Client transfers in long-term care: five years' experience

Randomized Trial of a Health Promotion Program For Frail Elders

This study evaluates a local health promotion project that may be widely adaptable to assist frail elderly persons to live longer at home. Subjects, enrolled in New Westminster, B.C., were men and women aged 65 and over living in their own homes but assessed and newly admitted to “personal care at home” by the Long Term Care (LTC) program of the B.C. Ministry of Health. About 90 per cent of eligible clients consented to participate. Randomized to Treatment or Control, they were followed for three years. Controls (n = 86) received standard LTC services, which included screening and pre-admission assessment, arrangement/purchase of needed services and review at three months and at least yearly thereafter. The Treatment group (n = 81) received standard LTC services plus visits from the project nurse who helped each subject to devise a personal health plan based on his or her needs in the areas of health care, substance use, exercise, nutrition, stress management, emotional functioning, social support and participation, housing, finances and transportation. The visits concentrated on setting goals and developing personal health skills, with referral to appropriate community services. An additional group of LTC clients (n = 81) from the adjacent community of Coquitlam was also followed. Success or “survival” was defined as “alive and still assessed for care at home”. After three years the “survival rate” for the Treatment group was 75.3 per cent, compared with 59.3 per cent for the Control group and 58.0 per cent for the Coquitlam group. Standard Kaplan-Meier “survival” graphs show that Treatment subjects were more likely to be alive and living at home at every time point during the three years. Differences between the Treatment and Control groups were statistically significant (p ≤ 0.05) both for simple cross-tabulations of care status at 24 and 36 months and in tests comparing “survival” curves. The results are especially striking because Control subjects received LTC services in a geographic area that offers universal access to health care and community resources and because the Control data were concurrent, not historical.

Transferring to an Institution — An Analysis of Factors behind the Transfer to Institutional Long-Term Care

L'analyse vise à déterminer l'incidence de divers facteurs sur le transfert de patients entre les différents niveaux de soins d'un système local de soins de longue durée aux personnes âgées et aux invalides. Une attention particulière est attachée au passage de soins non-institutionnels aux soins instutionnels. Cette analyse utilise des données recueillies, entre 1985 et 1991, dans la commune de Solna, Suède, au moyen de l'application du système de contrôle ASIM. L'analyse porte sur les facteurs âge, sexe, situation de famille, cohabitation, accessibilité au logement, soutien social informel et différentes forme d'invalidité. Il résulte de l'analyse à multivariées portant sur les facteurs relatifs à l'institutionnalisation — c'est-à-dire le transfert de personnes ayant bénéficié de soins à domicile ou ayant occupé un appartement dans un immeuble à services intégrés à une maison de retraite ou à un établissement hospitalier de soins de longue durée ou à une maison de soins — que le niveau d'invalidité, le jugement porté par le personnel sur le niveau de soins approprié et l'âge étaient les facteurs les plus significatifs. La démence sénile était le facteur d'invalidité individuel le plus important, des handicaps fonctionnels et l'incontinence influant également dans une certaine mesure sur la probabilité de transfert. La déficience de l'environnement social, telles que célibat, accessibilité insuffisante au logement ou manque de soutien social ne semblaient pas pertinents — probablement parce qu'elles étaient compensées de manière adéquate par le service public d'aide familiale.

Long-term-care residents: concerns identified by population and care trends

OBJECTIVE

Despite rising concern over population aging, few descriptions exist of long-term-care (LTC) residents, the people who are normally the oldest and the most dependent persons. This study sought to describe a LTC resident population and trends in this population.

METHODS

A descriptive-comparative quantitative analysis of all data (1988-1999) from a provincial (Alberta) LTC resident database was undertaken.

FINDINGS

Over the 10-year period, there was a significant increase in care needs. In the 1988, the mean Requirement Score was a "C" (indicating low to medium level care was required); by the 1999, the mean score was "E" (medium to high level care). There were both a substantial reduction in residents with low care needs and an increase in residents with high care needs. Although the mean age of LTC residents increased from 80.5 to 82.5, residents under age 65 had higher care needs. General linear modelling also revealed younger age was a significant influence in regard to higher care needs, along with larger (versus smaller) LTC admission to death also declined significantly from 6.9 to 3.4 years. Although this study may only confirm what is suspected about LTC residents, it should raise discussion over the impact of limited LTC beds on families, community-based health services, and acute care hospitals; and the implications of more dependent residents on LTC facility and personnel planning [corrected]

Evaluating institutionalization by comparing the use of health services before and after admission to a long-term-care facility

Despite concern over increased health services utilization with population aging, few studies describe health services utilization by long-term-care (LTC) residents. An investigation was designed to compare health services use before and after LTC admission. Comprehensive 1988 to 1999 data for all LTC residents (N = 47,510) in Alberta, Canada, were obtained. Utilization comparisons involved equal pre/post timeframes. Only non-hospital physician services increased post-LTC admission. Home care was not provided after admission (51% had been recipients). Hospital and ambulatory services use declined, with these patterns stable for 5 years pre- and post-LTC admission. When hospital or ambulatory care was sought by LTC residents, they were not disadvantaged in the type or scope of care as compared to the care received prior to LTC admission. These findings should raise interest in the services provided by LTC facilities and the outcomes of long-term, facility-based care. LTC services could be beneficial for people with advanced age and dependency.

Cost of managing complications resulting from type 2 diabetes mellitus in Canada

BACKGROUND

Decision makers need to have Canadian-specific cost information in order to develop an accurate picture of diabetes management. The objective of this study is to estimate direct medical costs of managing complications of diabetes. Complication costs were estimated by applying unit costs to typical resource use profiles. For each complication, the event costs refer to those associated with the acute episode and subsequent care in the first year. State costs are the annual costs of continued management. Data were obtained from many Canadian sources, including the Ontario Case Cost Project, physician and laboratory fee schedules, formularies, reports, and literature. All costs are expressed in 2000 Canadian dollars.

RESULTS

Major events (e.g., acute myocardial infarction: 18,635 dollars event cost; 1,193 dollars state cost), generate a greater financial burden than early stage complications (e.g., microalbuminuria: 62 dollars event cost; 10 dollars state cost). Yet, complications that are initially relatively low in cost (e.g., microalbuminuria) can progress to more costly advanced stages (e.g., end-stage renal disease, 63,045 dollars state cost).

CONCLUSIONS

Macrovascular and microvascular complication costs should be included in any economic analysis of diabetes. This paper provides Canadian-based cost information needed to inform critical decisions about spending limited health care dollars on emerging new therapies and public health initiatives.

Transitions through postacute and long-term care settings: patterns of use and outcomes for a national cohort of elders

OBJECTIVES

Despite the large number of elders using postacute and long-term care services, there is little information about transitions through different settings or the impact of transitions on elders' health. This gap in knowledge is addressed by analyzing the use of postacute and long-term care settings during a 2-year interval by a nationally representative cohort of elders.

METHODS

A 2-year longitudinal record of the use of short-stay hospitals and postacute and long-term care settings was constructed for all respondents to the 1994 National Long Term Care Survey age 65 or older in 1992. Indicators of potential transition problems include emergency room visits, potentially avoidable hospital stays, and return to an institutional setting following discharge to the community.

RESULTS

Almost 18% of elders, 4.9 million persons, were admitted to or discharged from a study setting between 1992 and 1994. A sizable number of these elders (22.4%) had subsequent health care use, suggesting a possible transition problem. Transitions from acute care hospitals to paid home care represent 20.8% of all transitions and are followed by relatively high rates of potential problems.

CONCLUSIONS

This study provides new information on patterns of postacute and long-term care use and the types of transitions most likely to be followed by potential problems. The results suggest three broad strategies for improving the outcome of transitions through postacute and long-term care settings.

Diabetes in Canada: direct medical costs of major macrovascular complications

OBJECTIVES

To estimate direct medical costs of managing major macrovascular complications in diabetic patients.

METHODS

Costs were estimated for acute myocardial infarction (AMI) and ischemic stroke by applying unit costs to typical resource use profiles. Data were obtained from many Canadian sources, including the Ontario Case Cost Project, provincial physician and laboratory fee schedules, provincial formularies, government reports, and peer-reviewed literature. For each complication, the event costs per patient are those associated with resource use specific to the acute episode and any subsequent care occurring in the first year. State costs are the annual costs per patient of continued management. All costs are expressed in 1996 Canadian dollars.

RESULTS

Acute hospital care accounts for approximately half of the first year management costs ($15,125) of AMI. Given the greater need for postacute care, acute hospital care has less impact (28%) on event costs for stroke ($31,076). The state costs for AMI and stroke are $1544 and $8141 per patient, respectively.

CONCLUSIONS

Macrovascular complications of diabetes potentially represent a substantial burden to Canada's health care system. As new therapies emerge that may reduce the incidence of some diabetic complications, decision makers will need information to make critical decisions regarding how to spend limited health care dollars. Published literature lacks Canadian-specific cost estimates that may be readily translated into patient-level cost inputs for an economic model. This paper provides two key pieces of the many needed to understand the scope of the economic burden of diabetes and its complications for Canada.

Utilization patterns of cohorts of elderly clients: a structural equation model

OBJECTIVE

To identify a model that takes into account the interrelationship of health services utilization variables, and that allows examination of the utilization patterns of health services for a cohort of elderly clients.

DATA SOURCES AND STUDY SETTING

The data of each client in the study were taken from three computer databases maintained for administrative purposes by the Ministry of Health in British Columbia. Time frame for the utilization variables is one year before and one year after admission to the long-term care program in BC which occurred in 1981-1982.

STUDY DESIGN

A basic model was fitted to the utilization data for the year before admission and patterns of utilization were assessed for each gender-age group for the year before admission and for the two periods, using LISREL: Fifteen utilization variables were included: number of GP and specialist visits in different settings (office, home, etc.) and number of other services such as lab tests, hospital stay, etc.

DATA COLLECTION

The three files were linked to produce one record per client.

PRINCIPAL FINDINGS

A model was identified that fits the data well. The total effect of GP emergency room visits on hospital stay is 0.30 compared to 0.19 direct effect. The additional impact is produced via the effect of specialist consultations on hospital stay. This and similar findings by age, gender, and period are consistent with the joint dependency of utilization variables.

CONCLUSIONS

The analysis shows that males and females have different utilization patterns, while age has no effect on utilization of health services by male clients and only a small effect on utilization patterns by female clients. Admission to LTC causes more specialist contacts resulting from contact with a GP and generally a more intensive use of diagnostic and surgical procedures. However, there is significantly less acute care hospital services utilization.

Sampling issues in nursing home research

It has been suggested that two common methods of sampling nursing home populations, cross-sectional sampling and discharge sampling, result in samples with different characteristics and lengths of stay. Comparison of these samples to a sample of nursing home admissions has not been studied. This study compares characteristics and lengths of stay among cross-sectional, discharge, and admission samples. All current residents of three nursing homes in February 1987 made up the cross-sectional sample, all admissions in the following year made up the admission sample, and all discharges in the same year made up the discharge sample. The results of comparing these three sampling techniques show that the most striking differences occur between the cross-sectional sample and the admission sample. Persons in the cross-sectional sample tended to have longer nursing home stays as well as less social support and more behavioral and functional problems than persons in the admission sample, who tended to have shorter stays and more acute medical problems. The discharge sample was more similar to the admission sample than it was to the cross-sectional sample; however, some differences were found between the discharge and admission samples. Based on the differences found among the three samples, appropriate uses for each sample are discussed.

The effect of admission to long-term care program on utilization of health services by the elderly in British Columbia

Utilization patterns of elderly clients admitted to the British Columbia Long Term Care (LTC) program were recorded and analysed. Patients were either located at home or in facilities and were classified into one of five levels of care. Data on GP and specialist contacts, acute care hospital admissions and hospital length of stay were analysed for each client (N = 7251) for two consecutive years, one before and one after admission to the program. There was only a slight decline or no change in utilization of ambulatory health services following admission to the program but a more pronounced reduction in utilization of hospital related services particularly by clients located in facilities (60-70%). When utilization rates were controlled for peak levels in the period around admission, more moderate trends evolved. Yet, clients located in facilities showed a 20% decrease in hospital admission rates and a 40% decrease in GP hospital visits in the period following admission. The data suggests that admission to LTC may reduce acute hospital utilization and consequent physician utilization among clients who are cared for in an institution.

First nursing home admissions: time spent at home and in institutions after discharge

We tracked 96 percent of a sample of 1,942 nursing home patients admitted to a nursing home for the first time in 1982-83. Patients discharged alive from the nursing home were followed for two years or until death. The relative time spent at home, in hospitals, and in skilled nursing facilities is reported. Of the 705 patients discharged from their initial nursing home admission to homes in the community, about 50 percent made only one transfer and only 15 percent made four or more transfers. Of the 509 discharged to a hospital, 26 percent died there and 37 percent of the 374 survivors made four or more moves in the next two years. In all, 1,332 patients were discharged alive and they spent almost two-thirds of the subsequent two years, or their remaining lifetimes, in the community. Of those who transferred only once, over two-thirds of their follow-up time was spent in their own homes. Policies concerned with long-term care should use some type of actuarial data base to successfully plan and implement long-term care insurance.

Utilization Patterns of Clients Admitted or Assessed but not Admitted to a Long-term Care Program – Characteristics and Differences

Clients who were either admitted to a long-term care program (N = 7251) or assessed but not admitted to the program (N = 1680) were evaluated for their utilization of health care services in 1981–82. Mean utilization values were calculated and analyses of variance were performed in order to respond to: a) whether utilization patterns of clients admitted to the program differed from patterns of clients who were not admitted; b) whether clients admitted to institutions were different from clients admitted to the program who stayed at home. The data show that among clients who were not admitted to the program utilization levels nearly tripled during the year following assessments. Among clients who were admitted to the program, hospital use decreased for facility dwellers only. The findings suggest that admission to the program can reduce health care utilization particularly if medical surveillance is provided in institutions.