Social and Health Factors Affecting Community Service Use by Vulnerable Older People

Abstract

This article reports on Outcomes for older people with complex or chronic care needs, a study undertaken by the Brotherhood of St Laurence and La Trobe University, examining older Victorians’ use of community services following Aged Care Assessment Service (ACAS) recommendations that they remain living at home. The paper reports on interviews with older people and carers undertaken at three-monthly intervals, over 12 months. This paper contributes to understanding the factors that impede or facilitate uptake of community aged care services that are critical to meeting the needs of older people and their carers. The study found that among other factors social isolation, high carer burden, and the older person reporting low mood were important barriers to service uptake. Cost, waiting lists, and service satisfaction were also identified in qualitative data as influencing factors. The study concludes there is a need for better means of identifying and supporting older people and carers at risk to improve community service uptake.     

Housing for Older People in Iceland: Apartments and Nursing Homes

The first residential and nursing homes in Iceland were built in the early 1920s, and the first apartments for older people in the early 1970s. Most of the existing housing for older persons was built in the last 30 years. Legislative provisions on housing and particularly on assisted living have not changed significantly since laws relating to the affairs of the elderly were first passed in 1983. While approximately 90% of older people in Iceland own their own home and the primary stated goal of the government is to support independent living, official policy relies on placement in nursing homes. Services and care at home, provided by social and home healthcare services, has not been developed to the same extent as in the other Nordic countries. Clearer guidelines on integrated service housing are needed to reach the government's primary stated goal. Placing more emphasis on delivering services, care, and rehabilitation to people living in the community could shorten individuals’ length of stay in hospitals, delay admission to nursing homes, and better meet the expectations of older people for independent living.     

The changing world of long-term care: a state perspective

Based on data from an eight year longitudinal study of Ohio's long-term care use patterns, this paper describes the changes now being experienced by this industry. Although Ohio has been a state with a heavy reliance on institutional services, the data suggest a change in how long-term care is provided in the state. Over the past eight years, despite an increasing disabled older population, nursing home occupancy rates have fallen from 92.5% to 83.5%. At the same time, in-home service and assisted living use has increased. The paper concludes by describing how such changes are likely to impact the system of the future.     

Late-Life Depression,Social Support,Instrumental Activities of Daily Living,and Utilization of In-Home and Community-Based Services in Older Adults

This study examined the relationship between social support, depression, instrumental activities of daily living (IADLs), and utilization of in-home and community-based services. The sample included 39 adults age 65 years old and older. The data were collected by distributing a self-administered questionnaire. Depression levels significantly decreased as levels of social support increased. IADLs functioning significantly decreased as depression levels increased. The number of in-home services used significantly increased as IADLs functioning decreased. The number of community-based services used significantly increased as depression levels decreased. The number of in-home and community-based services used significantly increased as levels of support decreased.     

Quality of life of older people in Israel: a comparison between older people living at home who are members of a ‘supportive community’ and nursing home residents

The supportive community is a program that was developed in Israel for older people who live at home. The program provides its members with a service package that includes medical and social services, emergency call-button, cultural activities, and a ‘community parent’ who is responsible for the members. Using quantitative method, this study compared the level of quality of life between 55 older people living in their homes who are members of a supportive community (average age = 74.7) and 60 elderly people living in nursing homes (average age = 75.8). As expected, results indicate that quality of life among the older people living at their homes who are members of a supportive community was higher than among the older people living in a nursing home. In addition, the quality of life of married, educated, functionally independent older people in good health and with a good economic situation was higher. Predictor variables of quality of life were: the place of residence, health status, and age. In light of increased life expectancy and the growing need to care for the older population, the practical application of the study focused on a recommendation for the social services to continue the support community development program.     

Perceptions of Communication and Monitoring Technologies Among Older Rural Women: Problem or Panacea?

The purpose of this study was to explore older rural women's perceptions of gerontechnologies, such as in-home monitoring and communication, which may be particularly useful in rural areas where support services are scarce. Forty-three women, ages 60–85 years, participated in focus group discussions. Qualitative analysis uncovered six primary themes: access and reliability, cost, privacy, usability, “use it or lose it” mentality, and caregiver burden. Results suggest that older women in rural areas are open to the potential of gerontechnologies to extend their ability to age in place but are skeptical about their actual implementation.     

Normalisation and 'Normal' Ageing: the social construction of dependency among older people with learning difficulties

This paper discusses the new phenomenon of the survival into old age of the increasing numbers of people with learning difficulties. This raises both theoretical and practical policy issues. In the UK health and social services for older people and for people with learning difficulties have followed quite different paths. One has been based on a limited, age discriminatory view of 'normal' ageing; the other has focused on a potentially liberating concept of normalisation. This distinction is being challenged by the advent of older people with learning difficulties, which is raising questions such as, what is the meaning of normalisation in older age? We focus on this key question, illustrating the different principles behind service provision for these two groups and argue that the concept of normalisation is flawed when applied to older people. The alternative of social integration is proposed as the basis for organising health and social services for both older people and those with learning difficulties.     

Expansion of formalized in-home services for Japan's aged

This article analyzes the social and political forces in Japan that led to the creation of the Gold Plan, a comprehensive national plan for formalized in-home services for the aged. The political strategies of the Gold Plan are examined from the following perspectives: (1) shifts from institutional to in-home services, (2) decentralization of in-home services policy, and (3) needs for expanding the number of in-home service workers. New nonprofit organizations called Resident-Participation Types (RPTs) are identified, which are self-help organizations to augment the delivery of in-home services to the aged. The current status of these new models for the aged are examined, using data from two different surveys conducted by the Japanese National Council of Social Welfare in 1992 and 1993. Finally, future issues regarding RTPs and in-home services for the aged and some policy recommendations are discussed.     

Expansion of Formalized In-Home Services for Japan's Aged

This article analyzes the social and political forces in Japan that led to the creation of the Gold Plan, a comprehensive national plan for formalized in-home services for the aged. The political strategies of the Gold Plan are examined from the following perspectives: (1) shifts from institutional to in-home services, (2) decentralization of in-home services policy, and (3) needs for expanding the number of in-home service workers. New nonprofit organizations called Resident- Participation Types (RPTs) are identified, which are self-help organizations to augment the delivery of in-home services to the aged. The current status of these new models for the aged are examined, using data from two different surveys conducted by the Japanese National Council of Social Welfare in 1992 and 1993. Finally, future issues regarding RTPs and in-home services for the aged and some policy recommendations are discussed.     

State commitment to home and community-based services: effects on independent living for older unmarried women

This study examines the impact of state variation in commitment to the provision of home and community-based services on the living arrangement outcomes of older unmarried females with functionallimitations. We combine data from the 1990 U.S. Census of Population (PUMS) with state-level information on long-term care home and community- based service expenditures, nursing home bed availability, and Medicaid nursing home costs from a special report that compares state variation in long-term care systems. Using multilevel logistic regression modeling techniques, we find that the risk of institutionalization compared to community living arrangements is reduced as spending for home and community-based services at the state level increases. We discuss these findings in light of policy changes during the 1990s.     

Barriers to Remarriage Among Older People: Viewpoints of Widows and Widowers

We conducted this research based on a qualitative approach to describe the opinions of older widows and widowers on remarriage obstacles. Based on purposive sampling and inclusion criteria, we chose 48 participants on maximum diversity of sex, age, education, employment, and socioeconomic status. Two thirds of the participants were female, 40% had spent more than 10 years widowed, and 65% were living with their children. We collected data individually through semistructured, face-to-face interviews. Based on conventional content analyses, 2 independent researchers implemented data analysis manually. Barriers to remarriage were finally categorized into 4 main themes: personal, normative, interactive, and financial factors. Results of this study showed that older people are more concerned about public opinions and social norms surrounding remarriage. As long as these thoughts and norms are not changed, the concept of remarriage among widows and widowers remains a vital taboo and concern.     

An exploration of older Hong Kong residents’ willingness to make copayments toward vouchers for community care

Because of its rapidly aging population, Hong Kong faces great challenges in the provision and financing of long-term care (LTC) and needs to explore sustainable funding mechanisms. However, there is a paucity of research on older people’s willingness to pay (WTP) for LTC services in Hong Kong. This study utilizes data collected in Hong Kong in 2011 (N = 536) to investigate older people’s receptivity to this financing mode by assessing their co-payments for a community care service voucher scheme and then testing how potential factors affect respondents’ amount of co-payment. Results show that respondents’ WTP was positively associated with family financial support, financial condition, and positive attitudes toward this novel policy and negatively associated with family caregiving support. Direct and moderating effects of family financial support on WTP were found. The policy-related implications of LTC financing to improve older people’s acceptance of co-payment mechanisms, financial condition, and shared responsibility of care are discussed.     

Evaluating the self-expressed unmet needs of emancipated foster youth over time

This study explores the self-reported unmet need for independent living services of young people making the transition to adulthood from foster care after the creation of the Chafee Foster Care Independence Program. We find that 34.5% of youth indicated that they had an independent living service need that went unmet at age 17, 27.9% at age 21 and 35.5% at age 23, with the largest percentage indicating they lacked preparation in the area of finance. Some of these youth expressed unmet need consistently while others' expression of unmet need fluctuated over time. Youth who indicated that they had mental health issues were significantly more likely to report unmet need at baseline and wave 3. Youth who indicated that they received more social support and independent living services were less likely to report unmet need at baseline and wave 3. These youth perspectives could lead to the enhancement of existing independent living skill provision as states prepare to extend the age of foster care benefits, ultimately making them more timely and effective.     

Extra Care Housing in the UK: Can it be a Home for Life?

Extra care housing is believed to constitute a home for life, precluding the need for institutional accommodations, but currently there is little substantiating evidence. Longitudinal data show that 8.2% of extra care housing residents will move to institutional accommodations after 5 years. Matching analyses suggest that extra care housing residents aged 80 years and older are approximately half as likely to enter institutional care compared with older people in the community in receipt of domiciliary care, albeit with some caveats. Extra care housing may embody a home for life for the majority of residents, although a substantial minority is likely to require institutional care.     

Factors Related to the Institutionalization of Older Aged Individuals Using Home- and Community-Based Care Services: Data From the South Korea Long-Term Care Insurance Program, 2008–2013

South Korea introduced a public long-term care insurance (LTCI) program in response to its rapidly aging population. This study analyzed the association between living arrangement and caregiver type with institutionalization in LTCI grade 1 (very severe limitations), 2 (severe limitations), and 3 (moderate limitations) beneficiaries using data from the LTCI cohort, 2008 to 2013. The dependent variable was alteration status from home to institutional care within 1 year of receiving home service. Independent variables were living arrangement and primary caregiver type. The analysis was conducted using the generalized estimating equation model. Higher likelihoods of institutionalization were found in individuals living with a non-family member compared to individuals living with their spouses. Individuals without a caregiver or with a paid caregiver were also more likely to experience institutionalization than individuals with a spouse primary caregiver. Our findings underscore the importance of monitoring identified vulnerable groups of individuals to attain LTCI sustainability and enhance elderly quality of life.     

Overcoming Old in Age-Friendliness

In this article, we explore views on an age-friendly space in the Netherlands by analysing the responses of older individuals (N = 54) in focus groups and by examining the perspectives around an age-friendly zone in the Netherlands, Parkstad Limburg. We found that a central issue in the wishes for living at a later age are adjustments to envisioned physical limitations that come with the ageing process; this includes adjustments to ensure safety, accessibility and mobility, in order to facilitate older individuals' efforts to stay engaged with the world around them. In their wishes, the older participants constructed ideal dwelling places that closely resembled a senior home, but at the same time they rejected wishing to live in a place that was identified as a senior home. We explain this paradox by the representation of such a space as being for old people, i.e. needy older individuals, which was not how the older participants wished to be identified. We conclude that the conception of age-friendly environments will have to face the difficult challenge of overcoming the association with old age, while simultaneously taking into account adjustments that signify and relate to the ageing process and that seem inescapably tied to oldness.     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

Estimating the expense of a mandatory home-and community-based personal assistance services benefit under Medicaid

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability. DESIGN AND METHODS: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS. RESULTS: New expenditures for PAS are estimated to be $1.4-$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA). IMPLICATIONS: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

Targeting Services to Those Most at Risk

Abstract

The budget crises facing many state Medicaid programs have increased interest in the goal of linking services and housing as a way to provide more options to people with disabilities at less cost than institutional care. This article examines some of the premises underlying this interest, especially with respect to linking supportive services and federally subsidized housing for older persons. The first section provides a brief history of the activity in this area. The second section examines the risk factors associated with nursing home admission and how those factors match the characteristics of renters receiving subsidies. The third section focuses specifically on the likelihood that subsidized renters will also become eligible for Medicaid. The fourth section explores the capacity of housing programs to meet the challenges associated with service delivery. Finally, the conclusion examines the implications for public policy decision-makers interested in linking services and housing in order to address the long-term care (LTC) needs of older persons with modest incomes.