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.     

Political and organizational barriers to satisfying low-income U. S. seniors' need for affordable rental housing with supportive services

A substantial share of the low-income older tenants who occupy U. S. government-subsidized rental housing has physical and cognitive limitations. These older tenants are often women living alone in their 70s and 80s, who need help obtaining community-based services, demand-responsive transportation, help with apartment housekeeping and maintenance, self-care assistance, and design modifications made to their dwellings. Other low-income and frail older persons who have large housing expense burdens or occupy physically deficient dwellings also need affordable rental housing with these supportive services. The unmet supportive service needs of these groups persist even as this country's major political and professional stakeholders are aware of their problems and have solutions. This paper examines five major political and organizational barriers that have restricted the availability of supportive services in affordable rental developments. It offers 12 policy recommendations.     

Supportive Housing Initiatives in Arkansas

Abstract

Arkansas has a significant need for improving the availability of affordable housing with access to supportive services for its large population of elderly and persons with disabilities. Factors that contribute to this need are the high level of poverty, general poor health, low employment rate for persons with disabilities, and the geographic and social isolation problems typical of a rural State.     

Where Is “Place” in Aging in Place? Transnational Issues for the Danish State and Its Retirement Migrants Abroad

The aim of this article is to contribute a transnational perspective to the field of environmental gerontology and the concept of aging in place. Seniors from the northern hemisphere, among them Danish citizens, are increasingly adapting to transnational lives as they move to warmer climates. This article builds on a qualitative study among Danish retirement migrants regarding their experiences with the need for care or support while living abroad. Denmark is a welfare state with a long history of public nursing homes and in-home care for frail elderly persons. This system of governance is influenced by universalism, aiming at equality in terms of access to health services and care. However, these welfare provisions seem to be deeply embedded in methodological nationalism, since only citizens with residence within the borders of Denmark have the right to live in public nursing homes or receive in-home help. It is argued that we should consider public solutions to the problems faced by frail Danish citizens in transnational settings, enhancing their opportunities to live abroad.     

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.     

The Coming Home Program

Abstract

This paper describes barriers and opportunities to creating affordable assisted living facilities for older persons eligible for Medicaid services. This information is based on the practical experiences of the Coming Home Program, a project of NCB Development Corporation (NCBDC) with funding from the Robert Wood Johnson Foundation (RWJF). Begun in 1992, this national program has contributed to the creation and adoption of state policies including regulations, implementation of state programs, creation of development and operational feasibility analysis tools, and the identification and structuring of financing sources. It has also fostered and supported public-private partnerships that have resulted in 31 operational affordable assisted living demonstration projects with another 73 in development.

The paper explains the need for affordable assisted living, Coming Home's definition of affordable assisted living, and the structure of the Coming Home Program. Four case studies are presented that summarize the goals and outcomes of the Coming Home Programs in Arkansas, Florida, Washington, and Vermont. The paper's conclusions provide lessons learned during the program's first twelve years and their implication for state policies and programs.     

Aging in the Shadow of the Law

Abstract

Historically, the frail elderly, as well as other vulnerable populations who are unable to care for themselves, have been subject to legal proceedings known as guardianships. Despite changes and reforms, adult guardianship law has survived as a fundamental legal institution aimed at protecting the frail elderly as well as other incompetent adults. However, very little is known on the reality of adult guardianship under Israeli law, and the experience of the adult population under guardianship was never empirically studied in Israel. The empirical void regarding the workings of the Israeli law in this area served as the impetus for this study. The study investigated the issue of adult and elder guardianship in Israel as revealed in Family Law Courts' rulings, while focusing in particular on the profile of the wards, the reasons and motives, the legal procedure, and the outcome of the guardianship process.

The study was a quantitative analysis, based on a random sample that included523 court cases requesting legal guardianship for adults due to impaired legal competence. Rulings on these cases were provided in Family Courts from Haifa, Nazareth, and the Krayot areas in the period of the years 2000-2002.

A clear but somber picture emerges from the findings of this study: Every year thousands of elderly individuals are subjected to the plenary legal authority of guardians appointed by law. This severe legal outcome takes place without providing these elderly the right to express their positions, without the provision of legal representation, and without their being seen or heard by the courts. These findings lead to the conclusion that there is urgent need in Israel to carry out extensive reform in the realm of civil legislation on the issue of guardianship foradults and the elderly.     

Aging in Place or Relocation: Perceived Awareness of Community-Based Long-Term Care and Services

ABSTRACT

This study used data from the Community Partnership for Older Adults Program Survey (N = 4,611) to examine associations between the perceived awareness of community-based long-term care and supportive services and the anticipation for aging in place and relocation. Respondents varied substantially in their knowledge about services and anticipation for aging in place and relocation. Perceived availability and unavailability of a series of community services was associated with the likelihood of anticipating aging in place and relocation, and awareness of the lack of visiting nurses, personal assistance, or transportation was related to respondents reporting a younger age at which they anticipated needing help to age in place or anticipating a need to relocate. Findings have implications for raising the public awareness of community-based services in addressing the needs of community-dwelling elders for aging in place and relocation.     

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.     

Families' Values and Attitudes Regarding Responsibility for the Frail Elderly

Abstract

This study examines the norms and values associated with care to disabled and frail aging parents, in particular those with regard to the sharing of responsibilities for care between families and formal services, and this within three age cohorts in Quebec, Canada. It is based on a telephone interview of 1,315 people. Factor analysis yielded four factors: (1) family responsibility; (2) uncompromising family obligations; (3) acceptance of services; (4) distrust of services. Analyses of the data indicate that all three age cohorts consider that families have responsibilities for their aging family members, at the same time that they score very high on the acceptance of service scale. This article discusses these seemingly paradoxical results and their implications for aging policy.     

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.     

Health Care for Older Persons in Singapore

Abstract

Health care policy in Singapore is similar to that in the United States and the United Kingdom, where a residualist strategy is used to pass health care costs to individuals and their families, the rationale being that this enables the state to concentrate on devolution of care to the community and ensure efficient and affordable service to all Singaporeans. The services include public restructured hospitals and outpatient poly-clinics as well as community services such as community hospitals and hospitals for the chronically ill, nursing homes, day care centers, and home help services. Availability does not translate into optimum usage because current and potential users and their families are not able to match their financial and social resources with the services. Instead, the state acts as the case manager and places parameters on what individuals can access.     

Family Caregivers for Seniors in Rural Areas

In this article, the demographic characteristics of family caregivers for seniors in rural communities are assessed to examine whether their circumstances could facilitate or impede their well-being. Services available in rural communities for family members providing ongoing care to frail seniors is examined, particularly those that provide health and social services. How families access these services and whether there are specific barriers in service provision are analyzed based on current social work practice and the research literature. Trends for future services are identified as well as whether these trends support new roles for social workers in rural settings.     

Human Resource Issues in University Health Services

Abstract

To provide first-rate services to students, college health services need the best possible staff. Managers and supervisors play a critical role in guiding the work of their employees so as to enhance performance. Reference checks for new employees and regular performance appraisal dialogues for ongoing employees are important tools in this process. The author discusses these issues and suggests formats for reference checks and performance appraisals.     

Conceptual Framework of Coalitions in an Organizational Context

Summary

Organizations are forming coalitions in their struggle to survive with fewer resources. Under the “Contract With America,” funds for human services are expected to be increasingly cut back. Organizational actors will continue to coalesce because of their compelling interests to serve disadvantaged populations in our communities. This article uses the political-economy perspective in presenting a conceptual framework of coalitions in organizational settings. We need access to various perspectives and models of coalition building in order to provide direction for organizational groups as they attempt to change the sociopolitical structures in which they must operate.     

An Overview and Critique of the Experience Corps for Independent Living Initiative

Abstract

This article presents findings of the evaluation of the Experience Corps for Independent Living (ECIL) initiative. The ECIL initiative was a two-year demonstration program designed to test innovative ways to use the experience, time, and resources of volunteers over 55 to expand significantly the size and scope of volunteer efforts on behalf of independent living services for frail older people and their caregivers in specific communities. Six demonstration projects were selected to participate in this initiative. The intensive volunteers, the critical component of the program, were more highly skilled than typical volunteers from existing senior volunteer programs. ECIL volunteers collaborated with agency partners to develop new programs, supervise direct service activities, and enhance the performance of the agencies being served. Although the projects addressed many of the goals of the initiative, they did not fully accomplish all of their objectives. The ECIL initiative was particularly successful in providing independent living services to frail elders and their families in the communities served. It was less successful in developing and maintaining the team and corps concept, in attracting and retaining the anticipated numbers of volunteers during the study period, and in becoming self-sufficient by the end of Year Three.     

Adding Long-Term Care to Medicare

The rancor accompanying the repeal of most of the 1988 Medicare Catastrophic Act reflects both the national need to improve health and long-term care benefits for the elderly and the political obstacles to finding new sources of financing for such benefits. Neither the need nor the obstacles will go away, but policymakers are now likely to look for lower-cost, efficient, and privately funded alternatives. The authors have developed and tested one such approach: the Social Health Maintenance organization (SHMO). Operating since 1985. the SHMO model integrates community-based, long-term care services into the managed,prepaid HMO design. The four test sites are adding long-term care to Medicare at no extra cost to the government and only modest premiums for the 17,000 current members. Although the benefits offer limited protection for long-term nursing home care, they do cover long-term care in community settings, where people tend to prefer to stay. Also, integration of the acute and long-term care s stems improves the ability to respond to the medical needs of frail members, who also have high acute-care use. The SHMO's model of front-end, community-oriented, long-term care benefits integrated with Medicare appears to be a practical, affordable, and clinically appropriate way to address the rising concern with the lack of coverage and services for long-term care.     

EDITORIAL

Abstract

Many faith-based organizations (FBO) provide services to poor people. A major challenge for these organizations is to determine who is eligible to receive services. Thus, these organizations seek to make sure that that the poor are “truly worthy” and do not take advantage of a particular charity. The purpose of the study is to determine the kinds of barriers to service delivery that confront volunteers as they provide services to the poor. Volunteers possess the motivation to assist; however, many volunteers are given limited training, which may only include a basic understanding of the resources available at the center. We used a combination of qualitative methodologies to observe two FBOs in Anne Arundel County, Maryland. We observed and interviewed a total of 24 volunteers; 12 from each site, over a 3-month period. The two sites were similar in that they were faith-based and relied on volunteers. One site was located in a middle to lower economic area and the other site was located in a more affluent area of the county. Support provided included donations of food and financial assistance for eviction, utilities, and other emergencies. From this qualitative analysis, four working hypotheses emerged: (1) Volunteers expressed a sense of frustration over the limited resources and the increasing number of people in need; (2) Many volunteers expressed frustration that increasing burdens limited their ability to utilize the centers as a place to obtain friendship and social networks; (3) Volunteers expressed concerns and praise for the leadership at the two sites, and (4) Volunteers commented on how their faith influenced their decision to volunteer. The authors explore methods to address these challenges so clients in need can be better served.     

Rolling forward: addressing needs in the homeless community

ABSTRACT

The purpose of this pilot study was to use a bottom up, or grounded, approach to understand, from the perspective of the individuals living in the homeless community, what they feel would enable them to become housed and stay permanently housed. Organizations which serve homeless individuals often use a top down approach and implement programs without asking the homeless what they most need to find permanent housing. This project used intensive interviews to determine the needs of unhoused individuals in a mid-sized city with a tourist-centered economy in the south eastern United States. Working local homeless shelters, and various other intermediaries we collected data from 102 homeless individuals and 11 service providers. The major theme that emerged in our research is that the homeless individuals we interviewed were, for the most part, they were able to meet many of their basic needs, such as securing food, clothing, a place to bathe and wash their clothes, as well as obtain physical and mental care. However, they perceived lack of reliable and affordable transportation to be a significant barrier to obtaining and maintaining employment, making and keeping appointments, and maintaining their social support network.