Home Care

The utility of examining the effectiveness of home care is illustrated by selected examples and applications. The growth rate of home care over the past decade, regarding the possibly substantial differenccs between the quality of home care in rural and urban America, and empirical evidence that suggests inferior quality of home care for health maintenance organization patients support the need for measuring and monitoring outcomes of home care. The conclusions of a research program targeted at developing a system of outcome measures for home care, and the resulting national demonstration program to implement and refine that system, are summarized.     

The Effect of Long-Term Care Insurance on Home Care Use Among the Disabled Elders

Using the 1998?C2004 Health and Retirement Study, this study uses Cox??s model to explore the effects of private long-term care insurance ownership on first home care use among the disabled elderly. Results show that long-term care insurance ownership and Medicaid eligibility did not significantly increase the likelihood of using home care services, while income and homeownership lowered this likelihood. Functional limitation was the key determinant of home care use and those who lived with children were less likely to use home care services. Based on the findings, this study provides foundations for long-term care policies and long-term care planning programs.     

The Third Shift: Gender and Care Work Outside the Home

Caregiving remains women's work far more than men's. Although women and men often attribute this difference to nature, this paper argues for the importance of structure, especially in employment. At least to some extent, women's employment—especially in jobs similar to men's—reduces the care work they do for kin, if not for friends. Examining the different amount and meanings that women and men—like Euro-Americans and African Americans—ascribe to care work, I suggest we view such care work as a survival strategy as well as a demanding labor of love. In this context, recent social policies should be seen as not only privatizing care but also producing growing inequality as well as a vacuum of care.     

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.     

The Development of a Computerized Information System for Integrated Home Care in The Netherlands

ABSTRACT

In September 1992, The Netherlands Institute of Care and Welfare (NEW) started development of GIRST_S a computerized information system for the new integrated home care services in The Netherlands. These services integrated home nursing and family care services, with many institutions merging to facilitate the process. Integration of services required reorganization of all of the information processes and new technology provided the opportunity for improvement in their quality. These factors of reorganisation and of new technology opportunities stimulated NIZW to develop GIRST, which is designed as a tool to facilitate provision of care. It is not focused on managerial issues but on the information needs and concerns of those who actually provide care. The process of providing home care can be divided into four stages which correspond with the four modules of GIRST: care coordination-care allocation-care in practice-care evaluation.     

Documenting Inadequate Care in the Nursing Home:

An undercover agent describes his experiences as a nurse's aide gathering evidence that was ultimately used in the prosecution of a corporate entity responsible for the deaths of two Philadelphia nursing home residents.     

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.     

HIV/AIDS and Home Based Care in Botswana

SUMMARY

The extent of the AIDS pandemic in Africa (and specifically in Botswana), and the lack of institutional frameworks to address concomitant issues, have necessitated the adoption of home based care for sufferers as national policy. The practice is beset by problems, given the severe symptomatic nature of the disease and the general lack of human and material resources to address the needs of patients and care-givers.

A study of one such programme in the Kweneng District of Botswana highlighted gender imbalances, poverty, lack of appropriate skills, over-involvement of the elderly, deficient specialised facilities, need for volunteer capacity building, inadequate income generating activities, insufficient counseling services, and culturally determined cognitive processes as areas requiring urgent attention. It is apparent that the programme needs strengthening through appropriate support mechanisms and that alternative strategies should be devised for those whose circumstances demand them.

The international hospice movement, represented in Botswana, exemplifies a philosophical and service model for multisectoral consideration and implementation on a nationwide scale. The article discusses, inter alia, day care centres and residential units for the terminally ill; a system of highly trained volunteers to work with patients and their families; consistent, skilled nursing services in home based care situations; and halfway houses for training of care-givers as possible solutions to the problem.

The contextualization of such measures will undoubtedly assist in bolstering Botswana's unchallenged record of high standards in governance and social development.     

Trade-Offs Between Formal Home Health Care and Informal Family CareGiving

Using 1994 National Long Term Care Survey data, we estimated logistic regressions of formal and informal home health care use and hours. Home health care use and intensity were differentially impacted by chronic conditions, are higher for Medicaid enrollees and rural or small town residents, but lower for HMO enrollees. Decreases in the probability of home health care use increased informal instrumental activities of daily living (IADL) support four hours and decreased informal activities of daily living (ADL) support eight hours weekly. IADL caregiving substituted for formal care, but ADL caregiving declined with reductions in formal care. Public policy reducing formal home health care access may reduce informal ADL caregiving and increase informal IADL caregiving, producing net declines in support.     

Commentary: The Physician's Role in Nursing Home Quality of Care: Focus on Restraints

The physician can play an important role in managing high-risk nursing home residents without restraints and working with interdisciplinary care teams in comprehensive fall evaluations. A reduction or elimination of physical restraints can be measured for a facility over time, and it represents a relevant quality indicator of physician and facility interactions during the process of care. We discuss how the physician's role fits into this quality of care equation for nursing homes and its implications for new clinical, research, and policy directions for long-term care.     

Client Satisfaction with Live-In and Live-Out Home Care Workers in Israel

Abstract

In an era of globalization where the migration of long-term care workers is common, foreign live-in home care workers can compensate for the unavailability of family members and, perhaps, even substitute for institutional care in the provision of long-term care services to disabled older persons.

This study examines differences in home care satisfaction between disabled older persons in Israel with “live-in” home care workers and those with “live-out” workers, and explores some differences in socio-demographic and personal characteristics between these two groups. Face-to-face interviews were held with a random sample of 93 older persons in Beer-Sheva.

Older persons with live-in home care workers were more satisfied with their home care service than those with live-out workers. Those with live-in workers were more severely disabled, tended not to have any children living in close proximity, although an adult child was available as an informal caregiver. Communication difficulties between the elderly persons and their home care workers were found not to affect negatively the satisfaction with the service.     

上海社区居家养老服务支持体系研究

上海人口结构的深度老龄化和日益增长的养老服务需求,为老龄事业发展提出更高的要求;创新社会治理和多元融合发展的趋向,为老龄事业发展提供了新的机遇和空间.目前,上海已基本形成了养老服务全局性的共识,确立了养老服务发展的总体思路,即从上海深度老龄化的实际出发,坚持积极应对老龄化的理念,努力构建社区居家养老服务支持体系.     

广州市社区居家养老问题及对策

随着社会经济不断发展和老龄化问题日趋显著,广州顺应时代要求积极探索社区居家养老新模式。但作为一种新生事物,它难免面临诸多问题,亟需进一步的改进和完善。     

Home Care Workers’ Skills in the Context of Task Shifting: Complexities in Care Work

Task shifting, which involves the transfer of care work from regulated health‐care professionals to home care workers (HCWs), is a strategy to ensure the efficient delivery of home care services in Canada and internationally. Using a feminist political economy approach, this paper explores the effects of task shifting on HCWs’ skills. Task shifting may be understood as a form of downward substitution—and an effort to increase control over workers while minimizing costs—as some of health‐care professionals’ responsibilities are divided into simpler tasks and transferred to HCWs. Our interviews with 46 home health‐care providers in Ontario, which focused explicitly on HCWs’ role in care provision, problematize the belief that “low skilled” care workers have little control over their work. HCWs’ skills become more complex when they do transferred tasks, and HCWs sometimes gain greater control over their work. This results in increased autonomy and mastery for many HCWs. In turn, this serves to reinforce the intrinsic rewards of care work, despite the fact that it is low paid and undervalued work. Le transfert des tâches consiste à transférer certaines activités des professionnels de la santé aux travailleurs de soutien à domicile, et s'avère être une stratégie visant à assurer la prestation efficace des services de soutien à domicile au Canada et à l'étranger. En utilisant la théorie de l'économie politique féministe, cet article explore l'impact du transfert des tâches sur les compétences des travailleurs de soutien à domicile. Le transfert des tâches peut être interprété comme une forme de substitution à la baisse avec un contrôle accru des travailleurs et une minimisation des coûts des services. Ceci se produit lorsque certaines des responsabilités des professionnels de la santé sont fragmentées en tâches plus simples pour être ensuite transférées aux travailleurs de soutien à domicile. Pourtant, le contenu de 46 entrevues avec des travailleurs de soutien à domicile et professionnels de la santé vient ébranler l'hypothèse selon laquelle les travailleurs de soutien à domicile «peu qualifiés» auraient peu de contrôle sur leurs tâches de travail. Les résultats de cette étude suggèrent que les compétences des travailleurs de soutien à domicile se complexifient lorsqu'il s'agit de tâches transférées, et que ces travailleurs obtiennent parfois plus d'autonomie à l'emploi. Donc, les travailleurs de soutien à domicile acquièrent une plus grande autonomie et un contrôle plus significatif à l'emploi. Par conséquent, le transfert des tâches renforce les gratifications intrinsèques du travail en relation d'aide et ce, en dépit d'une piètre rémunération et de la sous‐valorisation du métier.     

Transition from Home Care to Nursing Home: Unmet Needs in a Home- and Community-Based Program for Older Adults

A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.     

Policy Changes in Medicare Home Health Care: Challenges to Providing Family-Centered,Community-Based Care for Older Adults

The Balanced Budget Act of 1997 (BBA) established new reimbursement systems in the Medicare home health fee-for-service benefit. Reimbursements were reduced to 1993 levels and per-beneficiary capitated limits were introduced for the first time. This article analyzes the impact of these changes on chronically ill older adults and their families. The study combined a secondary analysis of the Provider of Service file (1996, 1999, 2002, and the Medicare Current Beneficiary Survey (1996, 1998) with qualitative interviews of home health agency directors. The greatest decreases in staff and visits were for medical social work and home health aide services. Patients with caregivers saw greater decreases in visits and reimbursements for all visits, skilled nursing, medical social work, and home health aide visits. Agency directors reported that they increased caregiver education, training, and involvement in care in order to discharge patients sooner. Additional research is needed to understand the long-term, adverse impact of these policy changes on chronically ill patients and their families.     

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.     

Beyond Clinical Complexity: Nonmedical Barriers to Nursing Home Care for Rural Residents

We conducted a qualitative content analysis of barriers to nursing home admission for rural residents. Data came from semi-structured interviews with 23 rural hospital discharge planners across five states (Georgia, Idaho, Minnesota, Pennsylvania, and Wisconsin). From those, we identified four themes around nonmedical barriers to rural nursing home placement with particular salience in rural areas: financial issues, transportation, nursing home availability and infrastructure, and timeliness. We also identified policy and programmatic interventions across four themes: loosen bureaucratic requirements, improve communication between facilities, increase rural long-term care capacity, and address underlying social determinants of health.