The Home Care Industry

The home care component of our long-term care system is increasingly being recognized as the preferred alternative to institutional care for the frail elderly and disabled. Dwindling resources, both human and fmancial, are likely to have a deleterious effect on home care. Findings from a 1987-88 survey of paraprofessional home care workers of the frail elderly in New York City are used to draw implications for the home care industry. The scope of problems inberent in the industry imply that changes are necessary on both the micro and macro levels; the article concludes with recommendations for both levels.     

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.     

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.     

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.     

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.     

Nonprofit and for-profit home care in Israel: clients' assessments

Clients' assessments of differences between nonprofit and for-profit organizations delivering home care services to Israel's frail elderly were studied. No significant differences were found between nonprofit and for-profit providers with respect to organizational efficiency; speed of placement and replacement of home care workers; responsiveness to clients' complaints; and supervision of care plans, schedules, and service delivery. Systematic differences were found, however, in clients' perceptions of workers employed by nonprofit versus for-profit service providers. The differences related to the home care workers' adaptation to clients' needs and wants; how well workers delivered services; and how satisfied clients were with the services received. Indications are that the relatively high efficiency of nonprofit organizations can largely be attributed to the performance of their home care workers.     

Nonprofit and For-Profit Home Care in Israel

Clients' assessments of differences between nonprofit and for-profit organizations delivering home care services to Israel's frail elderly were studied. No significant differences were found between nonprofit and for-profit providers with respect to organizational efficiency; speed of placement and replacement of home care workers; responsiveness to clients' complaints; and supervision of care plans, schedules, and service delivery. Systematic differences were found, however, in clients' perceptions of workers employed by nonprofit versus for-profit service providers. The differences related to the home care workers' adaptation to clients' needs and wants; how well workers delivered services; and how satisfied clients were with the services received. Indications are that the relatively high efficiency of nonprofit organizations can largely be attributed to the performance of their home care workers.     

Long-term care: a comparison of policies and services in Israel and the United Kingdom and implications for the United States

The issue of long-term care continues to be a main concern in the United States. As the country wrestles with the development of policies and services, the experiences of Israel, whose system rests upon national insurance, and that of the United Kingdom, which is based on grants to local authorities, can act as valuable teaching aids in the development of programs in the United States. Although both countries focus on community care with virtually universal access, concern over resources is forcing each to target their services increasingly to the most frail. The findings underscore the necessity for accurate planning and adequate resources if services are to meet the needs of the frail elderly population.     

Sensitizing nursing home staff to residents' psychosocial needs

Most of the direct care of nursing home residents is provided by nursing aides. Aides generally have had limited training and experience working with the frail elderly and may not be attuned to residents' psychosocial needs. This can result in aides working at cross purposes with the social worker, producing a system that is counterproductive. This paper describes a situation where inservice training was utilized to help aides gain a greater understanding of the residents in their care. Advantages of using in-service are discussed, potential pitfalls are considered, and illustrations of in-service training techniques are presented.     

On Lok: a pioneering long-term care organization for the elderly (1971-2008)

On Lok is a pioneering nonprofit organization that has delivered services to the frail and elderly since its founding in 1971. The agency began as a grassroots effort focused on improving the health care available to older adults living independently in the community. Over its 40-year history, On Lok has evolved into a $70 million nonprofit human service organization with a national reputation for innovation as a leading provider of care to frail elderly. The agency has developed its own model of care that has been replicated in cities around the country. The history of On Lok represents the important impact that donor and community support plays in an organization's long-term success.     

Cheaper for whom? Costs experienced by formal caregivers in adult family living programs

A current emphasis in Canadian public policy is on community care for frail seniors. Such care is viewed as attractive in part because public costs are lower than for traditional nursing home care. Adult Family Living (AFL) is seen as an exemplar of this community focus. Data from a multi-model evaluation of residential continuing care in western Canada are used to show that while AFL programs have lower public costs than nursing homes, AFL caregivers incur high levels of economic and non-economic costs. We address the question of the sustainability of this approach to community-based residential care in light of the apparent transfer of public costs to AFL caregivers.     

Setting priorities in aging populations: formal service use among Mexican American female elders

This study establishes empirical patterns of formal service use by a sample of 483 elderly Mexican American women, and identifies the predictors of formal service utilization. Results indicated two patterns of service use-in the home and at senior centers. Regression analysis demonstrated that the best predictors of who used formal in-home services were those with functional impairment in Instrumental Activities of Daily Living (IADLs) and those with the least amount of assistance with IADLs provided by family members. Living alone and attending group social events were the best predictors of the use of senior center services. Anticipated changes in the Mexican American population portend a growing need for both in-home and senior center services. These findings can be used to establish policy and programming priorities for this neglected population. If resources are to be effectively targeted to frail elders, in-home services should receive priority, and the provision of in-home services should be modified to include additional programs that facilitate care of the elderly by the family.     

Resource effects on access to long-term care for frail older people

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Physical Home Environment as a Determinant of Aging in Place for Different Types of Elderly Households

The aim of this research was to investigate the relationship between physical housing features and home modifications to aging in place or precipitating a housing transition among elderly households. Data was taken from two waves (1998 and 2000) of the Health and Retirement Survey. Univariate, bivariate, and multivariate analyses were performed. Residing in a multi-family home without an elevator was a predictor for housing transition for couple households, while residing in a home with small interior modifications was a predictor for remaining in place for single households. Implications for policy makers, health care providers, housing industry and elderly are discussed.     

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.     

Adding long-term care to Medicare: The Social HMO Experience

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 systems 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.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Telemedicine,rural elderly,and policy issues

Historically, rural America has had a difficult time providing health care to its residents, particularly its frail elderly population. Rural health care is often faced with a shortage of health care specialists, facilities with inferior equipment, and insufficient resources compared to health care in more urban areas. It is anticipated that the use of telemedicine will help address many of the problems facing the delivery of health care services to rural elderly. This paper reviews some innovative projects delivering services to the elderly. Also, the paper discusses several issues that need to be addressed before telemedicine can reach its full potential in improving access to health care, including reimbursement policies, patient and provider liability and confidentiality, and the infrastructure supporting telemedicine. Although telecommunications has tremendous potential to address the care needs of frail isolated elderly, without comprehensive reimbursement policies, guidelines for ethical conduct of a teleconsultation, acceptable security measures of patient records, and adequate as well as compatible infrastructure, that potential cannot be completely realized.     

Using HIT to deliver integrated care for the frail elderly in the UK: current barriers and future challenges

In this paper we briefly describe the results of a 3 year project examining the use of Health Information Technologies (e.g., electronic patient record systems) to deliver integrated care. In particular, we focus on one group of patient (the frail elderly) and efforts to design an e-health supported healthcare pathway (the frail elderly pathway--FEP). The aim of FEP is to bring together clinicians and staff from health and social care and allow them to share patient information. Our findings show that progress in delivering a fully-supported and working FEP has been slow, not least because of the difficulties experienced by healthcare staff in using current IT systems. In addition, there are many strategic and technical issues which remain unresolved (e.g., systems interoperability).     

Nursing home ownership: an historical analysis

The need to care for dependent elderly in the United States has been a constant since colonial times. Today, as in the earliest days, most care is provided at home by family members. Personal and health services outside the home are sometimes provided by nursing homes. The nursing home industry is large, dominated by private, for-profit ownership, and receives much of its income from public funds. Why are nursing homes publicly funded? Why are nursing homes privately rather than publicly owned? Why is ownership for-profit or proprietary rather than not-for-profit or voluntary? The answers to these questions are found in the history of social policies in the United States.