A profile of Department of Veterans Affairs hospital based home care programs

This paper describes the Department of Veterans Affairs (VA) home care program and compares it to community-based programs. Structure and process data were collected on hospital based home care programs in VA facilities nationwide (n=75). Supplemental data were obtained on staffing and patient attributes. Although the VA provides program guidelines, some variability was noted. The characteristics of VA programs and patients were then compared to National Center for Health Statistics survey data. This comparison revealed that VA programs provide a more comprehensive array of services to patients including physician home visits than most community-based programs.

Impact of joint impairment on longitudinal disability in elderly persons

Recent longitudinal data indicating that arthritis is a major contributor to disability in elderly persons are based on self-reported diagnostic information. This longitudinal study included baseline physical examinations of joints of 541 persons over age 60. Previous results from a cross-sectional multivariate model of disability in this sample found that joint impairment (and, its absence, arthritis pain) explained a significant proportion of variance in overall disability. We have retested this model using generalized estimation equations (GEE) analysis to estimate the effect of joint impairment and arthritis pain on baseline and Year 2 disability. Findings indicate that baseline joint impairment contributes substantially to longitudinal disability. If direct measures of baseline joint impairment are unavailable, concurrent self-reported arthritis pain also predicts longitudinal disability well. These findings indicate that longitudinal studies should monitor arthritis pain and that symptomatic arthritis is a risk factor for future disability.

Estimates and determinants of valid self-reports of musculoskeletal disease in the elderly

This study examined the extent and nature of bias associated with self-reported versus standardized physician-examination/assessment-based accounts of musculoskeletal disease in a sample of 406 persons chosen to represent an aging and dependency continuum. Prevalence of musculoskeletal disease based on standardized physician examination/assessments was 97%. Using the standardized findings as the criterion, the self-report underestimated prevalence by 16%. Overall, the results indicated that self-reports of musculoskeletal conditions by the elderly capture the vast majority of persons with painful or functionally significant disease and are most valid for persons from ages 65 to 74 but do not reflect the presence of asymptomatic joint pathology. Standardized physician examinations/assessments would more accurately determine the presence of risk factors in epidemiological studies of musculoskeletal disability.

Classification of adult day care: a cluster analysis of services and activities

Using data from a 1986 national census survey of 774 adult day care (ADC) centers, this study (a) determined whether distinct classes of ADC could be identified based on measures of program services and activities, and (b) delineated the distinguishing characteristics of such classes on other available measures of structure, process, and client population. A cluster analysis of 10 "process" measures of services and activities identified 6 classes of ADC centers: Alzheimer's Family Care, Rehabilitation, High Intensity Clinical/Social, Moderate Intensity Clinical/Social, General Purpose, and Low Scoring. Validity was examined by developing a set of expectations for pairs of classes on other available variables. Of 12 expectations, 11 were supported by the statistical tests. Finally, profiles of the 6 classes were developed to describe the classes on 30 other characteristics. The findings clarify the settings to which previous ADC studies are generalizable and indicate a need for effectiveness studies on special classes of ADC.

Cognitive predictors of suicide risk among hospitalized psychiatric patients: a prospective study

This prospective study examined the utility of several cognitive variables as predictors of suicide risk among 79 hospitalized psychiatric patients. These variables included pessimism (measured by the Hopelessness Scale), perceived and actual problem-solving ability (indexed by the Problem-Solving Inventory and Means-End Problem-Solving test, respectively), and polarized thinking, self-negativity, and construct system constriction and differentiation (derived from a repertory grid). Suicide risk was operationalized in terms of subsequent self-report of suicide ideation and staff records of time spent on suicide precautions. Results indicated that hopelessness, self-negativity, and poor problem-solving performance functioned as reliable predictors of suicide risk, whereas self-evaluated problem-solving ability did not. Interestingly, constriction emerged as a significant inverse predictor across.

Joint impairment and self-reported disability in elderly persons

Recent findings indicating that arthritis is a major contributor to disability in elderly persons are based on self-reported diagnostic information. We conducted physical examinations of the joints at baseline on 541 older persons. We then tested a multivariate model of total/generic disability which included respondent group, demographic and chronic disease variables (joint impairment and comorbid conditions), arthritis pain, and psychological status. Hierarchical multiple regression found that the model explained 55 percent (adjusted R2 = .55) of the variance in baseline disability with joint impairment accounting for 15 percent (change in R2 = .15) of the variance. When joint impairment was removed from the model, arthritis pain worked well as a surrogate. Together, these findings strongly support the importance of musculoskeletal disease in explaining disability in the elderly population.

A medicare adult day care model: proposed criteria and available supply

The study on which this article is based addressed the issue of the proportion of adult day care centers (ADCs) existing in 1986 that would qualify for Medicare funding under the 1989 U.S. Senate Medicare Adult Day Care Amendments. It also estimated the impact of the criteria on two policy-relevant subgroups of ADCs-that is, Alzheimer's vs. non-Alzheimer's and rural vs. urban-using data from a 1986 national census survey of ADCs. The five proposed Medicare criteria and the percentage of ADCs meeting them were: services to be provided directly, 14.6%; multi-disciplinary team, 20%; services to be provided directly or indirectly, 16%; program activities, 42%; and other, 53%. Only 3% met all five criteria while 13% met four out of five. Alzheimer's centers met the criteria more often than non-Alzheimer's centers, while urban centers qualified more often than rural centers. Based on the findings, implications for Medicare funding policy are discussed.

Program factors that influence utilization of adult day care

Health planners, policymakers, and providers urgently require methods and information that explain the factors that affect health services utilization. This information is especially critical for planning programs that are effective in maintaining the burgeoning elderly population in community care. In this study, correlation and regression analyses examined the characteristics of adult day care (ADC) centers that were associated with utilization as operationalized by demand for and actual attendance in 822 centers. Community, client population, services and activities, and structural characteristics were associated with demand per center whereas the social environment of the ADC center was not. The attendance rate was most strongly affected by services and activities and structural characteristics. The significance of the study, its limitations, and future directions for research are discussed.

Joint impairment and hand function in the elderly

OBJECTIVE

To test the contribution of joint impairment to observed hand function (grip strength and Williams Test) in the elderly, using a multivariate model.

DESIGN

Cross-sectional observational data (baseline data from an ongoing longitudinal study).

SUBJECTS

Five hundred forty-one persons over age 60, including continuing care retirement community (n = 222), homebound (n = 72), and ambulatory (n = 247) respondents. Mean age at assessment 76.7, (SD = 9.0).

MEASUREMENT

Independent variables included sociodemographics, physician measures of upper joint impairment, an index of comorbidities derived from physical examination or chart abstract, self-assessed arthritis pain, depression, and anxiety. The dependent variables included grip strength and a modified Williams Test [Williams Test (M)].

MAIN RESULTS

The multiple regression explained 59% (Adjusted R2 = .59) of the variance in grip strength, with joint impairment accounting for a change in R2 of .07. Upper joint impairment and grip strength accounted for 3% and 5%, respectively, of the variance in the Williams Test (M) (total amount of explained variance = 45%).

CONCLUSIONS

Demographics explain most of the variance in grip strength and performance on the Williams Test (M). Controlling for demographics, musculoskeletal disease represented by joint impairment is associated with diminished grip strength. Reduced grip strength is associated with poorer performance on the Williams Test (M).

Self-reported functional status predicts change in level of care in independent living residents of a continuing care retirement community

OBJECTIVE

To test the hypothesis that self-reported functional status predicts change in level of care from independent to dependent in residents of a continuing care retirement community (CCRC).

DESIGN

Two-year longitudinal descriptive study of change in level of care and survival.

SUBJECTS

One hundred fifty-two residents in the independent-living unit of a non-profit CCRC. Mean age at initial evaluation was 82.3 years, SD 6.2.

MEASUREMENT

Predictor variables assessed at baseline were age, sex, physician estimate of functionally significant disease, self-reported functional status, and performance-based hand function. Criterion variables collected at 2-year follow-up were level of care (independent/dependent) and survival (alive/dead).

MAIN RESULTS

Self-reported functional status (P less than 0.01) and age (P less than 0.05) were significant predictors of change in level of care in a logistic regression analysis containing all predictor variables. No variable predicted survival.

CONCLUSIONS

Self-reported functional status may help to predict dependency in older adults in good health who have few markers of dependency risk.

A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill

All admissions to a 1,100-bed Department of Veterans Affairs (VA) hospital were screened to identify 171 terminally ill patients with informal caregivers who were then randomly assigned to VA hospital-based team home care (HBHC, N = 85) or customary care (N = 86). Patient functioning, and patient and caregiver morale and satisfaction with care were measured at baseline, one month, and six months. Health services utilization was monitored over the six-month study period and converted to cost. Findings included no differences in patient survival, activities of daily living (ADL), cognitive functioning, or morale, but a significant increase in patient (p = .02) and caregiver (p = .005) satisfaction with care at one month. A substitution effect of HBHC was seen. Those in the experimental group used 5.9 fewer VA hospital days (p = .03), resulting in a $1,639 or 47 percent per capita saving in VA hospital costs (p = .02). As a result, total per capita health care costs, including HBHC, were $769 or 18 percent (n.s.) lower in the HBHC sample, indicating that expansion of VA HBHC to serve terminally ill veterans would increase satisfaction with care at no additional cost.

The GERI-AIMS. Reliability and validity of the arthritis impact measurement scales adapted for elderly respondents

We adapted the Arthritis Impact Measurement Scales (AIMS) for use with frail elderly respondents. The new instrument, called the GERI-AIMS, generates both generic and arthritis-specific impairment scores, to control for comorbid conditions that are commonly found in an older population. An analysis of scores obtained on 438 elderly persons (mean age 76) indicated that more than half of the total disability measured by the generic GERI-AIMS scores is related to arthritis. The GERI-AIMS scales have standardized-item alpha levels greater than 0.70 and correlate well with clinical measures of arthritis severity. Information gained by using the GERI-AIMS has important public policy implications, insofar as information on both generic and disease-specific functional impairment is needed to establish priorities for basic research, epidemiologic, and intervention studies.

Self report and performance-based hand function tests as correlates of dependency in the elderly

Preventing or minimizing functional dependency in older adults rests, in part, upon the ability to predict who is at risk. The purpose of this study was to compare the ability of five tests of hand function to discriminate the degree of dependency in older adults. Seven hundred sixty four subjects were assessed for hand function on performance-based (Williams Test of Hand Function, a test of Williams Board items only, Jebsen Test of Hand Function, grip strength), and self-reported (Dexterity Scale of the Geriatrics-Arthritis Impact Measurement Scale (GERI-AIMS] measures of hand function, and self-reported multidimensional functional status (GERI-AIMS). A trichotomous variable representing a continuum of dependency based upon living site (independent living, home-bound, institutional) was used as the measure of dependency. Sixty-two cases were dropped for incomplete data. Discriminant function analyses of the 702 subjects (age X = 76.78 years, SD = 8.79) showed that basic demographic variables explain 40.8% of the variance in dependency; all hand function tests significantly correlated with dependency; the Williams Board correlated best (additional 12.5% variance explained). However, a multidimensional functional status measure explains substantially more variance in dependency (16.9%) after controlling for demographic variables and performance on the Williams Board. This comparison of methods and tests available for measuring hand function was made to provide criteria for selecting an instrument for a given setting.

Screening elderly veterans for alcoholism

OBJECTIVE

To determine the sensitivity and specificity of an alcoholism screening test not previously tested in the elderly.

DESIGN

Cross-sectional study, face-to-face interviews.

SETTING

Veterans Administration (VA) outpatient facility.

PATIENTS/PARTICIPANTS

Men greater than or equal to 70 years old seeking care in a newly established VA outpatient facility were invited to participate in a health assessment program. Of 109 participants who enrolled, 96 completed both interviews.

INTERVENTIONS

The screening test was administered by an internist as part of a medical history. The Michigan Alcoholism Screening Test (MAST), used as the "gold standard," was administered by a trained interviewer as part of a longer structured interview.

MEASUREMENTS AND MAIN RESULTS

The screening test had a sensitivity of 0.52 and a specificity of 0.76 in this sample.

CONCLUSIONS

The sensitivity and specificity of the screening test were lower in this sample in comparison with previously reported results in a younger population. Differences in the test performance may be related to differences in attitudes and drinking behaviors of elderly veterans when compared with those of younger men and women.

Cost-effectiveness of Veterans Administration hospital-based home care. A randomized clinical trial

A randomized design was used to examine the cost-effectiveness of a Veterans Administration hospital-based home care program that case managed inpatient and outpatient care. Patients (N = 419) with two or more functional impairments or a terminal illness were randomized to hospital-based home care (n = 211) or customary care (n = 208). Functional status, satisfaction with care, and morale were measured at baseline and at 1 and 6 months after discharge from the hospital; health care utilization was tracked for 6 months. Findings included significantly higher (0.1 on a three-point scale) patient and caregiver satisfaction with care at 1 month and lower Veterans Administration and private sector hospital costs ($3000 vs $4245) for the experimental group. Net per person health care costs were also 13% lower in the experimental group. We conclude that this model of hospital-based home care is cost-effective and that its expansion to cover these two patient groups throughout the Veterans Administration system can improve patient care at no additional cost.

Survey of adult day care in the United States. National and regional findings

Before attempting to understand how a relatively new treatment modality such as adult day care (ADC) works, it is useful to understand what it is. To this end, this article describes the structural characteristics of ADC centers and the characteristics of ADC users in the United States and across the four U.S. census regions. A 1986 national census survey of 1,347 ADC centers yielded 974 usable responses (72.3%). Findings indicated that there is great variability in characteristics of ADC across the country. In general, ADC's are well-staffed, well-linked to other agencies, and well-equipped. However, demand and enrollment appeared low. A need for improved oversight and staff in-service training was indicated for a substantial proportion of centers. These and other findings provide the most detailed and comprehensive national and regional descriptions of ADC available to date.

A randomized trial of Veterans Administration home care for severely disabled veterans

This randomized study screened hospital admissions to all wards except Psychiatry and Spinal Cord Injured during a 3-year period to identify 233 severely disabled patients (2 impairments on the Katz Index of ADL) and caregivers who were willing to participate in a pretest-multiple posttest trial of the Hines VA Hospital-based Home Care (HBHC) Program. Patient functional status, morale, and satisfaction with care were measured at baseline, 1 month and 6 months post discharge. Caregiver satisfaction and morale were assessed at the same time periods. All health care services used by both groups were tracked over the 6-month period and converted to cost. Findings include improved 1-month satisfaction with care (P = 0.04) and improved 6-month cognitive functioning (P = 0.04) among HBHC patients and improved 1-month (P = 0.04) and 6-month satisfaction with care (P less than 0.01) among their caregivers. A nonsignificant 10% decrease in net cost of care, was found in the treatment group, largely due to lower use of private sector hospital care.

Impact of long-term home care on mortality, functional status, and unmet needs

This article reports the outcomes of a four-year follow-up evaluation of the Five Hospital Program, a long-term home care program in Chicago. Outcomes assessed include the mortality, comprehensive functional status, and perceived unmet needs of its frail elderly clientele (mean age 81 years at entry). The evaluation utilized a pretest, multiple posttest design with a comparison group consisting of similarly elderly and impaired individuals receiving OAA Title III-C home-delivered meals. Consecutively accepted treatment (N = 157) and comparison group clients (N = 156) were interviewed using the OARS Multidimensional Functional Assessment Questionnaire at baseline, 9 months, and 48 months after acceptance to care. A multivariate analysis of mortality rates revealed no between-group differences attributable to treatment on this outcome. Major findings included significantly better cognitive functioning and reduced unmet needs in the treatment group at nine months. A longer-range, continued beneficial effect of treatment on cognitive status was also observed at 48 months. We conclude that long-term home care provided important benefits to clients at both 9 and 48 months, with no effect on mortality. However, we suggest that the four-year findings be interpreted with caution, since only a small percentage of clients (18 percent) were still alive and receiving active care in the community at that time.

Impact of long-term home care on hospital and nursing home use and cost

This article reports the long-range impact of a long-term home care program in Chicago on hospital and nursing home use and on overall health care costs over four client-years of observation. The evaluation utilized a quasi-experimental design with a comparison group composed of clients who received home-delivered meals. The health services utilization experience of consecutively accepted treatment (N = 157) and comparison group (N = 156) subjects was monitored for 48 client-months following acceptance to care. Imputed costs were then assigned to each type of care measured. Findings include a significantly lower risk of permanent admission to sheltered and intermediate-level nursing home care in the treatment group but no difference in risk of permanent admission to skilled-level nursing home care. Despite savings in low-intensity nursing home days, preliminary findings indicate that total costs of care were 25 percent higher in the treatment group. However, these costs are accompanied by significant quality-of-life benefits in the treatment group (reported elsewhere).

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans. Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 +/- 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p less than .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p less than .05). Penetrating injury did not increase the risk of sinusitis (p greater than .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.

Diversification of health care services: the effects of ownership, environment, and strategy

The present findings suggest that the trend toward greater diversification of hospital services is likely to be most strongly influenced by state Medicaid policies and certain hospital characteristics. Increasing Medicaid eligibility and payment levels is likely to have a positive effect on services diversification. Growth in the number of inpatient services provided and a more severe case mix are also likely to be involved with greater service diversification. Affiliation with a not-for-profit hospital system is likely to be associated with more diversified hospital services but not affiliation with an investor-owned system. There is also some indication that the overall portfolio of services which a hospital offers in regard to market share and market growth characteristics influences diversification. Specifically, a low market share portfolio is likely to be associated with less diversification. Competition is likely to be associated with more diversification; particularly for hospitals belonging to systems. The effect of competition on hospital strategy and services diversification is a particularly important area for further investigation. Increasing Medicaid payment and eligibility levels are also likely to have a positive effect on the provision of services which are usually unprofitable. Raising such levels is likely to be particularly beneficial to inner-city hospitals who are already providing a greater number of such services. However, the present data suggest that investor-owned hospitals are least likely to provide such services. Increasing Medicaid eligibility levels is also likely to be associated with fewer services for which charity care has to be provided. State regulation in the form of rate review and certificate of need is likely to be associated with more services for which hospitals provide some charity care. But such policies alone do not deal with the larger issue of how to finance care for the medically indigent. Present data suggest the charity care issue may be particularly salient in markets characterized by a relatively high degree of competition. Finally, investor-owned hospitals provide as many services involving charity care as not-for-profit system hospitals, although investor-owned system hospitals provide fewer such services than not-for-profit freestanding hospitals. Throughout, the findings indicate the importance of distinguishing between ownership and system affiliation. Previous research has failed to make a distinction between ownership form and system affiliation, thus attributing to ownership form differences which, as present findings suggest, appear to be more associated with system affiliation.(ABSTRACT TRUNCATED AT 400 WORDS)

Use of nursing homes by a high-risk long-term care population

Limited information exists concerning lifetime use of nursing home services by the aged. This article examines the longitudinal experience, over four years, of elderly individuals at high risk of institutionalization, and develops a simple model of nursing home use based on these observations. This model allows us to predict future lifetime use under alternative assumptions. The main observations drawn from this sample are that high-risk elderly tend to move from the community to nursing homes, but not back to the community except for short, transitional stays. Further, despite high overall mortality rates, the expected nursing home use by these high-risk elderly is very high, due to long average stays by a minority of the sample that enters a nursing home and remains there longer than six months.