Kaiser Permanente's Manifesto 2005 Demonstration

Summary

In 1996, the eight-million member Kaiser Permanente HMO adopted a vision statement that said by 2005 it would expand its services to include home- and community-based services for its members with disabilities. It funded a 3-year, 32-site demonstration that showed that it was feasible to link HMO services with existing home-and community-based (HCB) services and that members appreciated the improved coordination and access. This private-sector project showed that devolution can produce innovative and feasible models of care, but it also showed that without federal financial and regulatory support, such models are unlikely to take hold if they are focused on “unprofitable” populations, for example, those who are chronically ill, poor, and/or disabled.     

Achieving Permanence in Foster Care for Young Children: A Comparison of Kinship and Non-Kinship Placements

ABSTRACT

A number of child welfare policies have reinforced the use of kinship care as the most preferred placement for foster children, reflecting the philosophy that maintaining children within their own extended family system contributes to their stability and well-being. Given the growing utilization and legislative emphasis on kinship care along with the push for an immediate implementation of permanency plans for children in foster care, this study examines how the permanency goal under the 1997 Adoption and Safe Families Act (ASFA) is being implemented and achieved. The reunification and permanency placement (adoption or legal guardianship) outcomes of children in relative and non-relative care are analyzed, focusing on the experiences of young children. Based on public child welfare agency data from 2000 to 2003, child, case, and placement variables are explored to identify which set of factors best explains case outcomes. The present study identifies the total length of foster placement (kinship and non-kinship), the length of family maintenance services, and the number of placement changes as the most important variables in determining family reunification and permanent placement (legal guardianship and adoption) outcomes for young children.     

Do Disabled Elderly Medicare Beneficiaries with Major Depression Make Less Use of a Consumer-Directed Home Care Voucher Benefit?

Older adults with major depression may underutilize consumer-directed long-term care. Systematic underutilization would create disparities in outcomes, undermining program effectiveness. The Medicare Primary and Consumer-Directed Care Demonstration included a consumer-directed indemnity benefit that paid for goods and services not financed by traditional Medicare. Overall and for most categories of goods and services there was little difference in use and expenditures between those with and without major depression. However, among those using the benefit to hire in-home workers, arguably the most important consumer-directed purchase, average spending for workers was about 30% lower for depressed persons. While our findings are generally reassuring for public policy, future research is needed to verify that major depression is associated with less spending on in-home workers.     

Young Mothers' Time Spent at Work and Time Spent Caring for Children

The association between the time a mother spends at work and in different child care activities is investigated, using data from the 1981 National Longitudinal Survey of Youth (NLSY). The mothers who worked on the index day spent almost one hour less time in physical care, one-half hour less time in interactive care, and over two hours less time in passive supervision of their children. The effects of a set of predictors on time use at work, time use in physical care, interactive care, and passive supervision of children were estimated using a covariance structure model. When the effects of these predictors are controlled, the number of hours at work predicts: (a) a small reduction in time spent in interactive care, and (b) larger reductions in time spent in physical care and passive supervision.     

Child care quality and affordability: Are they compatible?

Mothers have traditionally been the primary caregivers of children under school age in the United States. Increasing numbers of parents are seeking part-time or full-time alternatives for assistance with parenting and child care outside of the home. The variety of types of child care arrangements has greatly increased in the past 50 years. This paper addresses quality child care, child care options and cost. Despite the increase in child care provided outside the home, parents often have difficulty distinguishing quality care from less than quality care. Two prime considerations are quality and affordability. This paper addresses the need for a comprehensive spectrum of policies and child care programs for families in various cultural, economic, and social environments.     

Reimagining Nursing Homes: The Art of the Possible

Long-term care (LTC) needs to be reconceptualized. The current efforts to reinvent the nursing home perpetuate a flawed model of care. The heritage of the nursing home as the dominant model for LTC needs to be reexamined. The basic LTC building blocks—housing, services, and medical care—can be combined in various ways to meet consumers' needs and preferences. We need innovative solutions that can offer reasonable service while recognizing the value of acceptable risk taking. Modest personal care should not come at the price of surrendering one's autonomy.     

Child Care Use and Parental Desire to Switch Care Type Among a Low-Income Population

This study investigates the use of and satisfaction with child care among low-income families, who are those likely to be affected by recent changes in public policy that emphasize increased work effort. Data from the Survey of Wisconsin Works Families portray differences in the use of center-based care depending on whether or not the family received a child care subsidy. A multivariate analysis of a measure of parental satisfaction, whether a parent would switch child care sources if all care were available at no charge, suggests that parents tend to be more satisfied with center-based care than with alternative forms of care. The analysis also suggests that mothers who received a child care subsidy were significantly more likely to have their children in center-based care.     

Bringing Two Worlds Together: A Collaborative Interview With JoEllen Patterson

JoEllen Patterson is Professor in the Marital and Family Therapy Program at the University of San Diego. She is also an Associate Clinical Professor of Family Medicine and Psychiatry at the University of California, San Diego, directing a medical family therapy clinic embedded in a Family Medicine residency (equivalent to General Practice in New Zealand). She also works in Pediatrics and Reproductive Medicine at UCSD. At present her work involves training family therapy students and family medicine residents to do interdisciplinary work using a biopsychosocial model. Research suggests that our bodies are influenced by our mental health; our immune systems and cardiovascular systems seem especially susceptible to mind‐body interplay. JoEllen is particularly interested in how family functioning influences the mind‐body system. In 2003, JoEllen Patterson received a Fulbright Senior Scholars award to visit the Wellington School of Medicine and Health Sciences, and the Child, Adolescent and Family Service in Lower Hutt, New Zealand. She spent two weeks between the clinical service and the academic department, teaching, consulting and advising. I was lucky enough to arrange this posting and to spend time with her during it.     

Coordinating Health,Extended Care,and Community Support Services

Abstract

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.     

A place to heal: a qualitative focus group study of respite care preferences among individuals experiencing homelessness*

Homeless patients have longer hospital stays than housed persons due, in part, to a lack of safe discharge locations. Respite care for homeless individuals decreases hospital length of stay and readmissions rates. This study aimed to develop client-centered recommendations for medical respite care. We conducted four focus group interviews (n?=?25 participants) between August 2010 and February 2013 of homeless adult residents in Minnesota. Four domains of respite care were identified from content analysis of interviews: physical, relational, facilitation, and amenities. Novel recommendations include (a) a facility equipped to address mental health and substance dependence needs, (b) a standardized training protocol for respite staff, (c) the creation of a patient advocate, and (d) the creation of a respite case manager to facilitate post-discharge instructions and connection to primary care and social services. These new and actionable recommendations could help inform policies and the development of future medical respite care facilities.     

Long-Term Care Policy: Singapore’s Experience

Singapore, like many developed countries, is facing the challenge of a rapidly aging population and the increasing need to provide long-term care (LTC) services for elderly in the community. The Singapore government’s philosophy on care for the elderly is that the family should be the first line of support, and it has relied on voluntary welfare organizations (VWOs) or charities for the bulk of LTC service provision. For LTC financing, it has emphasized the principles of co-payment and targeting of state support to the low-income population through means-tested government subsidies. It has also instituted ElderShield, a national severe disability insurance scheme. This paper discusses some of the challenges facing LTC policy in Singapore, particularly the presence of perverse financial incentives for hospitalization, the pitfalls of over-reliance on VWOs, and the challenges facing informal family caregivers. It discusses the role of private LTC insurance in LTC financing, bearing in mind demand- and supply-side failures that have plagued the private LTC insurance market. It suggests the need for more standardized needs assessment and portable LTC benefits, with reference to the Japanese Long-Term Care Insurance program, and also discusses the need to provide more support to informal family caregivers.     

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

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

The education of children and adolescents in out-of-home care: a problem or an opportunity? Results of a longitudinal study

The education of children in care is an issue that often falls into a no man’s land in which responsibility always seems to be attributed to the other ‘department’. Furthermore, all too often, teachers, educators and foster parents find themselves working with these children with no support, as if they were isolated cases. The aim of this study is to get to know the school situation of children in different types of out-of-home care: residential, kinship and non-kinship care. Systematic data on the school situation of 11–16-year-olds (on class attendance, school behaviour, academic results and guidance towards post-compulsory education) were gathered over a period of 5 consecutive school years. A 3-year longitudinal study on the same items (N?=?391) was made and time-series data were gathered for 5 years (N?=?1841). Results show that the in-care population is at a clear disadvantage and inequality of opportunities compared to the general population in relation to their educational pathways and outcomes; the most disadvantaged being the population in residential care. Recommendations are included, posing the challenge that what has to date been considered a ‘problem’ should become an opportunity for these children.     

Children discharged from kin and non-kin foster homes: Do the risks of foster care re-entry differ?

This study investigates whether the type of pre-discharge placement, kinship versus non-kinship foster care, has a net impact on children's likelihood of re-entering substitute care after controlling for possible selection biases through the use of regression adjustment and propensity score matching (PSM). Children in kin and non-kin foster care are compared on their rates of foster care re-entry, using bivariate comparisons and accelerated failure time (AFT) models. Lower rates of foster care re-entry after reunification from kinship homes are attributed to differences in child characteristics at removal, greater stability of kin placements, and gate-keeping functions that agencies and courts exercise over discharge and re-entry options. Children adopted from kinship and non-kinship homes exhibit similar re-entry rates, but the results for legal guardianship are mixed.     

The White House Conferences on Aging

White House Conferences on Aging are anachronistic, expensive, and inefficient methods of developing debate and consensus on complex issues. To be effective, they need to derive their force from well-articulated expressed needs delivered by the President. Furthermore, to be effective in today's society, any such effort must combine state-of-the-art telecommunications technology combined with well-known techniques of community organization. Neither of those preconditions exist at the present time. It is suggested that the effort be better conducted by a nongovernmental coalition adequately funded and committed to a limited number of goals and to combined modern telecommunications technology and community organization.     

The Effectiveness of Adult Day Services for Disabled Older People

Abstract

Adult day care has attracted a considerable amount of attention among researchers, practitioners, and policymakers. However, there have been few efforts to synthesize empirical results. This paper reviews research that determines the effectiveness of adult day services in improving client functioning, alleviating caregiver stress, and delaying nursing home placement. In addition, the strengths and limitations of the research are considered. This paper concludes with a discussion of policy-relevant issues that must be addressed when determining the effectiveness of adult day services.     

Architectural Space in Respite and Intermediate Care: An Actor-Network Theory Analysis

This article presents an analysis of 2 short-term care facilities using actor-network theory with the aim of revealing performative processes in different networks in the buildings in use. The 2 facilities differed in architectural design, which was expected to influence their care model and organization. One facility was larger and accommodated 4 patients/residents in double rooms as well as permanent residents who stayed in single rooms. The other facility was smaller and accommodated only short-term care patients in single rooms. The study revealed that the latter facility received more care-demanding people than the other. The size and the type of patients/residents influenced the social environment. The larger facility was more busy and lively than the smaller one. However, the analysis did not show any difference in quality of care or ambiance. Both facilities were valued as either good or bad by different residents or staff members. The study concludes that therapeutic values and outcomes are defined and redefined in the ongoing performances of everyday interactions.     

Experience,Knowledge, and Concerns About Long-Term Services and Supports: Implications for Financing Reform

Using the 2014 Survey of Long-Term Care Awareness and Planning, this article examines Americans’ experiences, knowledge, and concerns about long-term services and supports (LTSS) and actions they are willing to take if they become disabled. The survey included 15,298 non-institutionalized respondents aged 40 to 70 years drawn from a nationally representative sample. Although many reported some experience with LTSS, knowledge of how LTSS worked was low. Respondents reported widespread concerns about becoming disabled. They preferred informal care over paid care, with a strong desire to remain in their homes. These results can be used to design reform initiatives and to motivate political support.     

Family and Friends as Respite Providers

Abstract

Consumer-directed service options in home- and community-based care are increasingly available to adults with chronic conditions and cognitive impairments and to their family caregivers. Few studies, however, examine the experience of family caregivers who, when given a choice of providers of respite assistance (i.e., relief from the stress of providing constant care), prefer to hire family or friends rather than service providers. This study describes the in-home respite experience of family caregivers served by California's Caregiver Resource Centers “direct-pay” program who hire family or friends (n = 39) or service providers (n = 77) to provide in-home respite assistance. Findings revealed similarities between the two groups with few exceptions: caregivers who hired family or friends reported poorer physical health, were slightly more satisfied with the respite assistance, and received more hours of respite at a lower unit cost. These findings lend support to consumer-directed respite service options where family caregivers are given flexible alternatives that may act to remove barriers to respite service availability and use.     

Factors Associated with Adoption and Adoption Intentions of Nonparental Caregivers

ABSTRACT

Data from the 2011–2012 National Survey of Children's Health and the 2013 National Survey of Children in Nonparental Care were used to fit a multinomial logistic model comparing three groups to those who never considered adoption: those who ever considered but are not currently planning adoption, those planning adoption, and those who adopted. Adoption may be more likely when the caregiver is a non-kin foster parent, a foster care agency was involved, and/or financial assistance is available. Those with plans to adopt but who have not adopted may face adoption barriers such as extreme poverty, lower education, and being unmarried.