International migrations and care provisions for elderly people left behind. The cases of the Republic of Moldova and Romania

International migrations are posing numerous challenges to care systems in both sending and receiving countries. Based on a multi-method research conducted between 2011 and 2013, this article looks at how the care provisions for elderly people are rearranged in two Eastern European countries affected by the care drain phenomenon (the Republic of Moldova and Romania). The author charts and compares how transnational families, but also the other facets of the care diamond, such as the public sector, the market and the not-for-profit sector, provide care to elderly people left to cope at home alone because their close relatives have migrated. The main findings of the article are that transnational families are the principal welfare provider for elderly people left behind, while there is a serious delay in the adoption of specific policies for the elderly.     

A portrait of homelessness.

The homeless elderly are vulnerable, silent, and fearful. Their trajectory into homelessness more often than not precludes recovery and takes them on a course toward early death or nursing home placement. Psychiatric nurses who work in community or acute care settings are in key positions to recognize elderly victims of homelessness, assess their needs, match them to services, start them on the road to recovery, and become their advocates. The definition of a homeless person as agreed on in the Report of the Federal Task Force on Homelessness and Severe Mental Illness (1992) is the one used in the Stewart B. McKinney Homeless Assistance Act (Public Law 100-77). A homeless person is someone "who lacks a fixed, regular, and adequate nighttime residence" and whose main nighttime residence is a "supervised public or private shelter designed to provide temporary living accommodations; an institution that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings." This definition, then, excludes those individuals living on the "fringes" in substandard or condemned housing, a condition that warrants attention in general and particularly among the elderly.     

Home care for the elderly: the role of relatives,friends and neighbors

We use data from the Survey of Health, Ageing and Retirement in Europe to examine the hours of home care received by the elderly. The existing empirical literature has mostly examined informal home care from children and formal home care. We identify two additional informal home care providers, namely, relatives (other than children) and friends (including neighbors) who provide about 30 % of the hours of informal home care. Our main new empirical finding is that single elderly persons who can rely less on children—and in particular daughters—for their home care receive not only more formal care but also more care from friends and neighbors. These findings suggest that policymakers need to take into account not only home care provision from children but also home care provision from friends and neighbors to obtain accurate projections concerning the increasing costs of formal care programs due to an aging population.     

A Descriptive Study of Home Modifications for People with Dementia and Barriers to Implementation

This study describes home environmental features, safety issues, and health-related modifications in a community dwelling sample of 82 elderly people with dementia. Main barriers to the accessibility of the homes were steps both inside and outside the home. The majority of the caregivers had made home modifications that pertained mainly to physical limitations. Home modifications to support cognitive deficits were made to a lesser extent. The main barrier to the implementation of home modifications to accommodate the care recipient's memory loss was skepticism about their usefulness. Regarding the removal of physical barriers, financial constraints were most frequently mentioned.     

Measures of Restoration in Geriatric Care Residences

Abstract

In this paper, we have studied how elderly people's frame of mind influences their response to experiencing nature, measured in terms of blood pressure, pulse rate, concentration and results from protocols. Two theories concerning the importance of psychological balance have been put forward earlier by Lawton and Kiiller, both of whom maintain that the surrounding everyday environment is one of the keys to a harmonious existence. We present findings supporting the theory that the positive experience of natural surroundings per se has a balancing and healing effect.

We have found that the people most affected by their surroundings are those with the greatest psycho-physiological imbalance. When the balance tilts, the balancing effect of the green experience can restore the individual to a state of better harmony. Time spent in the outdoors is, thus, especially important for individuals who easily lose their equilibrium or find it difficult to make compensatory changes to restore harmony on their own.

The research project is an intervention study in which fifteen elderly individuals living at a home for very old people participated. Their power of concentration, blood pressure and heart rate were measured before and after an hour of rest in a garden and in an indoor setting, respectively. Seven elderly people were randomly chosen to have their first series of tests in a garden, while eight elderly people had their first series of tests indoors. The results indicate that power of concentration increases for very old people after a visit in a garden outside the geriatric home in which they live, as compared to resting indoors in their favorite room.

The results did not show any effects on blood pressure or heart rate.

However, when we compared these results with the background variables, we found interesting correlations. Background variables included how often they took part in social activities, showed helpfulness toward other residents in group activities and tolerance/critique of other residents. After a factor analysis, the background variables formed three distinct factors, one of which showed significant correlation with blood pressure and heart rate: the factor psycho-physiological balance, with the variables “degree of tolerance,” “degree of helpfulness” and “frequency of hospital visits.” Elderly people with low psycho-physiological balance, that is, who had low tolerance of other residents, were not helpful in group activities and had a high frequency of hospital visits, were most affected by a stay in a garden, as could be measured in changes in heart rate and blood pressure. The results may be interpreted as showing that a garden can restore an elderly person with low psycho-physiological balance to a state of better harmony.

The present study show, first, that an outdoor visit is important for recovery from stress and fatigue and, second, that the improvement is especially significant for the most susceptible. Thus, it is of particular importance that weak groups, such as elderly in great need of care, have access to an outdoor space. Such groups are likely to include many people who are in psycho-physiological imbalance.     

Defining the challenges of providing long-term care: the case of the nursing home industry's response to the AIDS epidemic

Acquired Immune Deficiency Syndrome (AIDS) is now viewed as a chronic disease requiring long-term management. As a result, more persons with AIDS (PWAs) are seeking long-term care in facilities that have primarily served the elderly. In some regions, however, the nursing home market into which PWAs may introduce new demand is a market already characterized by excess demand. In light of this, competition for limited long-term care resources may develop between the frail elderly and PWAs. The nursing home industry has raised many issues regarding the feasibility of admitting AIDS patients as residents, but little is known about how important these issues are in deciding admissions policy. How the industry perceives and resolves the concerns it has regarding delivery of care to PWAs can affect the overall long-term care system and thus affect the traditional users-the frail elderly. Knowing the concerns and preferences of the industry may help guide and anticipate future changes in the system. In this pilot study, a random sample of 250 nursing home administrators in the five highest AIDS-incidence areas in the United States was surveyed to determine (1) the industry's concerns and issues regarding AIDS care, (2) data regarding requests for admission by PWAs to nursing homes, and (3) data concerning the industry's preferred way of delivering AIDS care. Important admissions policy issues cited by the respondents included the ability to meet special care needs, costs of care, and inadequate reimbursement. The majority also believed the most appropriate methods of providing care were special care units for AIDS within nursing homes or dedicated HIV/AIDS nursing facilities.     

“How to wind the clock of the day?” Solo living phenomena and the various stabilities of home

The domestic home is usually theorized as negotiated and structured space-time and as an emotional attachment to people and places. However, the increasing number of people living on their own brings about the question of how home is experienced, embodied, and narrated by solo-living individuals, especially in terms of ordering and stability under the flexible and fluid nature of some other realms, such as paid work. Following the affordance approach in studies of home, our aim is to integrate research on practices, materialities, and narratives of domestic homes. Our main question concerns how home is perceived, experienced, and performed by childless solo-living people and how they understand the stability of their dwelling—one of the main characteristics of home in social theory. To broaden this “traditional” concept of home, we build upon the emphasis on stability with the notion of flow, as presented by Deleuze and Guattari, along with the concept of boundary work, to describe the processes of delineation between these two from the level of mundane “doings.” Through in-depth interviews conducted using the go-along technique, combined with walking through the dwellings and some of the neighborhoods, we explore the ambivalence of stability, permanence, and temporariness, and the interconnection between materialities and meanings. The appropriation of space and time enables solo-living people to dwell comfortably, while also materializing and stabilizing the sometimes unwanted state of singleness or living alone. In contrast, the unfinished nature of some homes indicates a provisional state of being, pointing out that the current situation is still not satisfactory, being more open to change; however, it might lead to permanent living in unpleasant or even un-homey homes.     

High quality private long-term care insurance: can we get there from here?

The private long-term care insurance market has undergone rapid change in the last several years. Although the quality of policies has generally improved, problems remain. Consumer protection issues include the lack of adequate inflation protection features, how activities of daily living are measured, potentially high lapse rates and lack of nonforfeiture values, how home care benefits are defined, and the appropriate loss ratio standards. The concerns of consumer and elderly advocates about the quality of private long-term care insurance have prompted congress to consider the need for federal intervention. While there are numerous approaches that the federal government could take, mandatory standards substantially higher than the current model standards of the National Association of Insurance Commissioners may prove the most effective in improving the quality of policies on a nationwide basis.     

High Quality Private Long-Term Care Insurance

The private long-term care insurance market has undergone rapid change in the last several years. Although the quality of policies has generally improved, problems remain. Consumer protection issues include the lack of adequate inflation protection features, how activities of daily living are measured, potentially high lapse rates and lack of nonforfeiture values, how home care benefits are defined, and the appropriate loss ratio standards. The concerns of consumer and elderly advocates about the quality of private long-term care insurance have prompted Congress to consider the need for federal intervention. While there are numerous approaches that the federal government could take, mandatory standards substantially higher than the current model standards of the National Association of Insurance Commissioners may prove the most effective in improving the quality of policies on a nationwide basis.     

A Descriptive Study of Home Modifications for People with Dementia and Barriers to Implementation

This study describes home environmental features, safety issues, and health-related modifications in a community dwelling sample of 82 elderly people with dementia. Main barriers to the accessibility of the homes were steps, both inside and outside the house. The majority of the caregivers had made home modifications, which pertained mainly to physical limitations. Home modifications to support cognitive deficits were made to a lesser extent. The main barrier to the implementation of home modifications to accommodate the care recipient's memory loss was skepticism about their usefulness. Regarding the removal of physical barriers, financial constraints were most frequently mentioned.     

“The show must go on”: Behind the scenes of elderly spousal caregiving

Based on interviews with ten caregivers and on observations of their daily behavior, the present article sets out to clarify why, despite the burdens of care-giving, elderly individuals care for their spouses at home, even when the option to institutionalize them is available. Unlike traditional ways of approaching this question, founded on emic models, the analysis presented in this article is mainly an etic one, based on the dramaturgical approach. The findings indicate that caregiving is a stage for self-deceptive playacting, allowing caregivers to suspend time, awareness, and anxiety in a way that would not have been possible had they institutionalized their spouses. The study shows that features of caregiving, usually portrayed as burdens and hardships, serve in fact as coping mechanisms, which may explain elderly people's willingness to care for their spouses in their own homes.     

Assessment for home care: Negotiating solutions for individual needs

This article explores care management as an activity that regulates the distribution of society's resources for home care. It focuses on interaction in assessment meetings, which are part of the planning of services and care for old people in Sweden. The aim was to acquire an understanding of how old people, as applicants, account for their needs for care, and how these accounts are negotiated and positioned in talk. Twenty home care assessments were audio-taped and the data were analyzed using discursive analysis. It was found that the assessment meetings had an institutional structure within, which old people, as applicants and with individual needs for care, were assessed within fixed institutional categories. Furthermore, analysis showed how interaction during assessment meetings functioned as formal problem-solving, in which applicants' accounts of their health issues were negotiated, contributing to the construction of their identity as home care receivers.     

Family members' strategies when their elderly relatives consider relocation to a residential home - Adapting, representing and avoiding

The aim of this article is to reveal how family members act, react and reason when their elderly relative considers relocation to a residential home. Since family members are usually involved in the logistics of their elderly relative's relocation, yet simultaneously expected not to influence the decision, the focus is on how family members experience participation in the relocation process in a Swedish context. 17 family members are included in 27 open, semi-structured interviews and follow-up contacts. Prominent features in the findings are firstly the family members' ambition to tone down their personal opinions, even though in their minds their personal preferences are clear, and secondly, the family members' ambivalence about continuity and change in their everyday lives. Family members are found to apply the adapting, the representing, or the avoiding strategy, indirectly also influencing their interaction with the care manager. Siblings applied the adapting strategy, spouses the representing strategy, while family members in the younger generation at times switched between the strategies.     

Financing Reform for Long-Term Care

The way the nation provides for the financing and delivery of long-term care is badly in need of reform. The principal options for change are private insurance, altering Medicaid, and 110 FROM NURSJNG HOMES TO HOME CARE public long-term care insurance. This article uses the Brookings-ICE Long-Term Care Financing Model to evaluate each of these options in terms of affordability, distribution of benefits, and ability to reduce catastrophic out-of-pocket costs. So long as private insurance is aimed at the elderly, its market penetration and ability to finance long-term care will remain scverely limited. Affordability is a major problem. Selling to younger persons could solve the affordability problem, but marketing is extremely difficult. Liberalizing Medicaid could help solve the problems of long-term care, but there is little public support for means-tested programs. Finally, universalistic public insurance programs do well in meeting the goals of longterm care reform, but all social insurance programs are expensive and seem politically infeasible in the current political environment. The way the nation provides for the financing and delivery of long-term care is badly in need of reform. No other part of the health care system generates as much passionate discontent as does long-term care. At the heart of the problem is the absence of any satisfactory way to help people anticipate and pay for long-term care. The disabled elderly find, often to their surprise, that the costs of nursing home and home care are not covered to any significant extent by Medicare or private insurance. Instead, they must rely on their own savings or, failing that, turn to welfare in the form of Medicaid. At a national average cost of $40,000 a year for nursing home care, long-term care is a leading cause of catastrophic out-of-pocket health care costs for the elderly. In addition, despite the strong preferences of the disabled for home and community-based services, current financing is highly skewed toward care in nursing homes. While the debate over long-term care reform has many facets, it is primarily an argument over the relative merits of private- versus publicsector approaches. Differences over how much emphasis to put on each sector partly depend on values that cannot be directly proved or disproved. Some believe that the primary responsibility for care of the elderly belongs with individuals and their families, and that government should act only as a payer of last resort for those unable to provide for themselves. The opposite view is that the government should take the lead in ensuring comprehensive care for all disabled older people, regardless of financial need, by providing comprehensive, compulsory social insurance. In this view, there is little or no role for the private sector. Between these polar positions, many combinations of public and private responsibility are possible.     

A social capital approach to the prevention of elder mistreatment

The current demographic landscape features an increasing number of elderly individuals in the care of some trusted other. Being cared for by a trusted other raises the potential for mistreatment of the elder by that trusted other. The goal of this paper is to explore the possibility of preventing elder mistreatment by increasing the bridging and bonding social capital available to caretakers. Attending to social capital lets researchers expand their focus toward areas rarely examined through current stress-outcome models (e.g., interpersonal interactions). First, elder mistreatment and social capital are defined and discussed. Then, a model is forwarded that details how social capital might mitigate the effects of caretaker stress and decrease the probability that caretakers will engage in elder mistreatment in both home and long-term care institutional settings. Finally, implications for future research and practical intervention are discussed.     

Validity in an evaluation of Healthy Families Florida—A program to prevent child abuse and neglect

Evidence-based continuums have become a guide for identifying the level of evidence in evaluations of home visiting programs conducted to determine their effectiveness in preventing child abuse and neglect. While randomized controlled trials are required for the highest levels of evidence, quasi-experimental designs have also been specified as an appropriate alternative. Using a quasi-experimental evaluation of a home visiting program to prevent child abuse and neglect that adheres to the Healthy Families America model, this paper describes and illustrates how types of validity can be improved. More specifically, we address how threats to internal validity can be identified and reduced through statistical techniques; how construct validity may be strengthened using state records to measure the outcomes; and how external validity is affected by including or excluding study participants. After applying a variety of statistical adjustments to reduce selection bias, we found that the outcomes favored the home visiting program and increased after accounting for covariates that contributed to child abuse and neglect. This was true across the statistical techniques (traditional covariate and propensity score adjustment) used. For evaluations using quasi-experimental designs, recommendations relevant to the illustrations in the paper are also presented.     

Danish home care policy and the family: implications for the United States

This paper provides an overview of reforms in Danish long-term care initiated in the early 1980s, describes the relationship between elder care in Denmark and the family, and considers implications for U.S. policy. The success of Denmark's community-based experimentation with new models of home care and housing for the elderly resulted in a national decision to eliminate new construction of nursing homes and increase access to publicly funded home care. Lingering concern that the provision of paid assistance for the elderly could undermine family structure is allayed by the findings of a recent survey: Three-fourths of the elderly report seeing their children on a weekly or more frequent basis. Findings from the Danish experience provide evidence that community-based services can aid family caregivers, enable the frail elderly to live in the setting of their choice, and be cost-effective from a public policy perspective.     

Reflections on International Certified Nursing Assistants

The author, a former university faculty member who taught English to speakers of other languages and now a nursing home resident, shares her observations about how English language proficiency, culture, and religious differences affect her care. She provides examples of communication challenges that can be annoying or cause harm, her coping strategies, and reasons many certified nursing assistants might never be fully fluent in English. She explains how international certified nursing assistants can benefit residents because of skills developed by family-centered care in their countries of origin. She also discusses related issues—the importance of being culturally competent about U.S. culture. She points out how religiousness not only affects residents but is a buffer for staff against the stress of physically and emotionally demanding low-wage work. Overall, the author likes receiving care from individuals from other countries, finding reward in comparing how her personal struggle with illness and paralysis resonates with the trauma of migration and how learning firsthand about varying beliefs and attitudes clarifies her identity and place in world history.     

Changes in health, mortality, and disability and their impact on long-term care needs

The need for long-term care is driven both by the growth of the elderly population and changes in the age relations of morbidity, disability, and mortality. Data show these relations changed in the U.S. elderly population from 1982 to 1989. Chronic disability prevalence declined between the 1982 and 1989 U.S. National Long Term Care Surveys. Among those impaired, many persons using personal assistance to meet their needs shifted to the use of assisted housing and special equipment. The relation of these trends to other changes--such as the increasing educational level of the elderly population--is examined to estimate how future changes in disability and morbidity may affect the demand for long-term care. Disabilities at specific times as well as their transition rates were examined to determine how long individuals need long-term care. The analyses suggest that, while the amount of long-term care services needed will increase rapidly, the types and amounts of services used by the U.S. elderly population will undergo significant change.     

Changes in Health,Mortality, and Disability and Their Impact on Long-Term Care Needs

The need for long-term care is driven both by the growth of the elderly population and changes in the age relations of morbidity, disability, and mortality. Data show these relations changed in the U.S. elderly population from 1982 to 1989. Chronic disability prevalence declined between the 1982 and 1989 U.S. National Long Term Care Surveys. knong those impaired, many persons using personal assistance to meet their needs shifted to the use of assisted housing and special equipment. The relation of these trends to other changes-such as the increasing educational level of thc elderly population-is examined to estimate how future changes in disability and morbidity may affect the demand for long-term care. Disabilities at specific times as well as their transition rates were examined to determine how long individuals need long-term care. The analyses suggest that, while the amount of long-term care services needed will increase rapidly, the types and amounts of services used by the U.S. elderly population will undergo significant change.