The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Workforce Issues in Residential Care Facilities in Rural China

This study examined contemporary frontline workforce issues related to residential care for elders in rural China. Residential facilities in rural China are in transition from exclusively providing shelter to childless elders to providing long-term care for frail elders. These facilities are also under pressure to improve the quality of services that they provide. The study is based on in-depth interviews with administrators and field observations of facilities. The study focused on the following issues related to the workforce: recruitment and retention, training, work environment, workforce organization, regulations, compensation, and career ladders. The implications of resident characteristics for demands on the work force were examined. The study found that lack of skilled personnel is one of the major reasons that the overwhelming majority of facilities deny admission to frail and demented elders. Improving workers’ skill is critical if these facilities are to meet the increasing demand for institutional long-term care needs.     

Caregiving and long-term health care in the People's Republic of China

The growing proportion of frail elderly in the People's Republic of China has necessitated policy of the state toward their long-term care. In this decade, there has been an increase in the amount of data available on the care and needs of Chinese frail elders. This article synthesizes these data and traces the patterns of care of frail elders. It distinguishes between urban and rural patterns, and identifies the increasing role of the family and community in the caregiving of elders. State policy, evident from the data, suggests that the state's role in direct care of elders is minor but that it continues to influence and support eldercare as part of its policy of promoting the one-child per couple policy. This process can be seen in support programs for the childless elder, who symbolizes the expected condition of a large number of future elders under the one-child policy. The article identifies four factors that are influencing the changing patterns of long-term care of elders in China: (1) economic reform programs; (2) the political agenda of the Chinese Communist Party; (3) differences in urban and rural economic conditions; and (4) policy directed at long-term investment in health care technology.     

Questions I now ask: Spirituality in the liminal environment of assisted living

This article analyzes, through two case studies, how elders in a secular, urban, assisted living facility (ALF), use their spirituality to manage change and loss, and to answer questions concerning the meaning of life and death. This article asks: how does personal spirituality help elders deal with the liminal environment of assisted living in the latter stage of life?This article is based on research that explored the cultural construction of dying and death in long-term care facilities. In-depth interviews were conducted with 22 residents living in an ALF. We offer case studies concerning elders' lived experience of spirituality in order to demonstrate the significance of individual and cohort history and the elder's embeddedness in the culture of assisted living.A key finding of this paper is that elders' spirituality becomes both miniaturized and expanded in the assisted living environment. The miniaturization mirrors the diminishment of their physical world. The expansion reflects the need for a belief system expanded enough to contain the questions asked in this place, at this time of life.     

The Program of All-Inclusive Care for the Elderly (PACE): an innovative long-term care model in the United States

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Intergenerational Connections Through Book Discussion Groups

Abstract

Learning about intergenerational programming prepares health care professionals to be more competent and compassionate in working with a changing society. A unique teaching approach using intergenerational book discussion groups helps students learn about elders and provides a mutually beneficial experience. Assumptions, myths and biases held by each generation are often dispelled. Values and beliefs are clarified as members from differing generations learn about similarities and honor differences. The assignment becomes more than a technical learning situation and becomes one where friendships evolve and a deep respect for others develops. This article discusses how to plan and implement an intergenerational book discussion group for application within a variety of settings.     

Evaluating the Impact of Intergenerational Activities on Elders' Engagement and Expressiveness Levels in Two Settings

Abstract

This study evaluated the impact of intergenerational activities on elders' engagement and expressiveness levels in two settings. Study 1 was conducted with 22 well elders at a senior center and approximately 15 children from a nearby grade school. Data were collected using a momentary time sampling procedure, and inter-observer reliability averaged 88% (ranging from 78% to 97%). Elders were significantly more engaged (t(85) = 4.60, p > .001) and expressive (t(85) = 5.55, p > .001) in the treatment condition than the control condition. Study 2 was conducted with 25 older adults diagnosed with dementia, living in a special care unit. Twenty-eight second-graders were in the experimental group and 32 second-graders were in the comparison group. A momentary time sampling procedure was used to observe engagement, expressiveness, and inappropriate behavior levels. Inter-observer agreement averaged 94% (ranged from 85% to 100%). Elders were significantly more engaged in the structured activities with children than the structured activities without children, and significantly more engaged in structured activities without children than the no-activity condition, F(l) = 60.1; p > .01. Elders were also significantly more expressive in structured activities with children than the structured activities without children, and significantly more expressive in the structured activities without children than the no-activity condition, F(1) =26.5; p = 01. Further, there was no significant increase in inappropriate behaviors between any condition, F(1) =.322; p = .57. The analysis of variance regarding children's attitudes towards the elderly showed no significant differences whether they did or did not participate in the intergen-erational activities (F3.5, p < .05), with both groups maintaining positive attitudes of elders. These results reflect the importance of offering intergenerational activities to well and institutionalized elders as well as to children.     

Assessing Tradition in Chinese Elders Living in a Changing Social Environment

SUMMARY

Social workers are increasingly challenged to provide culturally sensitive services to older immigrants from diverse backgrounds. Assessment tools developed in the elder's own cultural context can maximize appropriate assessment and planning. This article describes the development of a tool for measuring adherence to tradition in Chinese elders. In Chinese tradition, an elder's purpose, meaning, and self-worth are derived, in large part, from their contribution to family, relatives, and the community. Existing measures of filial piety and acculturation do not capture this dimension. Filial piety involves being on the receiving end of care, honor, and obedience from younger generations. Acculturation is the opposite of adherence to tradition. One thousand five-hundred and two Chinese elders in China were asked questions on mutual aid and intergenerational exchange. Factor analysis extracted nine items loading into two factors reflective of traditional exchange. This measure could prove useful in understanding the effect of traditional beliefs upon various psychosocial outcomes.     

Families,Work, and an Aging Population

Abstract

This article examines the intersection of family caregiving, work, and long-term care. Supporting families who provide care in order to minimize negative work effects while enhancing the acceptability of care options is of common concern to employers, state and federal policymakers, and the homecare professionals in the community-based care system. The contribution of families to the long-term care system, how employer policies have developed, how the public policy agenda has addressed family caregiving, and the importance of a more effective partnership on the state level are discussed.     

Intergenerational Interaction Through Reminiscence Processes

Abstract

Introduction: The interest in intergenerational programmes is increasing. However, there is a need for evaluation and the development of a theoretical framework to explain the mechanism of changes in attitudes of participants which is the purpose of this paper.

Method: From July to December 2002 an intergenerational intervention was conducted with 111 students and 32 elders, who shared their life stories during class time. A Focus group technique was used to evaluate the programme and a theoretical framework was developed to explain the mechanism of changes in attitudes of adolescents towards elders and the attitudes of elders towards adolescents.

Results: The results showed that stereotypes and prejudice exist, from young people towards elders and from elders towards young ones. The theoretical framework developed showed why and how participants changed their views towards each other in an intergenerational programme using reminiscence processes as a means of interaction.

Conclusion: Although the study had some limitations, it was valuable in showing that older people had some negative images of adolescents. It also showed why and how participants changed their view towards each other.     

Global Convergence: Aging and Long-Term Care Policy Challenges in the Developing World

Aging around the world poses a global challenge in eldercare. This challenge is particularly felt in low- and middle-income countries (LMICs), where population aging outpaces the development of aged care policies and services. This Perspective highlights the phenomenon of global convergence in several unsettling trends and challenges shared across LMICs. These include the weakening of informal family care systems for the elderly, growing need for formal long-term care of the frail and disabled who can no longer be adequately supported by family members, and mounting pressures for policy responses to tackle these societal challenges. It is argued that policymakers should take a proactive stance. That is, when family care for the elderly falls short and family caregivers are increasingly under strain, the government should step in and step up support to fill in the gap by developing appropriate policies and a continuum of long-term care services that are accessible and affordable for the majority of older people in need. Three general principles are then suggested with regard to long-term care provision, financing, and quality assurance, which transcend national borders and can be used to guide long-term care policymaking across LMICs.     

Client Satisfaction with Home Care Services in Rural Russia

Abstract

The objective of this work is to explore the satisfaction of a sample of 300 frail elders living in a rural Russian area with the support services provided by social service agency staff. The client population lives in extremely difficult conditions in terms of housing and associated communal services. They reported very high levels of satisfaction with the agency-provided services, both general satisfaction and their satisfaction with the specific services received during the reference visit inquired about by the interviewer. The degree of satisfaction is likely related to the difficulty of their living environment and their probable poverty, as well as the quality of services received. Attempts to relate the variance in the satisfaction ratings to the extent of activity limitations and the volume of formal and informal care using multivariate analysis met with limited success, owing in part, at least, to the limited variance in the dependent variables. Nevertheless, the patterns identified are broadly consistent with expectations based on modeling previously done for the U.S. populations receiving at-home care. The results clearly indicate the value of providing such services to frail elders in such circumstances.     

Assessing Capacity in the Setting of Self-Neglect: Development of a Novel Screening Tool for Decision-Making Capacity

ABSTRACT

Compared with older adults with disabilities and those who autonomously choose to live in squalor, self-neglect syndrome arises from a predicate state of vulnerability in frail older adults. This state of vulnerability is characteristically associated with a decline in decision-making capacity regarding the ability to care for and protect oneself. We developed the COMP Screen to evaluate vulnerable older adults to identify potential gaps in decision-making capacity using a screening tool. A total of 182 older adults were evaluated and consistent declines in cognitive ability and decision-making processes were present in this population. However, there were no significant differences between elders referred for self-neglect and matched older adults. These findings suggest that declines in decision-making processes are not uncommon in vulnerable older adults but traditional conceptualizations of decision-making capacity may be inadequate for differentiating the capacity for self-care and protection in elders who self-neglect.     

An International Review of the Long-Term Care Workforce

Abstract

The developed world's population is aging, due to trends of increased life expectancies and decreased fertility rates. These trends are predicted to increase demand on long-term care services. At the same time, the long-term care workforce is in shortage in most of the developed world. Moreover, such shortages are expected to increase due to parallel socio-demographic factors. The increase in demand for long-term care, coupled with shortage in supply of care workers, has promoted some attention from policymakers. The current paper provides an international review of institutional arrangements for long-term care in different developed countries and in particular explores different strategies used or proposed to resolve the shortage in the long-term care workforce.     

Homes of Choice

Abstract

State policymakers increasingly recognize that housing is not only an important shelter resource for older persons, but also a key element of community-based care. Over the last two decades, significant state and local activity has led to an increase in service-enriched housing for older persons. Service-enriched housing refers to living arrangements that include health and/or social services in an accessible, supportive environment. Emerging forces are leading to increased pressure for the expansion of service-enriched housing. These forces include: a growing and diverse population of older renters; older adults' preferences to age in place; the increasing frailty of subsidized housing residents; the development of assisted living (AL); the enactment of Medicaid waivers; and implementation of the Olmstead decision. Although studies have not included cost-analysis, available research demonstrates that service-enriched housing promotes resident satisfaction, successfully provides services to frail populations, and supports aging in place.

Given both limited resources and research, this article addresses how states can adequately respond to and capitalize on these forces in order to best meet the long-term needs of older adults.     

Farm Friends

Abstract

Intergenerational programs have proliferated in community and educational settings, yet research on their effects and impacts lags (Kaplan, 2002; Kuehne, 1998/99), and the benefits and learning that occur for participants are under-theorized (Abrams and Giles, 1999; Smith and Yeager, 1999). Similarly, insufficient research has been reported on the learning that takes place in environmental education programs. In this paper we focus on the relationship that developed between community elders and elementary school-aged children during the first year of an intergenerational environmental education project. Our goal is to better understand these experiences so we can sustain participation and develop programs rich in rewards for elders and children. We are particularly interested in the nature of intergenerational learning that occurs when children are brought together with community elders for environmental education that is integrated into a school program. Granville and Ellis (1999) propose that for a program to be defined as intergenerational, it must show a benefit and value for both generations and “demonstrate an improvement in the quality of life for both, and from that, an improvement in the quality of life for all” (p. 236). We concur with these criteria and designed a program linking community elders with farming backgrounds with one class of 18 grade-seven girls for the purpose of fostering environmental consciousness. In this paper we focus our attention on the learnings of participants in order to understand the mutuallearning that occurs in an intergenerational environmental program.     

Impact of an Intergenerational Program on 4th Graders' Attitudes Toward Elders and School Behaviors

Abstract

The rapid growth of the elderly population coupled with research demonstrating the existence of ageist stereotypes even among very young children have led to the rise of intergenerational programs. Very limited research has been conducted, however, to demonstrate the effectiveness of these programs in producing attitudinal change or other beneficial outcomes for at-risk children. This study examined the impact of an intergenerational program on children's attitudes toward elders and on their school-based behaviors. Eighty-one 4th grade children enrolled in an inner-city school participated in the study. Forty-one children, with matched seniors partners, engaged in activities based on the 4th grade core curriculum within an outdoor classroom environment while the remaining 40 children participated in usual core curriculum activities. At the conclusion of the program those children who participated in the program had significantly more positive attitudes towards the elderly and significantly better school behavioral grades than did non-participating students. Implications and recommendations for intergenerational programming are discussed.     

Impact of an Intergenerational Program on 4th Graders' Attitudes Toward Elders andSchool Behaviors

Abstract

The rapid growth of the elderly population coupled with research demonstrating the existence of ageist stereotypes even among very young children have led to the rise of intergenerational programs. Very limited research has been conducted, however, to demonstrate the effectiveness of these programs in producing attitudinal change or other beneficial outcomes for at-risk children. This study examined the impact of an intergenerational program on children's attitudes toward elders and on their school-based behaviors. Eighty-one 4th grade children enrolled in an inner-city school participated in the study. Forty-one children, with matched seniors partners, engaged in activities based on the 4th grade core curriculum within an outdoor classroom environment, while the remaining 40 children participated in usual core curriculum activities. At the conclusion of the program those children who participated in the program had significantly more positive attitudes towards the elderly and significantly better school behavioral grades than did non-participating students. Impli-     

Homelessness Among Older Adults with Severe Mental Illness

ABSTRACT

This article tackles a problem that is often overlooked in the literature-the plight of homeless elders with severe mental disabilities. Drawing on his personal experience working with sheltered homeless persons who were mentally ill, the author argues for a focus not on self-sufficiency but on closely supervised care for this vulnerable population.     

Facility Ownership and Resident Satisfaction with Assisted Living

Abstract

Although the majority of assisted living facilities operate as for-profit organizations and serve increasingly frail elderly populations, little is known about the impact of ownership on the quality of care in assisted living. This study examines the relationship between facility ownership and the quality of care in assisted living, using resident satisfaction as a quality indicator. The assessed aspects of satisfaction include health care, housekeeping, physical environment, relationships with staff, and social life/activities. The relationship of facility ownership to resident satisfaction is examined controlling for resident psychological well-being, functional ability, facility size, and staff resources. Data were collected in personal interviews with 156 residents, including 96 residents in eight for-profit facilities and 60 residents in five nonprofit facilities in Maryland. Residents in the sampled nonprofit facilities were more satisfied with assisted living than were residents in the for-profit facilities. In particular, residents in nonprofit facilities were more satisfied with health care, physical environment, and social life/activities in the facility. Better understanding of the relationship between facility ownership and resident satisfaction can help administrators create environments that maximize resident satisfaction in both nonprofit and for-profit facilities.