unsupportive support, and systems challenges. Caregivers emphasized the interplay between unpredictability, transitions, and complexity and the interaction between the person receiving support, the caregiver's own situation, and the environment. Findings highlight the need, and provide a guide, for family assessment and for tailoring interventions matched to the profiles and self-identified challenges of families living with disability. Social workers can learn what families see as complex and what support broker behaviors families find helpful, and which not.

Understanding Effects of Flexible Spending Accounts on People with Disabilities: The Case of a Consumer-Directed Care Program

This study set out to explore the saving behavior, barriers, and facilitators along with effects of participating in a consumer-directed care program among people with disabilities in the state of West Virginia (N = 29). Results suggest that respondents were able to save money through the program to enable them to purchase goods and services they needed to enhance their welfare and quality of life. Generally, items saved for fell into 3 broad categories: household equipment, individual functioning, and home modification. Facilitators and barriers to saving were also indicated and so were the benefits of program participation. Program and policy implications are presented.

Racial and ethnic disparities in Alzheimer's disease pharmacotherapy exposure: an analysis across four state Medicaid populations

BACKGROUND

Treatment disparities in Alzheimer's disease (AD) have received little attention. Determining whether disparities exist in this subpopulation is an important health policy issue.

OBJECTIVE

The aim was to determine whether an association existed between race/ethnicity and exposure to AD pharmacotherapy across 4 state Medicaid populations.

METHODS

Data from the Centers for Medicare and Medicaid Services (CMS) were used in this retrospective study. Persons with AD enrolled in California, Florida, New Jersey, or New York Medicaid programs on January 1, 2004, and remained in that program for 1 year. Individuals had an AD diagnosis based on the ICD-9-CM code 331.0. Outcomes of interest were exposure to a cholinesterase inhibitor (ChEI) or memantine. Multivariate logistic regression was used to test for the association between race/ethnicity and exposure to a ChEI or memantine. Variables of interest included demographic characteristics and resource utilization factors. The Oaxaca-Blinder decomposition method was used to test for disparities to determine whether exposure to AD pharmacotherapy was influenced by race.

RESULTS

Race, age, long-term care admittance, inpatient care admittance, state of residence, and sex were significant predictors of AD pharmacotherapy exposure (P < 0.0001 for all variables). Racial/ethnic disparities were observed with respect to exposure to a ChEI or memantine between non-Hispanic whites and Hispanics (in favor of Hispanics) in Florida (P < 0.0001), between non-Hispanic blacks and Hispanics (in favor of Hispanics) in California (P < 0.0001) and Florida (P < 0.0001), between non-Hispanic blacks and non-Hispanic others (in favor of non-Hispanic others) in California (P < 0.0001) and New York (P < 0.0001), and between Hispanics and non-Hispanic others (in favor of non-Hispanic others) in California (P = 0.001) and New York (P < 0.0001).

CONCLUSIONS

Disparities in AD pharmacotherapy exposure among minority populations are just as prevalent, if not of greater magnitude, than minority/white disparities.

Health disparities in cost of care in patients with Alzheimer's disease: an analysis across 4 state Medicaid populations

OBJECTIVES

To investigate health disparities with respect to cost of care across 4 state Medicaid populations.

METHODS

Data were obtained from Centers for Medicare and Medicaid Services (CMS) for this retrospective study. Patients were enrolled in a California, Florida, New Jersey, or New York Medicaid programs during 2004, with a diagnosis of Alzheimer's disease (International Classification of Diseases, Ninth Revision 331.0). Outcome of interest was cost of care. Decomposition of cost to calculate disparities was estimated using the Oaxaca-Blinder model. An a priori α level of .01 was used.

RESULTS

Approximately 158 974 individuals qualified for this study. Disparities were found to exist between blacks and whites (with blacks having higher costs; P < .0001), whites and others (with whites having higher costs; P < .0001), blacks and Hispanics (with blacks having higher costs; P < .0001), blacks and others (with blacks having higher costs; P < .0001), and Hispanics and others (with Hispanics having higher costs; P < .0001).

CONCLUSIONS

Disparities in cost among minority-to-minority populations were just as prevalent, if not higher, than minority-white disparities.

Family caregivers' viewpoints towards quality of long-term care services for community-dwelling elders in Taiwan

The population of elderly people in Taiwan is increasing rapidly, and long-term gerontology care has become an important issue in this greying society. The purpose of this study is to explore family caregivers' viewpoints and opinions regarding the long-term care services for community-dwelling older adults in Taiwan. A qualitative study was conducted between August and December of 2005. Fifty family caregivers agreed to participate in this study. Data were collected by focus group interviews, in order to obtain the experience and expectation of family caregivers concerning long-term care services in their daily lives. Through content analysis and peer discussion,the data were categorized into five major themes: (1) praise for the services;(2) flexibility of long-term care services; (3) comprehensiveness of long-term services; (4) linkage and extension of existing resources; and (5) activeness of service provision. Study findings from the family caregivers' viewpoints should contribute to the improvement of long-term care services and provide a basis for designing suitable programmes to enhance community-dwelling in situ elderly people care.