Informal care substitution: what we don't know can hurt us

Empirical studies focusing on the relationship between formal and informal home care do little to quell the fears of policymakers that expanded access to public home care services will result in the withdrawal of informal support. A close examination of the studies designed to measure the withdrawal of informal support justifies this skepticism. Concerns about the withdrawal of informal care may hinder the introduction of more extensive home care benefits. Researchers have come some distance in trying to address this policy question. The conflicting nature of empirical findings, thus far, demonstrates that the answer depends heavily on how the question is framed, how home care is measured and over what time frame, and what sorts of analytic approaches are used to model the relationship between formal and informal community-based care. This article discusses these issues in greater detail and suggests strategies to address these problems in future research.

Differences between nursing home admissions and residents

The use of a cross-sectional sample of nursing home residents rather than a sample of admissions to estimate admission characteristics carries a potential bias. The purpose of this study was to fill this void by comparing abstracted records data for an admissions cohort (n = 1,118) and a residents cohort (n = 830) residing in the same nursing homes. Compared to residents, admissions were significantly more dependent in their ability to get around and to dress themselves, received more clinical services, and had a higher rate of medication use. Over a 12-month period, admissions had a fivefold greater likelihood of being discharged to community, but about the same mortality rate as residents. Within both groups, those discharged to the community as well as those who died had expenditures that were almost twice as high as those of their counterparts who remained alive in the nursing home.

HMO medical directors' perceptions of geriatric practice in Medicare HMOs

OBJECTIVE

To determine the extent to which health maintenance organizations (HMOs) with Medicare risk contracts utilize geriatricians and selected aspects of "organized" geriatric practice.

DESIGN

A telephone interview survey.

PARTICIPANTS

Eighty-two percent (64 of 78) of the HMOs with Medicare risk contracts as of June 1991.

MEASUREMENTS

Questions to medical directors of the Medicare HMOs on (1) the presence of geriatricians, (2) the roles of geriatricians, and (3) "organized" geriatric practice.

MAIN RESULTS

Fifty-three percent of the Medicare HMOs have one or more geriatricians, but only 19% have attempted to recruit geriatricians. Geriatricians provide primary care in 76% of the HMOs with geriatricians and serve as specialist consultants in 61%. Geriatricians are reported to be used actively in 32% of the HMOs that have them. The proportion of HMOs utilizing "organized" geriatric activities ranges from a high of 58% for a general health information questionnaire to a low of 12% for a special form(s) for comprehensive geriatric assessment. While the percentage of HMOs using each of the "organized" strategies is higher for the HMOs with geriatricians than for those without, this is statistically significant for only one strategy--the use of special approaches or formal protocols for problems frequently found in the elderly (P = 0.04).

CONCLUSIONS

The perception of Medicare HMO medical directors is that about half of the HMOs utilize geriatricians and that there is evidence of "organized" geriatric practice. However, it appears that geriatricians and many of the elements of organized geriatric practice are used to a much lesser extent than experts recommend. Medicare HMOs must themselves test the various components of organized geriatric practice in order to determine their utility.

Quality assurance for a program of comprehensive care for older persons

Quality assurance (QA) for comprehensive programs like the Program of All-inclusive Care for the Elderly (PACE) requires a special strategy. The assessment phase should be capable of looking across the usual subdivisions of care to recognize the contributions of various disciplines, and to focus on the effects of that care on the patient. Measures should thus include both problem-specific and patient-focused elements. The tracer technique which follows the care of specific problems provides an opportunity to look at both the process and outcomes of care. An outcomes focus which looks at patient functioning as well as condition-specific parameters can include specific sentinel events whose presence suggests untoward developments. Quality assurance implies more than assessment. It represents a commitment to act responsibly on the information obtained to improve the care rendered. It includes a strategy for proactive involvement where caregivers are prompted to consider pertinent information in a timely fashion, and a retrospective remedial approach where the data are analyzed and presented in a format that can be readily understood and which suggests next steps to improve care.

Qualitative analysis of the Program of All-inclusive Care for the Elderly (PACE)

The innovative model of capitated acute and chronic care for nursing-home-eligible elderly persons, which was developed at On Lok in San Francisco's Chinatown and stresses using community care in lieu of institutional care, has been replicated at eight sites around the country. The early experience in developing these sites tests the extent to which the principles of this approach, based on day health care, can be reproduced in a variety of other settings. Four of the eight sites have begun formal capitated care; enrollment has been less active than anticipated, apparently due to reluctance to change physicians and resistance to day care.

Inadequate treatment of depressed nursing home elderly

OBJECTIVE

To determine the prevalence of antidepressant drug treatment among nursing home elderly with major depression.

DESIGN

Survey early and late in nursing home stay.

SETTING

Sixty Medicaid/Medicare-certified skilled nursing homes.

PARTICIPANTS

Admission cohort of 5,752 residents age 65 or older in 1976 through 1983.

MEASURES

Chart review by nurse-abstractors of physicians' diagnoses, drug used, and alertness rating. Diagnosis of depression equivalent to DSM-III-R major depression.

RESULTS

Of 868 persons with a diagnosis of depression in the medical record, only 10% were treated with antidepressant drugs. More received neuroleptics and benzodiazepines than received antidepressants, but most (52%) received no psychoactive drug at all. A subset of 258 depressed persons had positive notations in their records supporting a mental status rating of "alert and oriented." Of that subset, only 15% received antidepressants. When followed from admission to discharge or end of study the prevalence rate of antidepressant drug treatment increased by 4%.

CONCLUSIONS

In the late 1970's and early 1980's, even when the primary care physician made and recorded a diagnosis of depression, most such nursing home residents remained untreated, incorrectly treated, or inadequately treated.

Longitudinal Study of Psychotropic Drug Use by Elderly Nursing Home Residents

In this longitudinal study of patterns of use of psychotropic drugs by a cohort of elderly nursing home residents (N = 5,752), drug use was examined upon admission, 3 months later, and at discharge/end of study. At each time point, 17% of the cohort used neuroleptics. Half of the subjects discontinued neuroleptics at each time point; however, a similar number were initiated on the drug. Benzodiazepines were used by 21%, 15%, and 15% at each of the three time points, respectively. Twice as many people were taken off benzodiazepines as initiated on them following admission. The 5% rate of antidepressant use was constant across the three time periods, although only half of those who took antidepressants upon admission were also taking them upon discharge/end of study. The amount of change due to discontinuation of these drugs and adjustment in dosage levels challenges the stereotype of the "neglected psychotropic drug user" in nursing homes.

Self-report versus medical record functional status

The importance of assessing functional status in the hospitalized patient is gaining recognition. However, the availability and accuracy of medical record functional status data are uncertain. We collected data on 2,504 patients greater than 65 years of age discharged alive. A personal interview conducted 2 days before discharge recorded the patient's self-reported ability to perform 5 activities of daily living scales. Medical record abstraction was used independently to determine ability to perform the same activities of daily living scales. Patients who required any human assistance to perform a function were considered dependent. Patients were also contacted after discharge to determine the site of posthospital care (28% discharged to a nursing home). The amount of missing medical record functional status data varied by function from 20% for bathing to 50% for dressing. Ten percent of patients had no medical record functional status documentation concerning any of the five functions. The prevalence of self-reported dependence at discharge varied by function from 24% for feeding to 93% for bathing. The total number of dependencies differed between the two methods (medical records, 2.3 +/- 1.9; self-report data, 3.2 +/- 1.5). There was exact agreement between the two methods on the total number of dependencies in 28% of cases and differences of greater than or equal to 3 in 20%. In a stepwise logistic model predicting discharge to a nursing home and adjusting for other relevant variables, the number of dependencies as determined by self-report and medical record data each remained significant (Odds Ratios = 1.6). Self-report and medical record functional status data differ substantially, and the medical record data remain independently associated with nursing home placement. Several possible explanations for this finding are explored.

Computerized assessment in neuropsychology: a review of tests and test batteries

This article contains detailed reviews of 13 computerized neuropsychological and performance test batteries and six stand-alone computer tests. Tasks found on these instruments are described and tables illustrate which batteries employ which measures. In addition to issues of reliability and validity, special considerations apply to computerized assessment. These issues are discussed and readers are provided information to help them assess computerized tests in relation to their particular clinical and research needs. Since many computerized tests were developed as performance assessment tools, the relationship between performance and neuropsychological assessment is examined.

Standardized and flexible batteries in neuropsychology: an assessment update

This article summarizes current literature relevant to commonly used tests and test batteries in clinical neuropsychology. The first section contains a discussion of the philosophy and relative advantages of standardized and flexible battery approaches in neuropsychology. The second contains historical background and a literature review of the two major standardized test batteries: the Halstead-Reitan and Luria-Nebraska. The third section includes reviews of tests that are frequently used in the flexible battery approach. Various tests of intellectual functioning, attention, memory, language, and spatial analyses are critiqued in this section. Contributions of the process approach are noted. The article ends by underscoring the need for continued research into the nature of neuropsychological measures and the abilities they assess.

Adult foster care for the elderly in Oregon: a mainstream alternative to nursing homes?

BACKGROUND

In Oregon, adult foster care (AFC) homes, which are private residences where a live-in manager cares for one to five disabled residents, have been covered by Medicaid since 1981 and seem to offer a mainstream alternative to nursing homes. They house almost 6000 older people, two thirds of which pay privately.

METHODS

In a cross-sectional study, we interviewed 400 AFC and 400 nursing home residents. Data analyses included descriptive cross-tabulations; hierarchial loglinear models for judging the effects of care setting and payment status on resident characteristics; and logit analyses for predicting care setting and payment status within care settings.

RESULTS

On average, nursing home residents were more physically and cognitively impaired than AFC residents, but there was considerable overlap in patterns of frailty in the two settings. Medicaid AFC residents were less disabled than privately paying AFC residents. AFC residents reported more social activity, even when we controlled for disability status. AFC residents and their families were more likely to value privacy and homelike settings when choosing a care setting, whereas nursing home residents were more likely to value rehabilitation and organized activity programs.

CONCLUSIONS

Both AFC and nursing homes are viable components of a long-term care repertoire. The greater disability levels of private-pay AFC residents refutes the criticisms that disabled Medicaid residents were being inappropriately channeled to AFC.

Improving primary care in nursing homes

We conducted a quasi-experiment to evaluate the impact of a Medicare waiver which allowed the use of nurse practitioners (NPs) and physicians assistants (PAs) to deliver primary care to Massachusetts nursing home patients and removed the limits on the reimbursable numbers of visits per month. A carefully matched set of 1,327 Medicaid patients from 95 non-participating homes in the same areas of Massachusetts was compared to 1,324 Medicaid demonstration patients from 75 homes. Information came from specially designed record reviews and the Medicaid and Medicare information systems. Separate analyses were done for newly admitted cases and rollovers. Comparisons of quality of care suggested that the medical groups using NPs and PAs provided as good or better care than did the physicians in the control group. There were no differences in functional status changes or in the use of medications. The demonstration patients received more attention, as reflected in more orders written and an average of one additional visit a month. Demonstration patients showed higher scores on three of seven specially designed quality tracers, congestive heart failure and hypertension for both new administrations and rollovers, and new urinary incontinence for new admissions. Rollovers had significantly fewer emergency and total hospital days. A cost analysis suggests that the use of NPs and PAs saves at least as much as it costs and may save additional money with more sustained use.

Using ADLs to establish eligibility for long-term care among the cognitively impaired

Using a database from the Oregon Medicaid program, we examined the differences in the potential insurance coverage of demented persons by using different formulations of ADL (activities of daily living) dependencies in which the definition of dependency did or did not include the need for supervision. For those with clear dementia, 81-88% of the persons with significant behavioral problems were correctly identified when a cut score of three or more ADLs was used; this percentage was even higher for two or more ADLs. This approach was not as effective in correctly discriminating those who had no behavioral problems.

Evaluation of neuroleptic drug use by nursing home elderly under proposed Medicare and Medicaid regulations

Federal regulations for use of neuroleptic drugs in Medicare- and Medicaid-certified nursing homes throughout the United States were implemented October 1, 1990. These regulations constitute the first time that prescription drugs are required, by law, to be justified by indications documented in the medical chart. This study used extant data to estimate ineligible neuroleptic use at the individual and nursing home levels had these regulations been in effect in 1976 through 1985. Subjects, randomly sampled admissions (N = 5752) and residents (N = 3191), were followed up for up to 24 months in 60 nursing homes. One half of neuroleptic use in each cohort could be considered ineligible under the regulations; all but one of the nursing homes had one or more individuals who were treated with the ineligible use of neuroleptics. Improvements in documentation and/or prescription of neuroleptic drugs for nursing home elderly will be needed to ensure compliance with these new regulations.

Forecasting the number of future disabled elderly using Markovian and mathematical models

The accuracy of forecasting the number of future disabled elderly people depends on the accuracy of projecting mortality rates and the rates of transition to and from functional disability. We describe a new two-step method for constructing mathematical models that project these future rates dynamically. (1) A Markovian model of elders' transitions between functional states is specified. (2) A mathematical model of the probability of each transition is created. We conducted pilot studies of the fundamental mathematical processes of this method using data from the Longitudinal Study of Aging. First we constructed prototypic mathematical models of the probabilities of remaining functionally able and of making transitions to disability and to death within 2 years. Then we used these models to project hypothetical rates of transition for white women of selected ages, morbidity ratings and health statuses.